LIFE INSURANCE APPLICATION RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY
ReliaStar Life Insurance Company (We)
TEMPORARY INSURANCE AGREEMENT AND RECEIPT (RECEIPT)
PROPOSED PRIMARY INSURED'S NAME (YOU) __________________________________________
Notice: The insurance you applied for is not now in effect. If, at the time all
the Conditions in the Receipt have been met, and the Receipt has not ended, we
will either: 1) Pay the Temporary Insurance Amount if an Event listed in the
Table of Benefits (Table) occurs; or 2) Issue the amount of insurance applied
for (limited by the amount listed for that type of insurance in the Table) if we
can insure all Proposed Insureds on the basis applied for in the application.
A. CONDITIONS
1. At least 10% of the initial annual premium is paid (one monthly premium if
the pre-authorized check method of collection is used), on all insurance
applied for with this application; or a government allotment, account
deduction or other premium payment authorization form is signed and
delivered to the agent with the application; or ownership of one or more
life insurance policies on the life of any Proposed Insured having cash
surrender values on the application date at least equal to the lesser of
$1000.00 or the initial minimum annual premium of all insurance applied
for with this application has been assigned to us under an Agreement for
the Exchange of Insurance Policies under Section 1035 of the Internal
Revenue Code.
2. All parts of the application, including medical exams and tests, if
required, are completed and no material misstatements are made.
3. No Proposed Insured has: a) In the last 12 months had any known or
suspected heart attack, stroke, or cancer, other than of the skin (except
melanoma), or been treated by any physician or other practitioner for any
of these conditions; b) Within the last 60 days been advised by any
physician or other practitioner to have any diagnostic test or surgery not
yet performed; or c) In the last 10 years been diagnosed and/or treated by
a member of the medical profession for positive HIV (Human
Immunodeficiency Virus) or AIDS (Acquired Immunodeficiency Syndrome).
4. An Event or change in insurability, which occurs after all the other
Conditions were met, was not the result of an intentional act.
B. AMOUNT The Temporary Insurance Amount in this and ALL OTHER RECEIPTS still in
effect is the insurance applied for or the amount listed in the Table for
that Event, whichever amount is less. No other benefit will be provided if
the Temporary Insurance Amount is paid.
TABLE OF BENEFITS - EVENT TYPE OF INSURANCE AMOUNT (INCLUDING ADB)
1. Death (natural or accidental) of Any combination of Life, AIR & TIR $500,000 per life
Proposed Primary or Additional Insured
2. Death of both Proposed Primary Any combination of Survivorship Life $500,000 total
and Joint Insureds and Survivorship Term Insurance
3. Death of the Proposed Insured Child Children's Insurance Rider-CIR $10,000 per child
4. Death of the Proposed Recognized Applicant Waiver on Recognized Applicant-RA Waiver of Premium until the Proposed
Insured Child reaches age 25
C. BENEFICIARY If Event 1 or 2 occurs, we will pay the Temporary Insurance
Amount to the beneficiary listed in the application, if living, otherwise to
the Proposed Owner or Recognized Applicant. If Event 3 occurs, we will pay
the Temporary Insurance Amount to the Proposed Primary Insured. If the
Temporary Insurance Amount is not sufficient to pay the designated share to
each beneficiary, each share will be reduced pro rata until the total amount
of all shares equals the Temporary Insurance Amount.
D. PREMIUMS
1. We will first apply premiums to all policies which become effective as a
result of the application.
2. We will refund the premiums if all these conditions are met: a) No claim
is paid under this Receipt; b) No coverage becomes effective under the
policy applied for; and c) No coverage becomes effective under a policy we
offer other than the policy applied for at the time of the application.
3. We will keep part of the premium equal to the premium for the kind,
amount, and period of coverage (but not less than one month) given under
this Receipt if a benefit is paid under the Receipt. Any remaining premium
will be refunded.
4. Cash surrender values of life insurance policies assigned to us under an
Agreement for the Exchange of Insurance Policies under Section 1035 of the
Internal Revenue Code will not be considered premiums for purposes of this
Receipt until the cash surrender value is received by us at our Home
Office and the Temporary Insurance provided under this Receipt has not
ended in accordance with E.
E. TERMINATION The Temporary Insurance under this Receipt will end at the
earliest of:
1. The date our Home Office approves the application as applied for;
2. The date the Proposed Owner or Recognized Applicant is offered: a) A
policy other than that applied for; b) A notice that the Temporary
Insurance has ended; or c) A notice rejecting the application;
3. The date an Event listed in the Table occurs; or
4. The date 180 days after the date of this Receipt.
No agent can change this Receipt. This Receipt is not effective if given for a
check or draft that is not honored. All premium checks must be made payable to
ReliaStar Life Insurance Company. Do not make check payable to the agent or
leave the payee blank.
AGENT'S STATEMENT: I received $___________ with the application bearing the same
date as this Receipt.
Date Agent Agent's Adddress
---------- ---------------------------- ------------------------------------
45675a Rev. 6/98
LIFE INSURANCE APPLICATION RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY
This application consists of sections X, X, X, X, X, X, X, L and O in all cases
and sections G, H, I, K, M, N, the medical exam and supplements when required by
the underwriting rules of the Company.
--------------------------------------------------------------------------------
SECTION A. PROPOSED PRIMARY INSURED INFORMATION
--------------------------------------------------------------------------------
1. First Name MI Last Name 2. Social Security Number
- -
------------------------ ---- ------------------ -------------------------
3. Date of Birth 4. Sex 5. Birth State 6. Country
/ / [ ] Male [ ] Female
-------------- ------------------- ------------------ ------------------
7. Home Phone Number 8. Business Phone Number 9. Driver's License Number State
( ) ( )
----------------- ------------------------ -------------------------- -----
10. Xxxxxxxxx Xxxxxx Xxxxxxx Xxxx Xxxxx Zip Code
------------------------------ --------------- ---------- --------------
11. Address for Premium Notice if City State Zip Code
other than Residence
------------------------------ --------------- ---------- --------------
12. Annual Income 13. Occupation
$
------------------------ ------------------------------------------------
14. Have you used tobacco in any form in the last 730 days (2 years)?
[ ] yes [ ] no
If yes, Type Daily Amount
------------------------ ----------------------------------------
15. Height 16. Weight 17. Weight Change in Last Year
----------- ------------ -----------
18. Do you have a personal physician or clinic? [ ] yes [ ] no
19. Name, Address and Telephone Number of Personal Physician/Clinic
----------------------------------------------------------------------------
20. Date Last Consulted 21. Reason for and Results of Consultation
/ /
------------------------- -----------------------------------------------
--------------------------------------------------------------------------------
SECTION B. PROPOSED OWNER INFORMATION
--------------------------------------------------------------------------------
Complete if the Owner is other than the Proposed Primary Insured. If the
Proposed Primary Insured is a minor, always specify the Owner.
