EXHIBIT (5)
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PRODUCER INSTRUCTIONS
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Important Reminders The following are guidelines for completing the application:
. All signatures must be original (i.e., not stamped, photocopied, or faxed).
. Complete appropriate sections prior to signing the application. Never sign or let anyone else sign a
blank application.
. Do not use dashes, blanks, and/or ditto marks to record answers. If any of these methods are used,
the application will be amended.
. Do not use "white out" to make changes. If a change is made to an answer, the appropriate party(ies)
must initial the change. If not initialed by the appropriate party(ies) the application will be
amended. If seven (7) or more changes are made, even if these changes are initialed, a new
application must be completed.
. Once the application is signed, no additional information can be added unless the change is made
and initialed by the appropriate party(ies).
. Prior to solicitation, the Producer must be licensed in the state of New York. Also, the Producer
must be appointed by Pacific Life & Annuity.
. The product being applied for must be approved for sale in the state of New York.
. The solicitation, execution of the application, medical exam, and delivery of the policy must take
place in the state of New York.
Note: The Producer/Home Office Administrative Worksheet, which is part of the illustration, will assist
you in completing the application.
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Signature Requirements Party When Signature is Required
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Applicant* Always required. The Applicant is the party that initiates and applies for the life
insurance policy.
Proposed Insured Required if other than Applicant. If the Proposed Insured is under age 16, a parent
or guardian must sign for the Proposed Insured.
Additional Insured If submitting an application for a Second-to-Die life insurance policy or additional
insured term rider.
Owner* If other than the Applicant or the Proposed Insured.
Producer Always required.
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*If a Corporation, the signature and title of an authorized officer other than the Proposed Insured(s)
is required, and the full name of the corporation must be shown. If a Trust, the signature of the
Trustee(s) is required.
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Temporary Insurance TIA Qualifications To qualify for temporary life insurance, the Proposed Insured(s) must be:
Requirements . able to answer "No" to all of the questions on the Temporary Insurance Agreement
. over 15 days of age and under the age of 70
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Submitting TIAs The TIA is limited to $1,000,000 for individual products and $1,500,000 for
Second-to-Die products.
When submitting money (or initial premium) with an application:
. it is preferred that the check for the TIA, application, and TIA form all have
the same date
. if the producer is unable to obtain a check at the time the application is
completed, the check may be dated up to 3 days later than the TIA and
application
. the check, TIA, and application must be sent to Pacific Life & Annuity at the
same time
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Sales Illustration The complete illustration including the Producer/Home Office Administration Worksheet and Input page(s),
representing how the policy is being applied for, must be submitted with the application. The following
are additional requirements by product type:
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Non-Variable Life Insurance The illustration must be signed by the Applicant and Producer.
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Variable Life Insurance The Illustration Disclosure - Form 85-21827, must be signed by the
Applicant.
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SPECIAL NEW YORK REQUIREMENTS
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Definition of To determine if a life insurance policy or annuity contract is to replaced, prior to taking the
Replacement application, the Producer must review the Definition of Replacement - Form 85-21774, with the
Applicant(s). The form must be signed by the Applicant(s) and Producer before an application can be
taken in the state of New York.
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If Then
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All of the questions on the No replacement is involved an application may be taken.
Definition of Replacement
form are answered "No"
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Any question on the A replacement is involved and an application may not be taken at that
Definition of Replacement time. The New York Regulation 60 Authorization to Release Information -
is answered "Yes" Form 85-21957 is required and the New York Regulation 60 procedures must
be completed. (Refer to the New York Regulation 60 Replacement Procedures
- Form 85-21956.)
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Note: The Definition of Replacement - Form 85-21774, must accompany every application for life insurance
even if a replacement is not involved.
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BUYER'S GUIDE New York requires a Buyer's Guide be given to the Applicant at or prior to taking an application.
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AP2004-NY 00-00000-00 10/2003
Pacific Life & Annuity Company
Mailing Life Insurance Operations Center [LOGO OF PL&A]
Address X.X. Xxx 0000 x Xxxxxxx Xxxxx, XX 00000-0000
(000) 000-0000
APPLICATION FOR LIFE INSURANCE, PART I
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SECTION A CLIENT INFORMATION
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Proposed Insured 1. Name of Proposed Insured: First MI Last (Print as to appear in policy) 2. Sex
Complete for all Life [_] Male [_] Female
Insurance Policies. ---------------------------------------------------------------------------------------------------------
3. Date of Birth 4.Age (Nearest birthday) 5. Place of Birth 0.Xxxxxx Security #
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7. Driver's License # & State 8. Telephone # 9. E-mail Address
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10. Address: Street City County State Zip Code 11. How Long
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12. Employer's Name
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13. Employer's Address: Street City County State Zip Code 14. How Long
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15. Occupation 16. Type of Business
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Proposed Additional 17. Name of Additional Proposed Insured: First MI Last (Print as to appear in policy) 00.Xxx
Insured [_] Male
Complete for a Joint [_] Female
and Last Survivor Life ---------------------------------------------------------------------------------------------------------
Insurance Policy or 19. Date of Birth 20. Age (Nearest birthday) 21. Place of Birth 22. Social Security #
for a Term Rider on
Another Covered ---------------------------------------------------------------------------------------------------------
Person for an 23. Driver's License # & State 24. Telephone # 25. E-mail Address
Individual Life
Insurance Policy. ---------------------------------------------------------------------------------------------------------
26. Employer's Address: Street City County State Zip Code 27. How Long
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28. Employer's Name
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29. Employer's Address: Street City County State Zip Code 30. How Long
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31.Occupation 32.Type of Business 33.Relationship to Insured
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Owner 34. Name of Owner(s) (Print as to appear in policy: First/Middle/Last)
Complete only if
Owner is other than ---------------------------------------------------------------------------------------------------------
the Insured(s). If 35. Address: Street City County State Zip Code
Trust, give name of
trust, trustee, and ---------------------------------------------------------------------------------------------------------
date of trust. 36. Relationship to Insured(s)
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37. Date of Birth 38. Soc. Sec. # / Tax ID # 39. Telephone # 40. E-mail Address
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Primary Beneficiary 41. Name of Beneficiary (Print as to appear in policy: First/Middle/Last)
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42. Relationship to Insured(s) 43. Social Security # / Tax ID #
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Contingent 44. Name of Contingent Beneficiary (Print as to appear in policy: First/Middle/Last)
Beneficiary
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45. Relationship to Insured(s) 46. Social Security # / Tax ID #
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AP2004-NY 00-00000-00 10/2003
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SECTION A CLIENT INFORMATION (Continued)
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BENEFICIARY FOR 47. Name of Beneficiary for Individual Term Rider (Print as to appear in policy: First/Middle/Last)
INDIVIDUAL TERM
RIDER ---------------------------------------------------------------------------------------------------------------
48. Relationship to Insured 49. Social Security # / Tax ID #
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PREMIUM NOTICES 50. Send Premium Notices to: [_] Insured [_] Owner [_] Other (If other, give name, relationship,
and address below)
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51A. Name B. Relationship to Insured(s)
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C. Address: Street City State Zip Code
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52. Method & Frequency of Payment (Select One):
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X.Xxxxxx B.[_] Electronic Funds Transfer C.List Xxxx (3 or more policies) D.[_] Single Premium
[_] Annually (EFT)(Monthly only) Attach [_] Annually
[_] Semi-Annually voided check and complete EFT [_] Semi-Annually
[_] Quarterly Authorization on page 10. [_] Quarterly
[_] Monthly
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AMOUNT PAID WITH 53A. Is an initial premium submitted with this application? [_] Yes [_] No
THIS APPLICATION (Do not submit money unless the Temporary Insurance Agreement is completed)
B. If yes, show amount of initial premium and complete the Amount $______________________________
next question.
