THE INSURED XXXXXXX XXX VARIABLE
LIFE INSURANCE
POLICY OWNER XXXXXXX XXX POLICY
EQUITABLE
FACE AMOUNT $100,000 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 5 DEPENDING UPON THE INVESTMENT EXPERIENCE OF THIS POLICY,
BUT SHALL NEVER BE LESS THAN THE FACE AMOUNT.
THE CASH VALUE OF THIS POLICY WILL VARY FROM DAY TO DAY. IT MAY INCREASE OR
DECREASE DEPENDING UPON THE INVESTMENT EXPERIENCE OF THIS POLICY.
Premiums are shown on page 3 and are fixed as to amount. They will not vary with
the investment experience of this policy.
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
Limited Payment Life Plan -- LEVEL FACE AMOUNT. Variable insurance
payable upon death. Guaranteed Minimum Death Benefit. Fixed premiums
payable for Premium Period shown on page 3 or until earlier death.
Non-Participating. Investment experience reflected in benefits.
Investment options described on page 6.
No. 85-01
EQUITABLE
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
Premiums, grace, lapse, reinstatement 4
Death Benefit 5
Cash Value 5
Loans 5
The Separate Account 6
Investment Options,
allocations, transfers 6
Options on Lapse 7
Exchange of Policy 7
General Provisions 8
Payment Options 9
Basis of Values 11
(Net rates of return, variable adjustment amount, benefit base, calculation of
cash values)
Any additional benefit riders and a copy of the application are included in this
policy after page 12.
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
premiums and 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 5;
o plus any additional benefits due from riders to this policy;
o plus or minus any adjustment for the last premium;
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 9.
We will pay these benefits only if premiums have been paid as called for by this
policy. However, even if premiums have been discontinued we may still pay
certain benefits. See Options on Lapse, page 7.
Payment of these benefits may also be affected by other provisions of this
policy. See the Suicide Exclusion, Incontestability and Age and Sex clauses on
page 8. Special exclusions or limitations (if any) are listed on page 3.
No. 85-01 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
*************************** BENEFITS AND PREMIUMS TABLE ************************
BENEFITS ANNUAL PREMIUM PREMIUM PERIOD
LIFE INSURANCE - VARIABLE $1,659.00 40 YEARS
THE FIRST PREMIUM IS $1,659.00 AND IS DUE ON OR BEFORE DELIVERY OF THE POLICY.
SUBSEQUENT PREMIUMS ARE DUE ON MAR 1, 1986 AND EVERY 12 MONTHS THEREAFTER DURING
THE PREMIUM PERIOD IN ACCORDANCE WITH THE ABOVE PREMIUM TABLE.
************************** TABLE OF NET ANNUAL PREMIUMS ************************
BEGINNING OF NET ANNUAL
POLICY YEAR PREMIUM
1 $ 752.00
2 - 4 1,455.00
5 - 40 1,526.00
****************** INVESTMENT ALLOCATION OF NET ANNUAL PREMIUMS ****************
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
V85-01-3 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 CASH VALUES *****************************
THE CASH VALUE OF THIS POLICY MAY BE GREATER OR LESS THAN AMOUNTS SHOWN
SEE PAGE 5 FOR CASH VALUE PROVISION
INTERIM TABULAR CASH VALUES IN FIRST POLICY YEAR
INTERIM INTERIM INTERIM
END OF TABULAR END OF TABULAR END OF TABULAR
POLICY CASH POLICY CASH POLICY CASH
MONTH VALUES MONTH VALUES MONTH VALUES
1 $0 5 $ 0 9 $278
2 0 6 16 10 366
3 0 7 104 11 452
4 0 8 192 12 540
TABULAR CASH VALUES AT ENDS OF POLICY YEARS*
END OF TABULAR END OF TABULAR END OF TABULAR
POLICY CASH POLICY CASH POLICY CASH
YEAR VALUES YEAR VALUES YEAR VALUES
1 $ 540 9 $12,069 17 $26,057
2 1,808 10 13,701 18 27,941
3 3,114 11 15,368 19 29,851
4 4,456 12 17,070 20 31,788
5 5,907 13 18,806 AGE 60 41,808
6 7,393 14 20,574 AGE 62 45,947
7 8,916 15 22,373 AGE 65 52,277
8 10,474 16 24,201 AGE 70 63,165
*VALUES NOT SHOWN WILL BE FURNISHED ON REQUEST.