1. First Name or Name of Trust MI Last Name 2. Date of Trust
--------------------------- ---- ----------------------- -----------------
3. Date of Birth 4. Social Security Number or Tax ID Number
/ /
-------------- ------------------------------------------------------------
5. Xxxxxxxxx Xxxxxx Xxxxxxx Xxxx Xxxxx Zip Code
------------------------------ --------------- ---------- ---------------
6. Relationship to Proposed Primary Insured [ ] Spouse [ ] Child [ ] Parent
[ ] Other (specify)
--------------------------------------------------------------------------------
SECTION C. CONTINGENT OWNER INFORMATION
--------------------------------------------------------------------------------
1. First Name or Name of Trust MI Last Name 2. Date of Trust
---------------------------- ---- ------------------- --------------------
3. Date of Birth 4. Social Security Number or Tax ID Number
/ /
-------------- ------------------------------------------------------------
45675a Page 1 Rev. 6/98
LIFE INSURANCE APPLICATION RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY
--------------------------------------------------------------------------------
SECTION D. BASE POLICY INFORMATION
--------------------------------------------------------------------------------
MUST ATTACH A COPY OF THE ILLUSTRATION SIGNED BY THE APPLICANT.
1. BASE FACE AMOUNT (Not Including Term Riders) 2. PRODUCT NAME
$
-------------------------------------------- -------------------------------
3. PRODUCT TYPE [ ] Fixed [ ] Variable - (Owner must receive a current
prospectus, and section N must be
completed if applying for a variable
universal life insurance policy.)
4. DEATH BENEFIT OPTION: [ ] Level [ ] Increasing/Variable
5. RATE CLASS QUOTED:
[ ] Preferred No-Tobacco [ ] No-Tobacco [ ] Preferred Tobacco [ ] Tobacco
[ ] Preferred Nonsmoker [ ] Nonsmoker [ ] Standard [ ] Other
--------
--------------------------------------------------------------------------------
SECTION X. XXXXX INFORMATION FOR ALL PRODUCTS
--------------------------------------------------------------------------------
CHECK APPROPRIATE BOX AND/OR ENTER AMOUNTS.
RIDERS:
[ ] Accelerated Benefit Rider [ ] Children's Insurance Rider.................[$ ]
[ ] Waiver of Monthly Deduction Rider [ ] Extension of Rate Guarantee Rider
[ ] Waiver of Specified Premium Rider [ ] Survivorship Term Rider....................[$ ]
(Specify Monthly Premium).........[$ ]
[ ] Four Year Term Rider (Survivorship Life)...[$ ]
[ ] Additional Insured Rider
(on Primary Insured)..............[$ ] [ ] Future Purchase Option Rider...............[$ ]
[ ] Additional Insured Rider [ ] Other _______________________________......[$ ]
(on Additional Insured)...........[$ ]
[ ] Other _______________________________......[$ ]
[ ] Accidental Death Benefit Rider ...[$ ]
--------------------------------------------------------------------------------
SECTION F. BENEFICIARY INFORMATION OF PROPOSED PRIMARY AND JOINT INSUREDS
--------------------------------------------------------------------------------
UNLESS OTHERWISE STATED, THE BENEFICIARY DESIGNATION IS REVOCABLE AND
BENEFICIARIES OF LIKE CLASS SHALL SHARE EQUALLY WITH RIGHT OF SURVIVORSHIP.
1. PRIMARY BENEFICIARY OF PROPOSED PRIMARY AND JOINT INSUREDS
-----------------------------------------------------------------------------
Provide name, address, date of birth, social security number, and
relationship to Proposed Insured. If Trust, provide name and date of trust
agreement. If Corporation, provide state of incorporation.
-----------------------------------------------------------------------------
2. CONTINGENT BENEFICIARY OF PROPOSED PRIMARY AND JOINT INSUREDS
-----------------------------------------------------------------------------
Provide name, address, date of birth, social security number, and
relationship to Proposed Insured. If Trust, provide name and date of trust
agreement. If Corporation, provide state of incorporation.
-----------------------------------------------------------------------------
--------------------------------------------------------------------------------
SECTION G. BENEFICIARY INFORMATION OF PROPOSED ADDITIONAL INSURED
--------------------------------------------------------------------------------
UNLESS OTHERWISE STATED, THE BENEFICIARY DESIGNATION IS REVOCABLE AND
BENEFICIARIES OF LIKE CLASS SHALL SHARE EQUALLY WITH RIGHT OF SURVIVORSHIP.
1. PRIMARY BENEFICIARY OF PROPOSED ADDITIONAL INSURED
-----------------------------------------------------------------------------
Provide name, address, date of birth, social security number, and
relationship to Proposed Additional Insured. If Trust, provide name and date
of trust agreement. If Corporation, provide state of incorporation.
-----------------------------------------------------------------------------
45675a Page 2 Rev. 6/98
LIFE INSURANCE APPLICATION RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY
--------------------------------------------------------------------------------
SECTION H. PROPOSED ADDITIONAL INSURED OR JOINT INSURED INFORMATION
--------------------------------------------------------------------------------
1. First Name MI Last Name 2. Social Security Number
- -
------------------------ ---- ------------------ -------------------------
3. Date of Birth 4. Sex 5. Birth State 6. Country
/ / [ ] Male [ ] Female
-------------- ------------------- ------------------ ------------------
7. Home Phone Number 8. Business Phone Number 9. Driver's License Number State
( ) ( )