C. Do you understand, accept, and agree to the terms of the Temporary Insurance Agreement? [_] Yes [_] No
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SPECIAL POLICY 54A. [_] Date to Save Age [_] Specific Date
DATING If either box is checked, give policy date and complete below: Month ___________ Day _______ Year _____
B. I understand that insurance charges and expenses begin on the Policy Date [_] Yes [_] No
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LIFE INSURANCE 55. Give details of all life insurance in force on any Proposed Insured. If none, check this box: [_]
IN FORCE ---------------------------------------------------------------------------------------------------------------
Will This
Year Policy Be
Insured's Name Company Policy Number Face Amount Issued Replaced?
YES NO
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[_] [_]
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[_] [_]
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[_] [_]
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[_] [_]
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REPLACEMENT & YES NO
1035 EXCHANGE ---------------------------------------------------------------------------------------------------------------
INFORMATION 56. Will the policy applied for replace, cause a change in, or involve a cash withdrawal
or loan from any life insurance or annuity on any Proposed Insured's life or in any
life insurance or annuity owned by the Applicant? If yes, give details in "Remarks." [_] [_]
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57. Is this a 1035 exchange? If yes, list the policies to be exchanged in "Remarks." [_] [_]
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58. If a 1035 exchange, will a loan be carried over? If yes, list in "Remarks" the
policies and the loan amount(s) to be carried over. [_] [_]
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
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AP2004-NY Page 2 00-00000-00 10/2003
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SECTION B GENERAL INFORMATION
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GENERAL Additional
INFORMATION Proposed Insured Insured
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Complete each question 1. Annual earned income from occupation (After $ $
for the Proposed and deduction of business expenses)
Additional Insured. ------------------------------------------------------------------------------------------------------
2. Other income (State source in "Remarks") $ $
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3. Net Worth $ $
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YES NO YES NO
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4. Do you contemplate leaving the USA for travel or [_] [_] [_] [_]
residence? (If yes, explain in "Remarks")
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5A. Do you plan to fly, or within the last 2 years [_] [_] [_] [_]
have you flown, as a pilot, student pilot, or
crewmember?
B. Do you plan to participate in, or within the last [_] [_] [_] [_]
2 years have you participated in, parachute
jumping, scuba diving, auto/motorboat/motorcycle
racing, hang gliding, or mountain climbing?
(If yes to A or B, complete a separate General
Questionnaire for each Proposed/Additional [_] [_] [_] [_]
Insured)
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6. Have you ever had insurance declined, rated, [_] [_] [_] [_]
modified, cancelled, or not renewed? (If yes,
explain in "Remarks")
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7. Have you been convicted of a felony within the [_] [_] [_] [_]
past 5 years? (If yes, explain in "Remarks")
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8. Have you had a driver's license restricted or
revoked or been convicted of 3 or more moving
violations within the past 5 years? (If yes,
explain in "Remarks") [_] [_] [_] [_]
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9. Have you applied for any other insurance within [_] [_] [_] [_]
the last 3 months? (If yes, explain in "Remarks")
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10. Have you smoked a cigarette in the last 12 [_] [_] [_] [_]
months?
(If yes, give date last smoked) Date:________________ Date:_________________
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11. Have you used any other form of tobacco within [_] [_] [_] [_]
the last 2 years? Type:________________ Type:_________________
(If yes, give type and date last used) Date:________________ Date:_________________
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JUVENILE INSURANCE 12A. If a child age 14 years and 6 months or younger is to be insured under this policy, answer B & C
below:
B. What is the relationship of the owner to the child?_____________________________________________
C. What is the total amount of insurance on the owner, which is in force and applied for in this
and all other companies?
$_____________________________________________________________________
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SECTION C MEDICAL CERTIFICATION
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MEDICAL 1. The attached examination is on the life of:
CERTIFICATION -------------------------------------------------------------------------------------------------------
Complete when Proposed Additional Name of Insurance Company Date of Examination
submitting a medical Insured Insured
examination of another -------------------------------------------------------------------------------------------------------
insurance company. [_] [_]
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[_] [_]
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2. To the best of your knowledge and belief, are the statements in the examination true as of today
Proposed Insured [_] Yes [_] No (If no, explain in Remarks)
Additional Insured [_] Yes [_] No
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3. Has the person who was examined consulted a doctor or other medical practitioner, or received
medical or surgical advice since the date of the examination?
Proposed Insured [_] Yes [_] No (If yes, explain in Remarks)
Additional Insured [_] Yes [_] No
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
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AP2004-NY Page 3 00-00000-00 10/2003
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SECTION D POLICY INFORMATION FOR VARIABLE LIFE INSURANCE
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PRODUCT/PREMIUM 1. Product Name 2A. Initial Premium B. Planned Annual Premium
$ $
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DEATH BENEFIT 3. Face Amount (Base Only) + Initial Annual Renewable Term Insurance Rider/ = Total Initial Coverage
Joint and Last Survivor Term Insurance Rider
$ $ $
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DEATH BENEFIT OPTION 4. Check one: [_] Option A [_] Option B [_] Option C (Face amount plus [_] Option D (Face amount
(Level) (Increasing) premiums less distributions) multiplied by a death
benefit factor)
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OPTIONAL BENEFITS 5. Individual Life Insurance Products Only 6. Joint and Last Survivor Life Insurance Products
A. [_] Annual Renewable Term Rider on Other Covered Only
Person A. [_] Individual Annual Renewable Term Rider on
$___________________________________________ the Proposed Insured $___________________
B. [_] Accidental Death Rider $____________________ B. [_] Individual Annual Renewable Term Rider
C. [_] Children's Term Rider _______________(units) on the Additional Insured $______________
(Complete Application Part 2, Non-Medical)
D. [_] Disability Benefit Rider $__________________
E. [_] Guaranteed Insurability Rider $_____________
F. [_] Waiver of Charges Rider (On Insured)
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7. If any optional benefit applied for cannot be approved, should the policy be issued without it? [_] Yes
[_] No
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PREMIUM ALLOCATION 8. Indicate how premiums are to be allocated until later changed by you or your authorized representative.
The total of the percentages must be 100%. Allocation percentages must be whole numbers.
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Premium Premium
Manager % Investment Options Manager % Investment Options
------- ------- ------------------ ------- ------- ------------------
[AIM _______ Blue Xxxx XXXXXXXXXXX _______ Emerging Markets
_______ Aggressive Growth _______ Multi-Strategy
_______ Main Street Core
CAPITAL GUARDIAN _______ Diversified Research
_______ Small-Cap Equity PIMCO _______ Inflation Managed
_______ International Large-Cap _______ Managed Bond
XXXXXXX SACHS _______ I-Net Tollkeeper PIMCOAdvisors- NFJ _______ Small-Cap Value
_______ Short Duration Bond
PACIFIC LIFE _______ Money Market
INVESCO _______ Financial Services _______ High Yield Bond
_______ Health Sciences _______ Fixed Account
_______ Technology _______ Fixed LT Account
_______ Telecommunications
XXXXXX _______ Equity Income
JANUS _______ Growth LT _______ Research
_______ Focused 30 _______ Equity
_______ Aggressive Equity
LAZARD _______ Mid-Cap Value
_______ International Value SALOMON _______ Large-Cap Value
MFS _______ Capital Opportunities XXX XXXXXX _______ Xxxxxxxx
_______ Global Growth _______ Mid-Cap Growth
_______ Real Estate]
MERCURY _______ Equity Index
_______ Small-Cap Index
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*The Fixed LT Account has less transfer liquidity and may credit a higher current rate of interest than the
Fixed Account. Both fixed account options credit a fixed minimum guaranteed interest rate. See the
prospectus for details.