V85-01-3A Page 3A
POLICY INFORMATION CONTINUED
TABLE OF NET SINGLE PREMIUMS
For $1.00 of Variable Adjustment Amount or Paid-Up Whole Life 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 $.09647 21 $.17350 41 $.32865 61 $.57583 81 $ .81560
2 .09871 22 .17890 42 .33918 62 .58929 82 .82496
3 .10126 23 .18450 43 .34995 63 .60272 83 .83394
4 .10397 24 .19031 44 .36096 64 .61610 84 .84259
5 .10685 25 .19635 45 .37222 65 .62940 85 .85096
6 .10990 26 .20263 46 .38370 66 .64260 86 .85909
7 .11312 27 .20915 47 .39541 67 .65565 87 .86704
8 .11650 28 .21591 48 .40733 68 .66851 88 .87488
9 .12005 29 .22293 49 .41945 69 .68114 89 .88268
10 .12377 30 .23021 50 .43176 70 .69350 90 .89050
11 .12764 31 .23775 51 .44424 71 .70559 91 .89841
12 .13166 32 .24556 52 .45688 72 .71744 92 .90648
13 .13581 33 .25366 53 .46968 73 .72908 93 .91479
14 .14008 34 .26205 54 .48261 74 .74057 94 .92350
15 .14447 35 .27073 55 .49568 75 .75194 95 .93291
16 .14897 36 .27970 56 .50886 76 .76319 96 .94339
17 .15360 37 .28896 57 .52214 77 .77427 97 .95520
18 .15835 38 .29850 58 .53550 78 .78512 98 .96810
19 .16323 39 .30830 59 .54892 79 .79566 99 .98063
20 .16828 40 .31835 60 .56237 80 .80583 100 1.00000
FEMALE INSURED
--------------
1 $.08586 21 $.15360 41 $.28896 61 $.52214 81 $ .77427
2 .08774 22 .15835 42 .29850 62 .53550 82 .78512
3 .08993 23 .16323 43 .30830 63 .54892 83 .79566
4 .09228 24 .16828 44 .31835 64 .56237 84 .80583
5 .09478 25 .17350 45 .32865 65 .57583 85 .81560
6 .09743 26 .17890 46 .33918 66 .58929 86 .82496
7 .10023 27 .18450 47 .34995 67 .60272 87 .83394
8 .10318 28 .19031 48 .36096 68 .61610 88 .84259
9 .10629 29 .19635 49 .37222 69 .62940 89 .85096
10 .10953 30 .20263 50 .38370 70 .64260 90 .85909
11 .11290 31 .20915 51 .39541 71 .65565 91 .86704
12 .11641 32 .21591 52 .40733 72 .66851 92 .87488
13 .12004 33 .22293 53 .41945 73 .68114 93 .88268
14 .12379 34 .23021 54 .43176 74 .69350 94 .89050
15 .12764 35 .23775 55 .44424 75 .70559 95 .89841
16 .13166 36 .24556 56 .45688 76 .71744 96 .90648
17 .13581 37 .25366 57 .46968 77 .72908 97 .91479
18 .14008 38 .26205 58 .48261 78 .74057 98 .92350
19 .14447 39 .27073 59 .49568 79 .75194 99 .93291
20 .14897 40 .27970 60 .50886 80 .76319 100 .94339
101 .95520
102 .96810
103 .98063
104 1.00000
V85-01-3B 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.
V85-01-3C 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 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 9 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.
PREMIUMS
AMOUNTS AND DUE DATES. Page 3 shows the amounts and due dates of premiums and
the period for which they are to be paid. Each premium is payable on or before
its due date at our Administrative Office.
You may write and ask us to change the frequency of premium payment. If we
approve the change, the new premium will be determined on the rate scale for
this policy.
GRACE PERIOD. We allow a grace period of 31 days for payment of each premium,
after the first premium. The insurance will continue during the grace period. If
a premium is paid during the grace period, then all benefits under this policy
will be the same as if such premium had been paid on its due date.
LAPSE. If a premium is not paid by the end of its grace period, the policy will
lapse as the premium due date. If this occurs, all insurance ends, except as
stated in Options on Lapse on page 7. Additional benefit riders do not continue
beyond the grace period of an unpaid premium.
REINSTATEMENT. You may reinstate this policy within five years after lapse if:
(1) the policy has not been given up for its net cash value; (2) you provide
evidence of insurability satisfactory to us; and (3) you pay the larger of: (a)
all overdue premiums with interest at 6% per year compounded annually; or (b)
110% of difference between the following Items (i) and (ii). Item (i) is the
excess of the cash value immediately after reinstatement over the cash value
immediately before reinstatement. Item (ii) is any policy loan, and accrued loan
interest, in effect when any option on lapse became effective, with loan
interest to the date of reinstatement.
