Exhibit 1A5(a)
NEV-7
New England Variable Life
Insurance Company
Variable Life Policy
Name of Insured
XXXX XXXXX
Policy Number
Specimen
Plan
30 Payment Variable Life
Face Amount
$25,000
New England Variable Life Insurance Company Agrees to pay the Death Benefit of
this Policy to the Beneficiary on receipt of proof of the death of the Insured;
and to provide the other rights and benefits of the Policy.
These agreements are subject to all the provisions of the Policy.
Signed on the Date of Issue for the Company at its
Administrative Office,
000 Xxxxxxxx Xxxxxx
Xxxxxx, XX 00000
Xxxxxx X. Xxxxxx
/s/
President
Xxxxxx X. Xxxxxxxxx
/s/
Secretary
Variable Life Policy
. The Death Benefit is payable at the death of the Insured.
. Premiums are payable to the Company for a specified period.
. Unscheduled Payments can be made.
. The Policy does not participate in dividends.
Please Read Your Policy Carefully
This Policy is a legal contract between you and the Company.
THE DEATH BENEFIT ON THE POLICY DATE WILL BE EQUAL TO THE FACE AMOUNT SHOWN IN
SECTION 1. THEREAFTER, THE DEATH BENEFIT CAN VARY FROM DAY TO DAY. IT CAN
INCREASE OR DECREASE, DEPENDING ON SEPARATE INVESTMENT ACCOUNT PERFORMANCE AND
ON FIXED ACCOUNT INTEREST; BUT IT WILL NOT BE LESS THAN THE FACE AMOUNT. SEE
SECTION 12.
THE CASH VALUE OF THIS POLICY CAN VARY FROM DAY TO DAY. IT CAN INCREASE OR
DECREASE. DEPENDING ON SEPARATE INVESTMENT ACCOUNT PERFORMANCE AND ON FIXED
ACCOUNT INTEREST. SEE SECTION 11.
Right to Return the Policy When this Policy is issued, you should examine it.
You can return the Policy to the Company or its Agent for any reason within the
latest of: (a) 10 days after you receive it from the Company; (b) 45 days after
Part I of the Application is signed; and (c) 10 days after the Company mails the
separate Notice of Withdrawal Right If you return the Policy: an amount equal to
any premium paid plus any Unscheduled Payment made will be refunded to you; and
the Policy will be cancelled from the start.
Policy Provisions
Section
1 Policy Schedule
2 Tabular Values
3 Surrender Charges
4 Contract
5 Premiums
6 Unscheduled Payments
7 The Variable Account
8 The Fixed Account
9 Nonpayment of Premiums
10 Reinstatement After Lapse
11 Cash Value of the Policy
12 Death Benefit
13 Policy Loans
14 Exchange of Policy
15 Policy Changes
16 Owner and Beneficiary
17 Payment of Benefits
18 Payment Options
19 Life Income Tables
. Riders, if any
. Copy of the Application
. Amendments and Endorsements
Alphabetical Guide
Section
1, 4 Age of Insured
16 Assignments
5 Automatic Premium Payment
16 Beneficiary
17 Benefits, Payment of
4 Claims of Creditors
4 Contestable
4 Contract
11 Cost of Insurance
1, 4 Date of Issue
1, 4 Date, Policy
12 Death Benefit
14 Exchange of Policy
1 Face Amount
8 Fixed Account
9 Fixed Extended Term Insurance
9 Fixed Paid-Up Insurance
5 Grace Period
11 Investment Return
9 Lapse Options
18, 19 Life Income Options
19 Life Income Tables
1 Loan Interest Rate
13 Loans, Policy
11 Net Cash Value
9 Nonpayment of Premiums
11 Monthly Deduction
16 Owner
15 Partial Surrender
15 Partial Withdrawal
18 Payment Options
4 Periodic Reports
15 Policy changes
13 Policy Loan Balance
4 Postponement of Payments
5 Premiums
10 Reinstatement
1 Schedule, Policy
7 Sub-Accounts
4 Suicide
3 Surrender charge
3, 11 Surrender of the Policy
2 Tabular Value
6 Unscheduled Payments
7 Variable Account
9 Variable Paid-Up Insurance
New England Variable Life
Insurance Company
1. Policy Schedule
Owner and Beneficiary As named in the Application or as later changed. See the
Owner and Beneficiary Section of the Policy.
Policy Number Age Sex
Specimen 35 Male
Policy Date Date of Issue Policy Class
September 1, 1993 September 1, 1993 Smoker Standard
Policy Loan Interest Rate Basis of Values Interest Rate
6% 4.5%
Death Benefit Option
1
Schedule of Benefits
30 Payment Variable Life (LIFE) $25,000
Schedule of Annual Premiums
Policy Years LIFE
First 30 $499.75
Total Premium on Policy Date
Annual Semi-Annual Quarterly
$499.75 $257.37 $131.18
Table of Net Annual Premiums (Amount Invested; Based on Maximum Premium Charges)
Beginning of
Policy Year Net Premium
First 30 $404.72
Annual Administrative Charge (Reflected in Net Annual Premium) $55.00
Each Net Unscheduled Payment will be equal to the Unscheduled Payment less 9%.
Sex-distinct Issue
Xxxxxx X. Xxxxxxxxx
/s/
Secretary
New England Variable Life
Insurance Company
2. Tabular Values
Policy Number
Specimen
Tabular Values are used to determine: the Death Benefit and the partial
withdrawal available for Death Benefit Option 2; and whether the Special Premium
Option can apply.
The amounts shown in this table assume that: an annual premium has been paid on
the first day of each policy year during the Policy's premium paying period; no
Unscheduled Payment has been made; no partial surrender has been made; no
partial withdrawal has been made; no Policy Loan has been made; the cost of
insurance rates are equal to the maximum guaranteed rates; the maximum Monthly
Deduction is deducted from the Cash Value in every month; the Face Amount of the
Policy has not been decreased; the actual net premiums credited are equal to the
net annual premiums shown in Section 1; and the Actual Investment Return is
equal to the Base Investment Return. The actual Tabular Values at any time will
reflect the frequency of premium payment then in effect.
End of End of
Policy Year Tabular Value Policy Year Tabular Value
1 $ 341.50 16 $6,804.50
2 694.50 17 7,329.00
3 1,059.00 18 7,864.50
4 1,435.00 19 8,412.00
5 1,822.00 20 8,969.50
6 2,219.50 25 Age 60 11,955.00
7 2,628.00 30 Age 65 15,392.50
8 3,047.00 35 Age 70 17,050.50
9 3,476.50
10 3,917.50
11 4,368.50
12 4,831.50
13 5,306.50
14 5,793.50
15 6,292.50
Xxxxxx X. Xxxxxxxxx
/s/
Secretary
New England Variable Life
Insurance Company
3. Surrender Charge
Policy Number
Specimen
A Surrender Charge will be deducted from partial surrender, full surrender,
decrease in Face Amount and lapse transactions during the first 15 policy years.
The Surrender Charge is equal to a Deferred Sales Charge plus any Deferred
Administrative Charge.
The Maximum Deferred Sales Charges for years 1 through 10 are shown in the table
on the next page. The Maximum Deferred Sales Charges for the last policy month
of each of years 11 through 15 are shown in the table on the next page; the
Maximum Charges for other months will reflect the number of completed policy
months in the year of surrender, lapse or decrease in Face Amount. If you paid
premiums at an annual, semi-annual or quarterly frequency, the actual Deferred
Sales Charges will be less than the Maximums shown.
The Deferred Administrative Charge for the first policy year is shown in the
table on the next page; the Charge is level throughout the year. The Charge for
the last policy month of each of years 2 through 10 is shown in the table on the
next page; the Charge for other months will reflect the number of completed
policy months in the year of surrender, lapse or decrease in Face Amount.
Xxxxxx X. Xxxxxxxxx
/s/
Secretary
New England Variable Life
Insurance Company
3. Surrender Charge (Second Page)
Policy Number
Specimen
Year of
Surrender, Maximum Deferred
Decrease or Deferred Administrative
Lapse Sales Charge Charge
1. $104.52 $67.50
2. 120.08 60.00
3. 266.85 52.50
4. 266.85 45.00
5. 266.85 37.50
6. 266.85 30.00
7. 266.85 22.50
8. 266.85 15.00
9. 266.85 7.50
10. 266.85 0.00
11. 213.48
12. 160.11
13. 106.74
14. 53.37
15. 0.00
Xxxxxx X. Xxxxxxxxx
/s/
Secretary
4. Contract
The Contract
This Policy is a legal contract between the Owner of the Policy (called "you")
and New England Variable Life Insurance Company, a Delaware corporation, (called
"the Company"). The Policy, which includes the attached Application, is the
entire contract between you and the Company. All riders are listed in Section 1.
A change in or waiver of the provisions of the Policy must be signed by the
President or the Secretary of the Company to be valid.
Payments Under the Contract
All contract amounts are in dollars of the United States of America. Payments by
the Company under the contract will be made at the Administrative Office of the
Company. The obligations of the Company are subject to all payments made and
actions taken by the Company under the Policy before receipt by the Company at
its Administrative Office of proof of death of the Insured.
Dates
Policy years, months and anniversaries are all measured from the Policy Date.
The contestable and suicide periods start on the Date of Issue. The Policy Date
and the Date of Issue are both shown in Section 1.
Not Contestable After Two Years
Insurance is issued by the Company in reliance on the statements made in the
Application for the insurance. Those statements are representations; they are
not warranties. No statement can be used to contest or rescind insurance or to
defend against a claim unless contained in the Application for the insurance.
The insurance issued under this Policy will not be contestable after it has been
in force during the life of the Insured:
. With respect to the amount of Death Benefit which results from other than
Unscheduled Payments, for two years from the Date of Issue; and
. With respect to any Death Benefit which results from an Unscheduled
Payment for which proof is required that the insured is insurable, for two
years from the date that Unscheduled Payment is received.
Suicide Within Two Years
If the Insured dies by suicide while sane or insane within two years from the
Date of Issue, the Death Benefit will be limited to: the amount of the premiums
paid; plus the amount of any Unscheduled Payments; less the amount of each
partial surrender; less the amount of each partial withdrawal; less any Policy
Loan
Balance on the date of death.
Age of Insured
The age of the Insured on the Policy Date and on policy anniversaries means the
age at the nearest birthday of the Insured. Between anniversaries, age means age
on the last anniversary plus elapsed time.
If the age or sex of the Insured has not been correctly stated in the
application, the values and benefits will be the amounts which the premiums and
Unscheduled Payments paid would have purchased for the correct age and sex.
The Company will reprocess each policy transaction to determine the current Cash
Value and Death Benefit based on the correct cost of insurance rates.
Claims of Creditors
The Policy and payments under it will be exempt from the claims of creditors to
the extent allowed by law.
Basis of Values
"1980 CSO" means Commissioners 1980 Standard Ordinary; it is used to describe
mortality tables. The B Tables are used for unisex issues and are weighted 80
per cent male and 20 per cent female. The Policy Class and issue basis are shown
in Section 1. Unisex issues provide the same rates, benefits and values for
males and females.
If the Policy is in a Nonsmoker Class, the table is the 1980 CSO Nonsmoker
Table.
If the Policy is in a Smoker Class, the table is the 1980 CSO Smoker Table.
If the age of the Insured on the Policy Date is less than 20, the table is the
1980 CSO Table.
Reserves and Cash Values are not less than those based on the mortality table
for this Policy. Reserves are not less than reserves computed by the
Commissioners Reserve Valuation Method. Net single premiums, Fixed and Variable
Paid-Up Insurance and Fixed Extended Term Insurance are based on the mortality
table for this Policy. Curtate monthly functions are used. Interest is
compounded monthly at the annual effective rate shown in Section 1. (See the
Basis of Values Interest Rate.) A detailed statement of the method of computing
values and net single premiums has been filed with the Insurance Department of
the state in which the Policy is delivered. All values are equal to or are in
excess of the minimum values required by, and all comply with, the law of that
state.
Periodic Reports
The Company will send you all reports required by law and regulation. Such
reports will be sent once each year or more often if required by law or
regulation. The annual report will include, as of the date for which the report
is made: the Death Benefit: the Cash Value; any Policy Loan Balance; and any
other required information. No annual reports will be sent while the Policy is
in force under the Fixed Paid-Up Insurance Option or the Fixed Extended Term
Insurance Option.
Postponement of Variable Benefits
The Company can postpone the determination of and the payment or transfer of
amounts based on separate investment account performance if:
. The New York Stock Exchange is closed for trading (except for normal
weekend and holiday closing) or when trading is restricted; or
. The Securities and Exchange Commission determines that a state of
emergency exists which may make payment or transfer impractical; or
. The Securities and Exchange Commission orders the New England Zenith Fund
or its successor or any other investment company in which the Variable
Account is invested to postpone payment or transfer of variable benefits.