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ACKNOWLEDGEMENT All questions must be answered. YES NO
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To be completed by 9. Do you understand that the amount and duration of the death benefit may vary,
the Applicant. depending on the investment performance of the variable investment options? [_] [_]
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10. Do you understand that the policy values may increase or decrease, depending
on the investment experience of the variable investment options? [_] [_]
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11. Did you receive the separate account and fund prospectuses (bound together) for
the policy applied for? If yes, give date below. [_] [_]
--------------------
Date of Separate Account & Fund Prospectuses: ____________________________________________________
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POLICY VALUES MAY INCREASE OR DECREASE, AND MAY EVEN BE REDUCED TO ZERO AND CAUSE THE POLICY TO LAPSE
WITHOUT VALUE, DEPENDING ON THE EXPERIENCE OF THE VARIABLE INVESTMENT OPTIONS. THE DEATH BENEFIT MAY BE
VARIABLE OR FIXED UNDER SPECIFIED CONDITIONS. A CURRENT ILLUSTRATION OF BENEFITS, INCLUDING DEATH BENEFITS,
POLICY VALUES AND HYPOTHETICAL CASH SURRENDER VALUES, IS AVAILABLE UPON REQUEST.
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AP2004-NY Page 4 00-00000-00 10/2003
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SECTION D POLICY INFORMATION FOR VARIABLE LIFE INSURANCE (Continued)
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REBALANCING 12. I authorize Pacific Life & Annuity Company to automatically rebalance the variable accounts to the
Optional allocation percentages shown in question 8.
Start Date: Frequency:
[_] Quarterly
____________________ _________ ________________ [_] Semi-Annually
Month Day Year [_] Annually
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FIRST YEAR TRANSFER 13. I elect First Year Transfer Program Yes [_] No [_] (if elected, submit the proper authorization form)
PROGRAM
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DOLLAR COST 14. I elect Dollar Cost Averaging Yes [_] No [_] (if elected, submit the proper authorization form)
AVERAGING
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
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SECTION E POLICY INFORMATION FOR TERM LIFE INSURANCE
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PRODUCT/FACE AMOUNT 1. Product Name 2. Face Amount
$
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OPTIONAL BENEFITS 3. [_] Premium Waiver (On Insured)
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4. If the optional benefit applied for cannot be approved, should the policy be issued without it?
[_] Yes [_] No
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SECTION F POLICY INFORMATION FOR AN ADDITIONAL OR ALTERNATE TERM LIFE INSURANCE POLICY
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(SELECT ONE) TERM LIFE INSURANCE POLICY [_] ADDITIONAL OR [_] ALTERNATE
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PRODUCT/FACE AMOUNT 1. Product Name 2. Face Amount
$
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OPTIONAL BENEFITS 3. [_] Premium Waiver (On Insured)
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4. If the optional benefit applied for cannot be approved, should the policy be issued without it?
[_] Yes [_] No
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
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AP2004-NY Page 5 00-00000-00 10/2003
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SECTION G POLICY INFORMATION FOR AN ADDITIONAL OR ALTERNATE FLEXIBLE PREMIUM LIFE INSURANCE POLICY
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(Select One) VARIABLE FLEXIBLE PREMIUM LIFE INSURANCE POLICY [_] ADDITIONAL OR [_] ALTERNATE
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PRODUCT/PREMIUM 1. Product Name 2A. Initial Premium B. Planned Annual Premium
$ $
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DEATH BENEFIT 3. Face Amount (Base Only) + Initial Annual Renewable Term Rider/ = Total Initial Coverage
Joint and Last Survivor Added Protection
Benefit Rider
$ $ $
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DEATH BENEFIT OPTION 4. Check one: [_] Option A [_] Option B [_] Option C (Face amount plus [_] Option D (Face amount
(Level) (Increasing) premiums less distributions) times the death
benefit factor)
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DIVIDEND OPTION 5. Check one: [_] Cash [_] Increase Accumulated Value
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OPTIONAL BENEFITS 6. Individual Life Insurance Products Only 7. Joint and Last Survivor Life Insurance Products
A. [_] Annual Renewable Term Rider on Other Covered Only
Person $____________________________________ A. [_] Individual Annual Renewable Term Rider on
B. [_] Accidental Death Rider $____________________ the Proposed Insured $____________________
C. [_] Children's Term Rider ______________ (units) B. [_] Individual Annual Renewable Term Rider on
(Complete Application Part 2, Non-Medical) the Additional Insured $__________________
D. [_] Disability Benefit Rider $__________________
E. [_] Guaranteed Insurability Rider $_____________
F. [_] Waiver of Charges Rider (On Insured)
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8. If any optional benefit applied for cannot be approved, should the policy be issued without it? [_] Yes
[_] No
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PREMIUM ALLOCATION 9. Indicate how premiums are to be allocated until later changed by you or your authorized representative.
The total of the percentages must be 100%. Allocation percentages must be whole numbers.
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Premium Premium
Manager % Investment Options Manager % Investment Options
------- ------- ------------------ ------- ------- ------------------
[AIM _________ Blue Xxxx XXXXXXXXXXX _________ Emerging Markets
_________ Aggressive Growth _________ Multi-Strategy
_________ Main Street Core
CAPITAL GUARDIAN _________ Diversified Research
_________ Small-Cap Equity PIMCO _________ Inflation Managed
_________ International Large-Cap _________ Managed Bond
XXXXXXX SACHS _________ I-Net Tollkeeper PIMCO NFJ _________ Small-Cap Value
_________ Short-Term Bond
PACIFIC LIFE ________ Money Market
INVESCO _________ Financial Services ________ High Yield Bond
_________ Health Sciences ________ Fixed Account
_________ Technology ________ Fixed LT Account
_________ Telecommunications
XXXXXX ________ Equity Income
JANUS _________ Growth LT ________ Research
_________ Focused 30 ________ Equity
________ Aggressive Equity
LAZARD _________ Mid-Cap Value
_________ International Value SALOMON ________ Large-Cap Value
MFS _________ Capital Opportunities XXX XXXXXX ________ Mid-Cap Growth
_________ Global Growth ________ Real Estate
________ Strategic Value]
MERCURY _________ Equity Index
_________ Small-Cap Index
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*The Fixed LT Account has less transfer liquidity and may credit a higher current rate of interest than the
Fixed Account. Both fixed account options credit a fixed minimum guaranteed interest rate. See the
prospectus for details.
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NOTE: IF APPLYING FOR AN ADDITIONAL OR ALTERNATE VARIABLE FLEXIBLE PREMIUM LIFE INSURANCE POLICY THE
ACKNOWLEDGEMENT ON PAGE 4, SECTION D, ALSO APPLIES TO THIS POLICY.
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10. If any optional benefit applied for cannot be approved, should the policy be issued without it? [_] Yes
[_] No
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
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AP2004-NY Page 6 00-00000-00 10/2003
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SECTION H CERTIFICATION OF OWNER'S TAXPAYER ID AND APPLICANT'S DECLARATIONS
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Certification of Under penalty of perjury, I certify that:
Owner's Taxpayer 1. The number shown in this application as my social security number or taxpayer identification number
Identification # is correct; and
2. I am not subject to backup withholding under Section 3406(a)(1)(c) of the Internal Revenue Code. (If
statement is false strike out and initial.)
3. I am a U.S. person (including a U.S. resident alien).
This certification is required by the Internal Revenue Service before any taxable distribution can be made.
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Declarations The answers in this application are true and complete to the best of my knowledge and belief. I understand
and agree that:
1. Except as provided in the terms or conditions of any Temporary Insurance Agreement that I may have received
in connection with this application, coverage will take effect when the policy is delivered and the entire
first premium is paid only if at that time the Proposed Insured(s) is alive, and all answers in this
application that are material to the risk are still true and complete to the best of my knowledge and
belief.
2. If I have given money with the application and received a Temporary Insurance Agreement and if the coverage
amount of the application exceeds the Temporary Insurance Agreement coverage limits, I understand that if
the Proposed Insured(s) die(s) before a policy is delivered, the death benefit will be limited to the
Temporary Insurance Agreement coverage limit.
