Exhibit 1A.5(a)
New England Variable Life
Insurance Company
Flexible Premium Adjustable Variable Survivorship Life Policy
Plan
Flexible Premium Adjustable Variable Survivorship Life
New England Variable Life Insurance Company Agrees to pay the Death Benefit of
this Policy to the Beneficiary on receipt of proof that the Last Death occurred
before the Maturity Date; or to pay the Net Cash Value of the Policy to the
Owner if at least one Insured is living on the Maturity Date; and to provide the
other rights and benefits of the Policy.
These agreements are subject to all of the provisions of the Policy.
Signed on the Date of Issue for the Company at its Administrative Office, 000
Xxxxxxxx Xxxxxx Xxxxxx, XX 00000
/s/ Xxxxxx X. Xxxxxx
Xxxxxx X. Xxxxxx
President
/s/ Xxxxxx X. Xxxxxxxxx
Xxxxxx X. Xxxxxxxxx
Secretary
Flexible Premium Adjustable Variable Survivorship Life Policy
. The Death Proceeds are payable at the Last Death, if the Last Death occurs
before the Maturity Date and the Policy is in force.
. The Net Cash Value, if any, is payable on the Maturity Date, if at least
one Insured is still living and the Policy is in force.
. The Policy can be adjusted by decreasing the Face Amount.
. The amount and frequency of premium payments can be changed.
. The Policy does not share in dividends.
THE DEATH BENEFIT ON THE POLICY DATE WILL BE EQUAL TO THE FACE AMOUNT SHOWN IN
SECTION 1. THEREAFTER, THE DEATH BENEFIT CAN VARY FROM DAY TO DAY. IT CAN
INCREASE OR DECREASE, DEPENDING ON
SEPARATE INVESTMENT ACCOUNT PERFORMANCE AND ON FIXED ACCOUNT INTEREST; BUT IT
WILL NOT BE LESS THAN THE FACE AMOUNT. SEE SECTION 9.
THE CASH VALUE OF THIS POLICY CAN VARY FROM DAY TO DAY. IT CAN INCREASE OR
DECREASE, DEPENDING ON SEPARATE INVESTMENT ACCOUNT PERFORMANCE AND ON FIXED
ACCOUNT INTEREST. SEE SECTION 13.
Please Read Your Policy Carefully
This Policy is a legal Contract between you and the Company.
Right to Return the Policy
When this Policy is issued, you should examine it. You can return the Policy to
the Company or its Agent for any reason within the latest of: (a) 10 days after
you receive it from the Company; (b) 45 days after Part I of the Application is
signed; and (c) 10 days after the Company mails the separate Notice of
Withdrawal Right. If you return the Policy: an amount equal to any premium paid
plus an unscheduled payment made will be refunded to you; and the Policy will be
cancelled from the start.
Policy Provisions Alphabetical Guide
Section Section
1 Policy Schedule 1, 6 Age of Insured
2 Table of Guaranteed 11 Amount at Risk
Insurance Factors Per 17 Assignments
$1,000 17 Beneficiary
3 Surrender Charge 18 Benefits, Payment of
4 Guaranteed Death Benefit 1 13 Cash Value
Fund 6 Claims of Creditors
5 Guaranteed Death Benefit 2 6 Contestable
Fund 6 Contract
6 Contract 1, 6 Date of Issue
7 The Variable Account 1, 6 Date, Policy
8 The Fixed Account 9 Death Benefit
9 Death Benefit 15 Decrease in Face Amount
10 Premiums 16 Exchange of Policy
11 Monthly Deduction 1 Face Amount
12 Reinstatement After Lapse 8 Fixed Account
13 Cash Value of the Policy 11 Grace Period
14 Policy Loans 2 Insurance Factors
15 Policy Changes 13 Investment Return
16 Exchange of Policy 18, 19 Life Income Options
17 Owner and Beneficiary 20 Life Income Tables
18 Payment of Benefits 1 Loan Interest Rate
19 Payment Options 14 Loans, policy
20 Life Income Tables 1 Maturity Date
. Riders, if any 11 Monthly Deduction
. Amendments and 13 Net Cash Value
Endorsements 17 Owner
. Copy of the Application 15 Partial Surrender
19 Payment Options
6 Periodic Reports
15 Policy Changes
14 Policy Loan Balance
6 Postponement of Payments
10 Premiums
12 Reinstatement
1 Schedule, Policy
7 Sub-Accounts
6 Suicide
3 Surrender Charge
3, 13 Surrender of the Policy
7 Variable Account
New England Variable Life
Insurance Company
1. Policy Schedule
Owner and Beneficiary
As named in the Application or as later changed. See the Owner and Beneficiary
Section of the Policy.
Policy Number
Specimen
Policy Date Date of Issue Maturity Date*
October 1, 1993 October 1, 1993 October 1, 2058
Policy Loan Interest Rate Death Benefit Option
5.5% C
THIS POLICY IS ADJUSTABLE. IF IT IS ADJUSTED, A NEW POLICY SCHEDULE WILL
SUPERSEDE THIS SCHEDULE.
Schedule of Insureds
Insured 1: Xxxx Xxxxx Age and Sex: 35 Male
Insured 2: Xxxxx Xxxxxxxx Age and Sex: 35 Male
Policy Class: Standard Smoker
Policy Class: Standard Smoker
Schedule of Benefits
Flexible Premium Adjustable Variable Survivorship Life
$100,000
Schedule of Premiums
Planned Annual Premium: $ 1,062.68**
Guaranteed Death Benefit 1 Premium: $ 1,361.79
Guaranteed Death Benefit 2 Premium: $ 1,062.68
Maximum Monthly Expense charge:
Year 1 $ 17.00
Thereafter 11.00
Premium Expense Charge: 12.5%
Maximum Monthly Administrative Charge $ 7.50
*This coverage may expire prior to the Maturity Date if premiums paid are
insufficient to continue the coverage to that date. There may be little or no
Cash Value on that date.
**If the Planned Annual Premium is paid on the first day of each policy year,
and the Actual Investment Return is 4% and the guaranteed maximum charges apply
in all years, this Policy will terminate in policy year 46 unless additional
premium is paid.
/s/ Xxxxxx X. Xxxxxxxxx
Xxxxxx X. Xxxxxxxxx
Secretary
New England Variable Life
Insurance Company
2. Table of Guaranteed Insurance Factors per
$1,000
Based on the 1980 CSO Smoker Table
Policy Number: Specimen
Policy Year Monthly Factor Policy Year Monthly Factor
1 $ .0006 34 $ 2.2448
2 .0019 35 2.5494
3 .0035 36 2.8913
4 .0055 37 3.2761
5 .0080 38 3.7166
6 .0111 39 4.2180
7 .0151 40 4.7750
8 .0199 41 5.3988
9 .0259 42 6.0596
10 .0331 43 6.7460
11 .0419 44 7.4456
12 .0522 45 8.1702
13 .0646 46 8.9418
14 .0790 47 9.7747
15 .0963 48 10.6882
16 .1165 49 11.6882
17 .1410 50 12.7422
18 .1702 51 13.8176
19 .2056 52 14.8807
20 .2482 53 15.9144
21 .2979 54 17.0246
22 .3560 55 18.1139
23 .4220 56 19.1958
24 .4978 57 20.2900
25 .5830 58 21.4397
26 .6817 59 22.8934
27 .7970 60 24.7464
28 .9320 61 27.4231
29 1.0905 62 31.9931
30 1.2737 63 39.9825
31 1.4824 64 54.8157
32 1.7133 65 83.3333
33 1.9683
/s/ Xxxxxx X. Xxxxxxxxx
Xxxxxx X. Xxxxxxxxx
Secretary
New England Variable Life
Insurance Company
3. Surrender Charge
Policy Number
Specimen
A Surrender Charge will be deducted from partial surrender, full surrender,
decrease in Face Amount and lapse transactions during the first 14 policy years.
The Surrender Charge is equal to a Deferred Sales Charge plus any Deferred
Administrative Charge. The schedule of Surrender Charges is different at and
after Reinstatement. (See below.)
The Maximum Deferred Sales Charges for years 1 through 5 are shown in the table
on the next page. The Maximum Deferred Sales Charges for the last policy month
of each of years 6 through 15 are shown in the table on the next page; the
Maximum Charges for other months will reflect the number of completed policy
months in the year of surrender, lapse or decrease in Face Amount.
The Deferred Administrative Charge for the first five policy years is shown in
the table on the next page; the Charge is level throughout each year. The Charge
for the last policy month of each of years 6 through 14 is shown in the table on
the next page; the Charge for other months will reflect the number of completed
policy months in the year of surrender, lapse or decrease in Face Amount.
Surrender Charge at and after Reinstatement
A Surrender Charge will be applied if the Policy lapses. If the Policy is
reinstated, the Charge will be credited to the Cash Value of the Policy. The
Surrender Charge on the date of reinstatement will be the same as it was on the
date of lapse. For the purpose of determining the Surrender Charge on any date
after reinstatement, the period the Policy was lapsed will not count.
/s/ Xxxxxx X. Xxxxxxxxx
Xxxxxx X. Xxxxxxxxx
Secretary
New England Variable Life
Insurance Company
3. Surrender Charge (Second Page)
Policy Number
Specimen
Year of
Surrender, Maximum Deferred
Decrease or Deferred Administrative
Lapse Sales Charge Charge
1 $223.16 $400.00
2 223.16 400.00
3 956.41 400.00
4 956.41 400.00
5 956.41 400.00
6 850.55 360.00
7 743.88 320.00
8 637.61 280.00
9 531.34 240.00
10 425.07 200.00
11 318.80 150.00
12 212.54 100.00
13 106.27 50.00
14 0.00 0.00
15 0.00 0.00
/s/ Xxxxxx X. Xxxxxxxxx
Xxxxxx X. Xxxxxxxxx
Secretary
New England Variable Life
Insurance Company
4. Guaranteed Death Benefit 1 Fund
Policy Number
Specimen
The Guaranteed Death Benefit 1 Fund is used to determine if the Minimum
Guaranteed Death Benefit 1 is in effect. (See Section 11.) The Fund assumes the
Guaranteed Death Benefit 1 Premium shown in Section 1 is paid on the first day
of each policy year. The Fund is equal to each Guaranteed Death Benefit 1
Premium accumulated at 4%.