Postponement of Loans and Surrender Under Fixed Lapse Options
If the Policy is in force under the Fixed Paid-Up or Fixed Extended Term
Insurance Option, the Company can postpone payment of the Net Cash Value for not
more than six months after surrender. If payment is postponed for more than 30
days it will be credited with interest from the date of surrender. The rate of
interest will be set each year by the Company; but the rate will not be less
than 3 1/2% per year.
If the Policy is in force under the Fixed Paid-Up Insurance Option, the Company
can postpone the making of any Policy Loan for not more than six months from the
day you apply, except Loans to pay premiums on policies issued by the Company.
Postponement of Surrenders, Transfers and Loans From The Fixed Account
The Company can postpone the payment of the portion of the Policy's Net Cash
Value which is in the Fixed Account for not more than six months after
surrender. If payment is postponed for more than 30 days, it will be credited
with interest from the date of surrender. The rate of interest will be set each
year by the Company; but the rate will not be less than 3 1/2% per year.
The Company can postpone transfers from the Fixed Account for not more than six
months from the date of the request. The effective date of the transfer is the
date on which values are transferred from the Fixed Account.
The Company can postpone the making of any Policy Loan from the Fixed Account
for not more than six months from the day you apply, except Loans to pay
premiums on policies issued by the Company.
5. Premiums
Payment
Premiums are scheduled payments to the Company for the Policy. Payments can be
made at the Administrative Office of the Company or at any Agency of the
Company. A receipt for payment signed by the Secretary of the Company will be
given on request. The Policy will not be in force until the first premium is
paid.
Amount and Frequency
Annual premiums for the Policy and for any riders are shown in Section 1.
Payments can be annual, semi-annual or quarterly or can be at any other
frequency agreed to by the Company. Payment is due in advance on the first day
of each payment period, starting on the Policy Date. Future Cash Values and
Death Benefits can be permanently affected:
. By payment of premiums at a frequency other than annual; and
. By changing the frequency of payment of premiums.
No premium will be due or payable for any period after the death of the Insured.
The company will send you a bill 25 days before the premium due date if you pay
premiums at an annual, semi-annual or quarterly frequency. The bill will show:
the premium due; any policy loan interest due; and any planned Unscheduled
Payment, if the premium due date is a policy anniversary. If you submit the bill
with a payment, the premium due will be paid, if the payment is large enough.
The amount of the payment which is in excess of the premium due will be used to
pay any policy loan interest due. Any remaining amount will be an Unscheduled
Payment. (See Section 6.) If you submit a payment without a bill, the payment
will be deemed to be the premium due if: the payment is received in the period
between 25 days prior to the premium due date and 31 days after the premium due
date; and the payment is large enough to pay the premium due. The amount of the
payment which is in excess of the premium due will be used to pay any policy
loan interest due; any remainder will be an Unscheduled Payment. Any payment
received that is less than the premium due will be deemed an Unscheduled
Payment. (See Section 6.)
If you pay premiums at any other frequency, each payment will be credited as
agreed to by you and the Company.
Grace Period
There is a grace period of 31 days in which to pay a premium, without interest,
after its due date. The insurance will be in force during the grace period.
There is no grace period for the first premium.
Special Premium Option
If you choose this Option in writing it will take effect after the first policy
year. When this Option is in effect, each time a premium has not been paid by
the end of its grace period, the Company will determine if the Option will
apply. This Option will apply if the following conditions are met:
. On the due date of the premium in default, the Cash Value less the
Tabular Value is equal to or greater than the total of the Policy and rider
premiums in default; and
. Use of the Option will not result in the Policy Loan Balance exceeding
the Loan Value of the Policy.
If the Option is applied, the Company will not require payment of the policy
premium less any substandard premium. The Company will deduct from the Cash
Value 91% of each of the following:
. Any substandard premium, if the Policy is in other than a Standard Policy
Class;
. Any rider premium in default; and
. The administrative charge for the policy premium.
If the premiums are being paid at a frequency other than annual, the amount of
the payment not required and the deduction will reflect the frequency of premium
payment.
The amount will be deducted in the same proportion as the Cash Value of the
Policy is in the sub-accounts and the Fixed Account. If this Option is applied,
the Policy will not lapse for nonpayment of the premium.
If you have chosen both this Option and the Option for Automatic Premium Payment
by Policy Loans, the Company first will determine if this Option will apply. If
this Option cannot be applied, the Company will determine if the Option for
Automatic Premium Payment by Policy Loans will apply.
You can choose in writing to use or to cancel the Special Premium Option.
Use of this Option can have a permanent effect on Cash Values and Death
Benefits.
Option for Automatic Premium Payment by Policy Loans
If this Option has been chosen in writing and a premium is not paid by the end
of its grace period, a premium will be paid using any available Loan Value of
the Policy as long as the Special Premium Option is not applied. (See Section
13.) If the unpaid premium is an annual or a semi-annual premium, it will be
paid in full, if possible. Otherwise, a premium will be paid to the next
quarterly due date, if possible. If the amount available is not enough to pay a
premium to the next quarterly due date, no premium will be paid. Loan interest
will be charged on automatic Policy Loans from the due date of the premium. You
can choose in writing to use or to cancel this Option.
Premium Adjustment at Death
The pro rata portion of any premium paid for a period beyond the date of death
will be added to the policy proceeds. This adjustment does not apply to Variable
Paid-Up, Fixed Paid-Up or Fixed Extended Term Insurance.
If the Insured dies during the grace period of an unpaid premium, the policy
proceeds will be reduced by a pro rata premium to the date of death.
6. Unscheduled Payments
Unscheduled Payments
Unscheduled Payments can be made subject to the following:
. The Policy must be in force on a premium paying basis; and
. The premiums for the Policy and any riders are not being waived under any
Waiver of Premiums rider attached to the Policy; and
. No Unscheduled Payment can be less than $25 except with the consent of the
Company; and
. No Unscheduled Payment can be made after the premium paying period except
with the consent of the Company; and
. If an Unscheduled Payment would increase the Death Benefit by more than
it would increase the Cash Value, proof that the Insured is insurable and
the Company's consent will be required; and
. If the Policy is in other than a Standard Policy class, the Company's
consent will be required.
Unscheduled Payments will not be waived by the Company under any Waiver of
Premiums rider attached to the Policy.
Each net Unscheduled Payment (see Section 1) will be applied to the Policy as of
the date it is received by the Company at its Administrative Office. There is no
grace period for Unscheduled Payments.
If the Policy lapses and you made an Unscheduled Payment during the grace period
of the premium in default, the amount of the Unscheduled Payment will be
refunded to you.
7. The Variable Account
The Variable Account
The Variable Account (called "the Account") is a separate investment account
established by the Company in accordance with Delaware law. The assets of the
Account are owned by the Company. The assets of the Account will be used to
provide values and benefits under this Policy and similar policies; but the
Account is not chargeable with liabilities arising out of any other business the
Company may conduct.
Sub-Accounts
The Account consists of sub-accounts, each of which is invested in shares of one
portfolio of the New England Zenith fund or its successor or any other
investment company in which the Account is invested. Shares of a portfolio are
purchased for a sub-account at their net asset value.
The Policy's first investment is made in the Money Market sub-account as of the
latest of:
. The Policy Date;
. The date of Part II of the Application, if any is required; and
. The date the first premium is received by the Company.
The Policy's Cash Value will be transferred, based on your choice, to the sub-
accounts and the Fixed Account as of the later of: 45 days after Part I of the
Application is signed; and 10 days after the Company mails the separate Notice
of Withdrawal Right. Before this transfer, the values and benefits of the Policy
will depend on the net investment performance of the Money Market sub-account.
After this transfer: each net premium allocated to the Account will be invested
in the sub-accounts you chose as of its due date; and each net Unscheduled
Payment allocated to the Account will be invested in the sub-accounts you chose
as of the date it is received by the Company at its Administrative Office.
Each distribution of income, dividends and capital gains from a portfolio to a
sub-account will be reinvested for the benefit of the owners of the policies in
that sub-account at net asset value in shares of the portfolio which made the
distribution.
The Cash Value of the Policy at any time cannot be allocated among more than 10
sub-accounts, except with the consent of the Company; and the Fixed Account will
be counted in the limit of 10.
The values and benefits of a policy depend on: the investment performance of
the portfolios in which the sub-accounts are invested; and the interest credited
to the Fixed Account. The Company does not guarantee the investment performance
of the portfolios of the sub-accounts. You bear the investment risk for amounts
invested in the sub-accounts for your Policy.
Choice of Sub-Accounts
You choose the sub-accounts in which net premiums and net Unscheduled Payments
are to be invested. You can change the choice for future premiums and future
Unscheduled Payments at any time by notice to the Company. The portion of the
net premium and the net Unscheduled Payment to be applied to each sub-account
chosen must be a whole percent not less than 10.
The portfolios as of the Date of Issue are listed in the then current prospectus
for the Account.
Change in Portfolios
The Company can add or remove portfolios as sub-account investments as permitted
by law. When a change is made, the Company will send you: a revised prospectus
for the Account which will describe all of the portfolios then available in the
New England Zenith Fund or its successor or any other investment company in
which the Account is invested; and any notice required by law.
When a portfolio is removed. the Company has the right to substitute a different
portfolio in which the sub-account will then invest:
. The value of the removed portfolio; and
. Future net premiums and future net Unscheduled Payments applied to that
sub-account.
Transfer Option
After the Right to Return the Policy period you can transfer all or a portion of
the Policy's existing share of a sub-account to another sub-account or to the
Fixed Account. (See Restriction of New Amounts Applied to the Fixed Account
provision.) Requests for transfers can be made in writing or by telephone. The
Company is not responsible for determining the authenticity of transfer
instructions received by telephone. Transfers will be subject to a limit of 4
in each policy year, except with the consent of the Company.
Change of Investment Policy
The investment policy of the Account will not be changed unless: (a) the change
has been approved by the Insurance Commissioner of the state of Delaware; and
(b) a statement of the approval process has been filed with the Insurance
Department of the state in which this Policy is delivered. If the investment
policy of the Account is changed, the Company will give you written notice of
the change. You can then choose to exchange this Policy for a new policy which
has a fixed death benefit. The exchange will be on the same basis as that
described in the Exchange of Policy section. (See Section 14.) If you choose to
make the exchange, the request for the exchange must be made within 60 days of
the later of: (a) the effective date of the investment policy change; or (b) the
date you receive the notice of the change.
Rights Reserved by the Company
The Company reserves the right to take certain actions subject to
compliance with law including, if required, the approval of the owners of the
policies. These actions are: (a) to create new investment accounts; (b) to
combine any two or more separate investment accounts, including the Account; (c)
to invest some or all of the assets of the Account other than in the New England
Zenith Fund; (d) to invest some or all of the assets of the Account in any other
investment company chosen by New England Variable Life Insurance Company; (e) to
remove a portfolio in which the sub-account is invested or to substitute a
different portfolio; (f) to operate the Account as a management investment
company and to charge investment advisory fees under the Investment Company Act
of 1940 or to operate the Account in any other form permitted by law; and (g) to
deregister the Account under the Investment Company Act of 1940 if registration
is no longer required.
8. The Fixed Account
The Fixed Account
The Fixed Account is a segmented fund within the general account of the Company.
If you choose the Fixed Account, the first date on which money is applied to the
Fixed Account for the Policy is the latest of:
. 45 days after Part I of the Application is signed;
. 10 days after the Company mails the separate Notice of Withdrawal Right;
and
. The effective date of the choice of the Fixed Account.
Before this date, the value of the portion of the net premium and any net
Unscheduled Payment allocated to the Fixed Account will depend on the net
investment performance of the Money Market sub-account of the Variable Account.
After this date: each net premium allocated to the Fixed Account will be applied
as of its due date; and each net Unscheduled Payment allocated to the Fixed
Account will be applied as of the date it is received by the Company at its
Administrative Office. Each transfer to the Fixed Account will be applied as of
the transfer date.
Fixed Account Interest
The rate of interest for each amount applied to the Fixed Account: will be the
rate set by the Company in advance for the date the amount is applied to the
Fixed Account; and will not be less than a rate equivalent to an annual
effective rate of 4.5%. The effective interest rate used on your Policy will be
the weighted average of all such rates for your Policy.
Each year, on the policy anniversary, the Company will determine a portion, if
any of the Policy's share of the Fixed Account
which will be reinvested at the rate effective on that date.
Interest will be credited to the Fixed Account on a daily basis.