3. I must inform the Producer or Pacific Life & Annuity Company in writing of any changes in the health of any
Proposed Insured(s) or if any of the statements or answers on this application change prior to delivery of
the policy.
4. My statements and answers in this application must continue to be true, to the best of my knowledge and
belief, as of the date I receive the policy.
5. No Producer is authorized to make or modify contracts or insurance policies on Pacific Life & Annuity
Company's behalf.
6. No Producer may alter the terms of this application, the Temporary Insurance Agreement, or the policy, nor
can the Producer waive any of Pacific Life & Annuity Company's rights or requirements.
7. I believe that the policy(ies) applied for will meet my insurance needs and financial objectives.
8. This application will be attached to and made part of the policy.
9. If this life insurance application is being submitted for purposes of obtaining business insurance, the
applicant and beneficiary have an insurable interest in the life or lives of the persons proposed to be
insured. For these purposes, the phrase "insurable interest" means a lawful and substantial economic
interest in the continued life, health or bodily safety of the person(s) proposed to be insured, as
distinguished from an interest which would arise only by, or would be enhanced in value by, the death,
disablement or injury of the persons proposed to be insured. New York Ins. Law ss.3205(a)(1)(B).
10. If this life insurance application is being submitted in connection with a non-qualified retirement plan,
each person proposed to be insured is a member of "a select group of management and highly compensated
employees" as that phrase is understood under the Employee Retirement Income Security Act of 1974.
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Signed and Dated by the Applicant:
In: __________________________________________________ _____________ ____________________________________________________
City State Month/Day/Year
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SIGNATURE OF APPLICANT
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X ________________________________________________________________________________________________________________________________
Applicant*
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SIGNATURE OF PROPOSED INSURED(S) - IF OTHER THAN THE APPLICANT OR SIGNATURE OF PARENT IF PROPOSED INSURED IS 14 YEARS AND 6 MONTHS
OR YOUNGER
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X ________________________________________________________________________________________________________________________________
Proposed Insured
X ________________________________________________________________________________________________________________________________
Proposed Additional Insured (if applicable)
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SIGNATURE OF OWNER - IF OTHER THAN THE APPLICANT OR THE PROPOSED INSURED
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X ________________________________________________________________________________________________________________________________
Owner*
*If a Corporation, the signature and title of any authorized officer other than the Proposed Insured(s) is required and the full
name of the corporation must be shown. If a Trust, the signature of the Trustee.
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PRODUCER'S CERTIFICATION
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I certify that I have truly and accurately recorded hereon the information supplied.
X _______________________________________________________________ _____________________________________________________________
Signature of Soliciting Producer Print Soliciting Producer's Name
AP2004-NY Page 7 00-00000-00 10/2003
Pacific Life & Annuity Company [LOGO OF PL&A]
X.X. Xxx 0000
Xxxxxxx Xxxxx, XX 00000-0000
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SECTION I AUTHORIZATION OF THE PROPOSED INSURED TO OBTAIN INFORMATION -
THIS AUTHORIZATION COMPLIES WITH THE HIPAA PRIVACY RULES
Complete for all I authorize any physician, health care professional, medical
applications. practitioner, other health care provider, hospital, clinic,
laboratory, pharmacy, medical facility, other medical or
medically related facility, insurance company, health plan, the
Medical Information Bureau, Inc., consumer reporting agency,
state motor vehicle agency, or employer to release to Pacific
Life & Annuity Company ("PL&A") its subsidiaries, reinsurers,
agents, employees and representatives, any information they may
have in their possession or under their control as to the
diagnosis, treatment, prognosis of any physical or mental
condition, human immunodeficiency virus (HIV) infection,
sexually transmitted diseases, treatment of mental illness, and
the use of tobacco, and any non-medical information, including
finances, avocations, occupation, foreign travel, and driving
record for me and any minor children who are to be insured.
Although Federal Regulation protects information related to
drug or alcohol abuse from disclosure, I give permission to
collect this information for those purposes described in the
Disclosure Notice.
This authorization is not affected or limited by any prior
agreements I may have made with any of the above persons or
entities to restrict the release of such information, and I
instruct them to release and disclose all such information
without restriction.
I understand that the reason for releasing such information
under this authorization is to determine eligibility for
insurance and that such information will not be released to any
person or organization except reinsurer, the Medical
Information Bureau, Inc., and other persons or organizations
performing business or legal services in connection with my
application, or as may be otherwise required by law, or as I
may further authorize. I understand that I may revoke this
authorization at any time by sending a written revocation
request to PL&A at: X.X. Xxx 0000, Xxxxxxx Xxxxx, XX
00000-0000. Such a revocation will not affect any action taken
or information released prior to the revocation, and will not
affect any legal right PL&A has to contest an insurance
policy/certificate, or to contest a claim under an
insurance policy/certificate. I understand that if I revoke
this authorization, PL&A may not be able to process my
application, and may not be able to make any benefit payments
due under any existing policy, certificate, or other binding
agreement. I also acknowledge receipt of the Disclosure Notice.
This authorization shall remain in force for 30 months after
the date of my signature below, and a copy of this
authorization is as valid as the original. I understand that
once any such health-related information is released pursuant
to this authorization, that information may be re-disclosed and
will no longer be covered or protected by the HIPAA rules
governing privacy and confidentiality of health information. I
acknowledge that I have received a copy of this authorization.
Signed and Dated by the Proposed Insured(s):
In:
------------------------------ --------- ----------------
City State Month/Day/Year
X
--------------------------------------------------------------
Signature of Proposed Insured (or signature of parent if
Proposed Insured is 14 years and 6 months or younger)
X
--------------------------------------------------------------
Signature of Proposed Additional Insured (if applicable)
--------------------------------------------------------------------------------
AP2004-AUTH-NY 00-00000-00 10/2003
Pacific Life & Annuity Company [LOGO OF PL&A]
X.X. Xxx 0000
Xxxxxxx Xxxxx, XX 00000-0000
-----------------------------------------------------------------------------------------------------------------------------------
SECTION J AUTHORIZATION FOR ELECTRONIC FUNDS TRANSFER - MONTHLY BANK DRAFT
-----------------------------------------------------------------------------------------------------------------------------------
To be completed, by the As a convenience to me, I request and authorize you to pay and charge to the bank account
Authorized Account referenced below any monthly debit entries on that account by and payable to the order of Pacific
Holder, only if Electronic Life & Annuity Company, provided there are sufficient collected funds in said account to pay the
Funds Transfer Billing same upon presentation. I agree that your rights in respect to each such debit shall be the same
Method (monthly bank as if it were a debit drawn on you and signed personally by me. This authority is to remain in
drafter) is requested. effect until revoked by me in writing, and until you actually receive such notice I agree that you
shall be fully protected in honoring any such debit.
Pacific Life & Annuity Company will determine the monthly draft date based upon my policy
effective date. However, any special drafting requests are indicated below.
Bank Account No. ____________________________________________________________________________
Bank Account in the Name(s) of: _____________________________________________________________
Special Drafting Request: _________________________ (All requests for special dating will
be reviewed against the policy date for eligibility)
Signed and dated at:
_____________________________________________ __________ ________________________________
City State Month/Day/Year
Signature of Authorized Account Holder:
X ___________________________________________________________________________________________
A voided check must be attached below. (A blank deposit slip will not be accepted)
Premium payments can only be drawn from authorized U.S. financial institutions. Some savings
and money market accounts may not qualify.