Year Year
1 $1,361.79 36 $105,672.61
2 2,778.05 37 111,261.30
3 4,250.96 38 117,073.54
4 5,782.79 39 123,118.28
5 7,375.89 40 129,404.80
6 9,032.72 41 135,942.78
7 10,755.82 42 142,742.28
8 12,547.84 43 149,813.76
9 14,411.54 44 157,168.10
10 16,349.80 45 164,816.62
11 18,365.58 46 172,771.07
12 20,461.99 47 181,043.70
13 22,642.26 48 189,647.24
14 24,909.74 49 198,594.92
15 27,267.92 50 207,900.51
16 29,720.43 51 217,578.32
17 32,271.04 52 227,643.24
18 34,923.67 53 238,110.76
19 37,682.40 54 248,996.98
20 40,551.49 55 260,318.65
21 43,535.34 56 272,093.19
22 46,638.54 57 284,338.70
23 49,865.87 58 297,074.04
24 53,222.30 59 310,318.79
25 56,712.98 60 324,093.34
26 60,343.29 61 338,418.86
27 64,118.81 62 353,317.40
28 68,045.35 63 368,811.89
29 72,128.96 64 384,926.15
30 76,375.91 65 401,684.99
31 80,792.73
32 85,386.23
33 90,163.47
34 95,131.80
35 100,298.86
/s/ Xxxxxx X. Xxxxxxxxx
Xxxxxx X. Xxxxxxxxx
Secretary
New England Variable Life
Insurance Company
5. Guaranteed Death Benefit 2 Fund
Policy Number
Specimen
The Guaranteed Death Benefit 2 Fund is used to determine if the Minimum
Guaranteed Death Benefit 2 is in effect. (See Section 11.) The Fund assumes the
Guaranteed Death Benefit 2 Premium shown in Section 1 is paid on the first day
of each policy year. The Fund is equal to each Guaranteed Death Benefit 2
Premium accumulated at 4%.
Year Year
1 1,062.68 26 47,089.20
2 2,167.87 27 50,035.45
3 3,317.26 28 53,099.55
4 4,512.63 29 56,286.21
5 5,755.82 30 59,600.34
6 7,048.73 31 63,047.04
7 8,393.36 32 66,631.60
8 9,791.77 33 70,359.54
9 11,246.12 34 74,236.60
10 12,758.65 35 78,268.75
11 14,331.68 36 82,462.18
12 15,967.62 37 86,823.34
13 17,669.01 38 91,358.96
14 19,438.45 39 96,076.00
15 21,278.67 40 100,981.72
16 23,192.49 41 106,083.66
17 25,182.87 42 111,389.69
18 27,252.87 43 116,907.96
19 29,405.66 44 122,646.96
20 31,644.57 45 128,615.51
21 33,973.03
22 36,394.63
23 38,913.10
24 41,532.30
25 44,256.27
/s/ Xxxxxx X. Xxxxxxxxx
Xxxxxx X. Xxxxxxxxx
Secretary
6. Contract
The Contract
This Policy is a legal contract between the Owner of the Policy (called "you")
and New England Variable Life Insurance Company, a Delaware corporation, (called
"the Company"). The Policy, which includes the attached Application and any
Application for adjustment of the Policy, is the entire contract between you and
the Company. All riders are listed in Section 1. No change in or waiver of the
provisions of the Policy is valid unless the change or waiver is signed by the
President or the Secretary of the Company.
Payments Under the Contract
All contract amounts are in dollars of the United States of America. Payments by
the Company under the contract will be made at the Administrative Office of the
Company. The obligations of the Company are subject to all payments made and
actions taken by the Company under the Policy before receipt by the Company at
its Administrative Office of proof of the Last Death.
Dates
Policy years, months and anniversaries are all measured from the Policy Date.
Contestable and suicide periods start on the Date of Issue. The Policy Date and
the Date of Issue are shown in Section 1.
Last Death
The Last Death is the later of: the death of Insured 1; and the death of Insured
2.
Not Contestable After Two Years
Insurance is issued by the Company in reliance on the statements made in the
Application for the insurance. Those statements are representations; they are
not warranties. No statement can be used to contest or rescind insurance on the
life of an Insured or to defend against a claim unless contained in the
Application for the insurance on that Insured. The insurance issued under this
Policy will not be contestable after it has been in force during the life of the
Insured:
. With respect to the amount of Death Benefit which results from other than
payments for which proof of insurability is required, for two years from
the Date of Issue; and
. With respect to any amount of Death Benefit which results from a payment
for which proof of insurability is required, for two years from the date
that payment is received.
Suicide Within Two Years
If either of the Insureds dies by suicide while sane or insane within two years
from the Date of Issue, the Death Benefit will be limited to: the amount of the
premiums paid; less any Policy Loan Balance; and less any partial surrenders.
The Policy will terminate as of the date of the first death by suicide.
Within 60 days after the first death by suicide, the Owner can purchase new life
insurance on an Eligible Insured without evidence of insurability. For purposes
of this provision, an Eligible Insured is a surviving Insured on whom the
Company would have issued a single life policy on the Policy Date of this
Policy. The new policy will be issued:
. On the most recently approved plan of single life variable insurance
issued by the Company on the Policy Date of the new policy, if the issue
age on the new policy is age 75 or younger;
. On a single life Ordinary Life plan with a level face amount issued by
New England Mutual Life Insurance Company on the Policy Date of the new
policy, if the issue age on the new policy is greater than 75;
. On a policy form and at rates in use on the Policy Date by the company
issuing the new policy;
. Subject to any assignments and limitations to which this Policy is
subject;
. With a Policy Date and Date of Issue the same as the date of the first
death by suicide under this Policy;
. Based on the underwriting class to which the Eligible Insured was
assigned by the Company on the Policy Date of this Policy;
. At the age of the Eligible Insured on that Insured's birthday nearest the
Policy Date of the new policy; and
. With a Face Amount equal to the Face Amount of this Policy plus the
amount of any single life term rider for the Eligible Insured under this
Policy.
Riders can be added to the new policy only with the consent of the company
issuing the new policy. Application for the new policy must be: in writing;
signed by the Owner and by the Eligible Insured; and received by the company
issuing the new policy within 60 days after the date of the first death by
suicide. However, a death benefit for the Eligible Insured's death will be paid
as if the new policy had been issued: if that Insured dies within this 60 day
period; and before the application for a new policy is received by the company
issuing the new policy; and, if the new policy is a variable life policy,
assuming all premiums for the new policy were allocated to the Fixed Account and
the Death Benefit Option chosen is equal to the face amount of the policy.
Notification of First Death
The Company should be notified immediately when the first death occurs. Even if
premiums continue to be paid after the first death, the Company has the right:
to contest the Policy under the Not Contestable After Two Years provision; or to
limit benefits and terminate the Policy under the Suicide Within Two Years
provision.
Age of insured
The age of an Insured on the Policy Date and on each policy anniversary means
the age at the nearest birthday of that Insured.
If the age or the sex of either Insured has not been correctly stated in the
Application, the Death Benefit will be the amount that the most recent Monthly
Deduction which was made would have provided for the correct age and sex.
Claims of Creditors
The Policy and payments under it are exempt from the claims of creditors to the
extent allowed by law.
Basis of Values
"1980 CSO" means Commissioners 1980 Standard Ordinary; it is used to describe
mortality tables. Minimum Cash Values, Reserves and Guaranteed Insurance Factors
are based on the mortality table shown in Section 2. Interest is compounded
daily at the effective rate of 4% per year. A detailed statement of the method
of computing values has been filed with the Insurance Department of the state in
which the Policy is delivered. All values are equal to or in excess of the
minimum values required by the law of that state.
Periodic Reports
The Company will send you all reports required by law and regulation. Such
reports will be sent once each year or more often if required by law or
regulation. The annual report will include, as of the date for which the report
is made: the Death Benefit; the Cash Value; any Policy Loan Balance; all
transactions in connection with the Policy since the most recent report; and any
other required information.
Policy Illustration of Benefits and Values
Upon written request the Company will send you a policy illustration which will
illustrate benefits and values under the Policy.
Postponement of Variable Benefits
The Company can postpone the determination of and the payment or transfer of
amounts based on separate investment account performance if:
. The New York Stock Exchange is closed for trading (except for normal
weekend and holiday closing) or when trading is restricted; or
. The Securities and Exchange Commission determines that a state of
emergency exists which may make payment or transfer impractical; or
. The Securities and Exchange Commission orders the New England Zenith Fund
or its successor or any other investment company in which the Variable
Account is invested to postpone payment or transfer of variable benefits.
Postponement of Surrenders, Transfers and Loans From The Fixed Account
The Company can postpone the payment of the portion of the Policy's Net Cash
Value which is in the Fixed Account for not more than six months after
surrender. If payment is postponed for more than 30 days, it will be credited
with interest from the date of surrender. The rate of interest will be set each
year by the Company; but the rate will not be less than 3 1/2% per year.
The Company can postpone transfers from the Fixed Account for not more than six
months from the date of the request. The effective date of the transfer is the
date on which values are transferred from the Fixed Account.
The Company can postpone the making of any Policy Loan from the Fixed Account
for not more than six months from the day you apply, except Loans to pay
premiums on policies issued by the Company.
7. The Variable Account
The Variable Account
The Variable Account (called "the Account") is a separate investment account
established by the Company in accordance with Delaware law. The assets of the
Account are owned by the Company.
The assets of the Account will be used to provide values and benefits under this
Policy and similar policies; but the Account is not chargeable with liabilities
arising out of any other business the Company may conduct.
Sub-Accounts
The Account consists of sub-accounts, each of which is invested in shares of one
portfolio of the New England Zenith fund or its successor or any other
investment company in which the Account is invested. Shares of a portfolio are
purchased for a sub-account at their net asset value.
The initial premium is allocated to the Account and the Fixed Account based on
allocation instructions in the Application for insurance. The portion of the
initial premium allocated to the Account is invested in the Money Market sub-
account as of the latest of:
. The Policy Date;
. The date of the last Part II of the Application, if any is required;
. The effective date of the choice of the Account; and
. The date the first premium is received by the Company.
The Policy's Cash Value in the Money Market sub-account will be transferred,
based on your choice, to the sub-accounts as of the later of: 45 days after Part
I of the Application is signed; and 10 days after the Company mails the separate
Notice of Withdrawal Right. Before this transfer, the values and benefits of the
Policy will depend on: the net investment performance of the Money Market sub-
account if any portion of the initial premium is allocated to the Account; and
the Policy's portion of the Fixed Account. After this transfer each net premium
allocated to the Account and each net unscheduled payment allocated to the
Account will be invested in the sub-accounts you chose as of the date it is
received by the Company at its Administrative Office.
