THE INSURED XXXXXXX XXX VARIABLE
LIFE INSURANCE
POLICY OWNER XXXXXXX XXX POLICY
FACE AMOUNT $100,000 EQUITABLE
VARIABLE LIFE INSURANCE COMPANY
[EVLICO LOGO]
POLICY NUMBER SPECIMEN
EQUITABLE VARIABLE LIFE INSURANCE COMPANY
A Stock Life Insurance Company
Agrees
o To pay the insurance benefits of this policy to the Beneficiary upon receiving
proof of the Insured's death; and
o To provide you (the policy Owner) with the other rights and benefits of this
policy.
These agreements are subject to the provisions of this policy.
THE DEATH BENEFIT OF THIS POLICY DURING THE FIRST POLICY YEAR WILL EQUAL THE
FACE AMOUNT SHOWN ON PAGE 3. THEREAFTER, IT MAY INCREASE OR DECREASE EACH YEAR
AS DESCRIBED ON PAGE 4 DEPENDING UPON THE INVESTMENT EXPERIENCE OF THIS POLICY,
BUT SHALL NEVER BE LESS THAN THE FACE AMOUNT.
THE ACCOUNT VALUE AND THE CASH VALUE OF THIS POLICY WILL VARY FROM DAY TO DAY.
THEY MAY INCREASE OR DECREASE DEPENDING UPON THE INVESTMENT EXPERIENCE OF THIS
POLICY.
The amount of the single premium for this policy is shown on page 3.
RIGHT TO EXAMINE POLICY. You may examine this policy and if for any reason you
are not satisfied with it, you may cancel it by returning the policy with a
written request for cancellation to our Administrative Office by the later of:
(a) the 10th day after you receive it; or (b) the 45th day after Part 1 of the
application was signed. If you do this, we will refund the premium that was
paid.
SPECIMEN SPECIMEN
Xxxxx Xxxxx Secretary Xxxxxxxx Xxxxxxx President
Single Premium Whole Life Plan -- Level Face Amount. Variable insurance
payable upon death. Guaranteed Minimum Death Benefit. Non-Participating.
Investment experience reflected in benefits. Investment options described
on page 6.
No. 85-09
VARIABLE LIFE INSURANCE COMPANY
[EVLICO LOGO]
0000 Xxxxxx xx xxx Xxxxxxxx, Xxx Xxxx, Xxx Xxxx 00000
CONTENTS
Insurance benefits 2
Policy owner and beneficiary 4
Death Benefit 4
Account Value 4
Cash Value 4
Loans 5
The Separate Account 5
Investment Options,
allocations, transfers 6
Exchange of Policy 6
General Provisions 7
Payment Options 8
Basis of Values 10
(Net rates of return, variable adjustment amount, benefit base, calculation of
Account Values)
A copy of the application for this policy is at the back of the policy.
IN THIS POLICY:
"We," "our" and "us" mean Equitable Variable Life Insurance Company.
"You" and "your" mean the Owner of the policy at the time an Owner's right is
exercised.
ADMINISTRATIVE OFFICE
The address of our Administrative Office is shown on page 3. You should send
requests to that address unless instructed otherwise.
INSURANCE BENEFITS
The insurance benefits we pay at the insured's death include:
o the Death Benefit described on page 4;
o minus any loan (and loan interest) on the policy.
We will add interest to the resulting amount for the period from the date of
death to the date of payment. It will be computed at the interest rate we are
then paying under the Deposit Option on page 8.
Payment of these benefits may be affected by other provisions of this policy.
See the Suicide Exclusion, Incontestability and Age and Sex clauses on page 7.
Special exclusions or limitations (if any) are listed on page 3.
No. 85-09 Page 2
POLICY INFORMATION
THE INSURED XXXXXXX XXX REGISTER DATE MAR 1, 1985
POLICY OWNER XXXXXXX XXX DATE OF ISSUE MAR 1, 1985
FACE AMOUNT $100,000 ISSUE AGE, SEX 35, MALE
POLICY NUMBER SPECIMEN BENEFICIARY XXXXXXXX X. XXX
STATE OF
RESIDENCE SPECIMEN STATE
************************** BENEFITS AND PREMIUMS TABLE *************************
BENEFITS SINGLE PREMIUM
FOR THIS POLICY
LIFE INSURANCE - VARIABLE $25,890.82
THE SINGLE PREMIUM IS $25,890.82 AND IS DUE ON OR BEFORE DELIVERY OF THE POLICY.
THE FOLLOWING DEDUCTIONS ARE MADE FROM THE SINGLE PREMIUM:
ADMINISTRATIVE EXPENSE: $200.00
STATE PREMIUM TAX: 517.82
THE NET SINGLE PREMIUM AMOUNT ALLOCATED TO THE SEPARATE ACCOUNT IS $25,173.00.
************** INVESTMENT ALLOCATION OF NET SINGLE PREMIUM AMOUNT **************
INVESTMENT DIVISIONS: COMMON STOCK 50%
MONEY MARKET 50%
******* ADMINISTRATIVE OFFICE: EQUITABLE VARIABLE LIFE INSURANCE COMPANY *******
SPECIMEN REGIONAL SERVICE CENTER
000 XXXXXXXX XX.
CITY, STATE 10001
V85-09-3 Page 3
POLICY INFORMATION CONTINUED
THE INSURED XXXXXXX XXX REGISTER DATE MAR 1, 1985
FACE AMOUNT $100,000 DATE OF ISSUE MAR 1, 1985
POLICY NUMBER SPECIMEN ISSUE AGE, SEX 35, MALE
********************************** TABULAR VALUES *****************************
THE ACCOUNT VALUE AND CASH VALUE OF THIS POLICY MAY BE GREATER OR LESS THAN
AMOUNTS SHOWN AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT
SEE PAGE 4 FOR ACCOUNT VALUE AND CASH VALUE PROVISIONS
TABULAR VALUES AT ENDS OF POLICY YEARS
END OF TABULAR TABULAR
POLICY YEAR ACCOUNT VALUES CASH VALUES
1 $26,019 $23,960
2 26,892 24,984
3 27,790 26,050
4 28,712 27,158
5 29,659 28,309
6 30,630 29,504
7 31,623 30,743
8 32,641 32,030
9 33,683 33,364
10 34,748 34,748
11 35,837 35,837
12 36,951 36,951
13 38,089 38,089
14 39,252 39,252
15 40,440 40,440
16 41,653 41,653
17 42,888 42,888
18 44,143 44,143
19 45,416 45,416
20 46,704 46,704
AGE 60 53,364 53,364
AGE 62 56,124 56,124
AGE 65 60,301 60,301
AGE 70 67,206 67,206
THESE VALUES DO NOT REFLECT LOANS. VALUES NOT SHOWN WILL BE FURNISHED ON
REQUEST.
