Aetna Life Insurance and Annuity Company
Hartford, Connecticut 06156
Supplement to Application for
Flexible Premium Variable Life Insurance
1. Proposed Insured:____________________________________________________________
First Middle Last
2. Initial Specified Amount:____________________________________________________
3. Initial Premium: $ __________________________________________________________
4. Planned Premium: $ _________________________________________________________
5. Guaranteed Death Benefit (Must be selected at application. Not available on
substandard policies.)
_______ Guaranteed Death Benefit Monthly Premium to Age 80
_______ Guaranteed Death Benefit Monthly Premium to Age 100
6. Premium Payment Allocation (whole %)
_____ General (Fixed) Account ______ Xxxxx American Small Cap Portfolio
_____ Aetna Variable Fund ______ Janus Aspen Growth Portfolio
_____ Aetna Variable Encore Fund ______ Janus Aspen Aggressive Growth Portfolio
_____ Aetna Income Shares ______ Janus Aspen Balanced Portfolio
_____ Aetna Investment Advisers Fund, Inc. ______ Janus Aspen Worldwide Growth Portfolio
_____ TCI Growth ______ Janus Aspen Short-Term Bond Portfolio
_____ Xxxxxxx International Portfolio
7. Billing Frequency: ______ Annual ______ Automatic Check Plan (Authorization)
______ Semi-Annual ______ Add to Existing ACP No. _________
______ Quarterly ______ Other _________________________
8. Death Benefit Option:
_____ Option 1 ______ Option 2
Option 1. The policy value is included Option 2. The policy value is in addition
in the Specified Amount. to the SpecifiedAmount.
Financial Data
National Association of Securities Dealers Inc. rules require that the Sales
Representative have reasonable grounds to believe that the sale is suitable for
the Policyowner, based on information provided by the Policyowner as shown on
this form and on information known by the Sales Representative. Please complete
all sections.
9. Social Security Number: _________________ 10. Age:_______ 11. Citizenship:
12. Marital Status: _________ 13. Number of Dependents: ________
14. Occupation:________________________
15. Employer Name and Address:__________________________________________________
16. Investment Objectives: (If applicable, check more than one):
|_| Retirement Income |_| Long-term Growth |_| Conservation of Principal
17. Estimated Net Worth of Immediate Family: |_| $0 - $10,000
|_| $10,001 - $50,000 |_| $50,001 - $100,000 |_| $100,001 - $200,000
|_| over $200,000
18. Total income of Immediate Family: (All sources)
A. |_| up to $25,000 C. |_| $50,001 - $100,000
B. |_| $25,001 - $50,000 D. |_| over $100,000
19. Is the Policyowner associated with a National Association of
Securities Dealers firm: (yes/no):______
20. If Policyowner is a business, provide the name(s) and signature(s) of the
person(s) authorized to exercise rights under this policy:
__________________________________________________________
I understand that:
THE AMOUNT AND DURATION OF THE DEATH BENEFIT MAY VARY UNDER SPECIFIED
CONDITIONS.
POLICY VALUES NOT IN THE FIXED ACCOUNT MAY INCREASE OR DECREASE IN
ACCORDANCE WITH THE EXPERIENCE OF THE SEPARATE ACCOUNT.
THE AMOUNT OF BENEFIT PAYABLE ON THE MATURITY DATE IS NOT GUARANTEED BUT
IS DEPENDENT UPON THE THEN CASH SURRENDER VALUE, UNLESS THE GUARANTEED
DEATH BENEFIT TO AGE 100 IS IN EFFECT.
ILLUSTRATIONS OF BENEFITS, INCLUDING DEATH BENEFITS, POLICY VALUES, AND
CASH SURRENDER VALUES ARE AVAILABLE UPON REQUEST.
I hereby acknowledge receipt of the following prospectuses dated May 1, 1994
for:
(1) AetnaVest Plus: Variable Life Account B (Flexible Premium
Variable Life Insurance); and
(2) Aetna Variable Fund, Aetna Income Shares, Aetna Variable Encore
Fund, Aetna Investment Advisers Fund, Inc., TCI Growth Portfolios
- TCI Growth, Xxxxxxx Variable Life Investment Fund -
International Portfolio, Xxxxx American Fund - Xxxxx American
Small Cap Portfolio, Janus Aspen Series - Growth Portfolio, Janus
Aspen Series - Aggressive Growth Portfolio, Janus Aspen Series -
Worldwide Growth Portfolio, Janus Aspen Series - Balanced
Portfolio, Janus Aspen Series - Short Term Bond Portfolio.
Signed at ____________ on ______________ by __________________________________
(City/State) (Mo/Day/Yr) Signature of Proposed Insured
X ___________________________ ______________________________________________
Signature of Agent Signature of Policyowner if Other than
Proposed Insured