Each distribution of income, dividends and capital gains from a portfolio to a
sub-account will be reinvested for the benefit of the owners of the policies in
that sub-account at net asset value in shares of the portfolio which made the
distribution.
The Cash Value of the Policy at any time cannot be allocated among more than 9
sub-accounts, except with the consent of the Company; and the Fixed Account will
be counted in the limit of 9.
The values and benefits of a policy depend on: the investment performance of
the portfolios in which the sub-accounts are invested; and the interest credited
to the Fixed Account. The Company does not guarantee the investment performance
of the portfolios of the sub-accounts. You bear the investment risk for amounts
invested in the sub-accounts for your Policy.
Choice of Sub-Accounts
You choose the sub-accounts in which net premiums and net unscheduled payments
are to be invested. You can change the choice for future premiums and future
unscheduled payments at any time by notice to the Company. The portion of the
net premium and the net unscheduled payment to be applied to each sub-account
chosen must be a whole percent not less than 10.
The portfolios as of the Date of Issue are listed in the then current prospectus
for the Account.
Change in Portfolios
The Company can add or remove portfolios as sub-account investments as permitted
by law. When a change is made, the Company will send you: a revised prospectus
for the Account which will describe all of the portfolios then available in the
New England Zenith Fund or its successor or any other investment company in
which the Account is invested; and any notice required by law.
When a portfolio is removed, the Company has the right to substitute a different
portfolio in which the sub-account will then invest:
. The value of the removed portfolio; and
. Future net premiums and future net unscheduled payments applied to that
sub-account.
Transfer Option
After the Right to Return the Policy period you can transfer all or a portion of
the Policy's existing share of a sub-account to another sub-account or to the
Fixed Account. (See Restriction of New Amounts Applied to the Fixed Account
provision.) Requests for transfers can be made in writing or by telephone. The
Company is not responsible for determining the authenticity of transfer
instructions received by telephone. Transfers will be subject to a limit of 4 in
each policy year, except with the consent of the Company.
Change of Investment Policy
The investment policy of the Account will not be changed unless: (a) the change
has been approved by the Insurance Commissioner of
the state of Delaware; and (b) a statement of the approval process has been
filed with the Insurance Department of the state in which this Policy is
delivered. If the investment policy of the Account is changed, the Company will
give you written notice of the change. You can then choose to exchange this
Policy for a new policy which has a fixed death benefit. The exchange will be on
the same basis as that described in the Exchange of Policy section. (See Section
16.) If you choose to make the exchange, the request for the exchange must be
made within 60 days of the later of: (a) the effective date of the investment
policy change; or (b) the date you receive the notice of the change.
Rights Reserved by the Company
The Company reserves the right to take certain actions subject to compliance
with law including, if required, the approval of the owners of the policies.
These actions are: (a) to create new investment accounts; (b) to combine any two
or more separate investment accounts, including the Account; (c) to invest some
or all of the assets of the Account other than in the New England Zenith Fund;
(d) to invest some or all of the assets of the Account in any other investment
company chosen by New England Variable Life Insurance Company; (e) to remove a
portfolio in which the sub-account is invested or to substitute a different
portfolio; (f) to operate the Account as a management investment company and to
charge investment advisory fees under the Investment Company Act of 1940 or to
operate the Account in any other form permitted by law; and (g) to deregister
the Account under the Investment Company Act of 1940 if registration is no
longer required.
8. The Fixed Account
The Fixed Account
The Fixed Account is a segmented fund within the general account of the Company.
The initial premium is allocated to the Account and the Fixed Account based on
allocation instructions in the Application for insurance. The portion of the
initial premium allocated to the Fixed Account is first invested in the Fixed
Account as of the latest of:
. The Policy Date;
. The date of the last Part II of the Application, if any is required;
. The effective date of the choice of the Fixed Account; and
. The date the first premium is received by the Company.
Thereafter, each net premium allocated to the Fixed Account and each net
unscheduled payment allocated to the Fixed Account will be applied as of the
date it is received by the Company at its Administrative Office. Each transfer
to the Fixed Account will be applied as of the transfer date.
Fixed Account Interest
The rate of interest for each amount applied to the Fixed Account: will be the
rate set by the Company in advance for the date the amount is applied to the
Fixed Account; and will not be less than a rate equivalent to an annual
effective rate of 4%. The effective interest rate used on the Policy will be the
weighted average of all such rates for the Policy.
Each year, on the policy anniversary, the Company will determine a portion, if
any, of the Policy's portion of the Fixed Account which will be reinvested at
the rate effective on that date.
Interest will be credited to the Fixed Account on a daily basis.
Restriction of New Amounts Applied to the Fixed Account
The Company reserves the right to restrict new amounts applied to the Fixed
Account if the rate of interest that would be used for the new amount is a rate
equivalent to an annual effective rate of 4%.
Transfers Out of the Fixed Account
You can transfer a limited amount of the Policy's portion of the Fixed Account
to the sub-accounts once within 30 days before each policy anniversary. The
transfer will be limited to the greater of: 25% of the Policy's portion of the
Fixed Account; and the amount of the Policy's portion of the Fixed Account
transferred to the sub-accounts the prior year. Requests for transfers can be
made in writing or by telephone. The Company is not responsible for determining
the authenticity of transfer instructions received by telephone.
Choice of the Fixed Account
You can choose to have net premiums and net unscheduled payments applied to the
Fixed Account. You can change the choice for future net premiums and future net
unscheduled payments at any time by notice to the Company in writing. (See the
Restriction of New Amounts Applied to the Fixed Account provision.) The portion
of the net premium and net unscheduled payment to be applied to the Fixed
Account must be a whole percent not less than 10.
9. Death Benefit
Death Benefit
If both Insureds die before the Maturity Date, the Company will pay a Death
Benefit to the Beneficiary. The amount of the Death Benefit will depend on the
Death Benefit Option in effect on the date of the Last Death. The amount payable
will be reduced by any Policy Loan Balance on the date of the Last Death. The
policy proceeds will be paid in one sum unless all or part of the proceeds are
applied to a Payment Option. (See Payment of Benefits, Section 18.)
Death Benefit Options
This Policy provides four Death Benefit Options. The Death Benefit Option will
be as chosen in the Application or as later changed. The Death Benefit Option is
shown in Section 1.
Option A (called "Enhanced with Face Amount") The Death Benefit is equal to the
greater of:
. The Face Amount shown in Section 1; and
. The greater of (a) and (b), where: (a) is equal to the lesser of the
percent of the Cash Value at the age of the younger Insured at the start of
the policy year as shown in Table I below AND: the Face Amount divided by
the Tabular Cash Value of the Policy at the start of the policy month;
times the Cash Value of the Policy; and (b) is equal to the percent of the
Cash Value at the age of the younger Insured at the start of the policy
year as shown in Table 11 below.
Option B (called "Enhanced with Face Amount Plus Cash Value")
The Death Benefit is equal to the greater of:
. The Face Amount shown in Section 1 plus the Cash Value; and
. The greater of (a) and (b), where: (a) is equal to the lesser of the
percent of the Cash Value at the age of the younger Insured at the start of
the policy year as shown in Table I below AND: the Face Amount plus the
Tabular Cash Value divided by the Tabular Cash Value of the Policy at the
start of the policy month; times the Cash Value of the Policy; and (b) is
equal to the percent of the Cash Value at the age of the younger Insured at
the start of the policy year as shown in Table II below.
Option C
The Death Benefit is equal to:
. The Face Amount shown in Section 1; or, if greater,
. The percent of the Cash Value of the Policy at the age of the younger
Insured at the start of the policy year as shown in Table II below.
Option D
The Death Benefit is equal to:
. The Face Amount shown in Section 1 plus the Cash Value; or, if greater,
. The percent of the Cash Value of the Policy at the age of the younger
Insured at the start of the policy year as shown in Table II below.
Tabular Cash Value
The Tabular Cash Value at the start of each policy month assumes: the Guaranteed
Death Benefit 1 Premium is paid on the first day of each policy year: maximum
charges are charged; and the Actual Investment Return is equivalent to an
effective annual rate of 4% in all policy years.
Table I
------------------------------------------------------------------------
Age Percent Age Percent
------------------------------------------------------------------------
20 through 40 362.50 63 179.80
41 352.35 64 176.90
42 342.20 65 174.00
43 332.05 66 172.55
44 321.90 67 171.10
45 311.75 68 169.65
46 303.05 69 168.20
47 294.35 70 166.75
48 285.65 71 163.85
49 276.95 72 160.95
50 268.25 73 158.05
51 258.10 74 155.15
52 247.95 75 through 90 152.25
53 237.80 91 150.80
54 227.65 92 144.20
55 217.50 93 137.70
56 211.70 94 131.30
57 205.90 95 126.25
58 200.10 96 121.20
59 194.30 97 116.15
60 188.50 98 111.10
61 185.60 99 106.05
62 182.70 100 100.00
Table II
------------------------------------------------------------------------
Age Percent Age Percent
------------------------------------------------------------------------
20 through 40 250 61 128
41 243 62 126
42 236 63 124
43 229 64 122
44 222 65 120
45 215
46 209 66 119
47 203 67 118
48 197 68 117
49 191 69 116
50 185 70 115
51 178 71 113
52 171 72 111
53 164 73 109
54 157 74 107
55 150 75 through 90 105
56 146 91 104
57 142 92 103
58 138 93 102
59 134 94 through 99 101
60 130 100 100
Changing the Death Benefit Option
After the first policy year you can change the Death Benefit Option on the first
day of any policy month by written application to the Company. However, if the
change would increase the amount at risk (see Section 11), the change can be
made: only if both Insureds are living on the Adjustment Date; and only if there
has been no change in the insurability of both Insureds. A change in Death
Benefit Option will be effective on the Adjustment Date shown in the new Policy
Schedule.
Except with the consent of the Company, a change from Option A or C to Option B
or D can be made only if the Face Amount after the change is at least $100,000.
If you change from Option A or C to Option B or D: the Face Amount will be
decreased by the amount of the Cash Value; and no Surrender Charge will apply. A
decrease in Face Amount may require a decrease in the amounts provided by riders
attached to this Policy.
If you change from Option B or D to Option A or C the Face Amount will be
increased by the amount of the Cash Value.
10. Premiums
Payment
Premiums are payments made to the Company to pay for the Policy. The Policy will
not be in force until the first premium is paid. After the first premium is
paid, premiums can be paid: at any time; and in any amount, subject to the
Limits on Premiums below. Payments can be made at the Administrative Office of
the Company or at any Agency of the Company. A receipt for payment signed by the
Secretary of the Company will be given on request. Unless you request otherwise
in writing to the Company, any payment received by the Company when a Policy
Loan exists on the Policy will be used: first, as a planned premium; and second,
as a repayment of the Policy Loan Balance; and third, as an unscheduled payment.