V85-09-3A Page 3A
POLICY INFORMATION CONTINUED
TABLE OF NET SINGLE PREMIUMS
For $1.00 of Variable Adjustment Amount or Paid-Up Whole Life Level Insurance.
Values shown are applicable on policy anniversaries. The net single premium as
of a date during a policy year shall be determined by interpolation between the
values applicable on the immediately preceding and immediately following
anniversaries.
Age of Age of Age of Age of Age of
Insured Net Insured Net Insured Net Insured Net Insured Net
(Nearest Single (Nearest Single (Nearest Single (Nearest Single (Nearest Single
Birthday) Premium Birthday) Premium Birthday) Premium Birthday) Premium Birthday) Premium
--------- ------- --------- ------- --------- ------- --------- ------- --------- -------
MALE INSURED
------------
1 $.08655 21 $.16103 41 $.30630 61 $.54739 81 $ .80702
2 .08901 22 .16584 42 .31623 62 .56124 82 .81756
3 .09165 23 .17087 43 .32641 63 .57516 83 .82774
4 .09441 24 .17613 44 .33683 64 .58909 84 .83745
5 .09731 25 .18165 45 .34748 65 .60301 85 .84665
6 .10038 26 .18744 46 .35837 66 .61689 86 .85536
7 .10361 27 .19351 47 .36951 67 .63072 87 .86362
8 .10702 28 .19985 48 .38089 68 .64453 88 .87153
9 .11061 29 .20646 49 .39252 69 .65831 89 .87920
10 .11436 30 .21334 50 .40440 70 .67206 90 .88679
11 .11828 31 .22049 51 .41653 71 .68574 91 .89444
12 .12232 32 .22790 52 .42888 72 .69929 92 .90237
13 .12645 33 .23558 53 .44143 73 .71262 93 .91083
14 .13063 34 .24352 54 .45416 74 .72564 94 .92013
15 .13484 35 .25173 55 .46704 75 .73828 95 .93048
16 .13906 36 .26019 56 .48007 76 .75052 96 .94201
17 .14330 37 .26892 57 .49324 77 .76238 97 .95459
18 .14757 38 .27790 58 .50655 78 .77391 98 .96774
19 .15193 39 .28712 59 .52002 79 .78517 99 .98064
20 .15640 40 .29659 60 .53364 80 .79621 100 1.00000
FEMALE INSURED
--------------
1 $.07178 21 $.13538 41 $.26197 61 $.47686 81 $ .77229
2 .07383 22 .13985 42 .27047 62 .49058 82 .78597
3 .07602 23 .14449 43 .27917 63 .50455 83 .79922
4 .07831 24 .14930 44 .28807 64 .51871 84 .81195
5 .08072 25 .15429 45 .29719 65 .53301 85 .82411
6 .08324 26 .15946 46 .30654 66 .54743 86 .83569
7 .08589 27 .16482 47 .31613 67 .56201 87 .84673
8 .08865 28 .17038 48 .32597 68 .57676 88 .85730
9 .09155 29 .17613 49 .33604 69 .59177 89 .86749
10 .09457 30 .18209 50 .34637 70 .60703 90 .87741
11 .09773 31 .18825 51 .35693 71 .62253 91 .88720
12 .10100 32 .19462 52 .36775 72 .63818 92 .89704
13 .10438 33 .20122 53 .37880 73 .65388 93 .90712
14 .10788 34 .20805 54 .39008 74 .66948 94 .91771
15 .11146 35 .21510 55 .40160 75 .68489 95 .92905
16 .11515 36 .22239 56 .41336 76 .70006 96 .94128
17 .11895 37 .22990 57 .42540 77 .71496 97 .95429
18 .12285 38 .23761 58 .43774 78 .72961 98 .96766
19 .12689 39 .24554 59 .45042 79 .74406 99 .98064
20 .13106 40 .25366 60 .46347 80 .75830 100 1.00000
V85-09-3B Page 3B
POLICY INFORMATION CONTINUED
DESCRIPTION OF INVESTMENT DIVISIONS
THE ASSETS IN EACH INVESTMENT DIVISION ARE INVESTED IN SHARES OF A DESIGNATED
PORTFOLIO OF AN INVESTMENT COMPANY. EACH PORTFOLIO REPRESENTS A DIFFERENT CLASS
(OR SERIES) OF SHARES ISSUED BY THE XXXXXX RIVER FUND, INC.
COMMON STOCK DIVISION - WE EXPECT THE INVESTMENTS IN THIS PORTFOLIO WILL BE,
PRIMARILY, COMMON STOCKS AND OTHER EQUITY-TYPE
INVESTMENTS.
MONEY MARKET DIVISION - WE EXPECT THE INVESTMENTS IN THIS PORTFOLIO WILL BE,
PRIMARILY, SHORT-TERM (NOT TO EXCEED ONE YEAR) MONEY
MARKET INSTRUMENTS, SUCH AS: UNITED STATES (U.S.)
GOVERNMENT AND U.S. GOVERNMENT AGENCY SECURITIES; BANK
MONEY INSTRUMENTS; TIME DEPOSITS; CERTIFICATES OF
DEPOSIT; HIGH GRADE COMMERCIAL PAPER, INCLUDING MASTER
DEMAND NOTES; AND REPURCHASE AGREEMENTS COVERING U.S.
GOVERNMENT OBLIGATIONS AND CERTIFICATES OF DEPOSIT.
INVESTMENT RESULTS WILL REFLECT FLUCTUATIONS IN MARKET VALUES OF SECURITIES.
PLEASE REFER TO THE CURRENT PROSPECTUS FOR THE XXXXXX RIVER FUND, INC. FOR A
COMPLETE DESCRIPTION OF THE FUND AND THE DESIGNATED PORTFOLIOS.
V85-09-3C Page 3C
POLICY OWNER AND BENEFICIARY
OWNER. The Owner of this policy is the Insured unless otherwise stated in the
application, or later changed. As Owner, you can exercise all the rights in this
policy while the Insured is living. You do not need the consent of anyone who
has only a conditional or future ownership interest in this policy.
BENEFICIARY. The Beneficiary is as stated in the application, unless later
changed. If two or more persons are named, those surviving the Insured will
share equally unless otherwise stated.
We will pay any benefit for which there is no stated Beneficiary living at the
death of the Insured to the children of the Insured who then survive, in equal
shares. If none survive, we will pay the estate of the Insured.
