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This application is to: [_] Xxxx Xxxxxxx Life Insurance Company or
[_] Xxxx Xxxxxxx Variable Life Insurance Company
which will sometimes hereinafter be referred to
as "the Company" and "Xxxx Xxxxxxx". X.X. Xxx
000, Xxxxxx, Xxxxxxxxxxxxx 00000
State of Issue __ __
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M Proprietary Products
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Instructions
1. Please print all answers legibly in black ink.
2. Any change or deletion must be initialed by the Proposed Insured or
Applicant.
3. Required medical information must be completed on all people
proposed for coverage unless they are to be medically examined.
(Form 156-MAJ-01)
4. Please confirm that each proposed insured is currently working at
least 30 hours per week in a normal capacity and not hospitalized or
absent from work due to illness or accident.
156-MAJM-01
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Master Application Number ______________________________________
A. CORPORATION
1. Name of Corporation 4. Address of Corporation
__________________________________________________________ ________________________________________________________________
NAME STREET ADDRESS
_____________________________________________________________
2. Name and title of Company Officer ________________________________________________________________
STREET ADDRESS
________________________________________________________________
CITY STATE ZIP
__________________________________________________________ ________________________________________________________________
NAME PHONE FAX
________________________________________________________________
5. Type of Business
__________________________________________________________
TITLE
_____________________________________________________________ ________________________________________________________________
3. Tax ID Number 6. Corporate Fiscal Date (Month/Day)
__ __ - __ __ __ __ __ __ __ ___ / ___
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B. CORRESPONDENCE INFORMATION
Name/Address/Phone for mailing of Name/Address/Phone for mailing of
policy statements and correspondence Premium Notices:(If same as address to left, state "same")
other than premium notices:
________________________________________________________ ______________________________________________________________
NAME NAME
________________________________________________________ ______________________________________________________________
XXXXXX XXXXXXX XXXXXX XXXXXXX
________________________________________________________ ______________________________________________________________
CITY STATE ZIP CITY STATE ZIP
________________________________________________________ ______________________________________________________________
PHONE FAX PHONE FAX
Billing Frequency [_] Annual [_] Semi-Annual [_] Qtly [_] Monthly - EC Case #______________________
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C. BENEFICIARY
(If beneficiary is not superseded by any individual application submitted as part of this case)
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D. SPECIAL REQUESTS
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E. OWNERSHIP INFORMATION (LEAVE BLANK IF INDIVIDUAL IS OWNER)
1. Owner 3. Social Security or Tax ID Number (no dashes)
_______________________________________________________ _____________________________________________
NAME
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2. Name and title of Owner/Trustee (Authorized Business Official)
______________________________________________________________
NAME TITLE
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THIS PAGE MUST BE COMPLETED FOR ALL VARIABLE PRODUCTS
F. PLAN
Choose One:
[_] Majestic Variable COLI [_] Variable MasterPlan Plus COLI [_] Majestic VUL 98
[_] Other (if applicable): ______________________
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G. VARIABLE INVESTMENT OPTIONS
Percentages must be Whole and Total 100%
Equities (Mid Cap) International/Global Equities Outside Trust Funds
___% Fundamental Mid Cap Growth ___% Global Balanced ___% AIM V.I. Value
___% Mid Cap Value ___% International Equity Index ___% Fidelity VIP Contrafund
___% Mid Cap Growth ___% International Opportunities ___% Fidelity VIP Growth
___% Real Estate Equity ___% Emerging Markets Equity ___% Janus Aspen Global Technology
___% Small/Mid Cap CORE Bonds ___% Janus Aspen Worldwide Growth
___% Small/Mid Cap Growth ___% Active Bond ___% MFS New Discovery
Equities (Large Cap) ___% Bond Index ___% Xxxxxxxxx International Securities
___% American Leaders Large Cap Value ___% Core Bond Mananged/Other(s)
___% Equity Index ___% Global Bond ___% Managed
___% Growth & Income ___% High Yield Bond ___% _____________
___% Large Cap Aggressive Growth ___% Short-Term Bond ___% _____________
___% Large Cap Growth Cash Equivalents/Fixed Account ___% _____________
___% Large Cap Value ___% Money Market ___% _____________
Equities (Small Cap) ___% Fixed Account* ___% _____________
___% Small Cap Growth
___% Small Cap Growth
*Liquidity restrictions apply when allocating funds to the Fixed Account
1. Have you received a prospectus for the policy applied for? (If YES,
Prospectus Date: ________________ ) [_] Yes [_] No
2. Is the policy and allocation of subaccounts in accord with your insurance
objectives and your anticipated financial needs? [_] Yes [_] No
3. Have you received an illustration of benefits based on your Planned Premium? [_] Yes [_] No
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H. TELEPHONE TRANSFER AUTHORIZATION
By checking the "yes" box below, I/We direct the Company to act upon
telephone instructions from the Owner (a trustee, if the Owner is a trust, or
an authorized business official, if the Owner is a business entitiy) and
my/our registered representative, if applicable, to change future payment
allocations and/or transfer existing funds amoung the investment options,
subject to the terms of the telephone transfer provision as described in the
current prospectus for the policy.