----------------- ------------------------ -------------------------- -----
10. Xxxxxxxxx Xxxxxx Xxxxxxx Xxxx Xxxxx Zip Code
------------------------------ --------------- ---------- --------------
12. Annual Income 13. Occupation
$
------------------------ ------------------------------------------------
14. Have you used tobacco in any form in the last 730 days (2 years)?
[ ] yes [ ] no
If yes, Type Daily Amount
------------------------ ----------------------------------------
15. Height 16. Weight 17. Weight Change in Last Year
----------- ------------ -----------
18. Do you have a personal physician or clinic? [ ] yes [ ] no
19. Name, Address and Telephone Number of Personal Physician/Clinic
----------------------------------------------------------------------------
20. Date Last Consulted 21. Reason for and Results of Consultation
/ /
------------------------- -----------------------------------------------
--------------------------------------------------------------------------------
SECTION I. PROPOSED CHILDREN'S INSURANCE RIDER INFORMATION
--------------------------------------------------------------------------------
PROPOSED INSUREDS
--------------------- ------ ------------ ----- ---------- --------- ------------------ -------------- ----------
Relationship Amt. of life
Proposed Insured's to proposed insurance Date of
full name Sex Birthdate Age Height Weight primary insured in force last issue
--------------------- ------ ------------ ----- ---------- --------- ------------------ -------------- ----------
--------------------- ------ ------------ ----- ---------- --------- ------------------ -------------- ----------
--------------------- ------ ------------ ----- ---------- --------- ------------------ -------------- ----------
--------------------- ------ ------------ ----- ---------- --------- ------------------ -------------- ----------
--------------------- ------ ------------ ----- ---------- --------- ------------------ -------------- ----------
--------------------- ------ ------------ ----- ---------- --------- ------------------ -------------- ----------
--------------------- ------------------------------------------------------ ------------ -----------------------
Proposed Date last
Insured's name Name, address and phone number of regular physician consulted Reason
--------------------- ------------------------------------------------------ ------------ -----------------------
--------------------- ------------------------------------------------------ ------------ -----------------------
--------------------- ------------------------------------------------------ ------------ -----------------------
--------------------- ------------------------------------------------------ ------------ -----------------------
--------------------- ------------------------------------------------------ ------------ -----------------------
--------------------- ------------------------------------------------------ ------------ -----------------------
45675a Page 3 Rev. 6/98
LIFE INSURANCE APPLICATION RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY
--------------------------------------------------------------------------------
SECTION J. GENERAL INFORMATION
--------------------------------------------------------------------------------
COMPLETE THE FOLLOWING ON ALL PROPOSED INSUREDS, INCLUDING CHILDREN TO BE
COVERED UNDER THE CHILDREN'S INSURANCE RIDER.
1. Life Insurance In Force (If none, check none.) [ ] none
------------------------ -------------------- -------------- -------------- --------------- --------
Personal Business Accidental Date
Proposed Insured's Name Company Life Benefit Life Benefit Death Benefit Issued
------------------------ -------------------- -------------- -------------- --------------- --------
------------------------ -------------------- -------------- -------------- --------------- --------
------------------------ -------------------- -------------- -------------- --------------- --------
------------------------ -------------------- -------------- -------------- --------------- --------
------------------------ -------------------- -------------- -------------- --------------- --------
2. Does any Proposed Insured have any existing life or annuity coverage to be
replaced, lapsed, surrendered, or borrowed against? (If yes, please list
company, policy number, and amount.).......................... [ ] yes [ ] no
------------------------ -------------------- -------------------------- ---------------------------
Proposed Insured's Name Company Policy Number Amount
------------------------ -------------------- -------------------------- ---------------------------
------------------------ -------------------- -------------------------- ---------------------------
------------------------ -------------------- -------------------------- ---------------------------
3. a. Does any Proposed Insured have any other application pending for life
insurance?................................................. [ ] yes [ ] no
b. If yes, will all applications now pending for life insurance be accepted
and placed in force?....................................... [ ] yes [ ] no
c. List company(ies) and amount(s) applied for.
------------------------------- ---------------------------------- ---------------------------------
Proposed Insured's Name Company Amount Applied For
------------------------------- ---------------------------------- ---------------------------------
------------------------------- ---------------------------------- ---------------------------------
------------------------------- ---------------------------------- ---------------------------------
4. Has any Proposed Insured in the last 12 months had any known or suspected
heart attack, stroke, or cancer, other than of the skin (except melanoma), or
been treated by any physician or other practitioner for any of these
conditions?................................................... [ ] yes [ ] no
5. Has any Proposed Insured in the last 60 days been advised by any physician or
other practitioner to have any diagnostic test or surgery not yet
performed?.................................................... [ ] yes [ ] no
6. Has any Proposed Insured in the last 10 years been diagnosed and/or treated
by a member of the medical profession for positive HIV (Human
Immunodeficiency Virus) or AIDS (Acquired Immunodeficiency
Syndrome)?.................................................... [ ] yes [ ] no
7. Has any Proposed Insured in the last five years had any motor vehicle
accidents, alcohol or drug related convictions while operating a motor
vehicle, or other moving violations?.......................... [ ] yes [ ] no
8. Details for yes answers to questions 4-7.
----------------------------- --------------- -------------------------------
Proposed Insured's Name Question # Details
----------------------------- --------------- -------------------------------
----------------------------- --------------- -------------------------------
----------------------------- --------------- -------------------------------
9. Has any Proposed Insured in the last five years made or does any Proposed
Insured anticipate making flights in an aircraft other than as a passenger on
a scheduled airline?.......................................... [ ] yes [ ] no
(If yes, complete the Aviation Questionnaire (Section K.1.), which will
become part of this application.)
10. Is any Proposed Insured in the Reserves, National Guard, on active duty in
the military, or enrolled in a college military program?..... [ ] yes [ ] no
(If yes, complete the Military Questionnaire (Section K.2.), which will
become part of this application.)
11. Has any Proposed Insured in the last three years engaged in or does any
Proposed Insured plan to engage in any of the following activities? (If yes,
give details in the Avocation and Sports Questionnaire (Section K.3.), which
will become part of this application.)
a. Scuba diving ............... [ ] yes [ ] no e. Rodeo ..................... [ ] yes [ ] no
b. Sky diving or parachuting .. [ ] yes [ ] no f. Motorized vehicle racing .. [ ] yes [ ] no
c. Hang-gliding ............... [ ] yes [ ] no g. Ultra-light flying ........ [ ] yes [ ] no
d. Mountain climbing .......... [ ] yes [ ] no
45675a Page 4 Rev. 6/98
LIFE INSURANCE APPLICATION RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY
--------------------------------------------------------------------------------
SECTION K. QUESTIONNAIRES
--------------------------------------------------------------------------------
COMPLETE 1, 2, AND 3 BELOW FOR ANY PROPOSED INSURED IF QUESTIONS 9, 10, OR 11 OF
SECTION J WAS ANSWERED YES.
1. Aviation Questionnaire
COMPLETE IF QUESTION 9 OF SECTION J WAS ANSWERED YES.
a. Name of Proposed Insured
--------------------------------------------------------------------------
b. Are you or do you intend to be a pilot or crew member of any military or
civilian aircraft?......................................... [ ] yes [ ] no
c. Type of License d. Total Number of Solo e. Type of Aircraft/Type of
Hours Flying (crop dusting,
instruction, test, etc.)