CHANGES. While the Insured is living, you may change the Owner or Beneficiary by
written notice in a form satisfactory to us. The change will take effect on the
date you sign the notice, except that it will not apply to any payment we make
or other action we take before we receive the notice at our Administrative
Office. If you change the Beneficiary, any previous arrangement you made under
the Payment Options provision on page 8 is cancelled.
ASSIGNMENT. You may assign this policy, but we will not be bound by an
assignment unless it is in writing and we have received it at our Administrative
Office. Your rights and those of any other person referred to in this policy
will be subject to the assignment. We assume no responsibility for the validity
of any assignment.
DEATH BENEFIT
The Death Benefit equals:
o the face amount shown on page 3;
o plus the sum, if positive, of the Variable Adjustment Amounts, for each
investment division under this policy in which you have a cash value, for
the policy year in which the Insured dies.
However, the Death Benefit will in no event be less than the amount of Paid-up
Whole Life Level Insurance that could be purchased by the Account Value at the
Insured's death on the basis of the Table of Net Single Premiums on page 3B.
See page 10 for a description of how the Variable Adjustment Amount for each
investment division is determined.
ACCOUNT VALUE
The policy's Account Value will vary daily with the performance of the
investment divisions in which you have Account Value under this policy. See page
11 for a description of how the Account Value is determined.
CASH VALUE
You may give up this policy for its net cash value at any time while the Insured
is living. The net cash value is the cash value minus any loan and loan
interest.
We will determine the net cash value on the date we receive your signed request
for it at our Administrative Office. The policy will terminate on the date you
send the policy and the request to us.
CASH VALUE. The policy's cash value will vary daily with the performance of the
investment divisions in which you have a cash value under this policy.
During the first ten policy years the cash value on any date will be equal to
the product of (1) and (2), where:
(1) is the Account Value on that date; and
(2) is the Tabular Cash Value divided by the Tabular Account Value for that
date.
Whenever the difference between the Account Value and cash value exceeds 9% of
the single premium for this policy, we will increase the cash value by the
amount of such excess.
Tabular Account Values and Tabular Cash Values are shown on page 3A.
After the tenth policy year, the cash value will equal the Account Value.
V85-09-4 Page 4
LOANS
You may get a loan on this policy while it has a loan value. This policy will be
the sole security for the loan.
The amount of the loan may not be more than the loan value. A loan must be at
least $100 more than any existing loan and loan interest. Any existing loan and
loan interest will be deducted from the new loan.
A loan, whether you repay it or not, will have a permanent effect on the
Variable Adjustment Amounts, Death Benefit, Account Value and cash value under
this policy.
We will allocate loans to the investment divisions based on your net cash value
in each investment division as of the dates the loans are made. We will allocate
loan repayments to the investment divisions based on the amount of your
outstanding loans as to each investment division as of the dates the repayments
are made.
LOAN VALUE. The loan value is 90% of the policy's cash value.
LOAN INTEREST. Interest on a loan accrues daily, at an annual rate of 5%.
Interest is due on each policy anniversary. If the interest is not paid when
due, it will be added to the loan and bear interest at the loan rate.
When a loan plus loan interest first exceeds the cash value, we will mail to you
and any assignee of record at last known addresses a notice that the policy will
terminate if such excess amount is not repaid within 31 days after we mailed
such notice.
REPAYMENT. You may repay a loan and loan interest in whole or in part at any
time while the Insured is living and this policy is in effect. We will deduct
any existing loan and loan interest from any benefits we pay at the Insured's
death.
THE SEPARATE ACCOUNT
The Separate Account is our Separate Account I (in unit investment trust form).
We established and we maintain it under the laws of New York State. Realized and
unrealized gains and losses from the assets of the Separate Account are credited
or charged against it without regard to our other income, gains, or losses.
Assets are put in the Separate Account to support this policy and other variable
life insurance policies. Assets may be put in the Separate Account for other
purposes, but not to support contracts or policies other than variable life
insurance.
The assets of the Separate Account are our property. The portion of its assets
equal to the reserves and other policy liabilities with respect to the Separate
Account will not be chargeable with liabilities arising out of any other
business we conduct. We may transfer assets of the Separate Account in excess of
such reserves and liabilities to our general account. We may transfer assets of
an investment division in excess of the reserves and other liabilities with
respect to that division to another investment division or to our general
account.
We will value the assets of each investment division on each business day. A
business day is generally any day on which the New York Stock Exchange is open
for trading.
INVESTMENT DIVISIONS. The Separate Account consists of "investment divisions".
Each division may invest its assets in a separate class (or series) of shares of
a designated investment company. Each class represents a separate portfolio in
the investment company. The investment divisions available on the Register Date
are described on Page 3C. If we add or remove investment divisions, we will send
you a new Page 3C reflecting this.
We have the right to change designated investment companies. We have the right
to add or remove investment divisions. We have the right to withdraw assets of a
class of policies to which this policy belongs from an investment division and
put them in another investment division. We also have the right to combine any
two or more investment divisions. The term "investment division" in this policy
shall then refer to any other investment division in which the assets of a class
of policies to which this policy belongs were placed. If we make any such change
we will send you a new Page 3C reflecting it.
V85-09-4 Page 5
THE SEPARATE ACCOUNT CONTINUED
We have the right to:
1. register or deregister either Separate Account under the Investment
Company Act of 1940;
2. run the Separate Account under the direction of a committee, and to
discharge such committee at any time;
3. restrict or eliminate any voting rights of policyowners, or other persons
who have voting rights as to the Separate Account; and
4. operate the Separate Account by making direct investments or in any other
form. If we do so, we may invest the assets of the Separate Account in any
legal investments. We will rely upon our own and outside counsel for
advice in this regard. Also, unless otherwise required by law or
regulation, the investment advisor or any investment policy may not be
changed without our consent.
CHANGE IN INVESTMENT OBJECTIVE OR POLICY. We will notify you of any material
change in an investment objective or policy of any investment company that is
invested in by an investment division to which net premiums have been allocated
under this policy.
If required by law or regulation, the investment policy of the Separate Account
will not be changed unless approved by the Superintendent of Insurance of New
York State or deemed approved in accordance with such law or regulation. If so
required, the process for getting such approval is filed with the insurance
supervisory official of the jurisdiction in which this policy is delivered.
INVESTMENT OPTIONS
ALLOCATION OF NET SINGLE PREMIUM. We will allocate to each investment division
as of the Register Date a percentage of the Net Single Premium Amount shown on
page 3. Such allocation will be based on the allocation percentages designated
in the application for this policy.