PLACE VOIDED CHECK HERE
If your check does not state your financial institution's name and address, please list below:
_____________________________________________________________________________________________
-----------------------------------------------------------------------------------------------------------------------------------
00-00000-00 10/2003
------------------------------------------------------------------------------------------------------------------------------------
SECTION K PRODUCER INFORMATION
------------------------------------------------------------------------------------------------------------------------------------
PRODUCER REPORT To be answered by the soliciting Producer YES NO
-------------------------------------------------------------------------------------------------------
Complete for all 1. Have you personally asked all applicable questions in this application? [_] [_]
applications. (If no, explain in "Remarks")
-------------------------------------------------------------------------------------------------------
2. Are you aware of any information not given in the application that might [_] [_]
affect the insurability of the Proposed Insured(s)? (If yes, explain in
"Remarks")
-------------------------------------------------------------------------------------------------------
3. Did the Proposed Insured/Additional Insured change his/her name during [_] [_]
the past 5 years? (If yes, give former name(s) in "Remarks")
-------------------------------------------------------------------------------------------------------
4. To the best of your knowledge, is this life insurance intended to replace, [_] [_]
or will it cause a change in, or involve a loan from any life insurance or
annuity on any Proposed Insured's life or in any life insurance or annuity
owned by the Applicant? (If yes, give details in "Remarks")
-------------------------------------------------------------------------------------------------------
5A. If sales materials were used in this sale, did you use only sales materials [_] [_]
approved by Pacific Life & Annuity Company?
B. If sales materials were used in the sale, did you leave sales materials with [_] [_]
the Applicant?
-------------------------------------------------------------------------------------------------------
6. Is application submitted on a:
[_] Medical Basis? [_] Guaranteed Issue Basis?
[_] Non-Medical Basis? [_] Guaranteed to Issue Basis?
-------------------------------------------------------------------------------------------------------
7. Check appropriate items that have been ordered:
[_] Medical Exam [_] H.O. Specimen
[_] Paramedical Exam [_] Inspection Report
[_] EKG [_] APS _________________________________________
[_] Blood Profile _________________________________________
-------------------------------------------------------------------------------------------------------
8. If this policy is used to fund a tax-qualified plan, indicate type:
[_] Pension/Profit Sharing [_] HR-10 [_] Other (Explain In "Remarks")
------------------------------------------------------------------------------------------------------------------------------------
BUSINESS INSURANCE 1. This life insurance policy is being purchased in conjunction with a:
A. [_] Buy/Sell D. [_] Split Dollar
Complete if applying for B. [_] Employee Fringe Benefit E. [_] Key Employee
business insurance. C. [_] Deferred Compensation F. [_] Other (Explain in "Remarks")
-------------------------------------------------------------------------------------------------------
% of Amount of
G. Name of Principal Officers, Partners, or Key Employees Position Business Insurance Owned
Owned by Business
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------
H. What is the current value of the business? $
---------------------------------------------------------------------------------------
I. What was the annual net profit (before taxes) of business? Last Year 2 Years Ago
$_________ $__________
J. Are other officers, partners, or key employees [_] Yes [_] No (If no, explain
proportionately insured? in "Remarks")
------------------------------------------------------------------------------------------------------------------------------------
JUVENILE INSURANCE 1. Did you personally observe the Proposed Insured? [_] Yes [_] No (If no, explain
in "Remarks")
Complete if the Proposed -------------------------------------------------------------------------------------------------------
Insured is 14 years and 6 2. Are the Proposed Insured's brothers and sisters insured [_] Yes [_] No (If no, explain
months or younger. for equal amounts? in "Remarks")
-------------------------------------------------------------------------------------------------------
3A. Name of Person on whom Proposed Insured depends for support: B. Relationship to Insured
-------------------------------------------------------------------------------------------------------
C. Estimated annual income D. Estimated net worth E. Estimated amount of life insurance
$ $ $
-------------------------------------------------------------------------------------------------------
4A. Name of Applicant B. Relationship to Insured
-------------------------------------------------------------------------------------------------------
C. Purpose of Insurance D. Amount of life insurance in force
$
------------------------------------------------------------------------------------------------------------------------------------
00-00000-00 10/2003
------------------------------------------------------------------------------------------------------------------------------------
SECTION L PRODUCER CERTIFICATION
------------------------------------------------------------------------------------------------------------------------------------
Complete for all I certify that to the best of my knowledge and belief: YES NO
applications. -------------------------------------------------------------------------------------------------------------
A. I have presented to the Company all pertinent facts and have correctly and completely
recorded all required answers. [_] [_]
-------------------------------------------------------------------------------------------------------------
B. I have given the Proposed Insured(s) (or Parent for Juvenile insurance) a copy of the
Disclosure Notice, and any other disclosure notice or statement required by state or
federal law. [_] [_]
-------------------------------------------------------------------------------------------------------------
C. I have fully explained the terms and conditions of the Temporary Insurance Agreement to
the Proposed Insured(s) (or Owner) and have given it to him/her (them). [_] [_]
-------------------------------------------------------------------------------------------------------------
D. I have complied with state and federal laws on cost comparison, illustration, and
replacement. [_] [_]
-------------------------------------------------------------------------------------------------------------
E. I have reviewed, with my Broker Dealer, as applicable, the purchase of this insurance
policy. [_] [_]
-------------------------------------------------------------------------------------------------------------
F. If sales activity (including solicitation, application and policy delivery) took place
in a state other than the application state, indicate the states and associated activity.
(If needed, use "Remarks" section below)
State(s)_________________________ Activity___________________________________________________________
------------------------------------------------------------------------------------------------------------------------------------
Signature(s) Of Soliciting Producer(s). Pay Commission as Indicated Below.
X____________________________________________________________ X____________________________________________________________
First Name Listed Below Will Be The Servicing Producer
------------------------------------------------------------------------------------------------------------------------------------
PHONE NUMBER FAX NUMBER SERVICING PRODUCER COMM
PRODUCER NAME (INCLUDE AREA CODE) E-MAIL ADDRESS (INCLUDE AREA CODE) OFFICE # CODE %
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
Broker Dealer Name______________________________________________________________________________________________________________
------------------------------------------------------------------------------------------------------------------------------------
REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
00-00000-00 10/2003
Pacific Life & Annuity Company [LOGO OF PACIFIC LIFE]
X.X. Xxx 0000
Xxxxxxx Xxxxx, XX 00000-0000
DISCLOSURE NOTICE
TO BE DETACHED AND LEFT WITH THE PROPOSED INSURED(S)
This is a brief description of our underwriting process ("process"). It will
help you understand how an application for insurance is handled, the types and
sources of information ("data") we may collect about you, the circumstances
under which we may disclose that data to others and your right to learn the
nature and substance of that data. The purpose of the process is to see if you
qualify for insurance under our rules, and if you do, to establish the proper
premium charge. This will assure that the cost of insurance is shared fairly
among all policy owners. To determine your insurability, we consider factors
such as your medical history, physical condition, occupation, and hazardous
avocations. We get this data from various sources.
Application and Medical Records - Your application, including the medical
history, is the primary source of data in the process. We may ask you to take a
physical exam or other special medical test. We may also ask for a report from
your doctor or hospital, another insurance company, or the Medical Information
Bureau, Inc. ("MIB"). When we do so, we will use the authorization you signed
with your application.
Medical Information Bureau, Inc. - MIB is a non-profit corporation, which
maintains a data exchange for member life insurance companies. As a member
company, we will ask MIB if it has a record for you. If you applied to a member
company for insurance, MIB may have data about you in its file. The purpose of
MIB is to protect member companies and their policy owners from those who would
conceal facts relevant to their insurability. The data, which is obtained from
MIB, may be used only as an alert to the possible need for further
investigation. It cannot be used as a basis to make a final underwriting
decision. Pacific Life & Annuity Company, its subsidiaries, or its reinsurer(s)
may make a brief report to MIB. If you later apply to another MIB member company
for life or health insurance coverage, or a claim for benefits is made to such a
company, MIB may supply the company with data it may have about you in its file.
At your request, MIB will arrange disclosure of any data it may have about you
in its file. If you question the accuracy of such data, you may contact MIB and
seek a correction in accordance with the federal Fair Credit Reporting Act
procedures. Their address is MIB, XX Xxx 000, Xxxxx Xxxxxxx, Xxxxxx, XX 00000.