Amount and Frequency
Planned annual premiums are shown in Section 1. Payments and Planned Premium
Dates can be annual, semi-annual or quarterly or can be at any frequency agreed
to by the Company. (See Limits on Premiums below.)
Unscheduled payments can be made at any time prior to the Maturity Date. (See
Limits on Premiums below.)
Cash Values and Death Benefits will be permanently affected by the amount and
frequency of planned and unscheduled payments.
Limits on Premiums
Payments are subject to these limits:
. No payment can be less than $25; and
. Total planned and unscheduled payments will be limited to the Company's
published maximum; and
. No planned premium or unscheduled payment can be made if it increases the
Death Benefit by more than it increases the Cash Value, except with the
consent of the Company.
This Policy is intended to qualify as a flexible premium adjustable life
insurance contract under the Internal Revenue Code and any interpretive
regulation or rulings by the Internal Revenue Service. To that end, premiums on
this Policy are limited to an amount no greater than that allowing the Policy to
continue to qualify.
Net Premium
The net premium is equal to: the premium payment; less the Premium Expense
Charge at the rate shown in Section 1.
11. Monthly Deduction
Monthly Deduction
On the first day of each policy month the Company will make a Monthly Deduction
for that policy month from the Cash Value of this Policy. The amount of the
Monthly Deduction for a policy month is equal to:
. The cost of insurance and the cost of any riders for the policy month;
PLUS
. An amount not greater than the Maximum Monthly Expense Charge shown in
Section 1;
PLUS
. An amount not greater than the Maximum Monthly Administrative Charge shown
in Section 1.
If either Minimum Guaranteed Death Benefit is in effect, the Monthly Deduction
will be made, whether or not premiums are paid, until the Cash Value equals
zero. Otherwise, the Monthly Deduction will be made, whether or not premiums are
paid, as long as the Net Cash Value is sufficient to cover the entire Monthly
Deduction. This provision will not continue the Policy beyond the Maturity Date;
nor will it continue any rider beyond the termination date as provided in the
rider.
The Monthly Deduction will be deducted in the same proportion as the Cash Value
of the Policy is in the sub-accounts and the Fixed Account.
Cost of Insurance
The monthly cost of insurance for the Policy is equal to: the amount at risk;
times the cost of insurance rate per $1,000 for that month divided by 1,000. The
amount at risk is equal to:
. The Death Benefit on the first day of the policy month discounted at the
monthly equivalent of 4% per year;
LESS
. The Cash Value on the first day of the policy month after the Monthly
Deduction has been processed.
Cost of Insurance Rates
The cost of insurance rates for each policy year are based on: the sexes of the
Insureds; the underwriting classes of the Insureds; and the ages of the Insureds
on the first day of the policy year. The rates will be set by the Company each
year on the policy anniversary, based on the expectations of the Company as to
future experience. The rates are guaranteed for one year. The Table of
Guaranteed Insurance Factors per $1,000 (see Section 2) shows the maximum
guaranteed factor for each policy month which starts on the Policy Date or a
policy anniversary. The factors between anniversaries vary monthly based on
uniform distribution of deaths throughout the policy year.
Monthly Deduction Adjustment At Death
The portion of any Monthly Deduction made for a period beyond the date of the
Last Death will be added to the policy proceeds. If the Last Death occurs during
the grace period, an amount will be deducted from the policy proceeds to cover
Monthly Deductions to the date of the Last Death.
Grace Period
If the Net Cash Value on the first day of a policy month is not enough to cover
the Monthly Deduction for that month, the Company will mail a premium notice to
you at your address on record with the Company, unless either Minimum Guaranteed
Death Benefit is in effect. There is a grace period of 62 days from the date
when the Monthly Deduction was due in which to pay a premium large enough to
permit the Monthly Deduction to be made. The insurance remains in force during
the grace period. If the premium remains unpaid at the end of its 62-day grace
period, the Policy will lapse without value. Any riders will also lapse without
value unless otherwise stated in the rider.
Minimum Guaranteed Death Benefits
This Policy provides two Minimum Guaranteed Death Benefits. On the first day of
each policy month the Company will determine if either Benefit is in effect. If
either Benefit is in effect the Policy will not be lapsed if the Net Cash Value
on the first day of the policy month is not enough to cover the Monthly
Deduction due for that month. If the Last Death occurs while either Benefit is
in effect, the Death Benefit of the Policy will be based on the Death Benefit
Option in effect on the date of the Last Death.
Benefit 1
While the Policy is in force, the Company will test for Benefit 1 until the
Maturity Date. This Benefit is in effect if:
. No Policy Loan exists; and
. The Benefit 1 Fund (see Section 4) is not greater than:
The total of the premiums paid in each policy year accumulated at 4% from
the first day of the policy year, except premiums paid within 20 days prior
to a policy anniversary are treated as if paid in the next policy year;
less
Every partial surrender accumulated at 4% from the date of surrender.
Benefit 2
While the Policy is in force, the Company will test for Benefit 2 until the
later of: attained age 80 of the younger Insured; and 20 years from the Policy
Date, or the Maturity Date if earlier. This Benefit is in effect if:
. No Policy Loan exists; and
. The Benefit 2 Fund (see Section 5) is not greater than:
The total of the premiums paid in each policy year accumulated at 4% from
the first day of the policy year, except premiums paid within 20 days prior
to a policy anniversary are treated as if paid in the next policy year;
less
Every partial surrender accumulated at 4% from the date of surrender.
12. Reinstatement After Lapse
Reinstatement
If the Policy lapses, the Policy and riders can be reinstated. (See Limitations
on Reinstatement below.) Reinstatement is subject to:
. Written application to reinstate; and
. Proof that both Insureds are insurable; and
. Payment of a premium large enough to keep the Policy and any riders in
force for at least two months: and
. Payment or reinstatement of any Policy Loan Balance which existed on the
date when the Policy lapsed.
Limitations on Reinstatement
The Policy and riders cannot be reinstated, except with the consent of the
Company, if more than seven years have passed since the date of lapse.
Any rider which provides life or disability insurance on a person other than one
of the Insureds can be reinstated only as stated in the rider.
Effective Date of Reinstatement
Reinstatement will take effect: only if the application for reinstatement is
approved by the Company; and only when the premium for reinstatement has been
paid, provided that at the time of payment there has been no change in
insurability as represented in the application for reinstatement.
Surrender Charge After Reinstatement
Any Surrender Charge applied when the Policy lapsed will be credited to the Cash
Value of the Policy at reinstatement. The Surrender Charge on the date of
reinstatement will be the same as it was on the date of lapse. For the purpose
of determining the Surrender Charge on any date after reinstatement, the period
the Policy was lapsed will not count.
Maximum Monthly Expense Charge After Reinstatement
For the purpose of determining the Maximum Monthly Expense Charge on any date
after reinstatement, the period the Policy was lapsed will not count.
13. Cash Value of the Policy
Cash Value
The first net premium will be credited to the Policy as of the latest of:
. The Policy Date;
. The date of the last Part II of the Application; and
. The date the first premium is received by the Company.
Each future net premium will be credited to the Cash Value as of the date it is
received by the Company.
The Cash Value of the Policy will depend on the net investment performance of
the Money Market sub-account and the Policy's portion of the Fixed Account (see
the Sub-Accounts provision of Section 7 and The Fixed Account provision of
Section 8) until the later of: 45 days after Part I of the Application is
signed; and 10 days after the Company mails the separate Notice of Withdrawal
Right. Thereafter, the Cash Value of the Policy is equal to: the
Policy's share of the chosen sub-accounts; plus the Policy's portion of the
Fixed Account; plus the amount of any assets transferred to the general account
of the Company because of Policy Loans. (See Section 14.) The amount of the Cash
Value depends on: the frequency and amount of net planned premiums; the
frequency and amount of net unscheduled payments; investment performance of the
chosen sub-accounts; interest credited to the Policy's portion of the Fixed
Account; Monthly Deductions; all chosen Death Benefit Options; partial
surrenders; transfers among sub-accounts and the Fixed Account; and Policy
Loans. The Cash Value can increase or decrease on a daily basis, depending on:
the actual investment performance of the chosen sub-accounts; and the interest
credited to the Policy's portion of the Fixed Account. (See Actual Investment
Return below.)
The Cash Value of the Policy is not increased by the cash value of any rider,
unless stated in the rider.
Net Cash Value
The Net Cash Value is equal to:
. The Cash Value of the Policy;
LESS
. Any Policy Loan Balance;
LESS
. The Surrender Charge that would apply upon surrender, whether or not there
is a surrender. (See Section 3.)
Surrender of the Policy
You can surrender the Policy for its Net Cash Value at any time before the
Maturity Date by notice to the Company in writing. The Policy will be cancelled
on the first day of the policy month which starts on or next following the date
of surrender. The Net Cash Value will be paid to you in one sum, unless you
choose in writing to apply all or part to a Payment Option. (See Payment of
Benefits, Section 18.)
Actual Investment Return
The Policy has an Actual Investment Return for each Valuation Period for its
share of each chosen sub-account and for its portion of the Fixed Account. The
Policy's Actual Investment Return for each sub-account for each Valuation Period
is equal to (a) minus (b); where:
. (a) is equal to the Policy's share of the sub-account as of the end of the
Valuation Period;
PLUS
the monthly charges deducted in the Valuation Period;
LESS
any net planned premium and net unscheduled payment credited during the
Valuation Period;
PLUS
the total of the partial surrenders made during the Valuation Period;
PLUS
the interest credited during the Valuation Period to any borrowed portion
of the Policy's Cash Value;
PLUS or LESS
a charge or credit for the Policy's share of any reserve for taxes which
the Company determines to apply to the sub-account; and
. (b) is equal to the Policy's share of the sub-account as of the end of the
most recent Valuation Period;
PLUS or LESS
a charge or credit for the Policy's share of any reserve for taxes which
the Company determines to apply to the sub-account.
The Actual Investment Return for the Fixed Account for each Valuation Period is
equal to (a) minus (b); where:
. (a) is equal to the Policy's portion of the Fixed Account as of the end of
the Valuation Period;
PLUS
the monthly charges deducted in the Valuation Period;
LESS
any net planned premium and net unscheduled payment credited during the
Valuation Period;
PLUS
the total of the partial surrenders made during the Valuation Period;
PLUS
the interest credited during the Valuation Period to any borrowed portion
of the Policy's Cash Value; and
. (b) is equal to the Policy's portion of the Fixed Account as of the end of
the most recent Valuation Period.