TRANSFER OF ACCOUNT VALUES. You may ask us to transfer all or part of your
Account Value in one investment division to another. Only two such transfers may
be made in a policy year. We will make the transfer as of the date we receive
your written request for it at our Administrative Office.
EXCHANGE OF POLICY
You may exchange this policy for a policy of permanent fixed benefit insurance
on the life of the Insured. You may make such an exchange within 24 months after
the Date of Issue shown on page 3. We will not require evidence of insurability.
We will require:
1. That this policy be in effect on the date of exchange; and
2. Repayment of any loan and loan interest on this policy.
The date of exchange will be the later of: (a) the date you send us this policy
and the signed request on our form of such exchange; or (b) the date we receive
at our Administrative Office any sum due to be paid for such exchange.
THE NEW POLICY. The new policy will be the "Single Premium Life Plan" policy
being offered by The Equitable Life Assurance Society of the United States
(Equitable) on the Date of Issue of this policy. It is a policy of permanent
fixed benefit life insurance. It will have the same face amount, Register Date,
Date of Issue, and Issue Age as this policy. The single premium for the new
policy will be based on Equitable's rates in effect on its Register Date for the
same class of risk as under this policy.
Upon request you will be told the amount of the single premium for the new
policy, and of any extra sum required or allowance to be made for a premium or
cash value adjustment that takes appropriate account of the premiums and cash
values under this policy and under the new policy. If so required, we have filed
a detailed statement of the method of computing such an adjustment with the
insurance supervisory official of the jurisdiction in which this policy is
delivered.
V85-09-6 Page 6
GENERAL PROVISIONS
THE CONTRACT. This insurance is granted in consideration of payment of the
single premium for this policy shown on page 3. This policy and the application
(a copy of which is attached at issue) constitute the entire contract. The
rights conferred by this policy are in addition to those provided by applicable
Federal and State laws and regulations.
The contract may not be modified, nor may any of our rights or requirements be
waived, except in writing signed by our President, one of our Vice Presidents,
or by our Secretary or Treasurer.
INCONTESTABILITY. All statements made in the application are representations and
not warranties. We have the right to contest the validity of this policy based
on material misstatements made in the application. However, this policy will
become incontestable after it has been in effect during the lifetime of the
Insured for two years from the Date of Issue shown on page 3.
No statement shall be used to contest a claim unless contained in the
application.
AGE AND SEX. If the Insured's age or sex has been misstated, any benefits will
be those that the premium paid would have purchased at the correct age and sex.
SUICIDE EXCLUSION. If the Insured commits suicide, while sane or insane, within
two years after the Date of Issue shown on page 3, our liability will be limited
to the payment of a single sum equal to the premium paid, minus any loan and
loan interest.
POLICY PERIODS AND ANNIVERSARIES. Policy years and policy anniversaries are
measured from the Register Date. If the end of a policy year is indicated by an
age, it ends on the policy anniversary nearest the birthday on which the Insured
reaches that age.
REPORTS. Each policy year after the first we will give you a report showing the
Death Benefit, the Account Value and the cash value as of the first day of such
year. The amount of any existing loan and the accrued loan interest for the
previous policy year will also be shown. We will also give you such other
reports as may be required by law.
BASIS OF COMPUTATION. Account Values, reserves and net single premiums are based
on the Commissioners 1980 Standard Ordinary Mortality Table. Continuous
functions are used with interest compounded annually at 4%.
The cash values are equal to or more than those required by law. If so required,
we have filed a detailed statement of the method of computing cash values with
the insurance supervisory official of the jurisdiction in which this policy is
delivered. The Tabular Account Value at the end of each policy year equals the
tabular reserve. Our expense and mortality results will not adversely affect the
dollar amount of insurance benefits or Account Values or cash values.
DETERMINATION AND PAYMENT OF VARIABLE BENEFITS. We will make payments under this
policy as follows:
o A cash value will be paid within 7 days after we receive your policy and
request at our Administrative Office;
o A loan will be paid within 7 days after we receive your request at our
Administrative Office; and
o The insurance benefits will be paid within 7 days after we receive at our
Administrative Office proof of the Insured's death and all other
requirements deemed necessary before such payment may be made.
We may not be able to determine the value of the assets of the investment
divisions if: (1) the New York Stock Exchange is closed; (2) the Securities and
Exchange Commission requires trading to be restricted or declares an emergency;
or (3) the Securities and Exchange Commission by order permits us to defer
payments for the protection of our policy owners. During such times we may
defer:
1. Determination of Account Values;
2. Determination and payment of cash values;
3. Payment of loans;
4. Determination of a change in a Variable Adjustment Amount, and payment of
any portion of the Death Benefit equal to the Variable Adjustment Amount;
5. Any requested transfer of Account Value; and
6. Use of insurance benefits under the Payment Options.
V85-09-6 Page 7
PAYMENT OPTIONS
Payments under these options will not be affected by the investment
experience of any investment division after proceeds are applied
under such options.
Instead of having the insurance benefits or net cash value paid immediately in
one sum, you can choose another form of payment for all or part of them. If you
do not arrange for this before the Insured dies, the Beneficiary will have this
right when the Insured dies. Arrangements you make, however, cannot be changed
by the Beneficiary after the Insured's death. The options are:
1. DEPOSIT OPTION: Left on deposit for a period mutually agreed upon, with
interest paid at the end of each month, each 3 months, each 6 months or each
12 months, as chosen.
2. INSTALMENT OPTIONS:
A. FIXED PERIOD: Paid in equal instalments for a specified number of years
(not more than 30). The instalments will not be less than those shown in
the Table of Guaranteed Payments on page 9.
B. FIXED AMOUNT: Paid in instalments as mutually agreed upon until the
amount applied, together with interest on the unpaid balance, is used up.
3. LIFE INCOME OPTIONS:
Paid as a monthly income for life in an amount we determine but not less
than shown in the Table of Guaranteed Payments on page 9. We guarantee
payments for life and in any event for 10 years, 20 years, or until the
payments we make equal the amount applied (called "refund certain"),
according to the "certain" period chosen.
4. OTHER: We will apply the sum under any other option requested that we make
available at the time of the Insured's death or net cash value withdrawal.
We guarantee interest under Option 1 at the rate of 3% a year and under Option 2
at 3-1/2% a year, or such higher rates as we may determine. We may allow excess
interest under Options 1 and 2.
The payee under an option may name and change a successor payee for any amount
we would otherwise pay the payee's estate.