Their phone no. is (000) 000-0000.
Investigative Consumer Report - We may request an investigative consumer report
("ICR") from a consumer reporting agency ("CRA"). An ICR confirms and
supplements the data in your application having to do with employment,
residence, smoking habits, marital status, occupation, hazardous avocations, and
general health. An ICR may also cover data about your general reputation, motor
vehicle driving record, criminal activity, personal characteristics, and mode of
living, except as may be related directly or indirectly to your sexual
orientation. This data may be obtained through personal interviews with you,
your family, friends, neighbors, and business associates. If an ICR is required
and you wish to be personally interviewed, please let us know and we will notify
the CRA. The data contained in the report may be retained by the CRA and later
disclosed to other companies to the extent permitted by the Fair Credit
Reporting Act. You have a right to make a written request within a reasonable
time to receive any other details about the nature and scope this report. An ICR
may have an adverse effect on your insurability. If it should, however, we will
notify you in writing and identify the CRA.
DISCLOSURE TO OTHERS
Data obtained about you during the process and at other times is private and
will not be disclosed to others without your written authorization except to the
extent necessary for the conduct of our business. Examples of situations where
we may share data about you are as follows:
1. The Producer may keep a copy of your application, and after a policy is
issued will have access to ongoing policy data to better serve you.
2. If reinsurance were required, the reinsurance company would have access to
our application file.
3. We may release data to another life insurance company to whom you have
applied for insurance or to whom you have submitted a claim for benefits, if
you have authorized it to obtain such data.
4. We may report data to MIB.
5. We will disclose data to government, law enforcement, and others where
required by law.
DISCLOSURE TO YOU
In general, you have a right to learn the nature and substance of any personal
data about you in our file upon written request. Whenever an adverse
underwriting decision is made, we will notify you of the reason(s) for the
decision and the source of the data on which our action is based. Medical record
data, however, will normally be given only to a licensed physician of your
choice. Please refer to the section on MIB for their disclosure procedures.
Should you feel that any data we have is not correct or complete, please write
to: Manager, Risk Selection Department, Pacific Life & Annuity Co., X.X. Xxx
0000 Xxxxxxx Xxxxx, XX 00000-0000. Your comments will be carefully considered
and corrections made where justified. We hope this Notice will help you to
understand how we obtain and use personal data in the underwriting process, and
the ways you can learn about this data. We are concerned with insuring privacy
as well as lives, and the collection, use, and disclosure of personal data is
limited to those specified in this Notice.
AP2003-DISC-NY 00-00000-00 10/2003
PACIFIC LIFE & ANNUITY COMPANY NONMD
Mailing Life Insurance Operations Center [Logo of PL&A]
Address X.X. Xxx 0000-Xxxxxxx Xxxxx, XX 00000-0000
(000) 000-0000
APPLICATION, PART II - NON-MEDICAL
-------------------------------------------------------------------------------------------------------------------------------
SECTION A COMPLETE ON PROPOSED INSURED (OVER 14 YEARS AND 6 MONTHS)
-------------------------------------------------------------------------------------------------------------------------------
1. Full Name 2a. Date of Birth 2b. Height 2c. Weight
MO. DAY YR. FT. IN. LBS.
-------------------------------------------------------------------------------------------------------------------------------
3. a. Name and address of physician or practitioner last visited:
-------------------------------------------------------------------------------------------------------------------------
(IF NONE, SO STATE)
b. Date: _________________ c. Reason consulted: ________________________________________________________________________
MO. YR.
Yes No Details of "Yes" answers. (Identify question, and
d. Did any symptoms prompt consultation? ................... include diagnoses, dates, duration, and names and
e. Was any treatment given or medication prescribed? ....... addresses of all attending physicians and medical
(IF "D" OR "E" ANSWERED "YES", GIVE DETAILS) facilities.) Use an additional sheet if necessary.
4. To the best of your knowledge and belief, during the past
10 years, have you been diagnosed or treated by a member
of the medical profession for:
(CIRCLE APPLICABLE ITEMS AND GIVE DETAILS)
a. disorder of the eyes, ears, nose or throat?..............
b. Dizziness, fainting, convulsions, headaches, speech
defect, paralysis or stroke, or mental or nervous
disorder? ..................................................
c. Hoarseness or cough, blood spitting, asthma,
pneumonia, emphysema, tuberculosis, or other
respiratory system disorder? ...............................
d. Chest pain, high blood pressure, rheumatic fever,
murmur, heart attack, or other disorder of the heart
or blood vessels? ..........................................
e. Jaundice, intestinal bleeding, ulcer, colitis,
diverticulitis, hepatitis, or other disorder of the
liver, gallbladder, stomach or intestines? .................
f. Sugar, albumin, or blood in urine, venereal disease,
stone or other disorder of kidney, bladder, prostate,
breasts or reproductive organs? ............................
g. Diabetes, thyroid, or other endocrine disorders? ........
h. Neuritis, sciatica, arthritis, gout, or disorder
of the muscles or bones, including the spine, back,
or joints? .................................................
i. Cancer, cyst, tumor, or disorder of skin, blood, or
lymph glands? ..............................................
j. Any disorder(s) of the immune system, including AIDS
(Acquired Immune Deficiency Syndrome) and ARC
(AIDS-Related Complex)? ....................................
5. a. Have you within the past 5 years been a patient
in a hospital, clinic, sanitarium, or other medical
facility? ..................................................
b. Are you now under regular medical observation or
taking treatment? ..........................................
6. a. Except as prescribed by a physician, have you used
heroin, morphine, or other narcotic drugs in the last
10 years? ..................................................
b. Except as prescribed by a physician, have you used
cocaine, LSD, marijuana, or other hallucinogenic
agents, or barbituarates, sedatives, tranquilizers,
or any amphetamines in the last 5 years? .....................
c. In the last 5 years have you received treatment
for or joined an organization because of alcoholism or
drug addiction? ..............................................
7. Other than as stated in answers above (and except as
regards HIV), have you within the past 5 years:
a. Had a checkup, consultation, illness, injury
or operation? ................................................
b. Had an electrocardiogram, blood test, other test
or X-ray? ....................................................
c. Been advised to have any diagnostic test,
hospitalization, or surgery that was not completed? ..........
8. Have you had any change in weight in the past year? ..........
9. Have either of your parents, brothers, or sisters
had diabetes, cancer, high blood pressure, heart
disease, or mental illness? ..................................
(IF "YES", STATE CONDITION, GIVE RELATIONSHIP AND
AGE AT ONSET)
10. Parents' Record (COMPLETE BELOW)
--------------------------------------------------------------------------------
IF LIVING IF DECEASED
-----------------------------------------------------------------
AGE STATE OF HEALTH AGE AT CAUSE OF DEATH
DEATH
--------------------------------------------------------------------------------
Father
--------------------------------------------------------------------------------
Mother
--------------------------------------------------------------------------------
The above statements are true and complete to the best of my knowledge and
belief. I agree that such statements and answers shall be attached to and made
part of the application.
Dated at __________________________ on ____________________ X___________________________________
CITY STATE MO. DAY YR SIGNATURE OF PROPOSED INSURED
__________________________________________________________________
WITNESS
AP9500-P2-NY PAGE 1 OF 3 00-00000-00 04/2002
PACIFIC LIFE & ANNUITY COMPANY NONMD
Mailing Life Insurance Operations Center [Logo of PL&A]
Address X.X. Xxx 0000-Xxxxxxx Xxxxx, XX 00000-0000
(000) 000-0000
APPLICATION, PART II - NON-MEDICAL
-------------------------------------------------------------------------------------------------------------------------------
SECTION B COMPLETE ON ADDITIONAL INSURED (OVER 14 YEARS AND 6 MONTHS)
-------------------------------------------------------------------------------------------------------------------------------
1. Full Name 2a. Date of Birth 2b. Height 2c. Weight
MO. DAY YR. FT. IN. LBS.