Upon reinstatement this policy will have the same Benefit Base and the same
Variable Adjustment Amount as to each investment division (as these are
determined in the Variable Adjustment Amount provision on page 11) as if default
had not occurred. Also, upon reinstatement this policy will have a loan equal to
the sum of the following Items (i) and (ii). Item (i) is any loan, and accrued
loan interest, in effect at the date any option on lapse became effective, with
loan interest to the date of reinstatement. Item (ii) is any loan arising after
the date any option on lapse became effective, with loan interest to the date of
reinstatement.
PREMIUM ADJUSTMENT. We will add to the insurance benefits any part of the last
premium paid that applies to a period beyond the policy month in which the
Insured dies. If the Insured dies during the grace period of an unpaid premium,
we will deduct from the benefits the part of the overdue premium for one policy
month.
V85-01-4 Page 4
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.
A description of how the Variable Adjustment Amount for each investment division
is determined is on page 11.
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 cash value of the policy will vary daily with the performance of
the investment divisions under this policy in which you have a cash value. See
page 12 for a description of how cash values are determined.
LOANS
You may get a loan on this policy while it has a loan value and it is not being
continued as extended term insurance under the Options on Lapse on page 7. This
policy will be the sole security for the loan.
The amount of the loan may not be more than the loan value. Except when used to
pay premiums, 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. We may also deduct any unpaid premium then due.
A loan, whether you repay it or not, will have a permanent effect on the
Variable Adjustment Amounts, Death Benefit and cash value under this policy. It
will have no effect on the amount of the premiums payable 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. See page 12 for a description of how the cash value in each investment
division is determined.
LOAN VALUE. If this policy has not lapsed, the loan value is 90% of the policy's
cash value. If this policy has lapsed and is being continued as Reduced Paid-up
Insurance under the Options on Lapse on page 7, the loan value is the cash value
on the next policy anniversary, minus interest at the loan rate to that date.
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. However, if this
policy has lapsed and you are continuing insurance under one of the Options on
Lapse on page 7, any loan that was deducted in determining the benefit on lapse
may not be repaid unless this policy is reinstated. We will deduct any existing
loan and loan interest from any benefits we pay at the Insured's death.
V85-01-4 Page 5
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 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.
We have the right to:
1. register or deregister the 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 policy owners, 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 ANNUAL PREMIUMS. If premiums are duly paid, we will allocate
to each investment division at the beginning of each policy year a percentage of
the Net Annual Premium shown on page 3 for that year. Such allocations will be
based on the allocation percentages then in effect. The allocation percentages
for the first policy year are as designated in the application for this policy.
Unless you change them, such percentages shall also apply in later years.
V85-01-6 Page 6
INVESTMENT OPTIONS CONTINUED
You may change the allocation percentages for policy years after the first by
notifying us in writing of the new percentages. Each allocation percentage
greater than zero must be a whole number of not more than 100%. The sum of the
percentages must equal 100%. A change will take effect on the next policy
anniversary if we receive the notice at our Administrative Office at least 7
days before such anniversary.
TRANSFER OF CASH VALUES. You may ask us to transfer all or part of your cash
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.
OPTIONS ON LAPSE
You have a number of options if the policy lapses. You may apply for
reinstatement. If there is a net cash value, you may withdraw it and give up the
policy. Or, you may continue insurance under one of the following options:
REDUCED PAID-UP INSURANCE. This fixed benefit insurance for the Insured's
lifetime and for the amount that the net cash value will buy.
EXTENDED TERM INSURANCE. This is fixed benefit term insurance for an amount
equal to the Death Benefit on the date of lapse, minus any unpaid loan and loan
interest. The insurance will continue from the date of lapse for as long a term
period as the net cash value will buy. In no event, however, will this period be
less than 90 days if premiums have been paid for at least three months before
lapse and there is no loan on this policy. This option is not available if so
stated on page 3.
An Option on Lapse will become effective on the date your written request for it
is received at our Administrative Office. If your request is not received within
three months after the date of lapse, extended term insurance will become
effective automatically at the end of such three month period. Reduced paid-up
insurance will apply instead if the extended term insurance option is not
available.