Any arrangements involving more than one of the options, or a payee who is not a
natural person (for example, a corporation) or who is a fiduciary, must have our
approval. Also, details of all arrangements will be subject to our rules at the
time the arrangement takes effect. These include rules on: the minimum amount we
will apply under an option and minimum amounts for installment payments;
withdrawal or commutation rights; naming payees and successor payees; and
proving age and survival.
Choices (or any later changes) under these options will be made and will take
effect in the same way as a change of Beneficiary. Amounts applied under these
options will not be subject to the claims of creditors or to legal process, to
the extent permitted by law.
V85-09-8 Page 8
TABLE OF GUARANTEED PAYMENTS
MINIMUM AMOUNT FOR EACH $1,000 OF ORIGINAL SUM
OPTION 2
FIXED PERIOD INSTALLMENTS
-------------------------
Number Monthly Annual
of Years' Instal- Instal-
Installments ment ment
------------ -------- ---------
1 $84.70 $1000.00
2 43.08 508.60
3 29.21 344.86
4 22.28 263.04
5 18.12 213.99
6 15.36 181.32
7 13.38 158.01
8 11.91 140.56
9 10.76 127.00
10 9.84 116.18
11 9.09 107.34
12 8.47 99.98
13 7.94 93.78
14 7.49 88.47
15 7.11 83.89
16 6.77 79.89
17 6.47 76.37
18 6.20 73.25
19 5.97 70.47
20 5.76 67.98
21 5.57 65.74
22 5.40 63.70
23 5.24 61.85
24 5.10 60.17
25 4.97 58.62
26 4.84 57.20
27 4.73 55.90
28 4.63 54.69
29 4.54 53.57
30 4.45 52.53
If installments are paid every 3 months, they will be 25.32% of the annual
installments. If they are paid every 6 months, they will be 50.43% of the annual
installments.
OPTION 3
MONTHLY LIFE INCOME
-------------------
10 Years Certain 20 Years Certain Refund Certain
---------------- ---------------- --------------
AGE Male Female Male Female Male Female
--- ---- ------ ---- ------ ---- ------
50 $4.50 $3.96 $4.27 $3.89 $4.28 $3.87
51 4.58 4.02 4.32 3.94 4.35 3.93
52 4.67 4.09 4.38 4.00 4.42 3.99
53 4.75 4.16 4.44 4.06 4.50 4.05
54 4.85 4.24 4.50 4.12 4.58 4.11
55 4.94 4.32 4.56 4.18 4.66 4.18
56 5.04 4.40 4.62 4.24 4.74 4.25
57 5.15 4.49 4.68 4.31 4.83 4.33
58 5.26 4.58 4.74 4.38 4.93 4.41
59 5.37 4.68 4.81 4.45 5.03 4.49
60 5.49 4.78 4.86 4.52 5.13 4.58
61 5.62 4.89 4.92 4.59 5.24 4.67
62 5.75 5.00 4.98 4.66 5.35 4.77
63 5.88 5.12 5.04 4.73 5.48 4.88
64 6.03 5.25 5.09 4.80 5.60 4.99
65 6.17 5.39 5.14 4.88 5.74 5.10
66 6.32 5.53 5.19 4.95 5.88 5.22
67 6.48 5.68 5.24 5.01 6.03 5.35
68 6.64 5.83 5.28 5.08 6.18 5.49
69 6.80 6.00 5.32 5.14 6.35 5.64
70 6.97 6.17 5.35 5.20 6.53 5.79
71 7.15 6.34 5.38 5.26 6.71 5.96
72 7.32 6.53 5.41 5.30 6.91 6.13
73 7.50 6.72 5.43 5.35 7.12 6.32
74 7.67 6.92 5.45 5.38 7.34 6.52
75 7.85 7.12 5.47 5.42 7.58 6.73
76 8.02 7.32 5.48 5.44 7.82 6.96
77 8.19 7.53 5.49 5.46 8.09 7.21
78 8.36 7.75 5.50 5.48 8.38 7.47
79 8.52 7.96 5.50 5.49 8.67 7.75
80 8.67 8.16 5.51 5.50 9.00 8.05
81 8.81 8.36 5.51 5.51 9.34 8.39
82 8.94 8.55 5.51 5.51 9.70 8.73
83 9.06 8.73 5.51 5.51 10.10 9.12
84 9.16 8.90 5.51 5.51 10.52 9.53
85 & over 9.26 9.05 5.51 5.51 10.96 9.97
Amounts for Monthly Life Income are based on age nearest birthday when income
starts. Amounts for ages not shown will be furnished on request.
V85-09-8 Page 9
BASIS OF VALUES
ACTUAL NET RATE OF RETURN (ACTUAL NRR). For each investment division, the Actual
NRR for a policy year reflects the division's:
o dividends received from the investment company;
o plus realized and unrealized capital gains of the division's investment in
the investment company;
o minus realized and unrealized capital losses of the division's investment
in the investment company;
o minus any charges for taxes or amounts set aside as a reserve for taxes;
o minus a charge not exceeding .50% per year for mortality and expense
risks.
The Actual NRR for each investment division will be increased to the extent that
expenses of the investment division exceed the charges for securities brokers'
commissions, transfer taxes, and other fees relating to securities transactions
and a charge for investment management expenses of .25% per year.
The Actual NRR for a period less than a year will be calculated in a consistent
manner.
BASE NET RATE OF RETURN (BASE NRR). The Base NRR is 4% per year. (It is a
pro-rata part of 4% for periods of less than a year.)
If the Actual NRR for all investment divisions always equals the Base NRR, then:
o the Death Benefit will always equal the Face Amount; and
o the Account Value at the end of each policy year will equal the Tabular
Account Value shown on page 3A.
VARIABLE ADJUSTMENT AMOUNT (VAA). The VAA for a policy year is the amount of
insurance in effect for that policy year due to investment performance in past
years. On each policy anniversary we will determine a new VAA for the next
policy year. We will do this independently for each investment division, taking
into account the Actual NRR for the last policy year.
For the first policy year the VAA for each investment division is zero. For
later policy years, the VAA for each investment division will equal the sum of
the VAA Change Amounts for all prior policy years, including the current year. A
VAA does not change during a policy year.
VAA CHANGE AMOUNT. For each policy year after the first, the VAA Change Amount
for each investment division may be positive or negative. It will equal the
product of the following Items (a) and (b) divided by Item (c).
(a) The Actual NRR for the investment division minus the Base NRR for that
policy year.
(b) The Benefit Base for the investment division as of the last policy
anniversary.
(c) The Net Single Premium per $1.00 of VAA for the current policy
anniversary as shown on page 3B.