-------------------------------------------------------------------------------------------------------------------------------
3. a. Name and address of physician or practitioner last visited:
-------------------------------------------------------------------------------------------------------------------------
(IF NONE, SO STATE)
b. Date: _________________ c. Reason consulted: ________________________________________________________________________
MO. YR.
Yes No Details of "Yes" answers. (Identify question, and
d. Did any symptoms prompt consultation? .................... include diagnoses, dates, duration, and names and
e. Was any treatment given or medication prescribed? ........ addresses of all attending physicians and medical
(IF "D" OR "E" ANSWERED "YES", GIVE DETAILS) facilities.) Use an additional sheet if necessary.
4. To the best of your knowledge and belief, during the past
10 years, have you been diagnosed or treated by a member
of the medical profession for:
(CIRCLE APPLICABLE ITEMS AND GIVE DETAILS)
a. disorder of the eyes, ears, nose or throat? ..............
b. Dizziness, fainting, convulsions, headaches, speech
defect, paralysis or stroke, or mental or
nervous disorder? ........................................
c. Hoarseness or cough, blood spitting, asthma, pneumonia,
emphysema, tuberculosis, or other respiratory
system disorder? .........................................
d. Chest pain, high blood pressure, rheumatic fever, murmur,
heart attack, or other disorder of the heart or
blood vessels? ...........................................
e. Jaundice, intestinal bleeding, ulcer, colitis,
diverticulitis, hepatitis, or other disorder of the
liver, gallbladder, stomach or intestines? ...............
f. Sugar, albumin, or blood in urine, venereal disease,
stone or other disorder of kidney, bladder, prostate,
breasts or reproductive organs? ..........................
g. Diabetes, thyroid, or other endocrine disorders? .........
h. Neuritis, sciatica, arthritis, gout, or disorder of
the muscles or bones, including the spine, back,
or joints? ...............................................
i. Cancer, cyst, tumor, or disorder of skin, blood, or lymph
glands? ..................................................
j. Any disorder(s) of the immune system, including AIDS
(Acquired Immune Deficiency Syndrome) and ARC (AIDS-
Related Complex)? ........................................
5. a. Have you within the past 5 years been a patient in
a hospital, clinic, sanitarium, or other medical
facility? ................................................
b. Are you now under regular medical observation or taking
treatment? ...............................................
6. a. Except as prescribed by a physician, have you used heroin,
morphine, or other narcotic drugs in the last 10 years? ..
b. Except as prescribed by a physician, have you used
cocaine, LSD, marijuana, or other hallucinogenic
agents, or barbiturates, sedatives, tranquilizers,
or any amphetamines in the last 5 years? ....................
c. In the last 5 years have you received treatment
for or joined an organization because of alcoholism or
drug addiction? .............................................
7. Other than as stated in answers above (and except as
regards HIV), have you within the past 5 years:
a. Had a checkup, consultation, illness, injury
or operation? ...............................................
b. Had an electrocardiogram, blood test, other test
or X-ray? ...................................................
c. Been advised to have any diagnostic test,
hospitalization, or surgery that was not completed? .........
8. Have you had any change in weight in the past year? .........
9. Have either of your parents, brothers, or sisters
had diabetes, cancer, high blood pressure, heart
disease, or mental illness? .................................
(IF "YES", STATE CONDITION, GIVE RELATIONSHIP AND
AGE AT ONSET)
10. Parents' Record (COMPLETE BELOW)
--------------------------------------------------------------------------------
IF LIVING IF DECEASED
-----------------------------------------------------------------
AGE STATE OF HEALTH AGE AT CAUSE OF DEATH
DEATH
--------------------------------------------------------------------------------
Father
--------------------------------------------------------------------------------
Mother
--------------------------------------------------------------------------------
The above statements are true and complete to the best of my knowledge and belief. I agree that such statements and answers
shall be attached to and made part of the application.
Dated at _____________________________ on __________________ X ________________________________________________________________
CITY STATE MO. DAY YR SIGNATURE OF PROPOSED INSURED
______________________________________________________________________
WITNESS
AP9500-P2-NY PAGE 2 OF 3 00-00000-00 04/2002
PACIFIC LIFE & ANNUITY COMPANY NONMD
Mailing Life Insurance Operations Center [Logo of PL&A]
Address X.X. Xxx 0000-Xxxxxxx Xxxxx, XX 00000-0000
(000) 000-0000
APPLICATION, PART II - NON-MEDICAL
-------------------------------------------------------------------------------------------------------------------------------
SECTION C COMPLETE IF APPLYING FOR CHILDREN'S TERM RIDER OR IF PROPOSED INSURED IS 14 YEARS AND 6 MONTHS OR YOUNGER
-------------------------------------------------------------------------------------------------------------------------------
1. AMOUNT OF
NAME OF RELATIONSHIP STATE INSURANCE AMT. OF INS.
PERSON TO BE TO PROPOSED DATE OF BIRTH OF HEIGHT WEIGHT NOW IN CURRENTLY
COVERED INSURED (MO./DAY/YR.) BIRTH (FT./IN.) (POUNDS) FORCE APPLIED FOR
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
2a. Name and address of your personal physician, practitioner, or health facility
-------------------------------------------------------------------------------------------------------------------------------
b. Date. c. Reason for and results of last visit
-------------------------------------------------------------------------------------------------------------------------------
3. Has any person named in Question 1 during the past 10 years had or been diagnosed or
treated by a member of the medical profession for:
(CIRCLE APPLICABLE ITEMS AND GIVE DETAILS) Yes No
A. Diabetes, cancer, or epilepsy?...........................................................
B. Heart murmur, high blood pressure, or any heart condition?...............................
C. Any disorder(s) of the Immune System, including AIDS (Acquired Immune Deficiency
Syndrome) and ARC (AIDS-Related Complex)?................................................
4. Has any person named in Question 1:
A. Been in a hospital, sanitarium, or other institution for diagnosis, treatment, or a
surgical operation within the past 5 years?..............................................
B. Had any medical consultation or treatment within the past 3 years, other than as
stated in any answer above?..............................................................
-------------------------------------------------------------------------------------------------------------------------------
QUESTION FIRST NAME REASON FOR CONSULTATION DATE DURATION-RESULT NAME AND ADDRESS OF
NO. PHYSICIAN
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
DECLARATIONS
-------------------------------------------------------------------------------------------------------------------------------
I represent that the foregoing answers and statements are correctly recorded, complete, and true to the best of
my knowledge and belief. I agree that such answers and statements shall be attached to and made part of the
application.
I understand that:
1. Except as otherwise provided in any Temporary Insurance Agreement, no insurance will take effect
before the policy for such insurance is delivered and the first premium paid during the lifetime(s) and
before any change in the health of the Proposed Insured(s). Upon such delivery and payment, insurance
will take effect if the answers and statements in this application are then true.
2. All changes, including policy type and amount of insurance, benefits, classification or age at issue, must
be accepted in writing to this life insurance policy.
3. No agent or medical examiner is authorized to make or modify contracts or to waive any of the
Company's rights or requirements.
Signed and Dated in:
at ________________________________ on _____________________ X _________________________________________
CITY STATE MO. DAY YR Signature of Proposed Insured's Parent
X _________________________________________
Signature of Proposed Insured's Parent
IF OWNER IS A CORPORATION, THE SIGNATURE AND TITLE OF AN AUTHORIZED OFFICER OTHER THAN THE PROPOSED
INSURED IS REQUIRED AND THE FULL NAME OF THE CORPORATION MUST BE SHOWN.
I certify that I have truly and accurately recorded hereon the information supplied.