If the Insured dies after the grace period but within three months from the date
of lapse, the greater of the benefit under reduced paid-up or extended term
insurance will apply. In this case, any restriction on page 3 as to extended
term insurance will not apply.
We will determine the amounts of these options as of the date the option becomes
effective. We will use net cash values as of the date the option becomes
effective, adjusted for any loan transaction on or after that date. A term
period will begin as of the date of lapse (the due date of the unpaid premium).
We will use net single premiums for the Insured's age as of the date of lapse.
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 18 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 with all premiums due
having been paid; 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 "Executive 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. The new policy will have the same face amount, Register Date, Date of
Issue, and Issue Age as this policy. Premiums 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. Any additional benefit riders in this policy will be
included in the new policy only if Equitable was offering them with the new
policy as of its Date of Issue.
V85-01-6 Page 7
EXCHANGE OF POLICY CONTINUED
Upon request you will be told the amount of the first 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. A detailed statement of the
method of computing such and adjustment has been filed with the insurance
supervisory official of the jurisdiction in which this policy is delivered.
GENERAL PROVISIONS
THE CONTRACT. This insurance is granted in consideration of payment of the
required premiums. 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.
See any additional benefit riders for modifications of this provision that apply
to them.
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 premiums paid minus any loan and
loan interest.
POLICY PERIODS AND ANNIVERSARIES. Policy years, policy months, policy
anniversaries and premium periods are measured from the Register Date. Each
policy month begins on the same day in each calendar month as in the Register
Date. If the end of a premium period or policy year is indicated by an age, it
ends on the policy anniversary nearest the birthday on which the Insured reaches
that age.
POLICY CHANGES. You may change this policy to another plan of insurance or add
additional benefit riders or make other changes, subject to our rules at the
time of change.
REPORTS. Each policy year after the first we will give you a report showing the
Death Benefit 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. No such reports will be given while this policy is lapsed.
We will also give you such other reports as may be required by law.
BASIS OF COMPUTATION. Cash values, reserves and net single premiums are based on
the Commissioners 1958 Standard Ordinary Mortality Table. For any extended term
insurance, they are based instead on the Commissioners 1958 Extended Term
Insurance Table. Continuous functions are used with interest compounded annually
at 4%.
The cash values and paid-up insurance benefits are equal to or more than those
required by law. A detailed statement of the method of computing values and
benefits has been filed with the insurance supervisory official of the
jurisdiction in which this policy is delivered. The tabular cash value at the
end of each policy year equals the reserve. Reserves referred to in this policy
are not less than reserves determined according to the Commissioners Reserve
Valuation Method. Our expense and mortality results will not adversely affect
the dollar amount of insurance benefits or cash values.
DETERMINATION AND PAYMENT OF VARIABLE BENEFITS. As long as this policy is not
being continued under one of the Options on Lapse, 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; and
o A loan will be paid within 7 days after we receive your request at our
Administrative Office; and
V85-01-8 Page 8
GENERAL PROVISIONS CONTINUED
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 and payment of cash values;
2. Payment of loans;
3. Determination of a change in a Variable Adjustment Amount, and payment
of any portion of the Death Benefit equal to the Variable Adjustment
Amount;
4. Any requested transfer of cash value; and
5. Use of Insurance Benefits under the Payment Options.
DEFERMENT UNDER OPTIONS ON LAPSE. We may defer payment of a cash value and the
making of a loan for up to six months after we receive a request at our
Administrative Office if this policy is being continued under one of the Options
on Lapse. We will allow interest, at a rate of at least 3% a year, on any cash
value payment we defer for 30 days or more.
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 of all or part (if at least
$2,500). 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 10.
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 10.
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.
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.
We reserve the right to change how often we make payments, so that each payment
is for at least $25. 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 (such as 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 withdrawal or commutation
rights, designation of payees and successor payees, and evidence of 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.
V85-01-8 Page 9
TABLE OF GUARANTEED PAYMENTS
(MINIMUM AMOUNT FOR EACH $1,000 APPLIED)
OPTION 2A
FIXED PERIOD INSTALMENTS
------------------------
Number
of Years' Monthly Annual
Instalments Instalment Instalment
------------ ----------- -----------
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 instalments are paid each 3 months, they will be 25.32% of the annual
instalments. If they are paid each 6 months, they will be 50.43% of the annual
instalments.
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
Income amounts for Life Income Options are based on age nearest birthday when
income starts. Income amounts for ages not shown will be furnished on request.