There is a daily charge for mortality risk and expense risk against the Policy's
share of the sub-accounts. This charge will not be greater than: a rate
equivalent to .90% per year; or, if less, the rate allowed by federal securities
law.
Valuation Periods and Valuation Dates
A Valuation Period for each sub-account is a period:
. Which starts on a Valuation Date; and
. Which ends on the next succeeding Valuation Date.
Each day the New York Stock Exchange is open for trading is a Valuation Date.
14. Policy Loans
Policy Loans
After the Right to Return the Policy period you can borrow all or part of the
Loan Value of the Policy by written request to the Company. Policy Loans are
made on the sole security of the Policy. The amount you can borrow at any time
is equal to the Loan Value less any Policy Loan Balance at that time.
Unless you request otherwise, Policy Loans will reduce first, the Policy's share
of the sub-accounts proportionately and second, the Policy's portion of the
Fixed Account, except as noted below in the Interest on Loans; Policy Loan
Balance provision. Assets equal to the amount of the Loan:
. Will be transferred to the general account of the Company; and
. Will earn interest at the effective rate per year of not less than: the
Policy Loan interest rate; less 1.5%.
Policy Loans, whether or not repaid, can have a permanent effect on Cash Values
and Death Benefits.
Loan Value
The Loan Value of the Policy on the date the Loan is made is equal to:
. 90% of the Cash Value of the Policy projected to the next policy
anniversary or, if earlier, to the next Planned Premium Date;
LESS
. The Surrender Charge that would apply upon surrender (whether or not there
will be a surrender) on the next Planned Premium Date or, if greater, on
the date the loan is made;
LESS
. Loan interest to the next loan interest due date.
The Cash Value will be projected with interest at the effective rate per year of
1.5% less than the Policy Loan interest rate.
Interest on Loans; Policy Loan Balance
Interest will be charged on Policy Loans at the rate shown in Section 1.
Interest accrues daily. The Policy Loan Balance at any time means Policy Loans
outstanding plus interest accrued to date. Loan interest is due on the policy
anniversary each year. Loan interest not paid when due will be added to the Loan
and interest will be charged on it; when loan interest is added to the Loan, the
Policy's share of the sub-accounts and the Policy's portion of the Fixed Account
will be reduced proportionately.
Repayment of Loans
Policy Loans can be repaid to the Company at any time in whole or in part. Loan
repayments will be allocated: first, to repay the Loans made against the Fixed
Account; and second, unless you request otherwise, to repay the Loans made
against the sub-accounts in the same proportion as the Policy is invested in the
sub-accounts.
A Policy Xxxx is a charge against the Policy. The proceeds of the Policy will be
reduced by any Policy Loan Balance on the date of the Last Death. If the Policy
Loan Balance at any time exceeds the Cash Value of the Policy less the Surrender
Charge on the next loan interest due date or, if greater, on the current
Valuation Date (called "excess Policy Loan"), the Company will mail a notice to
you and to any assignee. The notice will be mailed to the addresses on record
with the Company. If the excess amount is not paid to the Company within 62 days
after the mailing of the notice, the Policy will lapse without value.
Unless you request otherwise, any payment received by the Company when a Policy
Loan exists on the Policy will be used: first, as a planned premium; second, as
a repayment of the Policy Loan Balance; and third, as an unscheduled payment.
15. Policy Changes
Decrease in Face Amount
The Face Amount may be decreased on the first day of any policy month by written
request to the Company; but only if the Face Amount which will remain after a
decrease is at least $100,000, except with the consent of the Company. No
portion of the Cash Value will be paid to you. A Surrender Charge may apply to a
decrease in Face Amount. (See Section 3.) The Cash Value after the decrease in
Face Amount will be equal to: the Cash Value just prior to the decrease; less
any Surrender Charge for the decrease. The Death Benefit will be recalculated
based on the new Face Amount and the Cash Value after the decrease. A decrease
in Face Amount may require a decrease in the amounts provided by riders attached
to this Policy.
Partial Surrender
After the first policy year you can make a partial surrender on the first day of
any policy month by written request to the Company. A portion the Cash Value
will be paid to you. A Surrender Charge may apply if you make a partial
surrender. (See Section 3.) In each policy year, partial surrenders will be
limited, except with the consent of the Company, to: 20% of the Net Cash Value
on the day the first partial surrender is made for the policy year; or, if less,
the Loan Value minus any Policy Loan Balance. The amount of the partial
surrender will be deducted from the Cash Value. The Death Benefit of the Policy
will be based on the reduced Cash Value. The Face Amount of the Policy will be
reduced, if necessary, so the amount at risk before and after the partial
surrender is the same. The Face Amount which will remain after the partial
surrender must be at least $100,000, except with the consent of the Company. A
decrease in Face Amount may require a decrease in the amounts provided by riders
attached to this Policy.
Unless you request otherwise, a partial surrender will reduce: first, the
Policy's portion of the sub-accounts proportionately; and second, the Policy's
portion of the Fixed Account.
16. Exchange of Policy
Exchange of Policy
Within 24 months after its Date of issue, you can exchange this Policy, if the
Policy is in force, for a policy which provides fixed benefit insurance. The new
policy will be issued:
. By New England Mutual Life Insurance Company;
. On any plan of survivorship insurance with a level face amount issued by
New England Mutual Life Insurance Company on the Policy Date;
. With the same Insureds, Policy Date, and Face Amount as this Policy;
. Based on the age of each Insured on the Policy Date of this Policy;
. Based on the actual underwriting class to which each Insured was assigned
by the Company on the Date of Issue of this Policy;
. Subject to any cost or credit and the repayment of any Policy Loan Balance;
and
. Subject to any assignments of this Policy, and limitations on this Policy
stated in riders.
Riders which provide benefits that are the same as those provided by riders on
this Policy will be attached to the new policy, if they are available.
Change Cost or Credit
Any change cost or credit will be quoted by the Company on request.
A detailed statement of the method of computing the change cost or credit has
been filed with the Insurance Department of the state in which the Policy is
delivered.
17. Owner and Beneficiary
Owner
The Owner of the Policy is named in the Application (see copy attached); but,
the Owner can be changed. The new Owner will succeed to all rights of the Owner,
including the right to make a further change of Owner. At the death of the
Owner, his or her estate will be the Owner, unless a successor Owner has been
named. In this Policy "you" means the Owner, whether the Owner is a person, a
partnership, a corporation, a fiduciary or any other legal entity. The rights of
the Owner will end at the Last Death, except for Payment of Benefits. (See
Section 18.)
Beneficiary
The Beneficiary is named in the Application (see copy attached); but, the
Beneficiary can be changed before the Last Death. The Beneficiary has no rights
in the Policy until the Last Death. The
Beneficiary can be a person, a corporation, a partnership, a fiduciary or any
other legal entity. A person must survive the last Insured to die to qualify as
Beneficiary. If none survives, the proceeds will be paid to the Owner.
Change of Owner or Beneficiary
A change of Owner or Beneficiary must be in written form satisfactory to the
Company, and must be dated and signed by the Owner who is making the change. The
change will be subject to all payments made and actions taken by the Company
under the Policy before the signed change form is received by the Company at its
Administrative Office.
Assignments
An absolute assignment of the Policy by the Owner is a change of Owner and
Beneficiary to the assignee. A collateral assignment of the Policy by the Owner
is not a change of Owner or Beneficiary; but their rights will be subject to the
terms of the assignment. Assignments will be subject to all payments made and
actions taken by the Company before a signed copy of the assignment form is
received by the Company at its Administrative Office. The Company will not be
responsible for determining whether or not an assignment is valid.
Designation of Owner and Beneficiary
A numbered sequence can be used to name successive Owners or Beneficiaries. Co-
Beneficiaries will receive equal shares unless otherwise stated.
In naming Owners or Beneficiaries, unless otherwise stated:
. "Child" includes an adopted or posthumous child;
. "Provision for issue" means that if a Beneficiary does not survive both
Insureds, the share of that Beneficiary will be taken by his or her living
issue by right of representation; and
. A family relation such as "wife", "husband" or "child" means the relation
to Insured 1.
At the time for payment of benefits the Company can rely on an affidavit of any
Owner or other responsible person to determine family relations or members of a
class.
18. Payment of Benefits
Payment
The policy proceeds will be paid in one sum, unless all or part of the proceeds
are applied to a Payment Option. (See Section 19.) The Company will pay interest
on the death and maturity proceeds from the date the proceeds become payable to
the date of payment in one sum, or to the Option Date. The rate of interest will
be set each year by the Company. The rate will not be less than: that required
by law; or 3 1/2% per year. The interest payable on surrender proceeds is
described in Section 6.
Selection of Payment Options; Option Date
The selection of a Payment Option and the naming of the Payee must be in written
form satisfactory to the Company. You can make or change or revoke the selection
before the Last Death. The Option Date is the effective date of the Payment
Option, as stated in the selection form.
Payee
The Payee is a person, a corporation, a partnership, a fiduciary or any other
legal entity entitled to receive payment in one sum or under a Payment Option.
Selection by Payees
Any proceeds payable in one sum at the Last Death, or upon surrender or maturity
of the Policy, can be applied to any Payment Option chosen by the Payee.
Further, with the consent of the Company, any Payee who is entitled to receive
proceeds in one sum when a Payment Option ends, or at the death of a prior
Payee, or when proceeds are withdrawn, can choose to apply the proceeds to a
Payment Option.
Rights of Payees
In the selection of a Payment Option the right can be given to the Payee:
. To withdraw principal and interest under the Fourth or Fifth Option; or
. To withdraw the commuted value of payments certain under the First, Second,
or Sixth Option.
Under the Life Income Options only payments certain can be commuted. No Payee
can assign, commute or withdraw the payments under any Payment Option, unless
the right is reserved in the selection of the Option.
Limitations
If installments under an Option would be less than $20, proceeds can be applied
to a Payment Option only with the consent of the Company.
Life Income Options
Guaranteed Life Income Options are based on the age of the Payee on the Payee's
birthday nearest the Option Date. The Company will require proof of age. The
Life Income payments will be based: on the rates shown in the Life Income Tables
(Section 20); or, if they are greater, on the Payment Option rates of the
Company on the Option Date. If the rates at a given age are the same for
different periods certain, the longest period certain will be used.