BENEFIT BASE. For each investment division, the Benefit Base on the Register
Date is the product of the following Items (1) and (2):
(1) The Allocation Percentage designated in the application for this policy.
(2) The Net Single Premium Amount shown on page 3.
On policy anniversaries, the Benefit Base for an investment division is the sum
of the following Items (1) and (2), minus Item (3):
(1) The Tabular Account Value on that anniversary, multiplied by the
following amount immediately before that anniversary: The Benefit Base
in that investment division divided by the sum of the Benefit Bases for
all investment divisions in which you have an Account Value.
(2) The Net Single Premium for the VAA for that investment division on that
anniversary.
(3) Any outstanding loan, plus interest for the investment division as of
that policy anniversary.
The Net Single Premium Amount, Tabular Account and Cash Values and Net Single
Premiums for the VAA are shown on pages 3, 3A and 3B, respectively.
V85-09-10 Page 10
BASIS OF VALUES (CONTINUED)
For each investment division, the VAA Change Amount will also reflect the effect
of:
1. All new policy loans and repayments during the previous policy year; and
2. All transfers of Account Value to or from that investment division
during the previous policy year.
CALCULATION OF ACCOUNT VALUES. The Account Value of this policy on the Register
Date is the net single premium shown on page 3. The Account Value of this policy
on any date after the Register Date is the sum of your Account Values in each
investment division on that date. Your Account Value in each investment division
on any date is the sum of the following Items (1), (2) and (3):
(1) The tabular cash value on that date, multiplied by the following amount
immediately before that date: The Account Value in that investment
division divided by the sum of your Account Values in all of the
investment divisions.
(2) The Net Single Premium on that date for the current VAA for that
investment division.
(3) If the date is not a policy anniversary, the product of the following
Items (a) and (b):
(a) The Actual NRR for the investment division minus the Base NRR for
the time elapsed since the last policy anniversary.
(b) The Benefit Base for that investment division on the last policy
anniversary.
For each investment division, the Account Value will also reflect the effect of:
1. All new policy loans and repayments since the last policy anniversary;
and
2. All transfers of Account Value to or from that investment division since
the last policy anniversary.
If for any reason the Account Value in an investment division is zero, we will
cancel the VAA and any policy loan as to such investment division and reallocate
them to each other investment division proportionately.
TABULAR ACCOUNT AND CASH VALUES (TAV AND TCV). The tables of TAV's and TCV's on
page 3A show them at the end of the first 20 policy years and at certain
attained ages. We will determine the TAV and TCV on other dates in a consistent
manner with allowance for time elapsed. Any TAV's and TCV's not shown will be
furnished on request.
V85-09 Page 11
--------------------------------------------------------------------------------
PART 1 OF AN APPLICATION FOR INDIVIDUAL VARIABLE LIFE INSURANCE TO |_|JUV.
EQUITABLE VARIABLE LIFE INSURANCE COMPANY (EVLICO) |_|OPAI
--------------------------------------------------------------------------------
1. PROPOSED INSURED
a. Print name as it is to appear on policy.
_______RICHARD___________________________ROE____________________________________
First Middle Initial Last
b. |X| Mr. |_| Miss |_| Mrs. |_| Ms. |_| Other Title___________
c. List all current occupations -- Give Title(s) and Duties
_____________CORPORATE ATTORNEY_________________________________________________
________________________________________________________________________________
d. Date of Birth: Mo.__3__ Day__1__ Yr. 19__50__
e. Age Nearest Birthday: ___35___
f. Place of Birth: State of ___NEW YORK___
g. Residence: State of ___NEW YORK___
h. |X| Male |_| Female
2. PLAN INITIAL FACE AMOUNT
____SINGLE PREMIUM VARIABLE LIFE______________________ $______________
If Flexible Prem., will the Death Benefit include the value of the Account?
|_| No (Option A) |_| Yes (Option B)
INVESTMENT DIVISION ALLOCATION (WHOLE NUMBERS ONLY)
Common Stock __50%__ _________________ ___________%
Money Market __50___ _________________ ___________
_______________ _______ _________________ ___________
_______________ _______ _________________ ___________
_______________ _______ _________________ ___________
_______________ _______ _________________ ___________
100%
3. OPTIONAL BENEFITS
|_| Accidental Death Benefit* (Specify Amount): $____________
|_| Option to Purchase Add'l Ins. (Issue ages to 37 only): $____________
|_| Disability Premium Waiver* |_| Disability Benefit-Flexible Prem. Pol.*
|_| Waive Cost of Insurance
|_| Credit $_____________ per _____________
Term Riders:
Decreasing Term Per Month
|_| Family Income: ______Years $____________
|_| Mortgage Prot.: ______Years Initial Amt.: $____________
Renewable Term Yearly 10 Yr.
|_| On Insured: |_| |_| $____________
|_| On Add'l. Insured (See page 2): |_| |_| $____________
|_| Increasing Term
|_| Children's Term (See page 2): $__________Units______________
*If Proposed Insured is a Child (Issue Age 0-14) see Limitations on p.2.
4. BENEFICIARY FOR INSURANCE ON PROPOSED INSURED. Include FULL NAME and
RELATIONSHIP to Proposed Insured.
____________________________XXXXXXXX X. XXX, WIFE__________________________
____________________________________________________________________________
Unless otherwise requested, the contingent beneficiary will be the surviving
children of the Insured, in equal shares. If none survive, payment will be
made to the Insured's estate.
THE BENEFICIARY UNDER ANY TERM INSURANCE RIDER on an Additional Insured or
on a Child will be as stated in those riders, unless otherwise designated in
Special Instructions.
5. OWNER Owner's Soc. Sec. or Tax No. |0|0|0|0|0|0|0|0|0| |
The Owner is |X| Proposed Insured |_| Applicant for Child (See 10.c.)
|_| Other (Give Full Name):
____________________________________________________________________________
If "Other," complete the following:
|_| Mr. |_| Miss |_| Mrs. |_| Ms. |_| Other Title_____________
Relationship to Insured_____________________________________________________
Specify a successor Owner if desired
____________________________________________________________________________
If the Proposed Insured or the Applicant for a Child is not the Owner and if
all persons designated die before the Insured, the Owner will be the estate
of the last of such persons to die except where the Insured is a Child (see
Note in 10.c.).
