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EXHIBIT 1.A.(10)(a)
XXXXXXX XXXXX LIFE INSURANCE COMPANY
LITTLE ROCK, ARKANSAS
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Xxxxxxx Xxxxx Variable Life Insurance Policy Number
Account Number Application
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Ab PROPOSED INSURED NO. 1 Ab PROPOSED INSURED NO. 2 (IF JOINT AND LAST SURVIVOR)
[ ]MR. [ ]MRS. [ ]MISS [ ]MS. [ ]OTHER FIRST NAME [ ]MR. [ ]MRS. [ ]MISS [ ]MS. [ ]OTHER
----- ----- ---
M.I. LAST FIRST NAME M.I. LAST
- ---- ----- ----- ---- --------
ADDRESS ADDRESS
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CITY STATE ZIP SEX HEIGHT FT CITY STATE ZIP
-------- ---------- -------- ---- ---- --- ------------------ ---------- --------------
INS. WEIGHT LBS. SEX HEIGHT FT INS. WEIGHT LBS.
-- ------------ ---- ---- ------ ------------
MARITAL SOC. SEC. MARITAL SOC. SEC.
STATUS NUMBER STATUS NUMBER
-------- --------------- -------- ---------------
HOME BUSINESS HOME BUSINESS
PHONE( ) PHONE ( ) PHONE( ) PHONE ( )
------ -------- -------- ---------
DATE OF PLACE OF AGE NEAREST DATE OF PLACE OF AGE NEAREST
BIRTH BIRTH BIRTHDAY BIRTH BIRTH BIRTHDAY
----- ---- -------- --- ---- --------
OCCUPATION/DUTIES OCCUPATION/DUTIES
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RELATIONSHIP TO NO. 1
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Ba OWNER C BENEFICIARY DESIGNATION A proposed insured
[ ]Proposed Insured No.1[ ]Proposed Insured No.2 cannot be the beneficiary.
[ ]Both Proposed Insured with right of survivorship [ ]Other Show name(s) and relationship(s) to proposed insured(s).
(if other complete below)
FIRST NAME(S) M.I. LAST
------ ---- ----------- Relationship(s)
ADDRESS Primary Beneficiary(ies): to be proposed insured(s)
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CITY STATE ZIP
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TELE- SOC. SEC.
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PHONE ( ) OR TAX ID NO.
--------- ------- Contingent Beneficiary(ies):
RELATIONSHIP TO PROPOSED INSURED(S)#1 #2
-- --
Bb Contingent Owner (Optional)
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FIRST NAME M.I. LAST ----------------------------- -------------------------
--------- ---- ----------- The owner reserves the right to change the
Da PLAN APPLIED FOR (SINGLE LIFE) beneficiary(ies) unless indicated above.
[ ] Maximum Investment (Guarantee Period for Life) Db PLAN APPLIED FOR (JOINT AND LAST SURVIVOR)
[ ] Specified Face Amount of: $
-------------- [ ] Maximum Investment (Guarantee Period for Life)
[ ] Specified Face Amount of: $
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E INITIAL PREMIUM
Basic Coverage - Initial Premium $ Method of Payment
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Optional riders (check below and indicate
premium) [ ] Check
$
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[ ] Single Premium Immediate Annuity $ [ ] CMA Life Service
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[ ] Other $
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Total rider premium submitted with application $
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Total initial premium submitted with application
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F PLANNED PERIODIC PREMIUMS
(OPTIONAL) Complete this section only if the owner elects to pay planned periodic premiums after
the initial premium. Specify duration, amount, frequency, and method of payment.
Frequency: Method of Payment
Planned Period Amount of Planned [ ]Annual [ ]Quarterly [ ]Pre-Authorized Check
(monthly only)
Premium Duration Periodic Premium (Attach bank authorization form.)
Years $ [ ]Semiannually [ ]Monthly [ ]CMA Life
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2
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Show the amount in dollars or percentages
(in whole numbers)
G INITIAL INVESTMENT ALLOCATION (BASIC COVERAGE ONLY) Division Name
% or $ $
-------------------- --------------- ------------------ -
Note: Allocation of initial investment base is % $
subject to the provisions of the prospectus and -------------------- --------------- ---------------- ----
Xxxxxxx Xxxxx Insurance Company's rules and limits. % $
After the fee-look period, the owner may reallocate -------------------- --------------- ------------- -------
the investment base among the investment divisions. % $
-------------------- --------------- ---------- ----------
% $
-------------------- --------------- ------- -------------
Total 100% or
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H - INFORMATION ABOUT THE PROPOSED INSURED(S)
If answer to Question 1 is no, or 2 or 3, is yes, explain in Remarks (Section Proposed Insured Proposed Insured
1). No. 1 No.1
[ ] YES[ ] NO [ ] YES[ ] NO
1. Is the proposed insured now performing his or her usual occupational
duties (or usual daily duties if student, homemaker or retired) without
any disabling impairment?