Purchase of Increased Payment Option Benefits
On the Option Date, a one sum purchase payment can be made to the Company to be
added to the proceeds being applied to any Payment Option. The portion of Life
Income payments purchased in this way will be based on the Payment Option rates
of the Company on the Option Date, which may not be the rates shown in the Life
Income Tables (Section 20). The purchase payment will be limited to the
Company's published maximum for single premium immediate annuities on the Option
Date. A portion of the purchase payment may be used by the Company to pay
premium taxes on the purchase payment.
Death of Payee
If a Payee under a Life Income Option dies within 30 days after the Option Date,
the amount applied to the Option, less any payments made, will be paid in one
sum, unless a Payment Option is chosen by the successor Xxxxx. Otherwise,
amounts to be paid after the death of a Payee under a Payment Option will be
paid as due to the successor Xxxxx. If there is no successor Xxxxx, amounts to
be paid in one sum, or the commuted value of any unpaid payments certain, will
be paid in one sum to the estate of the last Payee to die.
Commutation Rate
The interest rate used to compute the commuted value of any unpaid payments
certain:
. Under the First Option will be 3 1/2% per year; and
. Under the Life Income Options will be the rate used by the Company in
computing the amount of the monthly payments.
19. Payment Options
Payment Options
All or part of the policy proceeds can be applied to any one of the following
Options, subject to Section 18, Payment of Benefits:
First Option: Income for a Specified Number of Years
The Company will make monthly payments which will include both principal and
interest. Payments will start on the Option Date and will continue for the
number of years chosen. The number of years chosen cannot be more than 30.
Interest is at the rate of 3 1/2% per year compounded yearly. Additional
interest paid by the Company for any year will be added to the monthly payments
for that year.
Guaranteed monthly payments per $1,000 of proceeds applied to the First Option
are shown below:
Number Number Number
of Years of Years of Years
1 $84.65 11 $9.09 21 $5.56
2 43.05 12 8.46 22 5.39
3 29.19 13 7.94 23 5.24
4 22.27 14 7.49 24 5.09
5 18.12 15 7.10 25 4.96
6 15.35 16 6.76 26 4.84
7 13.38 17 6.47 27 4.73
8 11.90 18 6.20 28 4.63
9 10.75 19 5.97 29 4.53
10 9.83 20 5.75 30 4.45
Second Option: Life Income
The Company will make equal payments. Payments will start on the Option Date and
will continue:
. During the life of the Payee, with no payment after the death of the
Payee, called "Life Income, No Refund"; or
. During the life of the Payee, but for at least 10 years, called "Life
Income, 10 Years Certain"; or
. During the life of the Payee, but for at least 20 years, called "Life
Income, 20 Years Certain".
Third Option: Life Income with Refund
The Company will make equal monthly payments. Payments will start on the Option
Date and will continue during the life of the
Payee. At the death of the Payee, if the total payments made are less than the
total proceeds applied to the Option, then:
. The difference will be paid in one sum, called "Life Income, Cash Refund";
or
. The equal monthly payments will continue until the total payments are
equal to the total proceeds applied to the Option, called "Life Income,
Instalment Refund".
Fourth Option: Interest
The Company will hold the proceeds at interest during the life of the Payee or
for any other period agreed to by the Company. Interest on the proceeds:
. Will be paid each month to the Payee starting one month after the Option
Date; or
. Will be added to the principal amount each year and will earn interest.
At the death of the Payee, or at the end of the period agreed to, the balance of
principal and any accrued interest will be paid in one sum. The rate of interest
will be set each year by the Company; but the rate will not be less than 3 1/2%
per year.
Fifth Option: Specified Amount of Income
The Company will make monthly payments which will include both principal and
interest. Payments will be in the amount chosen. Payments can be quarterly or at
any other frequency chosen, and payments can be for different amounts, all
subject to the consent of the Company. Payments will start on the Option Date
and will continue until the balance is fully paid out. At the death of the Payee
any unpaid balance and accrued interest will be paid in one sum. The rate of
interest will be set each year by the Company; but the rate will not be less
than 3 1/2% per year. Interest will be added each year to the principal and will
earn interest.
Sixth Option: Life Income for Two Lives
The Company will make monthly payments. Payments will start on the Option Date
and will continue:
. While either of two Payees is living, called "Joint and Survivor Life
Income"; or
. While either of two Payees is living, but for at least 10 years, called
"Joint and Survivor Life Income, 10 Years Certain"; or
. While two Payees are living, and after the death of one Payee, two-thirds
of the monthly amount while the other Payee is living, called "Joint and
2/3 to Survivor Life Income".
20. Life Income Tables
Life income Tables
Guaranteed monthly payments per $1,000 of amounts applied to the Life Income
Options are shown below:
--------------------------------------------------------------------------------
Second and Third Options: Life Income
--------------------------------------------------------------------------------
Age of No 10 Years 20 Years Cash Installment
Payee Refund Certain Certain Refund Refund
*15 $3.19 $3.19 $3.19 $3.18 $3.19
16 3.21 3.20 3.20 3.19 3.20
17 3.22 3.22 3.21 3.21 3.21
18 3.23 3.23 3.23 3.22 3.22
19 3.25 3.24 3.24 3.23 3.24
20 3.26 3.26 3.25 3.25 3.25
21 3.27 3.27 3.27 3.26 3.26
22 3.29 3.29 3.28 3.28 3.28
23 3.31 3.30 3.30 3.29 3.29
24 3.32 3.32 3.31 3.31 3.31
25 3.34 3.34 3.33 3.32 3.33
26 3.36 3.36 3.35 3.34 3.35
27 3.38 3.37 3.37 3.36 3.36
28 3.40 3.39 3.39 3.38 3.38
29 3.42 3.41 3.41 3.40 3.40
30 3.44 3.44 3.43 3.42 3.42
31 3.46 3.46 3.45 3.44 3.44
32 3.49 3.48 3.47 3.46 3.47
33 3.51 3.51 3.50 3.49 3.49
34 3.54 3.53 3.52 3.51 3.52
35 3.56 3.56 3.55 3.54 3.54
36 3.59 3.59 3.58 3.56 3.57
37 3.62 3.62 3.60 3.59 3.60
38 3.66 3.65 3.63 3.62 3.63
39 3.69 3.69 3.67 3.65 3.66
40 3.73 3.72 3.70 3.68 3.69
41 3.76 3.76 3.73 3.71 3.72
42 3.80 3.79 3.77 3.75 3.76
43 3.84 3.84 3.80 3.78 3.79
44 3.89 3.88 3.84 3.82 3.83
45 3.93 3.92 3.88 3.86 3.87
46 3.98 3.97 3.92 3.90 3.91
47 4.03 4.02 3.97 3.94 3.96
48 4.08 4.07 4.01 3.99 4.00
49 4.14 4.12 4.06 4.03 4.05
50 4.20 4.18 4.11 4.08 4.10
51 4.26 4.23 4.16 4.13 4.15
52 4.32 4.30 4.21 4.19 4.21
53 4.39 4.36 4.26 4.24 4.27
54 4.46 4.43 4.32 4.30 4.33
55 4.54 4.50 4.37 4.36 4.39
56 4.62 4.58 4.43 4.43 4.46
57 4.70 4.65 4.49 4.49 4.53
58 4.79 4.74 4.56 4.57 4.60
59 4.89 4.83 4.62 4.64 4.68
60 4.99 4.92 4.68 4.72 4.76
61 5.10 5.02 4.75 4.80 4.85
62 5.22 5.12 4.82 4.89 4.94
63 5.34 5.23 4.88 4.98 5.03
64 5.47 5.35 4.95 5.07 5.13
65 5.61 5.47 5.02 5.17 5.24
66 5.76 5.60 5.08 5.28 5.35
67 5.92 5.73 5.15 5.39 5.47
68 6.10 5.87 5.21 5.51 5.59
69 6.28 6.02 5.27 5.63 5.72
--------------------------------------------------------------------------------
Age of No 10 Years 20 Years Cash Installment
Payee Refund Certain Certain Refund Refund
70 $6.48 $6.17 $5.33 $5.76 $5.86
71 6.70 6.33 5.38 5.89 6.00
72 6.92 6.49 5.43 6.04 6.16
73 7.17 6.66 5.48 6.19 6.32
74 7.43 6.84 5.52 6.34 6.49
75 7.71 7.02 5.56 6.52 6.67
76 8.02 7.20 5.60 6.69 6.86
77 8.34 7.38 5.63 6.87 7.06
78 8.69 7.56 5.66 7.07 7.27
79 9.07 7.75 5.68 7.27 7.50
80 9 47 7.93 5.70 7.49 7.74
81 9.90 8.11 5.71 7.73 7.99
82 10.36 8.28 5.73 7.96 8.25
83 10.86 8.45 5.73 8.21 8.53
84 11.39 8.62 5.74 8.50 8.83
**85 11.96 8.77 5.75 8.78 9.14
--------------------------------------------------------------------------------
*and under **and over
--------------------------------------------------------------------------------
Sixth Option: Life Income for Two Lives
--------------------------------------------------------------------------------
Age of One Age of Other Payee
Payee
55 60 65 70 75
-----------------------------------------------------------------------------
Joint and Survivor
55 $4.04 $4.17 $4.28 $4.37 $4.43
60 4.17 4.36 4.53 4.68 4.79
65 4.28 4.53 4.79 5.02 5.22
70 4.37 4.68 5.02 5.38 5.71
75 4.43 4.79 5.22 5.71 6.22
80 4.47 4.87 5.37 5.98 6.68
Joint and Survivor, 10 Years Certain
55 $3.96 $4.09 $4.20 $4.36 $4.42
60 4.09 4.27 4.44 4.59 4.77
65 4.20 4.44 4.69 4.91 5.09
70 4.36 4.59 4.91 5.22 5.50
75 4.42 4.77 5.09 5.50 5.88
80 4.46 4.85 5.33 5.72 6.21
------------------------------------------------------------
Joint and 2/3 to Survivor
55 $4.37 $4.56 $4.76 $4.99 $5.23
60 4.56 4.78 5.02 5.30 5.59
65 4.76 5.02 5.33 5.67 6.03
70 4.99 5.30 5.67 6.10 6.57
75 5.23 5.59 6.03 6.57 7.18
80 5.48 5.89 6.41 7.06 7.84
------------------------------------------------------------
Payments for other ages will be quoted by the Company on request.
The rates shown above are based on an interest rate of 3 1/2% per year; and on
mortality: using a 60/40 male/female weighting; based on the Individual
Annuitant Mortality Table for 1983; and with projection on Scale G to the year
2000 and then on Scale B Modified to year 2010.