Restriction of New Amounts Applied to the Fixed Account
The Company reserves the right to restrict new amounts applied to the Fixed
Account if the rate of interest that would be used for the new amount is a rate
equivalent to an annual effective rate of 4.5%.
Transfers Out of the Fixed Account
You can transfer a limited portion of the Policy's share of the Fixed Account to
the sub-accounts once within 30 days before each policy anniversary. The
transfer will be limited to the greater of: 25% of the Policy's share of the
Fixed Account; and the amount of the Policy's share of the Fixed Account
transferred to the sub-accounts the prior year. Requests for transfers can be
made in writing or by telephone. The Company is not responsible for determining
the authenticity of transfer instructions received by telephone.
Choice of the Fixed Account
You can choose to have net premiums and net Unscheduled Payments applied to the
Fixed Account. You can change the choice for future net premiums and future net
Unscheduled Payments at any time by notice to the Company in writing. (See the
Restriction of New Amounts Applied to the Fixed Account provision.) The portion
of the net premium and net Unscheduled Payment to be applied to the Fixed
Account must be a whole percent not less than 10.
9. Nonpayment of Premiums
Lapse of Policy
Any premium which is not paid by its due date is in default. If it remains
unpaid at the end of its 31-day grace period and is not paid automatically under
one of the options in Section 5, the Policy will lapse and Unscheduled Payments
cannot be made. If the Policy lapses to Fixed Paid-Up Insurance or Fixed
Extended Term Insurance, it will not be affected by: the investment performance
of the Account; and the interest rates used for the Fixed Account.
Lapse Options
If the Policy lapses because a premium is not paid, any Net Cash Value of the
Policy less the amount of each partial surrender and partial withdrawal made
during the grace period of the premium in default will be: transferred from the
Fixed Account and the Account to the general account of the Company and used to
continue the Policy in force either as Fixed Paid-Up Insurance or Fixed Extended
Term Insurance as stated below; or left in the Fixed Account and the Account and
used to continue the Policy in force as Variable Paid-Up Insurance as stated
below. Any riders will lapse unless otherwise stated in the rider. Any Policy
Loan Balance will be cancelled when the Net cash Value is used for this purpose.
Choice of Lapse Option
If the Policy is in a Standard Policy Class (see Section 1), the use of the
Fixed Extended Term Insurance Option at lapse will be automatic unless you
choose the Fixed Paid-Up Insurance Option or the Variable Paid-Up Insurance
Option. You can make or change your choice at any time in writing, but not later
than 60 days after the due date of the premium in default. Unless Variable Paid-
Up Insurance applies:
. If the Net Cash Value less the amount of each partial surrender and partial
withdrawal made during the grace period of the premium in default will
provide an amount of Fixed Paid-Up Insurance equal to or greater than the
amount of Fixed Extended Term Insurance, the Fixed Paid-Up Insurance Option
will be used; and
. If the Insured dies within 60 days after the due date of the premium in
default, the Fixed Option which will provide the greater death benefit will
be used.
If the Policy is in other than a Standard Policy Class, only the Fixed Paid-Up
Insurance Option is available.
Fixed Paid-Up Insurance Option
Fixed Paid-Up Insurance is permanent life insurance for a level amount with no
premiums due. It has increasing Cash Values and Loan Values. The amount of Fixed
Paid-Up Insurance is payable at the death of the Insured.
Fixed Paid-Up Insurance will be provided by using the Net Cash Value of the
Policy less the amount of each partial surrender and partial withdrawal made
during the grace period of the premium in default as a net single premium at the
age of the Insured on the due date of the premium in default.
Fixed Extended Term Insurance Option
(Available only if the Policy is in a Standard Policy Class.) Fixed Extended
Term Insurance is life insurance for a level amount for a limited term with no
premiums due. It has Cash Values, but no Loan Value. The amount of Fixed
Extended Term Insurance is payable only if the Insured dies prior to the end of
the term.
Fixed Extended Term Insurance will be provided by using the Net Cash Value of
the Policy less the amount of each partial surrender and partial withdrawal made
during the grace period of the premium in default as a net single premium at the
age of the Insured on the due date of the premium in default. The amount of
Fixed Extended Term Insurance will equal the Death Benefit of the Policy on the
due date of the premium in default.
Variable Paid-Up Insurance Option
Variable Paid-Up Insurance is available:
. If the Policy is in a Standard Policy Class; and
. If the Initial Amount of Variable Paid-Up Insurance is at least $5,000.
If you chose this Option and the Initial Amount of Variable Paid-Up Insurance is
less than $5,000, Fixed Paid-Up Insurance will be provided.
Variable Paid-Up Insurance is permanent life insurance with no premiums due. The
Initial Amount of Variable Paid-Up Insurance
will be determined by using the Net Cash Value less the amount of each partial
surrender and partial withdrawal made during the grace period of the premium in
default as a net single premium at the age of the Insured on the due date of the
premium in default.
The Death Benefit will be equal to: the greater of the Variable Death Benefit
and the Initial Amount of the Variable Paid-Up Insurance; less any Policy Loan
Balance. The Variable Death Benefit for the first policy month after lapse is
equal to the Initial Amount. The Variable Death Benefit for each later policy
month is adjusted on the first day of that policy month. For each policy month
after the first, the Variable Death Benefit:
. Will increase if the Policy's Actual Investment Return for the Period plus
any cost of insurance adjustment is greater than the Base Investment
Return;
. Will remain the same if the Policy's Actual Investment Return for the
Period plus any cost of insurance adjustment is equal to the Base
Investment Return; and
. Will decrease if the Policy's Actual Investment Return for the Period plus
any cost of insurance adjustment is less than the Base Investment Return.
(See Actual Investment Return and Base Investment Return, Section 11.)
The amount by which the Variable Death Benefit will change each policy month is
equal to:
. The dollar amount by which the Policy's Actual Investment Return for the
Period plus any cost of insurance adjustment is greater or less than its
Base Investment Return;
DIVIDED BY
. The Net Single Premium per $1.00 of Variable Death Benefit at the age of
the Insured on the first day of the policy month.
The cost of insurance adjustment, if any, to be added to the Policy's Actual
Investment Return for the Period to compute the Variable Death Benefit is equal
to the difference between the maximum guaranteed cost of insurance and the
actual cost of insurance for the Policy.
Variable Paid-Up Insurance has Cash Values and Loan Values. The Cash Value and
Loan Value can increase or decrease on a daily basis, depending on: the
investment performance of the chosen sub-accounts; and the interest credited to
the Policy's share of the Fixed Account. (See Actual Investment Return, Section
11.)
The Cash Value of the Variable Paid-Up insurance is equal to: the Policy's share
of the chosen sub-accounts; plus the Policy's share of the Fixed Account; plus
the amount of any assets transferred to the general account of the Company
because of Policy Loans. (See Section 13.) The amount of the Cash Value depends
on: investment performance of the chosen sub-accounts; interest credited to the
Policy's share of the Fixed Account; cost of insurance charges; transfers among
sub-accounts and the Fixed Account; and Policy Loans.
The cost of insurance is deducted from the Cash Value:
. On the last day of each policy month; and
. On the date the Policy is surrendered if it is other than the last day of
the policy month.
The cost of insurance will be deducted in the same proportion as the Cash Value
of the Policy is in the sub-accounts and the Fixed Account.
The cost of insurance depends on the cost of insurance rate at the time of the
deduction and on the difference between the Variable Death Benefit and the Cash
Value on the last day of the month. The cost is pro rated in the event of
surrender during a policy month. (See Cost of Insurance Rates, Section 11.)
If a Policy Loan Balance exists and the Net Cash Value is not enough to cover
the cost of insurance, the difference will be treated in the same manner as an
excess Policy Loan. (See Section 13.)
The Loan Value of the Variable Paid-Up Insurance is described in Section 13.
10. Reinstatement After Lapse
Reinstatement
The Policy and riders can be reinstated at any time. (See Limitations on
Reinstatement below.) Reinstatement will be subject to:
. Application to reinstate; and
. Proof that the Insured is then insurable if reinstatement is applied for
more than 31 days after the end of the grace period of the premium in
default; and
. Payment, while the Insured is living, of the cost to
reinstate; and
. Payment or reinstatement of any Policy Loan Balance on the due date of the
premium in default, plus interest that would have accrued if the Policy had
not lapsed; and
. Payment or reinstatement of each partial surrender and partial withdrawal
made during the grace period of the premium in default.
The cost to reinstate is the greater of: (a) each unpaid premium plus interest
at the rate of 5% per year compounded yearly; and (b) 110% of any increase in
the Cash Value as the result of the reinstatement plus each unpaid rider premium
with interest at the rate of 5% per year compounded yearly.
If Fixed Extended Term Insurance is in force under Section 9, and there are at
least five years of the term left, proof that the Insured is insurable will not
be required to reinstate the Policy; but it may be required to reinstate riders.
If Policy Loans were made while the Policy was in force as Paid-Up insurance and
the Loans are not repaid, they will continue in force after the Policy is
reinstated.
Limitations on Reinstatement
The Policy and riders cannot be reinstated, except with the consent of the
Company:
. If more than seven years have passed since the due date of the premium in
default; or
. If the Policy has been surrendered for its Net Cash Value. (See Section
11.)
Any rider which provides life or disability insurance on a person other than the
Insured can be reinstated only as stated in the rider.
11. Cash Value of the Policy
Surrender of the Policy
You can surrender the Policy for its Net Cash Value at any time by notice to the
Company in writing. Upon surrender, the Policy will be cancelled. The Net Cash
Value will be paid to you in one sum, unless you choose in writing to apply all
or part of the Value to any Payment Option. (See Payment of Benefits, Section
17.)
Net Cash Value
The Net Cash Value of the Policy is equal to:
. The Cash Value of the Policy;
LESS
. Any Policy Loan Balance;
LESS
. Any Surrender Charge. (See Section 3.)
Cash Value
The Cash Value of the Policy will depend on the net investment performance of
the Money Market sub-account until the later of: 45 days after Part I of the
Application is signed; and 10 days after the Company mails the separate Notice
of Withdrawal Right. Thereafter, the Cash Value of the Policy if all premiums
due have been paid is equal to: the Policy's share of the chosen sub-accounts;
plus the Policy's share of the Fixed Account; plus the amount of any assets
transferred to the general account of the Company because of Policy Loans. (See
Section 13.) The amount of the Cash Value depends on: the frequency and amount
of net premiums; the frequency and amount of net Unscheduled Payments;
investment performance of the chosen sub-accounts; interest credited to the
Policy's share of the Fixed Account; Monthly Deductions; cost of insurance
charges; partial surrenders; partial withdrawals; decreases in Face Amount; the
use of the Special Premium Option; transfers among sub-accounts and the Fixed
Account; and Policy Loans. The Cash Value can increase or decrease on a daily
basis, depending on: the actual investment performance of the chosen sub-
accounts; and the interest credited to the Policy's share of the Fixed Account.
(See Actual Investment Return below.)
For 60 days after the due date of a premium in default, the Cash Value will not
be less than the Cash Value on the due date plus or less the Actual Investment
Return from the due date to the date of the calculation.
If the Policy is in force under the Fixed Paid-Up Insurance Option or the Fixed
Extended Term Insurance Option: the Cash Value of the Policy on any date is
equal to the net single premium which would be required to provide the insurance
at the age of the Insured on that date; and for 31 days after each policy
anniversary, the Cash Value will not be less than on the anniversary.
The Cash Value of the Policy is not increased by the Cash Value of any rider,
unless stated in the rider.
Monthly Charges
If the Policy is not lapsed, monthly charges are deducted from the Cash Value of
this Policy on the first day of each policy month for that policy month: for the
Monthly Deduction, only during the Policy's premium paying period; and for the
cost of insurance in all policy years. As long as the Cash Value less the Policy
Loan Balance is sufficient to pay the entire monthly charges, the monthly
charges will be deducted in the same proportion as the Cash Value of the Policy
is in the sub-accounts and the Fixed Account.
If a Policy Loan Balance exists and the Cash Value less the Policy Loan Balance
is not enough to cover the monthly charges, the difference will be treated in
the same manner as an excess Policy Loan. (See Section 13.)
The Monthly Deduction consists of an administrative charge and a minimum death
benefit guarantee charge. The maximum amount of the Monthly Deduction due for a
policy month is equal to 0.00005 times the Face Amount.
The monthly cost of insurance is equal to: the amount at risk; times the cost of
insurance rate per $1000 for that month divided by 1,000. The amount at risk is
equal to:
. The Death Benefit on the first day of the policy month discounted at the
monthly equivalent of 4.5% per year:
LESS
. The Cash Value on the first day of the policy month after the Monthly
Deduction, if any, has been processed.