---------------- -------------------- --------------------------
f.
------------------- --------------------- ---------------- --------------- ---------------- --------------
Type of Last 12 months 1-2 years ago Anticipated Lifetime Total
aviation activity Date of last flight (hours flown) (hours flown) Next 12 months (hours flown)
------------------- --------------------- ---------------- --------------- ---------------- --------------
------------------- --------------------- ---------------- --------------- ---------------- --------------
Pilot
------------------- --------------------- ---------------- --------------- ---------------- --------------
Other (specify)
------------------- --------------------- ---------------- --------------- ---------------- --------------
g. If you do not qualify for full coverage at standard rates, do you desire:
1. Full coverage with extra premium if available?.......... [ ] yes [ ] no
2. Restricted aviation coverage without extra premium if
available?.............................................. [ ] yes [ ] no
2. MILITARY QUESTIONNAIRE
COMPLETE IF QUESTION 10 OF SECTION J WAS ANSWERED YES.
-------------------------- ----------- ----------------- -----------------
a. Name of Proposed Insured Rank Pay Grade Branch of Service
-------------------------- ----------- ----------------- -----------------
-------------------------- ----------- ----------------- -----------------
b. Describe your duties
--------------------------------------------------------------------------
c. Have you been alerted for or assigned to overseas duty? (If yes, give
details in "e" below.)..................................... [ ] yes [ ] no
d. Are you a member of a Reserve, National Guard, or ROTC unit? (If yes, give
details in "e" below.)..................................... [ ] yes [ ] no
e. Details
--------------------------------------------------------------------------
3. AVOCATION AND SPORTS QUESTIONNAIRE
GIVE FULL DETAILS FOR EACH PROPOSED INSURED, INCLUDING FREQUENCY OF
PARTICIPATION, AND FUTURE PLANS FOR ALL YES ANSWERS TO QUESTION 11 OF
SECTION J. FOR EXAMPLE, FOR MOUNTAIN CLIMBING, SPECIFY ROCK OR TRAIL
CLIMBING.
a. Name of Proposed Insured
--------------------------------------------------------------------------
b. Full Details
--------------------------------------------------------------------------
--------------------------------------------------------------------------
c. Scuba Diving
1. Average Depth 2. Maximum Depth 3. Number of Dives
----------------- ---------------- --------------- ------------- --------------
Last 12 Months 1-2 Years Ago Next 12 Months
--------------- ------------- --------------
----------------- ---------------- --------------- ------------- --------------
45675a Page 5 Rev. 6/98
LIFE INSURANCE APPLICATION RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY
--------------------------------------------------------------------------------
SECTION L. DECLARATIONS OF THE PROPOSED INSUREDS
--------------------------------------------------------------------------------
COMPLETE THE FOLLOWING ON ALL PROPOSED INSUREDS, INCLUDING CHILDREN TO BE
COVERED UNDER THE CHILDREN'S INSURANCE RIDER.
(Give details under L.12. for any questions answered yes.)
PROPOSED OTHER PROPOSED
PRIMARY INSUREDS (ADDITIONAL,
INSURED JOINT, OR CHILDREN)
-------------- ---------------------
1. Has the Proposed Insured ever had any disease or injury of the following
organs or any sickness listed below in the last 10 years?
a. Paralysis, epilepsy, convulsions, fainting, brain, nervous system,
nervous or mental disorder .............................................. [ ] yes [ ] no [ ] yes [ ] no
b. High blood pressure, stroke, or circulatory problems, chest pain, heart
disease, irregular heart rate, palpitations, heart murmur, or rheumatic
fever ................................................................... [ ] yes [ ] no [ ] yes [ ] no
c. Cancer or tumor ......................................................... [ ] yes [ ] no [ ] yes [ ] no
d. Shortness of breath, lungs, bronchitis, asthma, tuberculosis, or
pneumonia ............................................................... [ ] yes [ ] no [ ] yes [ ] no
e. Large or small intestine, chronic diarrhea, rectum, hernia, kidney,
bladder, prostate, liver, gallbladder, jaundice, stomach, ulcers,
indigestion or thyroid .................................................. [ ] yes [ ] no [ ] yes [ ] no
f. Blood, pus, or protein in urine, diabetes or sugar in urine ............. [ ] yes [ ] no [ ] yes [ ] no
g. Sexually transmitted disease ............................................ [ ] yes [ ] no [ ] yes [ ] no
h. Anemia or other blood disorder .......................................... [ ] yes [ ] no [ ] yes [ ] no
i. Arthritis, neuritis, bone, joint, muscle or skin disorder ............... [ ] yes [ ] no [ ] yes [ ] no
2. Has the Proposed Insured experienced any symptoms for which they have not
yet consulted a health care provider? ....................................... [ ] yes [ ] no [ ] yes [ ] no
3. Is the Proposed Insured presently taking any medication, including any
non-prescription medication? ................................................ [ ] yes [ ] no [ ] yes [ ] no
4. Is the Proposed Insured presently under the care of a member of the medical
profession for any condition? ............................................... [ ] yes [ ] no [ ] yes [ ] no
5. Has the Proposed Insured had any operation(s) in the last 10 years? ......... [ ] yes [ ] no [ ] yes [ ] no
6. Has the Proposed Insured been advised to have any operation(s) not yet
performed in the last 10 years? ............................................. [ ] yes [ ] no [ ] yes [ ] no
7. Has the Proposed Insured had an electrocardiogram, x-ray, or other
diagnostic test in the last five years? ..................................... [ ] yes [ ] no [ ] yes [ ] no
8. Has the Proposed Insured sought help or treatment for an alcoholic habit ? .. [ ] yes [ ] no [ ] yes [ ] no
9. Is the Proposed Insured currently using, or has the Proposed Insured ever
received treatment or counseling for the use of, marijuana, cocaine,
amphetamines, barbiturates, hallucinogenic agents, opium derivatives, or
other drugs of abuse? ....................................................... [ ] yes [ ] no [ ] yes [ ] no
10. Has the Proposed Insured in the last 10 years been confined for observation,
care, or treatment in a hospital or other health care facility? ............. [ ] yes [ ] no [ ] yes [ ] no
11. Has the Proposed Insured in the last five years consulted any health care
providers not already identified for any reason including routine physical
examination? ................................................................ [ ] yes [ ] no [ ] yes [ ] no
45675a Page 6 Rev. 6/98
LIFE INSURANCE APPLICATION RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY
--------------------------------------------------------------------------------
SECTION L. DECLARATIONS OF THE PROPOSED INSUREDS (CONTINUED)