V85-01-10 Page 10
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 charge 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 Cash Value at the end of each policy year will equal the tabular
cash 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 first 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 VAA for
that division for the last policy year, plus the VAA Change Amount for that
division. 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 Annual Premium for the first policy year.
On policy anniversaries, the Benefit Base for an investment division is the sum
of the following Items (1) and (2):
(1) The allocation percentage for that anniversary, multiplied by the sum
of the following Items (a) and (b)
(a) The Tabular Cash Value on that anniversary.
(b) The Net Annual Premium for that anniversary.
(2) The Net Single Premium for the VAA for that investment division on
that anniversary.
V85-01-10 Page 11
BASIS OF VALUES CONTINUED
The Net Annual Premium, Tabular Cash Values and Net Single Premiums are shown on
pages 3, 3A and 3B, respectively.
For each investment division, the VAA Change Amount will also reflect the effect
of:
1. Any policy loans in effect on the last policy anniversary;
2. All new policy loans and repayments during the previous policy year;
and
3. All transfers of cash value to or from that investment division during
the previous policy year.
In addition, if you have changed the allocation percentages, we will reallocate
the VAA's among the investment divisions.
CALCULATION OF CASH VALUES. The cash value of this policy on any date is the sum
of your cash values in each investment division on that date. If no premium is
due and unpaid, your cash 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 allocation
percentage for that investment division in effect on the last policy
anniversary.
(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 lapsed since the last policy anniversary.
(b) The Benefit Base for the investment division on the last policy
anniversary.
If a premium is due and unpaid, then within three months after the due date your
cash value in each investment division is the sum of the following Items (1) and
(2):
(1) Your cash value in that investment division as of the due date of the
unpaid premium.
(2) The product of the following Items (a) and (b):
(a) The Actual NRR for the investment division minus the Net NRR for
the time elapsed since such due date.
(b) The cash value on such due date.
For each investment division, the cash value will also reflect the effect of:
1. Any policy loans in effect on the last policy anniversary;
2. All new policy loans and repayments since the last policy anniversary;
and
3. All transfers of cash value to or from that investment division since
the last policy anniversary.
More than three months after the due date of an unpaid premium, if you continue
the policy under one of the options on lapse, your cash value will equal the
reserve for the policy. In such case, the cash value within 30 days after a
policy anniversary will never be less than the cash value on that anniversary.
If at any time you have a policy loan allocated to an investment division and
your net cash value in that investment division is zero, we will cancel the VAA
and the policy loan as to such investment division and reallocate them to each
other investment division proportionately. Also, the premium allocation
percentage for such investment division will be reduced to zero and the
percentage for each other investment division will be increased proportionately.
TABULAR CASH VALUE (TCV). The tables of TCV's on page 3A show interim TCV's at
the end of each month in the first policy year and at the end of later policy
years. We will determine the TCV on other dates in a consistent manner with
allowance for time elapsed and premiums paid. Any TCV's not shown will be
furnished on request.
V85-01-12 Page 12
--------------------------------------------------------------------------------
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 Titles(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
____WHOLE LIFE LEVEL FACE AMOUNT________________________________ $__100,000_____
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|1|_|_|
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
|x| Annual |_| Semi-Annual |_|Quarterly
|_| Monthly |_| System-Matic (Attach S-M Form)
|_| 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 |x| No |_|
Date of Prospectus ______SPECIMEN____________________________
Date of any supplement ______SPECIMEN________________________
(ii) a Prospectus for The Xxxxxx River Fund, Inc.
Yes |x| No |_|
Date of Prospectus ______SPECIMEN____________________________
Date of any supplement ______SPECIMEN________________________
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)?
|X| Yes |_| No
c. With this in mind, is the policy in accord with your insurance objectives
and your anticipated financial needs? |X| 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 ten years used barbiturates, amphetamines, hallucinatory drugs
or narcotics? (Give full details.) |_| Yes |X| No
b. In the last ten years received counseling or treatment for 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
EQUITABLE
VARIABLE LIFE INSURANCE COMPANY
[EVLICO LOGO]
Home Office: 0000 Xxxxxx xx xxx Xxxxxxxx, Xxx Xxxx, Xxx Xxxx 00000
VARIABLE
LIFE
INSURANCE
POLICY
Limited Payment Life Plan -- LEVEL FACE AMOUNT. Variable insurance
payable upon death. Guaranteed Minimum Death Benefit. Fixed premiums
payable for Premium Period shown on page 3 or until earlier death.
Non-Participating. Investment experience reflected in benefits.
Investment options described on page 6.
No. 85-01