------------------------------------------------------------
Amendments and Endorsements (To be made only by the Company)
Please notify the Company of any change in your name or address. The Company
will communicate with you at your address on record with the Company.
New England Variable Life
Insurance Company
Administrative Office:
000 Xxxxxxxx Xxxxxx
Xxxxxx, Xxxxxxxxxxxxx 00000
Flexible Premium Adjustable Variable Survivorship Life Policy
. The Death Proceeds are payable at the Last Death, if the Last Death occurs
before the Maturity Date and the Policy is in force.
. The Net Cash Value, if any, is payable on the Maturity Date, if at least
one Insured is still living and the Policy is in force.
. The Policy can be adjusted by decreasing the Face Amount.
. The amount and frequency of premium payments can be changed.
. The Policy does not share in dividends.
000 Xxxxxxxx Xxxxxx
Xxxxxx, XX 00000
Policy Number__________
Application To New England Variable Life Insurance Company for Flexible Premium
Adjustable Variable Survivorship Life Insurance
Part I Section A (Section B must be completed for both Proposed Insureds.)
Address
1. Premium Notice Address
Name
------------------------------------------------
Street
----------------------------------------------
City/State/Zip
--------------------------------------
Beneficiary and Owner
(A family relation such as "wife", "husband" or "child" means the relation to
Proposed Insured 1.)
2. a. Owner (Use a numbered sequence to designate successive
owners.)
b. First Owner's Social Security or Taxpayer ID Number
----------------------------
3. Beneficiary,Primary
-----------------------------------------------------
Secondary
-----------------------------------------------------
Plan/Amount
4. Face Amount $
----------
5. Planned Annual Premium
Year 1 $ Renewal $
----------- -----------
(Continued)
Part I Application Continued
Section A Continued
6. Death Benefit Option
___ Option A (Enhanced with Face Amount)
___ Option B (Enhanced with Face Amount plus Cash Value)
___ Option C (Face Amount)
___ Option D (Face Amount plus Cash Value)
Benefits/Riders
7. a. ___ Survivorship Level Term
b. ___ Survivorship Four Year Level Term
Premium Payment (*Complete additional form.)
8. ___ Annual ___ Semi-Annual ___ Quarterly
___ Other
9. Prepayment* $__________ _____ None
(If question 11 or 12 in any Section B of this Application is answered YES,
no prepayment is permitted.)
Policy Date
10. If available, special Policy Date requested is:
_________________ (Month/Day/Year)
Note: Date more than 30 days prior to date of application not allowed.
Replacement
11. Any life Insurance or annuity in this or any other company which has been or
will be replaced as a result of this Application for insurance?
____ YES ___ NO (If YES, complete the following and submit replacement
forms if required.)
---------------------------------------------------------
Company 1035 Policy Policy Number Amount
Exch. Date
---------------------------------------------------------
$
---------------------------------------------------------
$
---------------------------------------------------------
$
---------------------------------------------------------
(Continued)
Part I Application Continued
Section A Continued
Variable Life Section
12. Account allocations (Whole %)(Minimum 10% in each selected account)*
--------------------------------------------------------------
% Capital Growth**
--------------------------------------------------------------
% Money Market**
--------------------------------------------------------------
% Bond Income**
--------------------------------------------------------------
% Stock lndex**
--------------------------------------------------------------
% Managed**
--------------------------------------------------------------
% Avanti Growth**
--------------------------------------------------------------
% Fund Value/Growth**
--------------------------------------------------------------
% Equity lncome**
--------------------------------------------------------------
% Overseas**
--------------------------------------------------------------
% Fixed Account
--------------------------------------------------------------
%
--------------------------------------------------------------
100% Total
13. Suitability Statement by Applicant
a. Did you receive the prospectus? ___ YES ___ NO
---------------
(If YES, give date of prospectus.) Month/Day/Year
b. Do you understand that:
the Option B and D death benefit may increase or decrease depending on the
policy's investment return?
___ YES ___ NO
the cash value may increase or decrease depending on the policy's
investment return? ___ YES ___ NO
c. Do you believe that this policy will meet your insurance needs and
financial objectives?
___ YES ___ NO
**Money allocated to this account will be invested in the Money Market account
for an initial period described on page 1 of the prospectus.
(Continued)
Part I Application Continued
Section A Continued
THE DEATH BENEFIT MAY BE VARIABLE OR FIXED UNDER SPECIFIED CONDITIONS.
THE CASH VALUE MAY INCREASE OR DECREASE IN ACCORDANCE WITH SEPARATE INVESTMENT
ACCOUNT EXPERIENCE.
Special Requests
-----------------------------------------------------
-----------------------------------------------------
-----------------------------------------------------
Note: The cost of insurance rates currently being charged are not guaranteed;
and the Company may charge the full maximum guaranteed rates.
(Continued)
Policy Number
------------
Proposed Insured Number
----------
Part I Application Continued
Section B (Section B must be completed for each Proposed Insured.)
Questions below pertain to the Proposed Insured.
Personal Data
1. Print Name as it is to appear on the policy. (First/Middle Initial/Last)
---------------------------------------------------------------------------
2. Social Security Number
-------------------
3. Birthplace State/Country
-----------------------
4. Marital Status
___ Single ___ Widowed ___ Separated
___ Married ___ Divorced
5. Birth Date (Month/Day/Year)
-------------------
6. Age As of Birthday Nearest Policy Date
------------------
7. Sex ___ Female ___ Male
Address
8. a. Residence
Street
------------------------------------------------
City/State/zip
----------------------------------------
b. Business
Street
------------------------------------------------
City/State/zip
----------------------------------------
Benefits/Riders
9. a. ___ Waiver of Monthly Deductions
b. ___ Benefits for Disability of Covered Insured
(Continued)
Part I Application Continued
Section B Continued
10. a. ___ Level Term $ _________________
b. ___ Decreasing Term for ____ years $____________
Health
11. Any treatment for or consultation with a physician concerning a heart
attack, a stroke or cancer (other than skin cancer) within past 2 years?
___YES ___NO (If YES, explain in REMARKS.)
12. Any change in health or any treatment by or consultation with a physician
since the date of Part II of this Application? ___YES ___NO (If YES,
explain in REMARKS.)
Existing Insurance
13. Life Insurance In Force (If none, so state.) Type: P = Personal, B =
Business, G = Group)
-------------------------------------------------------------
Company Type Yr of Issue Life Amount ADB Amount
-------------------------------------------------------------
$ $
-------------------------------------------------------------
$ $
-------------------------------------------------------------
$ $
-------------------------------------------------------------
$ $
-------------------------------------------------------------
Existing Insurance (Continued)
14. Any other negotiations for life, disability or accidental death insurance
pending or contemplated? ___YES ___NO (If YES, explain in REMARKS.)
15. Has life or disability insurance on your life ever been declined, postponed
or modified as to plan, amount or rate? ___YES ___NO (If YES, explain in
REMARKS.)
(Continued)
Part I Application Continued
Section B Continued
Smoking/Driving
16. Has Proposed Insured:
a. Used any tobacco in the past year? ___YES ___NO
If YES, complete the following:
How many cigarettes per day?
-------------
If other than cigarettes, please explain.
-------------
-------------------------------------------------------
b. Been convicted in the past 2 years of: driving under the influence of
alcohol or drugs; or 2 or more moving violations? ___YES ___NO (If
YES, complete supplemental form.)
17. a. Driver's License No.
-----------------------
b. State
-----------------
Avocation/Aviation/Foreign Travel
18. Have you in the past 2 years participated in, or do you intend to
participate in: any flights as a trainee, pilot or crew member; underwater
sports (SCUBA diving, skin diving, snorkeling, hardhat); sky sports (sky
diving, hang gliding, parachuting, ballooning); or motor racing (auto,
motorcycle, motorboat)? (If YES, complete supplemental form.)
___YES ___NO
19. Do you intend to travel or reside outside of the United States? (If YES,
give details in REMARKS.) ___YES ___NO
Occupation and Financial
20. a. Occupation
-------------------------------------------
(Give Job Title and Duties)
b. Employed by
------------------------------------------
21. a. Annual Income
--------------------
b. Net Worth
-----------------------
(Continued)
Part I Application Continued
Section B Continued
22. Is Proposed Insured currently employed less than full time? (If YES, give
details in REMARKS.) ___YES ___NO
Remarks (Attach additional sheet, if necessary.)
(Continued)
Application Continued
Company Use (Additions and Amendments)
Declarations
General. To the best of my knowledge and belief the answers recorded are
true and complete. In those states where written consent is required by
law, my agreement in writing is required to any entry made by the Company
in the "Company Use" section as to: (a) age; or (b) plan of insurance; or
(c) riders; or (d) amounts; or (e) rate class.
When Insurance Takes Effect. If a prepayment is made in connection with
this Application, the insurance will take effect as stated in the
Prepayment Receipt and Temporary Life Insurance Agreement. Otherwise, the
insurance will take effect only when the first premium is paid; provided
that at the time of such payment: (a) this Application has been approved by
the Company at 000 Xxxxxxxx Xxxxxx, Xxxxxx. MA; and (b) there has been no
change in insurability as represented in this Application since the date of
the Application.
Limitation on Authority of Agents and Examiners. Agents and Examiners do
not have authority: (a) to determine insurability; (b) to change any terms
of this Application; or (c) to make a contract for the Company.
Authorization
In order that insurance can be issued, I authorize each of the following
having records or knowledge of me or my health to give this information to
the Company: a medical practitioner; a medical facility; an insurance
company; the Medical Information Bureau; a consumer reporting bureau; and
any other company, concern or person. If insurance on any minor child is
applied for this authorization extends to records and knowledge of that
child and the child's health. Information received by the Company may be
disclosed to third parties in the conduct of the Company's business.
I understand that: I have a right of access to and correction of all
information obtained by the Company; I can ask to be interviewed with
respect to any investigative consumer report; and I can ask for a copy of
any such report. A photocopy of this authorization is as valid as the
original. This authorization is valid for 30 months from the date it is
signed. I have received a Notice of Information
(Continued)
Practices; this Notice gives a more detailed description of the information
practices of the Company.
Signatures
Signed at ________________________ Date _____________
city state month day year
All Proposed Insureds
-----------------------------------
-----------------------------------
Applicant if Other than
Proposed Insureds
---------------------------------------
Agent
--------------------------------------------------
End of Application
(Continued)
Owner's Certification (in lieu of W9)
Owner's Social Security or Taxpayer Identification Number:
I am I am not subject to backup withholding under Section
3406(a)(I)(C) of the Internal Revenue Code. Under penalties of perjury, I
certify that the information in this section is true, correct and complete.