--------------------------------------------------------------------------------
12. Complete the following for yes answers to questions 1-11.
-------------------------- ------------ -------------------------------------- -------------------------------
Question Names & Addresses of
Number Diagnosis, Date of Each Occurrence, Members of the Medical
Proposed Insured's Name or Letter Duration, Current Status Profession & Medical Facilities
-------------------------- ------------ -------------------------------------- -------------------------------
-------------------------- ------------ -------------------------------------- -------------------------------
-------------------------- ------------ -------------------------------------- -------------------------------
-------------------------- ------------ -------------------------------------- -------------------------------
-------------------------- ------------ -------------------------------------- -------------------------------
-------------------------- ------------ -------------------------------------- -------------------------------
13. Family Record
----------------------------------------------------------------------------
Proposed Insured's Name
----------------------------------------------------------------------------
Living/Health Age Deceased/Cause of Death Age
----------------------- ------- ------------------------ -------
Father
----------- ----------------------- ------- ------------------------ -------
Mother
----------- ----------------------- ------- ------------------------ -------
Sibling(s)
----------- ----------------------- ------- ------------------------ -------
----------------------------------------------------------------------------
Proposed Additional Insured's or Joint Insured's Name
----------------------------------------------------------------------------
Living/Health Age Deceased/Cause of Death Age
----------------------- ------- ------------------------ -------
Father
----------- ----------------------- ------- ------------------------ -------
Mother
----------------------------------------------------------------------------
Sibling(s)
----------------------------------------------------------------------------
--------------------------------------------------------------------------------
SECTION M. BUSINESS FINANCIAL INFORMATION
--------------------------------------------------------------------------------
COMPLETE FOR ALL BUSINESS COVERAGE.
1. a. Name of Business ________________________ b. Date Established ___________
c. State of Incorporation ________
d. Type of Business (Include a description of the number of employees, nature
of the business, i.e. products or services rendered.) ____________________
e. Type of Organization: [ ] Sole Proprietorship [ ] Partnership
[ ] Corporation
f. Purpose of Insurance: [ ] Buy/Sell [ ] Stock Repurchase
[ ] Retirement Planning [ ] Deferred Compensation
[ ] Debt Protection: Amount of loan $____________
Line of credit amount $_____________
[ ] Key Person (Explain if amount exceeds ten times
earned income.)
------------------------------------------------
g. Business Finances (Attach copies of most recent audited financial
statements.)
Net Worth $___________ Net Income $___________ Gross Sales $____________
h. List all Partners, Officers, or Persons Owning 10% or more of this
Business
----------------- ----------------- -------------- -------------------- ------------------
Percentage Active in Business Amount of Business
Name Title of Ownership (yes or no) Coverage In Force
----------------- ----------------- -------------- -------------------- ------------------
----------------- ----------------- -------------- -------------------- ------------------
----------------- ----------------- -------------- -------------------- ------------------
----------------- ----------------- -------------- -------------------- ------------------
i. Is other insurance being applied for concurrently on Proposed Insured or
other officers?............................................ [ ] yes [ ] no
If yes, complete the following:
------------------------------ ---------------- --------------------------
Insurance Company Name Amount Officer
------------------------------ ---------------- --------------------------
------------------------------ ---------------- --------------------------
------------------------------ ---------------- --------------------------
45675a Page 7 Rev. 6/98
LIFE INSURANCE APPLICATION RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY
--------------------------------------------------------------------------------
SECTION N. SUITABILITY
--------------------------------------------------------------------------------
THIS SECTION MUST BE COMPLETED ON THE PROPOSED OWNER ONLY IF APPLYING FOR A
VARIABLE UNIVERSAL LIFE INSURANCE POLICY. A SUPPLEMENT ALSO MUST BE COMPLETED TO
CHOOSE PREMIUM PAYMENT ALLOCATION.
IMPORTANT NOTICE: The Death Benefit and the Cash Surrender Value under the
Variable Account may increase or decrease with the investment performance of the
mutual funds. Regardless of the investment performance, the Death Benefit will
never be less than the Face Amount as long as there are no unpaid monthly
deductions or policy loans. There is no guaranteed Cash Surrender Value for
amounts in the Variable Account. Upon request, we will furnish you with a
comparison of benefits of the policy applied for and a fixed life insurance
policy.
1. Did the Proposed Owner(s) receive a Prospectus describing the policy,
investment divisions, and important features?................. [ ] yes [ ] no
2. If yes, which Prospectus was delivered?
a. [ ] N700.176 & 46623 b. [ ] N700.181 & 46623 c. [ ] 46203 & 46623
Date of Prospectus _____/_____ Date of Prospectus _____/_____ Date of Prospectus _____/_____
month year month year month year
d. [ ] 47161 e. [ ] 46816
Date of Prospectus _____/_____ Date of Prospectus _____/_____
month year month year
f. [ ] Other - Form number __________ Date of Prospectus _____ /_____
month year
3 a. Does the Proposed Owner(s) consent to delivery of prospectuses, prospectus
supplements, statements of additional information, transactional
confirmation and periodic statements in one or more of the following
forms? (CHECK ALL THAT APPLY.)
[ ] 3.5" Floppy Disk
[ ] CD rom
[ ] Internet Website
[ ] E-Mail, and my e-mail address is _____________________________________.
This consent is valid until revoked by the Proposed Owner(s) in writing.
The Proposed Owner(s) understands that ReliaStar Life may choose to
discontinue delivery of the above types at any time and may choose to
deliver a paper version.
b. Does the Proposed Owner(s) consent to eliminate duplicate mailings of
identical documents to the same household if they have more than one
ReliaStar Life policy? [ ] yes [ ] no
4. Does the Proposed Owner(s) understand that if premiums are allocated to the
Variable Account the Death Benefit may, under certain conditions, increase or
decrease depending on the investment performance of the Variable
Account?...................................................... [ ] yes [ ] no
5. Does the Proposed Owner(s) understand the Cash Surrender Value will increase
or decrease reflecting the investment performance of the Variable
Account?...................................................... [ ] yes [ ] no
6. Does the Proposed Owner(s) think that this policy will meet his or her
insurance needs and financial objectives? .................... [ ] yes [ ] no
7. a. Savings $__________________ b. Current Value of Securities $_____________
c. Equity in Home $___________ d. Assets $___________________________________
e. Debts $____________________ f. No. & Ages of Dependents __________________
45675a Page 8 Rev. 6/98
LIFE INSURANCE APPLICATION RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY
--------------------------------------------------------------------------------
SECTION O. AGREEMENT AND SIGNATURE
--------------------------------------------------------------------------------
BY SIGNING THIS APPLICATION, ALL WHO SIGN BELOW AGREE TO ALL OF THE FOLLOWING
TERMS AND CONDITIONS:
1. When no premiums are paid with this application, no benefits will be
provided on the basis of this application until all of the following
conditions are met:
a. A policy is delivered to the Applicant/Proposed Owner;
b. There has not been a change in the insurability of any Proposed Insured
after the date this application is signed and before a policy is
delivered to the Applicant/Proposed Owner; and
c. The first premium is paid during the lifetime of all Proposed Insureds.