Cost of Insurance Rates
The cost of insurance rates for each policy month are based on: the sex of the
Insured; the class of the Policy; and the age of the Insured on the first day of
the policy year. The rates will be set by the Company each year on the policy
anniversary, based on the expectations of the Company as to future experience
with regard to investment earnings, mortality, expenses and lapse rates. The
rates are guaranteed for one year. The rates are guaranteed not to be greater
than those based on the mortality table for the Policy. (See Basis of Values.)
Monthly Cost of Insurance Adjustment At Surrender
The pro rata portion of any monthly cost of insurance deduction made for a
period beyond the date of surrender will be added to the surrender proceeds.
Base Investment Return
The Policy has a Base Investment Return for each Valuation Period
for its share of each chosen sub-account and of the Fixed Account. The Policy's
Base Investment Return is the amount which would be earned by the Policy's share
if each sub-account had investment performance and the Fixed Account had
interest credited at a rate equivalent to an annual effective rate of 4.5% per
year. The Base Investment Return is used in the determination of: the Tabular
Value; and the Variable Death Benefit under the Variable Paid-Up Insurance
Option.
Actual Investment Return
The Policy has an Actual Investment Return for each Valuation Period for its
share of each chosen sub-account and of the Fixed Account. The Policy's Actual
Investment Return for each sub-account for each Valuation Period is equal to (a)
minus (b); where:
. (a) is equal to the Policy's share of the sub-account as of the end of the
Valuation Period;
PLUS
the monthly charges deducted in the Valuation Period:
LESS
any net premium and net Unscheduled Payment credited during the Valuation
Period;
PLUS
the total of the partial surrenders and partial withdrawals made during the
Valuation Period;
PLUS
the interest credited during the Valuation Period to any borrowed portion
of the Policy's Cash Value;
PLUS or LESS
a charge or credit for the Policy's share of any reserve for taxes which
the Company determines to apply to the sub-account; and
. (b) is equal to the Policy's share of the sub-account as of the end of the
most recent Valuation Period;
PLUS or LESS
a charge or credit for the Policy's share of any reserve for taxes which
the Company determines to apply to the sub-account.
The Actual Investment Return for the Fixed Account for each Valuation Period is
equal to (a) minus (b); where:
. (a) is equal to the Policy's share of the Fixed Account as of the end of
the Valuation Period;
PLUS
the monthly charges deducted in the Valuation Period;
LESS
any net premium and net Unscheduled Payment credited during the Valuation
Period;
PLUS
the total of the partial surrenders and partial withdrawals made during the
Valuation Period;
PLUS
the interest credited during the Valuation Period to any borrowed portion
of the Policy's Cash Value; and
. (b) is equal to the Policy's share of the Fixed Account as of the end of
the most recent Valuation Period.
There is a daily charge for mortality risk and expense risk against the Policy's
share of the sub-accounts. This charge will not be greater than: a rate
equivalent to .90% per yea; or, if less, the rate allowed by federal securities
law.
Valuation Periods and Valuation Dates
A Valuation Period for each sub-account is a period:
. Which starts on a Valuation Date: and
. Which ends on the next succeeding Valuation Date.
Each day the New York Stock Exchange is open for trading is a Valuation Date.
12. Death Benefit
Death Benefit
The amount of the Death Benefit will depend on the Death Benefit Option in
effect on the date of death. The amount payable will be reduced by any Policy
Loan Balance on the date of death.
Death Benefit Option
This Policy offers two Death Benefit Options. The Death Benefit Option will be
as chosen in the Application. The Death Benefit Option is shown in the Policy
Schedule.
Option 1
The Death Benefit on the date of death is equal to:
. The Face Amount shown in Section 1; or, if greater,
. The Cash Value divided by the net single premium at the attained age of the
Insured.
Option 2
The Death Benefit on the date of death is equal to:
. The Face Amount shown in Section 1 plus any excess of the Cash Value over
the Tabular Value; or, if greater,
. The Cash Value divided by the net single premium at the attained age of the
Insured.
13. Policy Loans
Policy Loans
After the Right to Return the Policy period you can borrow all or part of the
Loan Value of the Policy by written request to the Company. Policy Loans are
made on the sole security of the Policy. The amount you can borrow at any time
is equal to the Loan Value less any Policy Loan Balance at that time. Policy
Loans may be made automatically to pay premiums. (See Option for Automatic
Premium Payment, Section 5.) Unless you request otherwise, Policy Loans will
reduce first, the Policy's share of the sub-accounts proportionately and second,
the Policy's share of the Fixed Account, except as noted below in the Interest
on Loans; Policy Loan Balance provision. Assets equal to the amount of the Loan:
. Will be transferred to the general account of the Company; and
. Will earn interest at the effective rate per year of not less than: the
Policy Loan interest rate; less 1.5%.
Policy Loans, whether or not repaid, can have a permanent effect on Cash Values
and Death Benefits.
Loan Value
Unless the Policy is lapsed for Fixed Paid-Up Insurance or Fixed Extended Term
Insurance, the Loan Value of the Policy is the amount which with loan interest
will equal: 90% of the Cash Value of the Policy projected to the next policy
anniversary or, if earlier, to the next premium due date: less the Surrender
Charge on the next loan interest due date or, if greater, on the date the loan
is made. The Cash Value will be projected with interest at the effective rate
per year of 1.5% less than the Policy Loan interest rate.
If the Policy is in force under the Fixed Paid-Up Insurance Option, the Loan
Value is the amount which with loan interest will equal the Cash Value of the
Policy on the next loan interest due date. The Policy has no Loan Value while it
is in force as Fixed Extended Term Insurance. (See Section 9.)
Interest on Loans; Policy Loan Balance
Policy Loans bear interest as shown in Section 1. Interest accrues daily. The
Policy Loan Balance at any time means Policy Loans outstanding plus interest
accrued to date. Loan interest is due on the annual premium anniversary date
each year. Loan interest not paid when due will be added to the Loan and will
bear interest; when loan interest is added to the Loan, the Policy's share of
the sub-accounts and of the Fixed Account will be reduced proportionately.
Repayment of Loans
Policy Loans may be repaid to the Company at any time in whole or in part. Loan
repayments will be allocated: first, to repay the Loans made against the Fixed
Account; and second, unless you request otherwise, to repay the Loans made
against the sub-accounts in the same proportion as the Policy is invested in the
sub-accounts. A Policy Xxxx is a charge against the Policy. The proceeds of the
Policy will be reduced by any Policy Loan Balance on the date of death of the
Insured. If the Policy Loan Balance at any time exceeds the Cash Value of the
Policy less the Surrender Charge on the next loan interest due date or, if
greater, on the current Valuation Date (called "excess Policy loan"), the
Company will mail a notice to you and to any assignee. The notice will be mailed
to the addresses on record with the Company. If the excess amount is not paid to
the Company within 31 days after mailing of the notice, the Policy will lapse
without value.
14. Exchange of Policy
Exchange of Policy
Within 24 months after its Date of Issue, you can exchange this
Policy, if all premiums due have been paid, for a policy which provides fixed
benefit insurance. The new policy will be issued:
. By New England Mutual Life Insurance Company;
. On any plan of Whole Life or Endowment insurance with a level face amount
issued by New England Mutual Life Insurance Company on the Policy Date;
. With the same Insured, Age, Policy Date, Face Amount and underwriting class
as this Policy;
. Subject to any cost or credit and the repayment of any Policy Loan Balance;
and
. Subject to any assignments of this Policy, and limitations on this Policy
stated in riders.
Riders which provide benefits that are the same as those provided by riders on
this Policy will be attached to the new policy, if they are available.
Change Cost or Credit
Any change cost or credit will be quoted by the Company on request.
A detailed statement of the method of computing the change cost or credit has
been filed with the Insurance Department of the state in which the Policy is
delivered.
15. Policy Changes
Decrease in Face Amount
The Face Amount may be decreased by written request to the Company, if the
Company consents. No portion of the Cash Value will be paid to you. A Surrender
Charge will apply to a decrease in Face Amount. A decrease in Face Amount will
result in a decrease in premiums and Tabular Values. The Cash Value after the
decrease in Face Amount will be equal to: the Cash Value just prior to the
decrease; less any Surrender Charge for the decrease. The Death Benefit will be
recalculated based on the new Face Amount and the Cash Value after the decrease.
A decrease in Face Amount may require a decrease in the amounts provided by
riders attached to this Policy.
Partial Withdrawal and Partial Surrender
The total number of partial surrenders and partial withdrawals will be limited
to 4 in each policy year, except with the consent of the Company.
If Death Benefit Option 1 is in effect, you can make a partial withdrawal if the
Death Benefit is greater than the Face Amount of the Policy. If there is no
Policy Loan Balance, the partial withdrawal is limited to: the Cash Value; less
the Face Amount times the net single premium at the Insured's attained age. If
there is a Policy Loan Balance, the amount of the partial withdrawal will be
further limited to prevent the Policy Loan Balance from exceeding the Loan Value
of the Policy.
If Death Benefit Option 2 is in effect, you can make a partial withdrawal. If
there is no Policy Loan Balance, the partial withdrawal is limited to the Cash
Value less the Tabular Value. (See Section 2.) If there is a Policy Loan
Balance, the amount of the partial withdrawal will be further limited to prevent
the Policy Loan Balance from exceeding the Loan Value of the Policy.
A partial withdrawal will result in a decrease in Death Benefit and Cash Value.
The premium, Face Amount and Surrender Charge will not change.
Unless you request otherwise, a partial withdrawal will reduce: first, the
Policy's share of the sub-accounts proportionately; and second, the Policy's
share of the Fixed Account.
You also can make a partial surrender. A portion of the Cash Value will be paid
to you. A Surrender Charge will be applied if you make a partial surrender. (See
Section 3.) A partial surrender will result in a decrease in Cash Value,
premiums, Face Amount, Death Benefit and Tabular Value. The Face Amount which
will remain after the partial surrender must not be less than the Company's
published minimum, except with the consent of the Company.
Unless you request otherwise, a partial surrender will reduce: first, the
Policy's share of the sub-accounts proportionately; and second, the Policy's
share of the Fixed Account.
The Company will subtract the amount of each partial withdrawal and partial
surrender taken during the grace period of a premium in default from the Net
Cash Value used to determine the value of the Policy at lapse.
16. Owner and Beneficiary
Owner
The Owner of the Policy is named in the Application (see copy attached); but the
Owner can be changed. The new Owner will succeed to all rights of the Owner,
including the right to make a further change of Owner. At the death of the
Owner, his or her estate will be the Owner, unless a successor Owner has been
named. In this Policy "you" means the Owner, whether the Owner is a person, a
partnership, a corporation, a fiduciary or any other legal entity. The rights of
the Owner will terminate at the death of the Insured, except for Payment of
Benefits. (See Section 17.)
Beneficiary
The Beneficiary is named in the Application (see copy attached); but the
Beneficiary can be changed before the death of the Insured. The Beneficiary has
no rights in the Policy until the death of the Insured. A person must survive
the Insured to qualify as Beneficiary. If none survives, the proceeds will be
paid to the Owner. The Beneficiary can also be a corporation, a partnership, a
fiduciary or any other legal entity.
Change of Owner or Beneficiary
A change of Owner or Beneficiary must be in written form satisfactory to the
Company, and must be dated and signed by the Owner who is making the change. The
change will be subject to all payments made and actions taken by the Company
under the Policy before the signed change form is received by the Company at its
Administrative Office.
Assignments
An absolute assignment of the Policy by the Owner is a change of Owner and
Beneficiary to the assignee. A collateral assignment of the Policy by the Owner
is not a change of Owner or Beneficiary; but their rights will be subject to the
terms of the assignment. Assignments will be subject to all payments made and
actions taken by the Company before a signed copy of the assignment form is
received by the Company at its Administrative Office. The Company will not be
responsible for determining whether or not an assignment is valid.
Designation of Owner and Beneficiary
A numbered sequence can be used to name successive Owners or Beneficiaries. Co-
Beneficiaries will receive equal shares unless otherwise stated.
In naming Owners or Beneficiaries, unless otherwise stated:
. "Child" includes an adopted or posthumous child;
. "Provision for issue" means that if a Beneficiary does not survive the
Insured, the share of that Beneficiary will be taken by his or her living
issue by right of representation; and
. A family relation such as "wife", "husband" or "child" means the relation
to the Insured.
At the time for payment of benefits the Company can rely on an affidavit of any
Owner or other responsible person to determine family relations or members of a
class.