Signature Date
of Owner -------------------
------------------------- month day year
(Continued)
Agent's Certificate
(Completion required in every case.)
Questions
1. Did you see each Proposed Insured on the date the application was signed?
(If NO, attach additional sheet with explanation.) ___YES ___NO
2. Is each Proposed Insured a citizen of the U.S.?
___YES ___NO If NO, specify the date of entry and the type of visa for
each Proposed Insured who is not a citizen of the U.S.
-------------------------------------------------------
-------------------------------------------------------
-------------------------------------------------------
3. If a Proposed Insured's name has been changed in the past 10 years, give
former name(s). (Attach additional sheet, if necessary.)
---------------------------------------------------------
---------------------------------------------------------
4. Provide phone number where each Proposed Insured can be contacted and
preferred calling time.
--------------------------------------------------------------------------------
Proposed Phone Time Proposed Phone Time
Insured Number ___am ____ pm Insured Number ___am ____ pm
--------------------------------------------------------------------------------
5. Has a nonmedical been submitted based on expanded nonmedical limit? If YES,
give physician's name and address and the date of the physician's exam
detailed in APS. ___YES ___NO (Attach additional sheet, if necessary.)
-------------------------------------------------------------------------
Proposed Physician's Name
Insured Date and Address
-------------------------------------------------------------------------
-------------------------------------------------------------------------
-------------------------------------------------------------------------
(Continued)
Agent's Certificate Continued
(Completion required in every case.)
6. Do you have knowledge or reason to believe that any insurance or annuity in
this or any other company has been or will be replaced as a result of this
Application for insurance? ____YES ____NO
7. Is there a corporate, partnership or association beneficiary (excluding
regular split dollar plans) or is this to fund a buy-sell agreement?
____YES ____NO (If YES, complete the following.)
a. Are other key individuals, owners or partners being insured for
similar amounts? (If NO, state why not.)
--------------------------------------------------------
--------------------------------------------------------
b. What percentage of the business does each Proposed Insured own or
control?
Give names and amount of business coverage in force and/or applied
for for all key associates, plus the percentage of ownership in each:
Name Amount % Name Amount %
---------------------------------------------------------------------------
$ $
---------------------------------------------------------------------------
c. Year Business was established. ________
d. For the Business, provide approximate amount of:
Assets Liabilities Net Worth Net Income
---------------------------------------------------------------------------
$ $ $ $
---------------------------------------------------------------------------
8. State Source of Funds if $10,000 or greater.
--------------------------------------------
Signatures
To the best of my knowledge, I have presented the Company all pertinent
facts regarding the Proposed Insureds and regarding this Application.
(Continued)
Agent Certificate Continued
(Completion required in every case.)
Signature --------------------
of Agent Date month day year
-----------------------
Accepted for --------------------
the Company by Date month day year
-----------------------
General Agent's Certificate
If Agent of another company, give name of company.
-------------------------------
Is Agent licensed where Application is written?
___YES ___NO
Signature of --------------------
General Agent Date month day year
---------------------------
Agent's Identification
---------------------------------------------------------------
Agent's Name Agent Agency Commission Split
Number Number
---------------------------------------------------------------
First Renewal
------------------
------------------
------------------
------------------
------------------
---------------------------------------------------------------
COMPLETE ABOVE DATA IN ALL CASES FOR PROPER CREDITING OF COMMISSIONS.
(Continued)
Amendment to Application for Insurance
Proposed Insured 1: _____________ No. _________________
Proposed Insured 2:
----------------
Date of Application:
----------------
I agree to these changes which the Company has noted in the "Additions and
Amendments" space of the Application.
Date:
------------- ---------------------------------
Proposed Insured 1
Date:
------------- ---------------------------------
Proposed Insured 2
Date:
------------- ---------------------------------
Applicant, if other than
Proposed Insured 1 or 2
New England Variable Life Insurance Company
Administrative Office:
000 Xxxxxxxx Xxxxxx, Xxxxxx, Xxxxxxxxxxxxx
/s/ Xxxxxx X. Xxxxxx /s/ Xxxxxx X. Xxxxxxxxx
Xxxxxx X. Xxxxxx Xxxxxx X. Xxxxxxxxx
President Secretary
New England Variable Life Insurance Company
Administrative Office:
000 Xxxxxxxx xxxxxx
Xxxxxx, Xxxxxxxxxxxxx 00000
Prepayment Statement For
Flexible Premium Adjustable Variable Survivorship Life
Proposed Insured 1:
-------------------------------------
Proposed Insured 2:
-------------------------------------
Date of Part I:
-------------------------------------
Face Amount:
-------------------------------------
This Statement is in connection with the Application to the New England Variable
Life Insurance Company for life insurance described above.
These statements are made to the best of my knowledge and belief.
1. The answer to every question in the Application and any other material
information disclosed in the Application are reaffirmed as of this date.
2. Since the date of Part I of the Application, the Proposed Insureds have not
consulted with or been examined by a physician or other practitioner,
except in connection with the Application described above, and have
undergone no change in health.
Exceptions to foregoing:
Signed at Date
--------------------- -----------------
City and State
------------------ ------------------ -----------------------
Agent Proposed Insured 1 Applicant if other than
Proposed Insured 1 or 2
------------------
Proposed Insured 2
NOTICE: This form is to be used in cases where prepayment is made other than on
the date of Part I of the Application. No prepayment is permitted if
any question listed in the Prepayment Receipt Amount question of Part I
of the Application:
is answered "YES;" or
---
Would now be answered "YES."
---
NEV APP-25-93
New England Variable Life Insurance Company
Administrative Office:
000 Xxxxxxxx Xxxxxx
Xxxxxx, Xxxxxxxxxxxxx 00000
PREPAYMENT RECEIPT AND TEMPORARY LIFE INSURANCE AGREEMENT
TEMPORARY LIFE INSURANCE AGREEMENT
TEMPORARY LIFE INSURANCE AGREEMENT, $50,000 MAXIMUM
Temporary life insurance on the life of the Proposed Insureds will become
effective on the later of:
. The date of this Receipt and Agreement; and
. The date of the latest Part II of the Application for the Proposed
Insureds.
There will be no insurance until a Part II on each Proposed Insured is
completed. The temporary life insurance will be all joint life or part joint
life and part single life insurance, based on the policy and any riders applied
for.
This insurance will be subject to the terms of the policy applied for. The sum
of all benefits payable under this Agreement upon the Last Death will be the
amount applied for on the last Proposed Insured to die; but the sum will be
limited to a maximum of $50,000.
The Last Death is the later of: the death of Proposed Insured 1; and the death
of Proposed Insured 2.
INCREASE IN MAXIMUM AMOUNT OF TEMPORARY LIFE INSURANCE
If the Company determines that both of the Proposed Insureds are insurable, but
at least one of them is not insurable as a standard risk, the $50,000 maximum
will increase to $250,000.
If the Company determines that both of the Proposed Insureds are insurable as
standard risks, the $50,000 maximum will increase to $500,000.
This increase in maximum will be retroactive to the effective date of the
temporary life insurance without regard to change of insurability or death after
that date.
(Continued on Reverse Side)
PAGE 1
PAGE 2
If more than one Temporary Insurance Agreement is in effect on the same proposed
insureds, the temporary life insurance will in no event exceed the sum of
$500,000.
STATEMENTS IN APPLICATION
The temporary life insurance is issued by the Company in reliance on the
statements made in the Application for the insurance. Those statements are
representations; they are not warranties. No statement can be used to contest
or rescind insurance or to defend against a claim unless contained in the
Application for the insurance.
TERMINATION OF TEMPORARY LIFE INSURANCE
Any policy issued on the basis of the Application will replace the temporary
life insurance if: (a) at least one of the Proposed Insureds is living when the
policy is delivered to the Owner; and (b) the Owner accepts the policy; and (c)
any balance of premium then due is paid.
If the policy is not accepted and paid for at the time of delivery: (a) the
temporary life insurance will terminate; and (b) the policy will not be in
force; and (c) the prepayment will be refunded to the Owner.
The Company can terminate the temporary life insurance before the Last Death by:
(a) notice of termination to the Owner at the premium notice address shown in
Part 1 of the Application; and (b) refund of the prepayment to the Owner at the
same address.
If it is not sooner terminated, life insurance will expire 120 days after the
date of the latest of Part II of the Application for the Proposed Insureds.
Notice of the termination will be sent to the Owner. If both Proposed Insureds
die while the temporary life insurance is in force, the prepayment will be used
as the premium; any excess will be refunded to the Owner or any additional
premium due will be deducted from the death proceeds.
INSURABILITY AND POLICY DATE
The Company will determine if the Proposed Insureds are insurable; (a) using the
regular underwriting rules, limits and standards of the Company; and (b) as of
the effective date of the temporary life insurance, but the Company can require
for this purpose further medical examinations, tests and reports after the
effective date. Any policy issued on the basis of the Application will be dated
as of the effective date of the temporary life insurance.
PAGE 3
CONDITIONS
This Receipt and Agreement is subject to these conditions. (a) It must be
signed by the Applicant and countersigned by a licensed agent of the Company.
(b) Any check, draft or money order for the prepayment must be collectable.
(c) No agent has authority to make any change in the terms of the printed text.
(d) The liability of the Company if any Proposed Insured commits suicide will be
limited to refund of the prepayment.
--------------------------------------------------------------------------------
PREPAYMENT RECEIPT
Proposed Insured 1 Applicant
------------------------- ---------------------
Proposed Insured 2
-------------------------
Prepayment as shown below has been received.
It is in connection with Policy No.
-------------------------
This Application is for: Life Insurance
Face Amount $ ; Prepayment $
-------------- -------------------
New England Variable Life Insurance Company
BY
/s/ Xxxxxx X. Xxxxxxxxx
Secretary
Countersigned at (City and State)
--------------------------------------------------------------------------------
on (date)
-----------------------------------------------------------------------
BY
------------------------------------------------------------------------------
The Applicant has read carefully, understands and agrees to all of the limits,
conditions and provisions of this Receipt and Agreement.
Signature of Applicant
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NOTICE: This form must be signed in duplicate. The Company and the Applicant
should keep a signed copy. If a prepayment is made other than on the date of
Part 1 of the Application, an Insurability Statement (Form NEV APP-26) is
required.
Page 4
ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO THE COMPANY; DO NOT MAKE CHECKS
PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK.