2. When premiums are paid, or government allotment, account deduction, 1035
Exchange Form or other premium payment authorization form is completed with
this application, I acknowledge receipt of the Temporary Insurance Agreement
and Receipt (Receipt). I have read, understand, and accept the terms of this
Receipt. Premiums of $ ________________ (enter amount or "none") have been
paid with this application.
3. The responses in Sections A, B, C, D, E, F, G, H, I, J, K, L, M, N, and O of
this application and in any supplements and amendments thereto are:
a. Complete and true to the best of my knowledge or belief; and
b. To be considered the basis for any insurance issued.
4. Knowledge of any Proposed Insured is knowledge of the Proposed Owner.
5a. If I am applying for a variable universal life insurance policy, then I
agree to arbitrate, under the rules and procedures of the National
Association of Securities Dealers, Inc., any dispute, claim, demand, or
controversy arising out of such policy including without limitation, the
sale thereof, and involving one or more of the following persons: ReliaStar
Life Insurance Company (ReliaStar Life), its affiliated broker dealers,
including Washington Square Securities, Inc. (WSSI), representatives
thereof, and any unaffiliated broker dealer and representatives thereof. Any
arbitration awarded or rendered against any party may be entered as judgment
in any court of competent jurisdiction. b. I authorize the following to
communicate by telephone/fax to ReliaStar Life on my behalf in accordance
with my instructions described in paragraph c below which I could give
myself under the under the terms of the Authorization:
[ ] yes [ ] no _________________________, the PROPOSED INSURED (if Proposed
Insured and Proposed Owner are different); and/or
[ ] yes [ ] no _________________________, the REGISTERED REPRESENTATIVE
servicing the policy.
I understand that I am responsible for promptly reviewing all confirmation
notices. I agree to report in writing to Washington Square Securities, Inc.,
X.X. Xxx 00, Xxxxxxxxxxx, Xxxxxxxxx 00000 within five days of my receipt of
confirmation, any erroneous or unauthorized transaction.
c. I authorize ReliaStar Life to act upon my telephone/fax instructions 1) to
transfer Policy Values among the available Sub-accounts of the SelectHLife
Variable Account and the Fixed Account, and 2) to change the allocation for
future payments. I authorize ReliaStar Life to use my Social Security Number
or Tax Identification Number as my personal identification code. I
understand that ReliaStar Life must be given my Personal Identification Code
whenever telephone/fax instructions are made. I hereby acknowledge that all
telephone instructions given pursuant to this Authorization are subject to
the conditions set forth in the SelectHLife Variable Account Prospectus for
the proposed policy and that ReliaStar Life and/or WSSI will not be liable
for any loss, liability, cost, or expense when ReliaStar Life and/or WSSI
act in accordance with the telephone/fax transfer instructions which are
received, and if by telephone, are recorded on voice recording equipment.
ReliaStar Life will employ reasonable procedures to confirm that
instructions communicated by telephone/fax are genuine. If ReliaStar Life
does not employ such procedures, ReliaStar Life may be liable for any losses
due to unauthorized or fraudulent instructions.
--------------------------------------------------------------------- ----------
Signed at (City) State
--------------------------------------------------------------------- ----------
Signature of Proposed Primary Insured if age 10 or older Date
--------------------------------------------------------------------- ----------
Signature of Proposed Owner (IF OTHER THAN PROPOSED PRIMARY INSURED) Date
--------------------------------------------------------------------- ----------
Signature of Proposed Additional or Joint Insured Date
--------------------------------------------------------------------- ----------
Signature of Parent or Guardian if other than Proposed Owner and Date
Proposed Primary Insured is a Minor
--------------------------------------------------------------------- ----------
Signature of Agent Date
------------------------------- --------------------- --------------------------
Agent's Name (PLEASE PRINT) Agent's ID Number Agent's License Number
------------------------------- --------------------- --------------------------
45675a Page 9 Rev. 6/98
LIFE INSURANCE APPLICATION RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY
X.X. Xxx 00, Xxxxxxxxxxx, Xxxxxxxxx 00000
AUTHORIZATION AND ACKNOWLEDGMENT
For underwriting and claim purposes, I give my permission to any physician or
other medical practitioner, hospital, clinic, insurance or reinsuring company,
Medical Information Bureau, Inc. (MIB), any consumer reporting agency, or any
other organization to give ReliaStar Life Insurance Company (ReliaStar Life) or
its authorized representative (including any consumer reporting agency) acting
on its behalf ALL INFORMATION on my behalf (except as limited below). This
includes but may not be limited to: (a) findings on medical care, psychiatric or
psychological care or examination, or surgery, as they apply to me or any of my
children who are to be insured; and (b) any non-medical information as it
applies to me or any of my children who are to be insured.
I give my permission to ReliaStar Life to get consumer or investigative consumer
reports about these same persons.
I give my permission to ReliaStar Life and other insurance companies affiliated
with ReliaStar Life to get any and all medical record information for the
purposes described in this form. I know that my medical records, including any
alcohol or drug abuse information, may be protected by Federal Regulations - 42
CFR Part 2. I may revoke this permission as it applies to any information
protected by 42 CFR Part 2 at any time, but not to the extent action has been
taken in reliance on it. I specifically consent to the re-disclosure of medical
record information as set forth in this form.
In connection with any application for life insurance, or other insurance
transaction that I may have with ReliaStar Life or any of its affiliated
insurance companies, I understand that a report of some or all of the
information obtained by this authorization may be communicated between ReliaStar
Life and its affiliates, and may be sent to MIB, reinsurers, employees, or
contractors who process transactions regarding any insurance coverage I may have
applied for or have with ReliaStar Life or its affiliated companies. I
understand that I may request that this information not be communicated to
companies affiliated with ReliaStar Life.