17. Payment of Benefits
Payment
The policy proceeds will be paid in one sum, unless all or part of the proceeds
are applied to a Payment Option. (See Section 18.) The Company will pay interest
on the proceeds from the date they become payable to the date of payment in one
sum, or to the Option Date. The rate of interest will be set each year by the
Company; but the rate on death and maturity proceeds will not be less than that
required by law and the rate on other proceeds will not be less than 3 1/2% per
year. The interest payable on surrender proceeds is described in Section 4.
Choice of Payment Options; Option Date
The choice of a Payment Option and the naming of the Payee must be in written
form satisfactory to the Company. You can make or change or revoke the choice
before the death of the Insured. The Option Date is the effective date of the
Payment Option, as stated in the form on which you made your choice.
Payee
A Payee is a person, a corporation, a partnership, a fiduciary or any other
legal entity entitled to receive payment in one sum or under a Payment Option.
Choices By Payees
Any proceeds payable in one sum at the death of the Insured, or upon surrender
of the Policy, can be applied to any Payment Option chosen by the Payee.
Further, subject to the consent of the Company, any Payee who is entitled to
receive proceeds in one sum when a Payment Option ends, or at the death of a
prior Payee, or when proceeds are withdrawn can choose to apply the proceeds to
a Payment Option.
Rights of Payees
The Payee under a Payment Option can be given the right:
. To withdraw principal and interest under the Fourth or Fifth Option; or
. To withdraw the commuted value of payments certain under the First, Second
or Sixth Option.
Under the Life Income Options only payments certain can be commuted. No Payee
has the right to assign, commute or withdraw the payments under any Payment
Option, unless the right is reserved to the Payee.
Limitations
If instalments under an Option would be less than $20, proceeds can be applied
to a Payment Option only with the consent of the Company.
Life Income Options
Life Income Options are based on the age of the Payee on the Payee's birthday
nearest the Option Date. The Company will require proof of age. The Life Income
payments will be based: on the rates shown in the Life Income Tables (Section
19); or, if they are greater, on the Payment Option rates of the Company on the
Option Date. If the rates at a given age are the same for different periods
certain, the longest period certain will be used.
Purchase of Increased Life Income Benefits
On the Option Date, a one sum purchase payment can be made to the Company to be
added to the proceeds being applied to any Payment Option. The portion of Life
Income payments purchased in this way will be based on the Payment Option rates
of the Company on the Option Date, which may not be the rates shown in the Life
Income Tables (Section 19). The purchase payment will be limited to the
Company's published maximum for single premium immediate annuities on the Option
Date. A portion of the purchase payment may be used by the Company to pay
premium taxes on the purchase payment.
Death of Payee
If a Payee under a Life Income Option dies within 30 days after the Option Date,
the amount applied to the Option, less any payments made, will be paid in one
sum, unless a Payment Option is chosen by the successor payee. Otherwise,
amounts to be paid after the death of a Payee under a Payment Option will be
paid as due to the successor Xxxxx. If there is no successor Xxxxx, amounts to
be paid in one sum, or the commuted value of any unpaid payments certain, will
be paid in one sum to the estate of the last Payee to die.
Commutation Rate
The interest rate used to compute the commuted value of any unpaid payments
certain:
. Under the First Option will be 3 1/2% per year; and
. Under the Life Income Options will be the rate used by the Company in
computing the amount of the monthly payments.
18. Payment Options
Payment Options
All or any part of the policy proceeds can be applied to any one of the
following Options, subject to Section 17, Payment of Benefits:
First Option: Income for a Specified Number of Years
The Company will make equal monthly payments which will include both principal
and interest. Payments will start on the Option Date and will continue for the
number of years chosen. The number of years chosen cannot be more than 30.
Interest is at the rate of 3 1/2% per year compounded yearly. Additional
interest paid by the Company for any year will be added to the monthly payments
for that year.
Guaranteed monthly payments per $1,000 of proceeds applied to the First Option
are shown below.
------------------------------------------------
Number Number Number
of Years of Years of Years
------------------------------------------------
1 $84.65 11 $9.09 21 $5.56
2 43.05 12 8.46 22 5.39
3 29.19 13 7.94 23 5.24
4 22.27 14 7.49 24 5.09
5 18.12 15 7.10 25 4.96
6 15.35 16 6.76 26 4.84
7 13.38 17 6.47 27 4.73
8 11.90 18 6.20 28 4.63
9 10.75 19 5.97 29 4.53
10 9.83 20 5.75 30 4.45
Second Option: Life Income
The Company will make equal monthly payments. Payments will start on the Option
Date and will continue:
. During the life of the Payee, with no further payment after the death of
the Payee, called "Life Income, No Refund"; or
. During the life of the Payee, but for at least 10 years, called "Life
Income, 10 Years Certain"; or
. During the life of the Payee, but for at least 20 years, called "Life
Income, 20 Years Certain".
Third Option: Life Income with Refund
The Company will make equal monthly payments. Payments will start on the Option
Date and will continue during the life of the Payee. At the death of the Payee,
if the total payments made are less than the total proceeds applied to the
Option, then:
. The difference will be paid in one sum, called "Life Income, Cash Refund";
or
. The equal monthly payments will continue until the total payments are equal
to the total proceeds applied to the Option, called "Life Income,
Instalment Refund".
Fourth Option: Interest
The Company will hold the proceeds at interest during the life of the Payee or
for any other period agreed to by the Company. Interest on proceeds:
. Will be paid each month to the Payee starting one month after the Option
Date; or
. Will be added to the principal amount each year and will earn interest.
At the death of the Payee, or at the end of the period agreed to, the balance of
principal and any accrued interest will be paid in one sum. The rate of interest
will be set each year by the Company; but the rate will not be less than 3 1/2%
per year.
Fifth Option: Specified Amount of Income
The Company will make equal monthly payments which will include both principal
and interest. Payments will be in the amount chosen. Payments may be quarterly
or at any other frequency
chosen, and payments may be for different amounts, all subject to the consent of
the Company. Payments will start on the Option Date and will continue until the
balance is fully paid out. At the death of the Payee any unpaid balance and
accrued interest will be paid in one sum. The rate of interest will be set each
year by the Company; but the rate will not be less than 3 1/2% per year.
Interest will be added each year to the principal and will earn interest.
Sixth Option: Life Income for Two Lives
The Company will make equal monthly payments. Payments will start on the Option
Date and will continue:
. While either of two Payees is living, called "Joint and Survivor Life
Income"; or
. While either of two Payees is living, but for at least 10 years, called
"Joint and Survivor Life Income, 10 Years Certain"; or
. While two Payees are living; and after the death of one Payee, two-thirds
of the monthly amount while the other Payee is living, called "Joint and
2/3 to Survivor Life Income".
19. Life Income Tables
Life Income Tables
Guaranteed monthly payments per $1,000 of proceeds applied to the Life Income
Options are shown below:
--------------------------------------------------------------------------
Second and Third Options: Life Income
--------------------------------------------------------------------------
Age of No 10 Years 20 Years Cash Installment
Payee Refund Certain Certain Refund Refund
--------------------------------------------------------------------------
*15 $3.19 $3.19 $3.19 $3.18 $3.19
16 3.21 3.20 3.20 3.19 3.20
17 3.22 3.22 3.21 3.21 3.21
18 3.23 3.23 3.23 3.22 3.22
19 3.25 3.24 3.24 3.23 3.24
20 3.26 3.26 3.25 3.25 3.25
21 3.27 3.27 3.27 3.26 3.26
22 3.29 3.29 3.28 3.28 3.28
23 3.31 3.30 3.30 3.29 3.29
24 3.32 3.32 3.31 3.31 3.31
25 3.34 3.34 3.33 3.32 3.33
26 3.36 3.36 3.35 3.34 3.35
27 3.38 3.37 3.37 3.36 3.36
28 3.40 3.39 3.39 3.38 3.38
29 3.42 3.41 3.41 3.40 3.40
30 3.44 3.44 3.43 3.42 3.42
31 3.46 3.46 3.45 3.44 3.44
32 3.49 3.48 3.47 3.46 3.47
33 3.51 3.51 3.50 3.49 3.49
34 3.54 3.53 3.52 3.51 3.52
35 3.56 3.56 3.55 3.54 3.54
36 3.59 3.59 3.58 3.56 3.57
37 3.62 3.62 3.60 3.59 3.60
38 3.66 3.65 3.63 3.62 3.63
39 3.69 3.69 3.67 3.65 3.66
40 3.73 3.72 3.70 3.68 3.69
41 3.76 3.76 3.73 3.71 3.72
42 3.80 3.79 3.77 3.75 3.76
43 3.84 3.84 3.80 3.78 3.79
44 3.89 3.88 3.84 3.82 3.83
45 3.93 3.92 3.88 3.86 3.87
46 3.98 3.97 3.92 3.90 3.91
47 4.03 4.02 3.97 3.94 3.96
48 4.08 4.07 4.01 3.99 4.00
49 4.14 4.12 4.06 4.03 4.05
50 4.20 4.18 4.11 4.08 4.10
51 4.26 4.23 4.16 4.13 4.15
52 4.32 4.30 4.21 4.19 4.21
53 4.39 4.36 4.26 4.24 4.27
54 4.46 4.43 4.32 4.30 4.33
55 4.54 4.50 4.37 4.36 4.39
56 4.62 4.58 4.43 4.43 4.46
57 4.70 4.65 4.49 4.49 4.53
58 4.79 4.74 4.56 4.57 4.60
59 4.89 4.83 4.62 4.64 4.68
60 4.99 4.92 4.68 4.72 4.76
61 5.10 5.02 4.75 4.80 4.85
62 5.22 5.12 4.82 4.89 4.94
63 5.34 5.23 4.88 4.98 5.03
64 5.47 5.35 4.95 5.07 5.13
65 5.61 5.47 5.02 5.17 5.24
66 5.76 5.60 5.08 5.28 5.35
67 5.92 5.73 5.15 5.39 5.47
68 6.10 5.87 5.21 5.51 5.59
69 6.28 6.02 5.27 5.63 5.72
--------------------------------------------------------------------------
Age of No 10 Years 20 Years Cash Installment
Payee Refund Certain Certain Refund Refund
--------------------------------------------------------------------------
70 $6.48 $6.17 $5.33 $5.76 $5.86
71 6.70 6.33 5.38 5.89 6.00
72 6.92 6.49 5.43 6.04 6.16
73 7.17 6.66 5.48 6.19 6.32
74 7.43 6.84 5.52 6.34 6.49
75 7.71 7.02 5.56 6.52 6.67
76 8.02 7.20 5.60 6.69 6.86
77 8.34 7.38 5.63 6.87 7.06
78 8.69 7.56 5.66 7.07 7.27
79 9.07 7.75 5.68 7.27 7.50
80 9.47 7.93 5.70 7.49 7.74
81 9.90 8.11 5.71 7.73 7.99
82 10.36 8.28 5.73 7.96 8.25
83 10.86 8.45 5.73 8.21 8.53
84 11.39 8.62 5.74 8.50 8.83
**85 11.96 8.77 5.75 8.78 9.14
--------------------------------------------------------------------------
*and under **and over
--------------------------------------------------------------------------
Sixth Option: Life Income for Two Lives
-------------------------------------------------------------------
Age of One Age of Other Payee
Payee 55 60 65 70 75
-------------------------------------------------------------------
Joint and Survivor
55 $4.04 $4.17 $4.28 $4.37 $4.43
60 4.17 4.36 4.53 4.68 4.79
65 4.28 4.53 4.79 5.02 5.22
70 4.37 4.68 5.02 5.38 5.71
75 4.43 4.79 5.22 5.71 6.22
80 4.47 4.87 5.37 5.98 6.68
-------------------------------------------------------------------
Joint and Survivor. 10 Years Certain
55 $3.96 $4.09 $4.20 $4.36 $4.42
60 4.09 4.27 4.44 4.59 4.77
65 4.20 4.44 4.69 4.91 5.09
70 4.36 4.59 4.91 5.22 5.50
75 4.42 4.77 5.09 5.50 5.88
80 4.46 4.85 5.33 5.72 6.21
-------------------------------------------------------------------
Joint and 2/3 to Survivor
55 $4.37 $4.56 $4.76 $4.99 $5.23
60 4.56 4.78 5.02 5.30 5.59
65 4.76 5.02 5.33 5.67 6.03
70 4.99 5.30 5.67 6.10 6.57
75 5.23 5.59 6.03 6.57 7.18
80 5.48 5.89 6.41 7.06 7.84
-------------------------------------------------------------------
Payments for other ages will be quoted by the Company on request.
The rates shown above are based on an interest rate of 3 1/2% per year; and on
mortality: using a 60/40 male/female weighting; based on the Individual
Annuitant Mortality Table for 1983; and with projection on Scale G to the year
2000 and then on Scale B Modified to year 2010.