2. During the last two years, has the proposed insured been hospitalized,
treated, advised or diagnosed by a member of the medical profession for [ ] YES[ ] NO [ ] YES[ ] NO
any heart, liver, ling or kidney trouble, high blood pressure, stroke,
diabetes, cancer, nervous disorders or disorders of the immune system
(including AIDS or ARC)?
3. Has the proposed insured ever been refused life insurance, been offered a
modified or rated policy, or applied for or received disability benefits
from any source?
4. Has the proposed insured smoked any cigarettes within the last year?
5. Will this policy replace or change an existing insurance policy or
annuity? [ ] YES[ ] NO [ ] YES[ ] NO
(If yes, list all companies and policy numbers in Remarks, Section 1.)
[ ] YES[ ] NO [ ] YES[ ] NO
[ ] YES[ ] NO [ ] YES[ ] NO
[ ] YES[ ] NO [ ] YES[ ] NO
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I REMARKS (ATTACH PAGES IF NECESSARY)
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J SUITABILITY, AGREEMENT AND AUTHORIZATION
Suitability
By signing below, the applicant acknowledges receipt of the appropriate
prospectus and understands that the death benefit under the policy may increase
or decrease depending upon the investment results of the policy, but will never
be less than the face amount. The duration for which a policy is in effect may
depend on the Investment results of the policy, but will never be less than the
Guarantee Period. The policy's cash surrender value may increase or decrease
on any day depending upon the investment results. No minimum cash surrender
value is guaranteed. The policy is a long-term commitment to meet insurance
needs and financial goals.
Agreement
You agree that to the best of your knowledge and belief, all statements and
answers in the application are complete and true and may be relied upon in
determining whether to issue the policy. Your answers will form a part of any
policy to be issued, and to medical examiner or registered representative has
authority to modify this agreement or waive any of Xxxxxxx Xxxxx'x rights or
requirements. If Xxxxxxx Xxxxx makes a change as indicated in Section L, it
will be approved by acceptance of the policy where permitted by state
regulation. Any change in plan, benefits applied for, amount of insurance, age
at issue, or underwriting class must be agreed to in writing. You also
understand that unless otherwise provided by the Temporary Insurance Agreement,
no policy will take effect unless, while the insured(s) is (are)living, the
initial premium is paid, the policy is delivered to and accepted by the 9owner,
the answers and statements in this application continue to be complete and true
at the time of such payment and delivery, and the proposed insured's
insurability and condition of health
20182 -2- REV. 2/92
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remains as stated in the application. Upon request, illustration of death
benefits and cash surrender values comparing the policy applied for and a fixed
life insurance policy of the same premium will be furnished. We will furnish
any information that may be currently required by the insurance supervisory
official of the jurisdiction in which this policy is delivered.
Authorization
I, the proposed insured, authorize any physician, hospital or other medical
practitioner or facility, insurance company, Medical Information Bureau, or any
other organization, institution or person that has any information about my
health or any nonmedical information relevant to my insurability or that of my
minor children who are to be insured to release such information to Xxxxxxx
Xxxxx and its reinsurers. I authorize Xxxxxxx Xxxxx to obtain investigative
consumer reports, if appropriate. I understand that I have a right to learn
the content and receive a copy of any such report. This authorization is valid
for 1 - 1/2 years from the date signed and a photographic copy is as valid as
the original. I acknowledge receipt of the Fair Credit Reporting Act and
Medical Information Bureau Notices.
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K SIGNATURES
SIGNED AT ON
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CITY STATE DATE
X X
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PROPOSED INSURED NO. 1 (PARENT/GUARDIAN PROPOSED INSURED NO. 2 (PARENT/GUARDIAN
IF PROPOSED INSURED IS UNDER AGE 15) IF PROPOSED INSURED IS UNDER AGE 15)
X X
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APPLICANT/OWNER (IF OTHER THAN EITHER PROPOSED INSURED) AGENT WITNESS
NAME OF FINANCIAL SOC. SEC. NO.
CONSULTANT OFFINANCIAL
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CONSULTANT BROKER DEALER BRANCH OFFICE/NUMBER
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L AMENDMENTS (H.O. USE ONLY)
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20182 -3- REV. 2/92