I understand that my further written consent will be required before any
information described above is given, sold, transferred, or, in any way, relayed
to another party not before specified. My further consent must be provided on a
form that states the new use of the information or why another party needs it.
With regard to any investigative consumer report on me, please contact me at
home or work between the hours of _______ and _______. My telephone number is
(______)____________________.
I know that I have a right to get a copy of this form. A photocopy of this form
will be as valid as the original. This form will be valid for two years from the
date shown below.
I acknowledge that I have been given ReliaStar Life's: Notice Regarding Consumer
Reports; Notice Regarding MIB; and Notice Regarding Information Practices.
Signature of Proposed Primary Insured if age 10 or older Date
--------------------------------------------------------------- ----------------
/ /
--------------------------------------------------------------- ----------------
Signature of Proposed Additional or Joint Insured Date
--------------------------------------------------------------- ----------------
/ /
--------------------------------------------------------------- ----------------
Signature of Parent or Guardian if other than Proposed Owner Date
and Proposed Primary Insured is a Minor
--------------------------------------------------------------- ----------------
/ /
--------------------------------------------------------------- ----------------
45675a Rev. 6/98
LIFE INSURANCE APPLICATION RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY
REQUEST AND AUTHORIZATION AGREEMENT FOR
PRE-ARRANGED PAYMENTS OR ELECTRONIC BANK DEBIT PLAN FOR PAYMENT OF PREMIUMS
ReliaStar Life Insurance Company is hereby requested and authorized to draw
checks or initiate bank debits to be charged against the account described in
the Authorization below.
Please X one of the boxes below: Policy number Proposed Insured's name Monthly deduction
--------------- ------------------------ -----------------
[ ] Start new Month-O-Matic Plan $
--------------- ------------------------ -----------------
[ ] Add to existing Month-O-Matic $
Plan No. ________________ --------------- ------------------------ -----------------
$
[ ] Change existing bank name --------------- ------------------------ -----------------
or account no. $
--------------- ------------------------ -----------------
I request the day of withdrawals or debits to my account to be on or about the
__________ of each month. (Any day from the 1st through the 28th of the month
may be selected.)
BANK ACCOUNT INFORMATION AND TYPE (PLEASE CHECK ONE BOX, EITHER CHECKING OR
SAVINGS)
--------------------------------------------------------------------------------
[ ] Checking [ ] Savings
STAPLE
VOIDED CHECK HERE Savings Account Number ___________________
- NOT DEPOSIT SLIP - Savings Account Routing Transit Number (9 digits)
_________________________
Name of Bank or Credit Union __________________________
Street ________________________________________________
City _________________ State __________ Zip ___________
--------------------------------------------------------------------------------
TERMS OF THE MONTH-O-MATIC(R) PLAN
Each debit shall be: (1) in an amount sufficient to pay a proper proportion of
the annual premium at the Company's Month-O-Matic premium rate; (2) notice of
premium due and no further notice of premium shall be given; (3) a receipt for
the amount stated thereon if and when the Company receives actual payment at its
Home Office. If a debit is not honored by the bank upon presentation for payment
by the Company, such action by the bank shall be notice of nonpayment of
premium.
The Month-O-Matic Plan for premium payment may be terminated by the Policyowner
or by the Bank Depositor by written notice filed with the Company at its Home
Office and may be terminated by the bank in which the account is maintained. The
Company also may terminate without notice if any debit is not honored upon
presentation, otherwise upon 30 days written notice to the Policyowner. In the
event the Plan is terminated for any cause, any unpaid premiums, and premiums
which have due dates that occur on or after the date of termination, shall be
paid directly to the Company at the premium rate and on the premium due date
which would have been applicable to each policy if it had not been placed under
the Month-O-Matic Plan for premium payment.
The Company may, at its discretion from time to time, effect payments by use of
pre-arranged payments (debit) or an electronic bank debit system.
AUTHORIZATION AGREEMENT FOR PRE-ARRANGED PAYMENTS (DEBITS)
I (we) authorize ReliaStar Life Insurance Company (Company) to make variable
charges to my (our) checking or savings account identified above, and authorize
the financial institution named above to withdraw funds from (debit) such
account and pay to Company's order accordingly. This authorization will remain
in effect until the financial institution has received and has had reasonable
time to act on a written request from me (us) to terminate this agreement.
I (we) understand that I (we) can stop payment of any debit by notifying the
financial institution at least three days before the withdrawal is made. I (we)
can have the amount of an erroneous charge immediately credited to the account
up to 15 days following issuance of my (our) bank statement or 45 days after
posting, whichever occurs first.
I have read and understand the above statement.
---------------------------------- --------------------------------- -----------
Signature of Bank Account Owner Social Security/Tax I.D. Number Date signed
---------------------------------- --------------------------------- -----------
Applicant signature Social Security/Tax I.D. Number Date signed
---------------------------------- --------------------------------- -----------
45675a Rev. 6/98
AGENT'S REPORT RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY
--------------------------------------------------------------------------------
SECTION 1. AGENT IDENTIFICATION
--------------------------------------------------------------------------------
TO BE COMPLETED BY THE AGENT. FOR QUESTIONS ABOUT THIS APPLICATION OR
UNDERWRITING REQUIREMENTS, CALL 0-000-000-0000.
---------------------- --------------- ------------ --------------- ------------
Hierarchy Hierarchy
Agent Name Agent ID # % Split Pointer ID Pointer Name
---------------------- --------------- ------------ --------------- ------------
---------------------- --------------- ------------ --------------- ------------
---------------------- --------------- ------------ --------------- ------------
------------------------------------------ ------------------------------------------
SECTION 2. SECTION 4. 3. If this application is on a
PREMIUM INFORMATION COMPLIANCE INFORMATION juvenile, please indicate the amount
------------------------------------------ ------------------------------------------ of life insurance in force on each
parent or sibling.
[ ] COD 1. Did you obtain the Proposed
[ ] 1035 Exchange Insured's Declarations in this Father..... $________________________
[ ] Attained Age Exchange application in person and record
[ ] Home Office Credit them in the presence of the Proposed Mother..... $________________________
Insured? (IF YOU DID NOT, THE
INITIAL SETTLEMENT NON-MEDICAL PRIVILEGE IS NOT Siblings... $________________________
AVAILABLE.)
Initial Single Deposit: $______________ [ ] Yes [ ] No 4. What type of insurance is being
applied for on the Proposed Insured?