Please notify the Company of any change in your name or address. The Company
will communicate with you at your address on record with the Company.
New England Variable Life
Insurance Company
Administrative Office:
000 Xxxxxxxx Xxxxxx
Xxxxxx, Xxxxxxxxxxxxx 00000
Variable Life Policy
.The Death Benefit is payable at the death of the Insured.
.Premiums are payable to the Company for a specified period.
. Unscheduled Payments can be made.
.The Policy does not participate in Dividends.
------------------------------------------------------------
Amendments and Endorsements (To be made only by the Company)
NEV APP-20-87
The New England
Your Financial Partner
For Company Use Only
No.
-----------
Part I - Application to the New England Life
Insurance Company for Insurance on the Proposed Insured
For use when Proposed Insured is under Age 15.
Proposed Insured:
----------------------------------------------------
(Print name as it should appear in policy)
Questions below pertain to Proposed Insured unless otherwise indicated.
1. Residence Address (Include street and number, city, state and zip code)
2. Premium Notice Address __ Applicant at address in 1.
___Other (Give Name and Address)
----------------------------------------------------------------------
(Street) (City) (State) (Zip Code)
3. Social security or Employer
Identification Number
Proposed
Insured
---------------------------
First Owner
------------------------------
4. Birthplace
---------------------------
(City) (State or Country)
5. Citizen of
---------------------------
6. Birth Date
--------------------------------------
(Month) (Day) (Year)
7. Age (Nearest Birthday)
-------------------------------------------
8. Sex Male ___ Female ___
9. Grade in School
---------------------------
New England Life Insurance Company, 000 Xxxxxxxx Xxxxxx, Xxxxxx, Xxxxxxxxxxxxx,
00000
Continued on Reverse Side
10. Name of Applicant
-------------------------------------------------
Relation to Proposed Insured
-------------------------------------------------
11. State relation and amount of life insurance in force or applied for on
person responsible for support of Proposed Insured.
Relation to Proposed Insured
-------------------------------------------------
Amount of Insurance
-------------------------------------------------
12. Life Insurance in Force (if none, so state)
Company Year of Issue Amount A.D.B.
--------------------- ---------- --------- ---------
--------------------- ---------- --------- ---------
--------------------- ---------- --------- ---------
13. Any insurance or annuity in this or any other company which has been or
will be replaced as a result of this application for insurance? (if "Yes",
complete required replacement forms; list company, policy number, and
amounts in 21.) ___Yes ___No
14. My other negotiations for life or accidental death insurance pending or
contemplated? _____Yes _____No (If "Yes", see 2l)
15. Any intent to travel or reside outside USA? ____Yes ____ No (if "Yes", see
21)
16. Any participation within the past 3 years or intent to participate in:
SCUBA diving; sky diving; hang gliding; or motor racing? (If "Yes",
complete applicable Questionnaire) _____Yes _____ No
17. Plan of Insurance
-----------------------------------------------
Riders
___ a. Waiver of Premiums ___b. Acc. Death Ben. $_______
___ Disability of Insured ___c. Purchase Option $_______
___ Payor Death Only ___d. Other (see 21)
___ Payor Death or Disability
18. Face Amount of Policy
$
----------------------
19. If available under policy applied for, state Planned Annual Unscheduled
Payment.
$
-------------------------
20. Death Benefit Option (If available under policy applied for):
___ Option 1 (Face Amount)
___ Option 2 (Face Amount plus any Excess Cash Value)
21. Explain "Yes" answers. Indicate any special request. (Attach memo if more
space needed)
------------------------------------------------
-------------------------------------------------------------
-------------------------------------------------------------
New England Life Insurance Company, 000 Xxxxxxxx Xxxxxx, Xxxxxx, Xxxxxxxxxxxxx
00000
--------------------------------------------------------------------------------
22. Beneficiary (Include relation to Proposed Insured)
(1) Primary (2) Secondary
------------------------------ ------------------
23. Owner (Include relation to Proposed Insured)
------------------------
(Note: A numbered sequence may be used to name successive Owners. An Owner
who is a minor may need a guardian and court order to exercise rights.)
24. Premium Mode ___ Annual ____ Semi-Annual
___ Quarterly ____ Other (see 21)
25. If available under policy applied for, are premiums in default to be paid
automatically by policy loan? ____Yes ___No
26. If available under policy applied for, is the Special Premium Option
elected for premiums in default? _____Yes _____No
27. Any history of a blood disorder, tumor or heart disease? ___Yes ____No
28. Any change in health or any treatment by or consultation with a physician
since the date of Part II of this Application? (Answer only if Part II is
dated prior to Part I. If "Yes", see 2l). ____Yes ____No
29. Prepayment Receipt Amount
____ $___________________ _____ None If Question 27 or 28 is answered
"Yes", no prepayment is permitted.
30. Account Allocation (whole %) (Minimum 10% in each selected account.)
_________% Capital Growth
_________% Money Market
_________% Bond Income
_________% Stock Index
_________% Managed
-----------
100% Total
31. Suitability Statement by Applicant:
a. Did you receive the prospectus? ____Yes _____No
(If "Yes", give date of prospectus:______________)
b. Do you understand that:
___ the death benefit may increase or decrease depending on the policy's
investment return, but will never be less than the guaranteed
minimum? _____Yes _____No
___ the cash value may increase or decrease depending on the
investment return? _____Yes ____No
c. Do you believe that this policy will meet insurance needs and
financial objectives? _____Yes ____No
. THE DEATH BENEFIT MAY BE VARIABLE OR FIXED UNDER SPECIFIED CONDITIONS.
. THE CASH VALUES MAY INCREASE OR DECREASE IN ACCORDANCE WITH SEPARATE
INVESTMENT ACCOUNT EXPERIENCE
Administrative Office Use: Additions and Amendments
--------------------------------------------------------------------------------
General: To the best of my knowledge and belief, the answers recorded are true
and complete. In those states where written consent is required by law, my
agreement in writing is required to any entry made by the Company in "Additions
and Amendments" as to (a) age; or (b) plan of insurance; or (c) riders; or (d)
amounts; or (e) rate class.
When Insurance Takes Effect. If a prepayment is made in connection with this
Application, the insurance will take effect as stated on the Prepayment Receipt
and Temporary Life Insurance Agreement. Otherwise, the insurance will take
effect only when the first premium is paid; provided that at the time of such
payment: (a) this Application has been approved by the Company at its
Administrative Office; and (b) there has been no change in insurability as
represented in this Application since the date of the Application.
Limitation on Authority of Agents and Examiners. Agents and Examiners do not
have authority: (a) to determine insurability; or (b) to change
any terms of this Application; or (c) to make a contract for the Company.
Cost of Insurance Rates May Change. The cost of insurance rates for the policy
may change. The rates currently being charged are not guaranteed; and the
Company may charge the full maximum guaranteed rates.
Signed at (City and State)__________________ Date________19___
------------------ ----------------------------------- -----------------
Agent (Signature Optional) Proposed Insured Applicant
Agent's Certificate
Questions regarding Proposed Insured
1. How long have you known Proposed Insured?
-----------------
2. Did you personally see Proposed Insured? ___Yes ___No
(if "No", explain)
3. After investigation. are you completely satisfied that Proposed Insured is
in good health, and that there is nothing in the physical condition,
personal or family history, or home environment of Proposed Insured which
would adversely affect the risk? ____ Yes _____No (if "No ", explain in
separate memo)
4. a. Does Proposed Insured live with parents?
____ Yes ____ No (If' "No", explain)
b. If Proposed Insured changed residence within past 2 years. give
previous address.
5. Show ages of all living brothers and sisters and insurance in force or
applied for, if any.
Brothers' Ages Amount Sisters' Ages Amount If no insurance,
give reason
--------------- --------- --------------- --------- ----------------
--------------- --------- --------------- --------- ----------------
--------------- --------- --------------- --------- ----------------
--------------- --------- --------------- --------- ----------------
6. Do you have knowledge or reason to believe that any insurance or annuity in
this or any other company has been or will be replaced as a result of this
application for insurance? _____ Yes _____ No
Questions regarding Applicant
7. Source of Client (Check only one)
Previous TNE Policyholder New Policyholder
___ a. Agent's Own Client ___ d. Acquaintance
___ b. Orphan Policyholder ___ e. Referred Lead
___ c. TNE Group Insured ___ f. Direct Mail
___ g. Published Sources
___Agent's Immediate Family ___ h. Other
8. How long have you known Applicant?
--------------------------------
9. Indicate source of premiums for this insurance
-------------------------------------------------------
(If corporate or guardianship funds involved, evidence of authority may be
required)
10. What is your estimate (in figures) of Applicant's:
a. Earned income $__________ b. Other Income $__________
c. Total Income $__________ d. Net Worth $__________
e. Spouse's Income $__________
11. Education ___a. High School ____ b. Attended College
___ c. College Graduate ____ d. Graduate School
12. Applicant's Occupation
13. Applicant's Employer and Business Address:
-------------------
-------------------------------------------------------------
14. Applicant's Employment Status (Check Employer and Field and Level or Other
Status)
Employer Field Level Other Status
_a. Government _a. Business _a. Professional _j. Armed Forces
_b Non Profit Org. _b. Sales _b. Executive _k. Student
_c. Corporation _c. Medicine _c. Middle Mgr. _j. Homemaker
_d. Partnership _d. Law _d. Supervisory _m. Unemployed
_e. Sole Proprietorship _e. Agriculture _e. Technical _n. Retired
_f. Self Employed _f. Education _f. Clerical
_g. Other _g. Craftsman
_h. Laborer
To the best of my knowledge, I have presented the Company all pertinent facts
regarding the Proposed Insured and regarding this application.
Date
------------------------------- -------------------
Signature of Agent
Accepted for the Company
By: Date
---------------------------- -------------------
General Agent's Certificate
1. If agent of another company, name other company
-----------------------------------------------------
2. Is the agent licensed where the application is written?
Date
------------------------- ---------------------------------------
Signature of General Agent
Agent's Identification Plate
(Agent's
Code (Commission
(Agent's Name) Number) Split %)
Owner's Certification Section (in lieu of W9):
Owner's Social Security or Employer Identification Number:
--------------------
___ I am ____ I am not subject to backup withholding under Section
3406(a)(1)(c) of the Internal Revenue Code. Under penalties of perjury, I
certify that the information provided in this section is true, correct, and
complete.
---------------------- -------------
Owner's Signature Date
Exhibit 1.A. (10)
NEV APP-19-87
The New England
Your Financial Partner
For Company Use Only
No
-------------------
Part I - Application to The New England Life
Insurance Company for Insurance on the Proposed Insured
Insured Proposed:
--------------------------------------
(Print name as it should appear in policy)
Questions below pertain to Proposed Insured unless otherwise indicated.
1. Address (Include street and number, city, state and zip code)
a. Residence
-------------------------------------------------------
b. Business
-------------------------------------------------------
2. Premium Notice Address - Proposed Insured
___ at 1 .a. ____ at 1 .b.
___ Other than Proposed Insured (Give Name and Address)
------------------------------------------------------------
(Street) (City) (State) (Zip Code)
3. Social Security or Employer Identification Number
Proposed
Insured
--------------------------------
First Owner
--------------------------------
4. Birthplace
-----------------------------------
(City) (State or Country)
5. Citizen of
-----------------------------------
6. Birthdate
------------------------------------------
(mo/day/yr)
7. Marital Status
___ Married ___ Single
___ Divorced ___ Widowed ___ Separated
Continued on Reverse Side
8. Age (Nearest Birthday)
--------------------------------------------
9. Sex ___Male ____ Female
10. a. Occupation
---------------------------------
b. Principal Duties
---------------------------------
c. Other Duties
---------------------------------
11. a. Employer
-----------------------------------
b. Nature of Business
---------------------------------
---------------------------------
12. a. Annual income after business expenses and before income
taxes: (Answer every item)
Earned income: $___________ Other income:$_______________
(Describe in 23)
b. Net worth: $__________________
13. Life Insurance (Personal, Business and Group) in Force (If none, so state)
(Put "B" to the left of any business insurance listed)
Company Year of Issue Amount ADB
------------------- ------------------- -------- -----------
------------------- ------------------- -------- -----------
------------------- ------------------- -------- -----------
14. Any insurance or annuity in this or any other company which has been or
will be replaced as a result of this application for insurance? (If "Yes',
complete required replacement forms; list company, policy number & amounts
in 23)
___ Yes ____ No
15. a. Any cigarette smoking in past year? ____ Yes ___No
b. Any other tobacco use in past year? ____ Yes ___No
16. Any other negotiations for life, disability or accidental death insurance
pending or contemplated? ____ Yes ___No
(If "Yes", see 23)
17. Any intent to travel or reside outside USA? ___ Yes ___ No
(If "Yes", see 23)
Continued on Reverse Side
18. Any participation within the past 3 years or intent to participate in: any
flights as a trainee, pilot or crew member; SCUBA diving; sky diving; hang
gliding; or motor racing? (If "Yes", complete applicable Questionnaire
___Yes ___ No
19. Any suspension or revocation of driver's license within past 2 years?
___ Yes ___ No (If "Yes" see 23)
20. Any treatment for or consultation with a physician concerning a heart
attack, a stroke or cancer (other than skin cancer) within past 2 years?