[_] Yes If yes, please check one: [_] Owner(s) and Registered Representative
[_] Owner(s) only
[_] No
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I. TELEPHONE LOAN OPTION
I direct the Company to act upon telephone instructions from the owner (a trustee, if the owner is a trust, or an authorized
business official, if the Owner is a business entity) to process policy loans, subject to the provisions of the policy, and any
other requirements. [_] Yes [_] No
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Page 3 (Variable Investment Options)
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J. AGREEMENTS
All statements in this application are, to the best of my knowledge and belief,
true, complete, and correctly recorded. I assent to this application and also
agree that:
1. The statements and answers in this application are representations and not
warranties and attachments hereto will be relied upon and form the basis of
any insurance.
2. No information will be considered as having been given to Xxxx Xxxxxxx
unless it is written in this application.
3. No agent or medical examiner or any other person, except an officer of Xxxx
Xxxxxxx, is authorized to make or discharge contracts or waive or change
any of the conditions or provisions of any application or policy, or to
accept risks or pass on insurability. Any such unauthorized action is not
notice to or knowledge of the company. A medical examiner is not an agent
of the Company. In order for any of the above events to take effect they
must be provided for in writing signed by an officer of the Company.
4. Any policy issued on the basis of this application will take effect as of
the Date of Issue, but (i) only upon approval of the application by Xxxx
Xxxxxxx and delivery to and acceptance by the Applicant of the policy and
payment of the minimum initial premium (in accordance with the billing
frequency chosen) and (ii) only if, at the time of such delivery and
payment, the person proposed for insurance in Parts A and B of this
application is living and has not consulted or been examined or treated by
a physician or practitioner since the latest Part B was completed.
5. All benefits, payments, and values, including the Death Benefit and Account
or Cash Value, under any policy issued which is based upon the investment
experience of a separate investment account may increase or decrease in
accordance with the investment experience of the separate investment
account and are not guaranteed as to fixed dollar amount. The Account Value
or Cash Value may even decrease to zero.
6. The registered representative's signature below certifies that a prospectus
for the policy applied for has been given to the Proposed Insured and/or to
the Applicant and that no written sales materials other than those approved
by the Company have been used.
Any person who, with intent to defraud or knowing that he is facilitating a
fraud against an insurer, submits an application or files a claim containing
a false or deceptive statement may be guilty of insurance fraud
______________________________________________ Dated At _________________________________________ on _________________,_________
Applicant's Signature City or Town State Date
______________________________________________ Dated At _________________________________________ on _________________,_________
Registered Representative City or Town State Date
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K. SALES CREDIT FOR APPLICATION
Producer(s) Earning Credit for Case
Producer Name/Number Firm Name/Number % Credit
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___________________________________ _______________________ _____________
___________________________________ _______________________ _____________
___________________________________ _______________________ _____________
___________________________________ _______________________ _____________
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