Annualized Planned Periodic Premium 2. Have you delivered the Notice
Payment: $__________________ Regarding Consumer Reports, the [ ] Personal [ ] Business
Notice Regarding MIB Inc., and the
Requested Modal Payment: $_____________ Notice Regarding Information 5. What is the purpose of the type of
Practices to the Proposed Insured(s) insurance indicated above?
Cash Collected: $_________________ or Proposed Owner?
[ ] Basic Life Needs [ ] Estate Planning
Age used in calculating premium _______ [ ] Yes [ ] No [ ] Education Funding [ ] Retirement
Planning
$_________ Cash Received by Home Office 3. To the best of your knowledge and [ ] Pension [ ] Debt Protection
(TO BE COMPLETED BY HOME OFFICE.) belief, will any existing life or Maximization
annuity coverage be replaced, [ ] Key Person [ ] Executive Bonus
MODE OF PAYMENT lapsed, surrendered, or borrowed [ ] Deferred Compensation
[ ] Annually against? (IF YES, PLEASE LIST [ ] Buy/Sell Stock Redemption
[ ] Semi-Annually COMPANY, POLICY NUMBER, AND AMOUNT
[ ] Quarterly ON A SEPARATE SHEET OF PAPER.) 6. a. Did you use a fact finder or
[ ] Monthly (COMPLETE MONTH-O-MATIC FORM.) [ ] Yes [ ] No needs analysis tool in connection
[ ] Military Allotment (COMPLETE with this sale?
SECTION 3.) 4. If settlement was accepted, was the [ ] Yes [ ] No
[ ] Payroll Deduction/List Xxxx (ENTER Temporary Insurance Agreement and b. If yes, which one(s)?
SPECIAL COLLECT NUMBER IF PLAN ALREADY Receipt completed and delivered to
EXISTS.) the Proposed Insured or Proposed ____________________________________
______________________________________ Owner?
[ ] Other ________________________________ [ ] Yes [ ] No ------------------------------------------
SECTION 6. REMARKS
------------------------------------------ 5. If the application was for a ------------------------------------------
SECTION 3. GOVERNMENT/ variable universal life insurance
MILITARY ALLOTMENT policy, was a new account __________________________________________
------------------------------------------ information form completed?
[ ] Yes [ ] No __________________________________________
Payor's Name ___________________________
------------------------------------------ ------------------------------------------
Social Security Number _________________ SECTION 5. SECTION 7. AGENT'S
INSURED INFORMATION SIGNATURE SECTION
Payor's Branch _________________________ ------------------------------------------ ------------------------------------------
Agent's Signature
Amount of Allotment ____________________ 1. How long have you known the
Proposed Insured?____________________ __________________________________________
Date first allotment should begin ______ Date
Are you related? .......[ ] Yes [ ] No
[ ] New Allotment [ ] Increased Allotment __________________________________________
If yes, how? ________________________ Phone Number
RUSL Term Exchange [ ] Yes [ ] No
2. How much insurance does the spouse __________________________________________
own payable to the Proposed Insured Fax Number
or other dependents? $_______________
__________________________________________
E-mail Address
__________________________________________
45675a Rev. 6/98
LIFE INSURANCE APPLICATION RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY
X.X. Xxx 00, Xxxxxxxxxxx, Xxxxxxxxx 00000
CONSUMER PRIVACY NOTICE
NOTICE REGARDING CONSUMER REPORTS
Insurance companies commonly ask an outside source to verify and add to the
information given in an application. The agency that makes the report will be
one that is discreet and impartial. If you wish, we will send you the name,
address, and phone number of any agency we ask to prepare a consumer report
about you. You can ask that the agency interview you if you so state on the
authorization form. The agency will then try to get in touch with you.
Consumer reports are used to help us decide if you are eligible for the
insurance you have applied for. The report deals with your: mode of living;
character; general reputation; and such personal items as your health, job, and
finances. It may include information on the following: your marital status, past
and present employment record, job duties, driving record, avocation, health
history, use of alcohol and drugs, and hazardous sports activities. The agency
may get information in these ways: from public records, and by contacting you,
members of your family, business associates and employers, financial sources,
friends, or others you know. This information will not be used to determine your
sexual orientation. If the report affects your application as requested, we will
notify you and provide you with the name and address of the reporting firm.
We use the report only to be sure that each application is evaluated on a fair
basis. We will not reveal any of the information we obtain to your friends or
associates. We may reveal the information we obtain to other companies or
entities affiliated with ReliaStar Life. You may request that this information
not be communicated to other companies affiliated with ReliaStar Life.
The information may be kept by the consumer reporting agency; it may also later
be given to others who have a legitimate need for these reports. It will be
given only to the extent permitted by these laws: the Federal Fair Credit
Reporting Act as amended by the Consumer Credit Reporting Reform Act of 1996;
your state's Fair Credit Reporting Act, if any; or your state's Insurance
Information and Privacy Protection Act, if any. The agency will give you a copy
of the report if you ask for one and give proper identification.
NOTICE REGARDING MIB (MEDICAL INFORMATION BUREAU, INC.)
We or our reinsurers may make brief reports to MIB. The reports will include the
factors that affect the insurability of any person for whom coverage is being
requested.
MIB is a nonprofit organization of life insurance companies. It operates an
information exchange for its members. If you apply to some other member company
for life or health coverage, or send in a claim for benefits, MIB may supply
that company with any information in its file. If you ask, MIB will arrange to
disclose to you the information it has in your file. If you question the
accuracy of the information in MIB's file, you may contact MIB. Ask them to
correct it as provided in the Federal Fair Credit Reporting Act. The address of
the MIB's information office is: Post Xxxxxx Xxx 000, Xxxxx Xxxxxxx, Xxxxxx,
Xxxxxxxxxxxxx 00000. MIB's phone number is (000) 000-0000.
We or our reinsurers may also release information in our files. We may release
it to other life insurance companies to whom you may apply for life or health
insurance or to whom a claim for benefits may be submitted.
NOTICE REGARDING INFORMATION PRACTICES
To issue an insurance policy, we need to obtain information about you and any
other persons proposed for insurance. Some of that information will come from
you. Some will come from other sources. That information and any information
collected by us later may, in certain circumstances, be disclosed to third
parties without your specific permission.
You have a right to access and correct the information collected about you. This
right does not extend to information that relates to a claim or civil or
criminal proceeding.
If you wish to have a more detailed explanation of our information practices,
please write to us at: Xxx 00, Xxxxxxxxxxx, Xxxxxxxxx 00000.
45675a Rev. 6/98