6. MAILING ADDRESS |_| Business (Give Full Name) |x| Residence
|1|0|0|_|S|P|E|C|M|E|N|_|S|T|.|_|_|_|_|_|_|_|_|_|0|9|_|_|
No. Street Apt.
|N|E|W| |Y|O|R|K|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
City
|N|E|W| |Y|O|R|K|_|_|_|_|_|_|_|_|_|_|_|1|0|0|0|1|
State Zip
7. PREMIUM PAYMENT PLAN
Check mode, and if Flexible Premium complete the following:
Initial Prem. Payment $ _______________________________
Planned Periodic Prems. $ _____________________________
|_| Do not send premium reminder notices
| | Annual |_| Semi-Annual |_|Quarterly
|_| Monthly |_| System-Matic (Attach S-M Form)
|X| Single
|_| Military Allotment: Branch __________________________
Register Date_____________________
|_| Salary Allotment: Register Date_____________________
Unit Name______________________________________________
Unit/Sub-Unit No. if established:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Divisible by |_| 2 |_| 4 Payroll No.________________
|_| Hold Premium $______________________
8. SUITABILITY
a. Have you the Proposed Insured and the Purchaser if other than the Proposed
Insured received: (i) a Prospectus for the policy applied for?
|_|Yes |_| No
Date of Prospectus _________________________________________
Date of any supplement _____________________________________
(ii) a Prospectus for The Xxxxxx River Fund, Inc.
|_|Yes |_| No
Date of Prospectus _________________________________________
Date of any supplement _____________________________________
b. Do you understand that, under the policy applied for (exclusive of any
optional benefits), the amount of the death benefit and the xxxx xxxxxxxx
value may increase or decrease depending upon investment experience (if the
policy has a guaranteed minimum death benefit or cash surrender value it is
only the amount above such minimum that may increase or decrease)?
|_| Yes |_| No
c. With this in mind, is the policy in accord with your insurance objectives
and your anticipated financial needs? |_| Yes |_| No
9. SPECIAL INSTRUCTIONS
a. |_| Preliminary Term (PT) period of ________ days
ending _______________ . PT Premium $_______
Mo. Day Yr.
b. |_| Date to save insurance age: _____________
c. |_| Check here to request an adjustable policy loan interest rate
(if available) instead of a fixed rate.
d. Other:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
--------------------------------------------------------------------------------
NOTE: UPON REQUEST, WE WILL FURNISH ILLUSTRATIONS OF BENEFITS, INCLUDING DEATH
BENEFITS AND CASH VALUES, FOR (A) THE VARIABLE LIFE INSURANCE POLICY APPLIED FOR
AND (B) A FIXED BENEFIT LIFE INSURANCE POLICY FOR THE SAME PREMIUM.
--------------------------------------------------------------------------------
EV4-200Q 1
10. COMPLETE IF PROPOSED INSURED IS A CHILD (ISSUE AGES 0-14).
a. Will there be more life insurance in effect on the Child
than on any older child in the family? |_| Yes |_| No
If yes, explain: ___________________________________________
_____________________________________________________________
b. APPLICANT-COMPLETE IF OTHER THAN THE CHILD.
i. _________________________________________________________
First Name Middle Initial Last Name
ii. |_| Mr. |_| Miss |_| Mrs. |_| Ms. |_| Other Title_______
iii. Date of Birth___________________________________19____
Month Day Year
iv. |_| Male |_| Female
v. Relationship to Child:___________________________________
vi. Total Life Insurance now in effect: $ _________________
c. OWNER. If the Applicant is to be the Owner, after the
Applicant's death the Child will be the Owner unless
otherwise designated in Special Instructions (in any such
designation include Owner's FULL NAME, RELATIONSHIP to
Child, and Social Security or Tax Number).
NOTE: Consider designating an adult secondary Owner to
reduce the chance of a minor Child becoming the Owner. If
all persons designated die before the Child, the Owner will
be the Child.
d. OPTIONAL BENEFIT ON APPLICANT.
|_| Supplemental Protective Benefit. Give Applicant's:
i. Age Nearest ii. Place of
Birthday ______________ Birth_____________
State
iii. Height______Ft.____In. Weight______lbs.
iv. Occupations-Give Title(s) and Duties:__________________________________
________________________________________________________________________
ALSO ANSWER QUESTIONS ON PAGE 3 AS TO APPLICANT.
e. LIMITATIONS ON CHILD'S ADB AND DPW BENEFITS. If the Accidental Death Benefit
is applied for on the Child, the benefit is payable only if the Child dies
after the Child's first birthday.
If the Disability Premium Waiver Benefit is applied for on the Child, the
benefit is effective only if the Child becomes totally disabled on or after
the Child's 5th birthday.
--------------------------------------------------------------------------------
11. COMPLETE FOR CHILDREN'S TERM RIDER.
Give Names of Children below and answer the Questions on page 3 as to each
Child.
CHILDREN PROPOSED FOR INSURANCE:
NOTE: To be eligible, children (including stepchildren and legally adopted
children) must not yet have reached their 18th birthday. Coverage
does not begin until a child is 15 days old. DATE OF BIRTH
--------------------------------------------------------------------------------
First Name Middle Initial Last Name |SEX| MO.| DAY| YR.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
12. COMPLETE FOR RENEWABLE TERM RIDER ON ADDITIONAL INSURED.
Complete below and answer the Questions on page 3 as to the Additional Insured.
PROPOSED ADDITIONAL INSURED
a. Print name as it is to appear on the Policy.
________________________________________________________________________________
First Middle Initial Last
b. List all current occupations -- Give Title(s) and Duties.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
x. Xxxx of Birth: Mo.__________ Day________ Yr. 19____
d. Age Nearest Birthday _______________________________
e. Place of Birth: State of __________________________
f. Residence: State of________________________________
g. |_| Male |_| Female
h. Owner's Relationship to Additional Insured:_________________________________
________________________________________________________________________________
--------------------------------------------------------------------------------
13. COMPLETE IF USING EXISTING OPTION TO PURCHASE INSURANCE.
i. Existing Individual Policy No. _________________________
ii. Option Date_______ iii. Option Amount: $______________
iv. |_| Regular Option or
|_| Option on Birth or Adoption of Child
Child's Name _______________________________________
Date of Birth or Adoption___________________________
v. If applying for Disability Premium Waiver, is Proposed Insured now
totally disabled as defined in the Disability Premium Waiver
provision of the above policy? |_| Yes |_| No
This application is made under a provision in the policy indicated above
permitting the purchase of individual life insurance (the "Option Provision").
If this application is made within the time allowed and in accordance with the
other terms in the Option Provision, including timely payment of the full first
premium for the option insurance, then the option insurance shall take effect
upon the terms of the policy EVLICO would issue. Otherwise, the option insurance
shall not take effect.