____ Yes ___No
21. Any change in health or any treatment by or consultation with a physician
since the date of Part II of this Application? (Answer only if Part II is
dated prior to Part I. If "Yes'; see 23)
____ Yes ___No
22. Is Proposed Insured currently employed less than full time? ____ Yes ___No
23. Explain "Yes" answers (Attach memo if more space needed)
----------------------------------------------------------
----------------------------------------------------------
----------------------------------------------------------
----------------------------------------------------------
24. Plan of Insurance
-------------------------------------------------------
Riders (Complete any additional application needed)
___ Waiver of Premiums
___ Acc. Death Ben. $
------------------
___ Purchase Option $
------------------
___ Level Term $
------------------
25. Face Amount of Policy $
------------------------------------------------
26. If available under policy applied for, state Planned Annual Unscheduled
Payment.$
----------------------
27. Death Benefit Option (if available under policy applied for):
___ Option 1 (Face Amount)
___ Option 2 (Face Amount plus any Excess Cash Value)
28. Indicate any special request (Attach memo if more space needed)
------
---------------------------------------------
29. Beneficiary (Include relation to Proposed Insured)
Continued on Reverse Side
(1) Primary (2) Secondary
--------------------------- ---------------------------
30. Is Proposed Insured to own the policy? ____ Yes ___No
(If "No" name the Owner (Include relation to Proposed Insured) (Note: a
numbered sequence may be used to name successive Owners)
--------------------------------------------------------------
31. Premium Mode
___ Annual ___ Semi-Annual ___ Quarterly
___ Other (see 28)
32. If available under policy applied for, are premiums in default to be paid
automatically by policy loan?
____ Yes ___No
33. If available under policy applied for, is the Special Premium Option
elected for premiums in default?
____ Yes ___No
34. Prepayment $____________ ____ None (If Question 20 or 21 is answered
"Yes", no prepayment is permitted)
35. Account Allocation (whole %) (Minimum 10% in each selected account)
___% Capital Growth
___% Money Market
___% Bond Income
___% Stock Index
___% Managed
100% Total
36. Suitability Statement by Applicant
a. Did you receive the prospectus? ____ Yes ___No
(If "Yes", give date of prospectus)__________
b. Do you understand that
- the death benefit may increase or decrease depending on the
policy's investment return, but will never be less than the
guaranteed minimum? ____ Yes ___No
- the cash value may increase or decrease depending on the
investment return? ____ Yes ___No
c. Do you believe that this policy will meet insurance needs & financial
objectives? ____ Yes ___No
Continued on Reverse Side
. The death benefit may be variable or fixed under specified conditions.
. The cash values may increase or decrease in accordance with separate
investment account experience.
Administrative Office Use: Additions and Amendments
General To the best of my knowledge and belief, the answers recorded are true
and complete. In those states where written consent is required by law, my
agreement in writing is required to any entry made by the Company in "Additions
and Amendments" as to: (a) age; or (b) plan of insurance; or (c) riders; or (d)
amounts; or (e) rate class.
When Insurance Takes Effect. If a prepayment is made in connection with this
Application, the Insurance will take effect as stated in the Prepayment Receipt
and Temporary Life Insurance Agreement. Otherwise, the insurance will take
effect only when the first premium is paid; provided that at the time of such
payment: (a) this Application has been approved by the Company at its
Administrative Office; and (b) there has been no change in insurability as
represented in this Application since the date of the Application.
Limitation on Authority of Agents and Examiners. Agents and Examiners do not
have authority: (a) to determine insurability; or (b) to change any terms of
this Application; or (c) to make a contract for the Company.
Cost of Insurance Rates May Change. The cost of insurance rates for the policy
may change. The rates currently being charged are not guaranteed; and the
Company may charge the full maximum guaranteed rates.
Signed at (City and State)_________________Date __________19____
-------------------- -------------------- ---------------------------
Agent Proposed Insured Applicant if other than
Proposed Insured
New England Life Insurance Company, 000 Xxxxxxxx Xxxxxx, Xxxxxx, Xxxxxxxxxxxxx
00000
Agent's Certificate
Proposed Insured No.
---------------------------------------------------- ------------------
Completion Required in Every Case
1. Source of Client (Check only one)
Previous TNE Policyholder
___ a. Agent's Own Client
___ b. Orphan Policyholder
___ c. TNE Group Insured
New Policyholder
___ d. Acquaintance
___ e. Referred Lead
___ f. Direct Mail
___ g. Published Sources
___ h. Other
Agent's
___ x. Own Life
___ k. Immediate Family
___ i. Business Associate
2. How long have you known Proposed Insured?
--------------
3. If name of Proposed Insured has changed within past 10 years by Marriage or
otherwise, give previous name.
4. Give Proposed Insured's addresses for the past 5 years.
a. Residence Address shown on Part I?
Former Business Addresses:
From Mo. Yr.
-----------------------
To Mo. Yr. Present
-------------------
b. Business Address shown on Part I?
Former Business Addresses:
From Mo. Yr.
-----------------------
To Mo. Yr. Present
-------------------
5. If Proposed Insured is a minor or married
a. Give full name and relationship of person responsible for support, if
a minor; or spouse, if married.
--------------------------------------------------
b. How much insurance is in force or applied for on person named above?
-----------------------------------
6. Explain insurable interest of applicant, proposed beneficiary or proposed
owner if not a relative nor a business partner or associate of Proposed
Insured.
----------------------------------------------------------------------
----------------------------------------------------------------------
7. a. Your estimate (in figures) of annual income after business
expenses and before income taxes of Proposed
Insured's:
Earned Income $
-----------------
Other Income $
-----------------
Total Income $
--------------
Spouse's income $
-------------
b. Your estimate (in figures) of Proposed Insured's networth:
$
-------------
8. Indicate who will pay premiums for this insurance (If
guardianship funds involved, evidence of authority is
required.)
------------------------------------------
9. Has insurance on the life of the Proposed Insured ever been declined,
postponed, or modified as to plan, amount or rate? (If "Yes", explain
fully) _____Yes No_____
10. Do you have knowledge or reason to believe that any insurance or annuity in
this or any other company has been or will be replaced as a result of this
application for insurance? _____Yes No_____
11. Does Proposed Insured contemplate any change in
occupation or duties? _____Yes No_____
(If "Yes" explain fully)
12. Education
___a. High School ___b. Attended College
___c. College Graduate ___Graduate School
13. Employment Status (Check Employer and Field and Level, or check Other
Status)
Employer Corporation Field Level Other Status
_a. Government _1) Professional _a. Business _a. Professional _j. Armed Forces
_b Non Profit Org. _2) Closely Held _b. Sales _b. Executive _k. Student
_c. Partnership _3) Other _c. Medicine _c. Middle Mgr. _j. Homemaker
_d. Sole Proprietorship _d. Law _d. Supervisory _m. Unemployed
_e. Self Employed _e. Agriculture _e. Technical _n. Retired
_f. Education _f. Clerical
_g. Other _g. Craftsman
_h. Laborer
14. Purpose Of Policy Life
Personal Estate Plan Business
__a. Single Need __f. Liquidity __k. Key EE.
__b. Program __g. Capital & Income __l. Buy-Sell
__c. Gift __h. Char. Gifts __m. Def. Comp.
__d. Salary Svngs. __j. Other __n. Salary Cont.
__e. Other __o. Split Dollar
(If purpose is business, complete Questions 16-20 on reverse)
15. Ledger Services Used
a. Capital Needs or Income Analysis ___Yes ___No
b. Estate Analysis Service ___Yes ___No
To the best of my knowledge, I have presented the Company all pertinent facts
regarding the Proposed Insured and regarding this application.
------------- --------------------------
Date Signature of Agent
Accepted for the Company
By:
------------------------- ---------------
Date
General Agent's Certificate
If agent of another Company, give name of other
Company
--------------------------------------
Is agent licensed where this application is written?
------------- -------------------------------
Date Signature of General Agent
For Business Life Insurance Only
16. If premiums are to be paid by corporation, give exact name of corporation
and State of incorporation.
Submit evidence of authority, unless corporation is sole beneficiary and
sole owner.
17. a. Give names of other officers, key employees or partners on whom
business insurance is in force or proposed and amount of business
insurance on each.
Name Title Amt. of Business Amt. Of Business
Ins. in force Ins. Proposed
------------------ ------------------ ---------------- ------------------
------------------ ------------------ ---------------- ------------------
------------------ ------------------ ---------------- ------------------
b. Are there any officers, key employees or partners among the executives
or partners on whom business insurance is not in force or proposed?
____Yes ____No (If "Yes" give details)
-------------------------------------------
-------------------------------------------
18. If Applicant is a Corporation
a. What is the present net worth? $
--------------
b What percentage of stock is held by Proposed Insured?
________%
19. If Applicant is a Partnership, give full names of partners, and percent of
interest of each
____________________________ _____________%
____________________________ _____________%
____________________________ _____________%
20. It is frequently advisable to describe a Proposed Insured's value to the
business including skills, financial loss expected, financial resources,
etc. which warrant the amount of insurance requested (Submit a separate
letter if more space needed)
-----------------------------------------------------------------
-----------------------------------------------------------------
-----------------------------------------------------------------
Owner's Certification Section (in lieu of W9)
Owner's Social Security or Employer Identification Number.
--------------------------------------------
___ I am ___ I am not subject to backup withholding under Section
3406(a)( 1 )(c) of the Internal Revenue Code. Under penalties of perjury, I
certify that the information provided in this section is true, correct and
complete.
----------------------------- --------------
Owner's Signature Date
Enter any request for additional or alternate life policies.
Agent's Identification Plate
(Agent's
Code
(Agent's Name) Number) (Commission Split %)
APP-557-91
----------------------------------------------------------------------------------------------
Application To Policy Number
-----------------------------------
NEW ENGLAND LIFE INSURANCE COMPANY
Questions below pertain to the Proposed Insured unless otherwise indicated.
Part I
----------------------------------------------------------------------------------------------
Personal 1. Print Name as it is to appear on the 2. Social Security Number
policy.
------------------------------------- --------------------------------
Data
--------------------------------
-------------------------------------
First MI Last
-------------------
3. Birthplace 4. Marital [_] Single [_] Married
------------------- Status [_] Widowed [_] Divorced
(state/county) [_] Separated
------------------- -----
5. Birth Date 6. Age Nearest 7. Sex [_] Female
------------------- Birthday ----- [_] Male
month day year
----------------------------------------------------------------------------------------------
------------------------------------------------------------------
Address 8.a. Residence
------------------------------------------------------------------
Street City State Zip
------------------------------------------------------------------
b. Business
------------------------------------------------------------------
Company/Street City State Zip
c. Premium [_] Proposed Insured [_] Other (Give name and address.)
--------------------------------------------
Notice [_] a. Residence
Address [_] b. Business
Street
City/State/Zip
--------------------------------------------
----------------------------------------------------------------------------------------------
Beneficiary 9. Beneficiary 10. Owner [_] Proposed [_] Other
and Owner Primary Insured
----------------------------
If other, specify below. (Use a numbered
sequence to designate successive owners.)
----------------------------
Names and Relation to Proposed ------------------------------------------
Insured
Secondary
---------------------------- ------------------------------------------
Names and Relation to Proposed Insured
First Owner's Social Security
---------------------------- or Taxpayer ID Number
Names and Relation to Proposed -------------------------------------------
Insured
------------------------------------------
----------------------------------------------------------------------------------------------
Part I
Application
Continued
--------------------------------------------------------------------------------------------
------------------------ ------------------------
Plan/Amount 11. Plan 12. Face Amount $
------------------------ ------------------------
-------------------------------------------------------------------------------
13. [_] Universal Life Product*
a. Planned Annual Premium c. Death Benefit Option
--------------------- [_] Option 1 (Face Amount)
Year 1 $
--------------------- [_] Option 2 (Face Amount plus
Cash Value)
---------------------
Renewal $
---------------------
b. [_] Waiver of Monthly Deductions
--------------------------------------------------------------------------------------------
14. [_] Variable Life Product*
(Complete Variable Life Section (questions 35 through 39)
for scheduled premium, allocations, etc.)