____________________________________ _____________________________________
Signature of Soliciting Agent Please Print Soliciting Agent Name
AP9500-P2-NY PAGE 3 OF 3 00-00000-00 04/2002
GENERAL QUESTIONNAIRE RISK AVOC
PACIFIC LIFE & ANNUITY COMPANY
000 Xxxxxxx Xxxxxx Xxxxx [Logo of PL&A]
Xxxxxxx Xxxxx, XX 00000
-------------------------------------------------------------------------------------------------------------------------------
FULL NAME (Print) DATE OF BIRTH
Mo. Day Yr.
-------------------------------------------------------------------------------------------------------------------------------
SECTION A AUTOMOBILE, MOTORCYCLE AND/OR POWER BOAT RACING
------------------ ------------------------------------------------------------------------------------------------------------
1. Type of racing? ___Midget ___Go-Kart ___Modified Stock ___ Drag Racing ___ Motorcycle
-------------------------------------------------------------------------------------------------------------------------------
___ Powerboat ___ Other (explain) _____________________________________________________
-------------------------------------------------------------------------------------------------------------------------------
2. Make? _________________ Model? _____________________ Displacement? ________________
-------------------------------------------------------------------------------------------------------------------------------
Class? _________________ Engine Make & Model? ____________________ HP? _____________
-------------------------------------------------------------------------------------------------------------------------------
3. (a) Number of races 12-24 months ago? ______________ (b) Past 12 months? ________________
-------------------------------------------------------------------------------------------------------------------------------
(c) Date of last race? ________________ (d) Est. next 12 months? ________________________
-------------------------------------------------------------------------------------------------------------------------------
4. Type of race? __ Midget __ Sports Car __ Stock Car __ Championship __ Drag __ Kart ___ Hillclimb
-------------------------------------------------------------------------------------------------------------------------------
__ Cross Country __ Hound & Hare __ Moto-Cross __ Other (explain) _______________________________________
-------------------------------------------------------------------------------------------------------------------------------
5. Type of course? __ Paved __ Dirt __ Drag Strip __ Oval __ Other (explain) __________________________
-------------------------------------------------------------------------------------------------------------------------------
___________________________________________________________________________________________________________________
-------------------------------------------------------------------------------------------------------------------------------
6. Where do you race? __ Local? If not, where? ______________________________________________________________
-------------------------------------------------------------------------------------------------------------------------------
7. Competition against? __ Other cars __ Clock __ Straightaway __ ______________________________________________
-------------------------------------------------------------------------------------------------------------------------------
8. Average Speed? __________________ Top Speed? _____________________ Average miles per race? ______________
--------------------------------------------------------------------------------------------------------------------------------
9. Is your __ Professional __ Amateur __ Other (explain)
racing? ________________________
--------------------------------------------------------------------------------------------------------------------------------
SECTION B UNDERWATER DIVING (SKIN OR SCUBA)
--------------------------------------------------------------------------------------------------------------------------------
1. What type of equipment do you use? ________________________________________________________________________________
--------------------------------------------------------------------------------------------------------------------------------
2. Location of diving activities? ________________________ Diving for pleasure? ____________ Pay? _______________
--------------------------------------------------------------------------------------------------------------------------------
3. Do you belong to club or association?_____________________ Do you ever dive alone? ________________________________
--------------------------------------------------------------------------------------------------------------------------------
4. Depths of Dives During Past 12 Months Expected Next 12 Months
--------------------------------------------------------------------------------------------------------------------------------
No. Dives Average Time No. Dives Average Time
--------------------------------------------------------------------------------------------------------------------------------
a. Less than 40 feet
--------------------------------------------------------------------------------------------------------------------------------
b. 40 feet to 60 feet
--------------------------------------------------------------------------------------------------------------------------------
c. 60 feet & Over
--------------------------------------------------------------------------------------------------------------------------------
d. Maximum depth obtained
--------------------------------------------------------------------------------------------------------------------------------
SECTION C PARACHUTE JUMPING AND SKY DIVING
--------------------------------------------------------------------------------------------------------------------------------
1. Are you now a member of any parachute or sky diving club or association? ________________________________________________
2. Are all of your jumps made under auspices of your club or association? _________________________________________________
3. (a) Number of jumps 12-24 months ago? ________________ (b) Past 12 months? _____________ (c) Next 12 months? _________
4. Do you participate in delayed chute opening competition or other stunts? ___________________________________________
5. Location of jump areas? ___________________________________ Date of last jump? _________________________________
--------------------------------------------------------------------------------------------------------------------------------
REMARKS IDENTIFY SECTION AND QUESTION
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
I represent that the foregoing answers and statements are correctly recorded, complete, and true to the best of my knowledge
and belief. I agree that such answers and statements shall be attached to and made part of the application.
Date ______________________________ X ____________________________________________________________________________
Mo. Day Year Signature of Proposed Insured (or Parent if Proposed Insured is under age 15)
__________________________________
Signature of Soliciting Agent
_______________________
Agency No.
AP7503-NY Page 1 of 2 00-00000-00 5/2000
GENERAL QUESTIONNAIRE RISK AVI
PACIFIC LIFE & ANNUITY COMPANY
000 Xxxxxxx Xxxxxx Xxxxx [Logo of PL&A]
Xxxxxxx Xxxxx, XX 00000
--------------------------------------------------------------------------------------------------------------------------------
FULL NAME (Print) DATE OF BIRTH
Mo. Day Yr.
--------------------------------------------------------------------------------------------------------------------------------
SECTION D AVIATION
--------------------------------------------------------------------------------------------------------------------------------
1. Type of Activity FOR CIVILIAN AND MILITARY PILOTS:
5. A. Type of license/certificate/rating held (CHECK
HOURS FLOWN APPROPRIATE BOXES):
----------------------------------------
__ Student __ Private __ Commercial ATR __ IFR
----------------------------------------
Last 12-24 All Prior Ext. Next B. Date of last renewal: _______________________________
12 months Mo. Ago Years 12 Mo.
---------------------------------------- C. Purpose of flights: _________________________________
Civilian Pilot
---------------------------------------- ________________________________________________________
Military Pilot
---------------------------------------- D. Total flying hours to date: _________________________
Member of Crew
---------------------------------------- E. Date of last flight: ________________________________
Yes No
2. Have you ever done or do you intend to FOR CREW MEMBERS:
engage in flying for the purpose of exhibition,
endurance tests, racing, stunt flying, testing, air 6. A. Duties aboard aircraft: _____________________________
cargo operations, crop dusting or spraying, or _____________________________________________________
instruction of student pilots?..................... B. Purpose of flights: _________________________________
_____________________________________________________
3. A. Have you ever flown or do you intend to X. Xxxx of last flight: ________________________________
fly outside of the United States?.............. D. Do you plan to take instructions as a pilot? Yes No
B. Have you ever been involved in any (IF "YES", EXPLAIN IN "REMARKS")
accident due to flying activities?.............
C. Have you ever been charged with any 7. If aviation activity does not permit standard
violation of air regulations?.................. unrestricted coverage, please issue as follows:
(IF "YES" TO QUESTIONS 2, 3A OR 3C, EXPLAIN IN ___ Full aviation coverage, if available, with
"REMARKS".) appropriate extra premium.
___ Aviation exclusion rider.
4. Describe type of aircraft flown in (including
alphabetic & numeric code).
-------------------------------------------------------------------------------------------------------------------------------
REMARKS IDENTIFY SECTION AND QUESTION
-------------------------------------------------------------------------------------------------------------------------------
_______________________________________________________________________________________________________________________________
I represent that the foregoing answers and statements are correctly recorded, complete, and true to the best of my knowledge
and belief. I agree that such answers and statements shall be attached to and made part of the application.
Date ______________________________ X______________________________________________________________________________
Mo. Day Year Signature of Proposed Insured (or Parent if Proposed Insured is under age 15)
___________________________________
Signature of Soliciting Agent
___________________________________
Agency No.
AP7503-NY Page 2 of 2 00-00000-00 5/2000