Answer the Questions on page 3 only if evidence of insurability is required in
connection with an optional benefit or any excess of the insurance amount
applied for over the insurance amount permitted by the Option Provision (the
option insurance).
EV4-200Q 2
OTHER INFORMATION -- HAS ANY PERSON PROPOSED FOR INSURANCE:
14.a. Ever had a driver's license suspended or revoked or, within the last three
years, been convicted of two or more moving violations or driving under the
influence of alcohol or drugs? (Give full details -- including dates, types of
violation, and reason for license suspension or revocation.) |_| Yes |X| No
b. Any plan to travel or reside outside the U.S.? (Give full details.)
|_| Yes |X| No
c. Any other life insurance now in effect or application now pending? (State
companies and amounts.) |_| Yes |X| No
d. Smoked cigarettes within the last 12 months? |_| Yes |X| No
15.a. In the last year flown other than as a passenger or plan to do so?
|_| Yes |X| No
If yes: Total flying time at present________________ Hours;
Last 12 mos.________Hours; Next 12 mos._________Est. Hours.
(Complete Aviation Supplement for pilot instruction; competitive, test,
stunt or military flying; or crop dusting.)
b. Engaged within the last year, or any plan to engage in motor racing on land
or water, underwater diving, sky diving, ballooning, hang-gliding or
parachuting? (If yes, complete Avocation Supplement.) |_| Yes |X| No
c. Ever had an application for life or health insurance declined, that required
an extra premium or was otherwise modified? (Give full details.) |_| Yes |X| No
d. Replaced or changed any existing insurance or annuity (or any plan to do so)
assuming the insurance applied for will be issued? (State companies, plans and
amounts.) |_| Yes |X| No
ANSWER QUESTIONS 16, 17 AND 18 ONLY IF NON-MEDICAL.
16. Proposed Insured:__________Height___6____Ft.____1____In. Weight__185__lbs.
Additional Insured:________Height________Ft._________In. Weight_______lbs.
HAS ANY PERSON PROPOSED FOR INSURANCE:
17.a. Ever been treated for or had any indication of heart trouble, stroke, high
blood pressure, chest pain, diabetes, tumor or cancer? (Give full details.)
|_| Yes |X| No
b. In the last 5 years, consulted a physician, or been examined or treated at a
hospital or other medical facility? (Include medical check-ups in the last 2
years. Do not include colds, minor virus infections, minor injuries, or normal
pregnancy.) (Give full details.) |_| Yes |X| No
18.a. In the last 10 years used barbiturates, amphetamines, hallucinatory drugs
or narcotics? (Give full details.) |_| Yes |X| No
b. In the last 10 years received counseling or treatment regarding the use of
alcohol or drugs? (Give full details.) |_| Yes |X|No
19. DETAILS. For each yes answer give Question number, name of person(s)
affected and full details. For 17 and 18 also include conditions, dates,
durations, treatment and results, and names and addresses of physicians and
medical facilities.
No. Name of Person Affected Details
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
20. COMPLETE IF FIRST PREMIUM IS PAID BEFORE THE POLICY IS DELIVERED:
Have the undersigned read and do they agree to the conditions of EVLICO's
Temporary Insurance Agreement, including (i) the requirement that all of the
conditions in that Agreement must be met before any insurance takes effect, and
(ii) the $250,000 insurance amount limitation? |_| YES |_| NO (If "No," a
premium may not be paid before the policy is delivered.)
AMOUNT PAID: $___________. (Draw checks to order of EVLICO.)
AGREEMENT. Each signer of this application agrees that:
(1) The statements and answers in all parts of this application are true and
complete to the best of my knowledge and belief. EVLICO may rely on them in
acting on this application.
(2) EVLICO's Temporary Insurance Agreement states the conditions that must be
met before any insurance takes effect, if the full first premium for the
policy applied for is paid before the policy is delivered.
(3) EXCEPT AS STATED IN THE TEMPORARY INSURANCE AGREEMENT, NO INSURANCE SHALL
TAKE EFFECT ON THIS APPLICATION: (A) UNTIL A POLICY IS DELIVERED AND THE
FULL FIRST PREMIUM FOR IT IS PAID WHILE THE PROPOSED INSURED IS LIVING; (B)
BEFORE ANY REGISTER DATE SPECIFIED IN THIS APPLICATION; AND (C) UNLESS TO
THE BEST OF MY KNOWLEDGE AND BELIEF THE STATEMENTS AND ANSWERS IN ALL PARTS
OF THIS APPLICATION CONTINUE TO BE TRUE AND COMPLETE, WITHOUT MATERIAL
CHANGE, AS OF THE TIME SUCH PREMIUM IS PAID.
(4) No agent or medical examiner has authority to modify this Agreement or the
Temporary Insurance Agreement, nor to waive any of EVLICO's rights or
requirements. EVLICO shall not be bound by any information unless it is
stated in application Part 1, 1A or 2.
--------------------------------------------------------------------------------
Signature of Agent________/s/ Xxxx X. Agent_____________________________________
IT IS UNDERSTOOD THAT UNDER THE POLICY APPLIED FOR (EXCLUSIVE OF ANY OPTIONAL
BENEFITS) THE AMOUNT OF THE DEATH BENEFIT AND THE CASH SURRENDER VALUE MAY
INCREASE OR DECREASE BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT
AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT (IF THE POLICY HAS A GUARANTEED
MINIMUM DEATH BENEFIT OR CASH SURRENDER VALUE IT IS ONLY THE AMOUNT ABOVE SUCH
MINIMUM THAT MAY INCREASE OR DECREASE).
Dated at __NEW YORK_____NY__________________on___3/1_____19__85__
City State
(X)___/s/ Xxxxxxx Xxx___________________________________________________________
Signature of Proposed Insured or of Applicant if Proposed Insured is a Child,
Issue Age 0-14.
________________________________________________________________________________
Signature of Additional Insured if required.
________________________________________________________________________________
Signature of Purchaser if not Proposed Insured or Applicant.
(If corp. show firm's name and signature of authorized officer.)
EV4-200Q 3
VARIABLE
LIFE
INSURANCE
POLICY
EQUITABLE
VARIABLE LIFE INSURANCE COMPANY
[EVLICO LOGO]
Home Office: 0000 Xxxxxx xx xxx Xxxxxxxx, Xxx Xxxx, Xxx Xxxx 00000
Single Premium Whole Life Plan -- Level Face Amount. Variable
insurance payable upon death. Guaranteed Minimum Death Benefit.
Non-Participating. Investment experience reflected in benefits.
Investment options described on page 6.
No. 85-09