-------------------------------------------------------------------------------
* COST OF INSURANCE RATES MAY CHANGE. The cost of insurance rates for the
policy may change. The rates currently being charged are not guaranteed;
and the Company may charge the full maximum guaranteed rates.
--------------------------------------------------------------------------------------------
Benefits/ 15. Waiver of Premiums Benefits
Riders a. [_] Waiver of Premium - c. [_] Applicant's Waiver** -
(**Complete Proposed Insured Juvenile Insured
additional [_] Death or Disability
form.) b. [_] Applicant's Waiver** - [_] Death Only
Adult Insured
-------------------------------------------------------------------------------
---------------
16. a. [_] Acc. $ f. [_] Paid-Up Additions
Death ---------------
-------------
[_] Lump Sum $
At Issue -------------
---------------
b. [_] Level $
Term ---------------
[_] Annual
---------------
c. [_] Purchase $
Option ---------------
-------------
At Issue $
-------------
-------------
d. [_] Children's Insurance Rider** Thereafter $
-------------
---------------
$
---------------
g. [_] 1 Year Term (dividends)
e. [_] Additional Protection (FTR)
First Year Total Coverage -------------
(FTR Amount plus h. [_] Spouse $
Amount shown in 12.) Rider** -------------
--------------- -------------------
$ i. [_] Other
--------------- -------------------
[_] Level
[_] Increasing
Increase
-------
Percentage %
-------
-------
Number of Years
-------
[_] Offset Amount (for list
billed policies only)
---------------
$
---------------
--------------------------------------------------------------------------------------------
Part I
Application
Continued
-------------------------------------------------------------------------------------------------------------------------------
Health 17. Any treatment for or consultation with a physician [_] YES [_] NO
concerning a heart attack, a stroke or cancer (other than
skin cancer) within past 2 years? (If YES, explain in REMARKS.)
18. Any change in health or any treatment by or [_] YES [_] NO
consultation with a physician since the date of Part II of
this Application? (If YES, explain in REMARKS.)
-------------------------------------------------------------------------------------------------------------------------------
Premium 19. [_] Annual [_] Semi Annual [_] Quarterly
Payment
(*Complete ----------------- ----------------
additional [_] MSA No. [_] List Bill No.
form.) ----------------- ----------------
[_] New Account* [_] Level Billing Option* (For graded
premium life plans only.)
[_] Add to Existing Account
----------------
Amount $
----------------
-------------------
20. Prepayment* $ [_] None
-------------------
(If question 17. or 18. is answered YES, no prepayment is permitted.)
21. [_] Automatic Payment of Premium in Default (if available)
From Dividend Accumulations [_] YES [_] NO
By Policy Loan [_] YES [_] NO
-------------------------------------------------------------------------------------------------------------------------------
Dividend 22. a. [_] Cash b. [_] Premium Reduction c. [_] Paid-Up Additions
Option d. [_] Accumulations e. [_] Add to Cash Value (Universal Life Only)
23. If available under policy applied for, state year in which: dividend option is
to be changed to Premium Reduction; and any remainder of the premium
is to be paid with surrendered Paid-Up Additions or Accumulations. ----------------
----------------
-------------------------------------------------------------------------------------------------------------------------------
Policy 24. If available, special Policy Date requested is:
Date -----------------
[_] a. or [_] b. latest date that retains Proposed
----------------- Insured's age last birthday.
mo day yr
Note: Date more than 30 days prior to date of application not allowed if Paid-Up Additions Riders,
Variable Life or Universal Life applied for.
-------------------------------------------------------------------------------------------------------------------------------
Existing 25. Life Insurance In Force (If none, so state. Type - P = Personal, B = Business, G = Group)
Insurance
Yr of
Company Type Issue Life Amount ADB Amount
------------------------------------------------------------------------------------------------------------
$ $
------------------------------------------------------------------------------------------------------------
$ $
------------------------------------------------------------------------------------------------------------
$ $
------------------------------------------------------------------------------------------------------------
$ $
------------------------------------------------------------------------------------------------------------
26. If Juvenile Insured, state relation to and amount of life insurance in force or applied for on person
responsible for support of Proposed Insured.
Relation to Proposed Insured Amount of Insurance
---------------------------- -------------------
-------------------------------------------------------------------------------------------------------------------------------
Part I
Application
Continued
--------------------------------------------------------------------------------------------
Existing 27. Any life Insurance or annuity in this or any other [_] YES [_] NO
Insurance company which has been or will be replaced as a
(Cont'd) result of this Application for insurance? (If YES,
complete the following and submit replacement forms
if required.)
1035
Company Exch. Policy Date Policy Number Amount
-------------------------------------------------------------------------
$
-------------------------------------------------------------------------
$
-------------------------------------------------------------------------
$
-------------------------------------------------------------------------
28. Has life or disability insurance on your life ever [_] YES [_] NO
been declined, postponed or modified as to plan, amount or
rate?
(If YES, give details in REMARKS.)
--------------------------------------------------------------------------------------------
Smoking/ 29. Has Proposed Insured:
Driving
a. Used any tobacco in the past year? [_] YES [_] NO
If YES, complete the following:
---------------------
How many cigarettes per day?
---------------------
If other than cigarettes, please explain.
---------------------------------------------------------------
---------------------------------------------------------------
b. Been convicted in the past 2 years of: driving [_] YES [_] NO
under the influence of alcohol or drugs; or 2 or more
moving violations?
(If YES, complete supplemental form.)
------------------------ ---------------
30. a. Drivers License No. b. State
------------------------ ---------------
--------------------------------------------------------------------------------------------
Avocation/ 31. Have you in the past 2 years participated in, or do
Aviation/ you intend to participate in: any flights as a trainee,
Foreign pilot or crew member; underwater sports (SCUBA diving,
Travel skin diving, snorkeling, hardhat); sky sports (sky diving,
hang gliding, parachuting, ballooning); or motor racing
(auto, motorcycle, motorboat)? [_] YES [_] NO
(If YES, complete supplemental form.)
32. Do you intend to travel or reside outside of the [_] YES [_] NO
United States?
(If YES, give details in REMARKS.)
--------------------------------------------------------------------------------------------
Occupation (If Juvenile Insured, complete with Payor data.)
And ----------------------------------------------------------
Financial 33. a. Occupation
----------------------------------------------------------
(Give Job Title and Duties)
----------------------------------------------------------
b. Employed by
----------------------------------------------------------
-------------------- -------------------------
34. a. Annual b. Net
Income Worth
-------------------- -------------------------
--------------------------------------------------------------------------------------------
Remarks/ (Attach additional sheet, if necessary.)
Special
Requests for
additional
coverage
--------------------------------------------------------------------------------------------
Part I
Application
Continued
--------------------------------------------------------------------------------
Variable 35. If available under policy applied for, state Planned Annual
Life Unscheduled Payment.
Section ---------------------
$
---------------------
36. Death Benefit Option (if available under policy applied for):
(See Prospectus for further explanation.)
[_] Option 1 (Face Amount)
[_] Option 2 (Face Amount plus any Excess Cash Value)
37. If available under policy applied for, is the
Special Premium Option elected for premiums in default?
[_] YES [_] NO
38. Account allocations (Whole %) (Minimum 10% in each selected
account)*
-----------------------
% Capital Growth
-----------------------
-----------------------
% Money Market
-----------------------
-----------------------
% Bond Income
-----------------------
-----------------------
% Stock Index
-----------------------
-----------------------
% Managed
-----------------------
-----------------------
% Fixed Account
-----------------------
-----------------------
%
-----------------------
-----------------------
100% Total
-----------------------
39. Suitability Statement by Applicant
a. Did you receive the prospectus? [_] YES [_] NO
(If YES, give date of prospectus.)
--------------------
--------------------
b. Do you understand that:
- the Option 2 death benefit may increase or [_] YES [_] NO
decrease depending on the policy's investment
return, but will never be less than the
guaranteed minimum?
- the cash value may increase or decrease [_] YES [_] NO
depending on the policy's investment return?
c. Do you believe that this policy will meet your [_] YES [_] NO
insurance needs and financial objectives?
* The Cash Value will be allocated to the Money Market account,
for an initial period described on page 1 of the prospectus.
THE DEATH BENEFIT MAY BE VARIABLE OR FIXED UNDER SPECIFIED CONDITIONS.
THE CASH VALUE MAY INCREASE OR DECREASE IN ACCORDANCE WITH SEPARATE
INVESTMENT ACCOUNT EXPERIENCE
--------------------------------------------------------------------------------
Part II
Application
(Complete only if medical or paramedical exam is not required.)
--------------------------------------------------------------------------------------------
Family 40. a. Age b. Mother Age
Father
-------------------------- -------------------------
if living at death if living at death
-------------------------- -------------------------
-------------------------- -------------------------
-------------------------------------------------------------------------------------------------
--------------------------
Medical 41. a. Height ft. in. c. Any weight change
-------------------------- in the past year? [_] YES [_] NO
Data ------------- ----------
b. Weight lbs. If YES: lbs. [_] Gain [_] Loss
------------- ----------
-------------------------------------------------------------------------------------------------
Give details for each YES answer to questions 42 through YES NO
46 in question 47.
42. Have you ever been treated for or had any known indication
of: frequent fatigue; frequent loss of appetite; frequent
night sweats; chronic diarrhea; enlarged lymph nodes;
unexplained infections; or unusual skin lesions?
[_] [_]
43. Have you ever:
a. Received treatment, advice or counseling from a physician,
other practitioner or an organization for an alcohol
problem? [_] [_]
b. Used cocaine or other drugs except as prescribed by a
physician or licensed practitioner? [_] [_]
44. Have you ever been treated for, or been diagnosed by a member
of the medical profession as having Acquired Immune
Deficiency Syndrome (AIDS) or AIDS-Related Complex (ARC)? [_] [_]
45. Have you ever been treated for or diagnosed as having:
a. Cancer; tumor; or diabetes? [_] [_]
b. High blood pressure; stroke; or disease of
heart, blood or circulatory system? [_] [_]
c. Any mental or nervous disorder; epilepsy; any
muscular or skeletal disorder; or any paralysis or
deformity? [_] [_]
d. Disease or disorder of: kidneys; lungs;
stomach; liver; digestive system; or urinary
system? [_] [_]
46. Other than above, have you within the past 5 years: had a [_] [_]
check up or consultation; been a patient in a medical
facility; or been advised to have any diagnostic test,
hospitalization or surgery?
--------------------------------------------------------------------------------------------
47. Give details to each YES answer to questions 42 through 46.
(Attach additional sheet, if necessary.)
------------------------------------------------------------------------------
Detail and severity of condition.
Ques. # Onset Recov Number of attacks. Specific Physician/Health
Letter Mo/Yr Mo/Yr. diagnosis, medication/treatment. Facility address
------------------------------------------------------------------------------
Illness
-----------------------------------
Treatment
------------------------------------------------------------------------------
Illness
-----------------------------------
Treatment
------------------------------------------------------------------------------
Illness
-----------------------------------
Treatment
------------------------------------------------------------------------------
Illness
-----------------------------------
Treatment
------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------
Application
Continued
--------------------------------------------------------------------------------
Company Use
(Additions and
Amendments)
--------------------------------------------------------------------------------
Declarations General. To the best of my knowledge and belief the answers
recorded are true and complete. In those states where written
consent is required by law, my agreement in writing is required
to any entry made by the Company in the "Company Use" section as
to: (a) age; or (b) plan of insurance; or (c) riders; or (d)
amounts; or (e) rate class.
When Insurance Takes Effect. If a prepayment is made in
connection with this Application, the insurance will take effect
as stated in the Prepayment Receipt and Temporary Insurance
Agreement. Otherwise, the insurance will take effect only when
the first premium is paid; provided that at the time of such
payment: (a) this Application has been approved by the Company
at 000 Xxxxxxxx Xxxxxx, Xxxxxx, XX; and (b) there has been no
change in insurability as represented in this Application since
the date of the Application.
Limitation on Authority of Agents and Examiners. Agents and
Examiners do not have authority: (a) to determine insurability;
(b) to change any terms of this Application; or (c) to make a
contract for the Company.
--------------------------------------------------------------------------------
Authorization In order that insurance can be issued, I authorize each of the
following having records or knowledge of me or my health to give
this information to the Company: a medical practitioner; a
medical facility; an insurance company; the Medical Information
Bureau; a consumer reporting bureau; and any other company,
concern or person. If insurance on any minor child is applied
for this authorization extends to records and knowledge of that
child and the child's health. Information received by the
Company may be disclosed to third parties in the conduct of the
Company's business.
I understand that: I have a right of access to and correction of
all information obtained by the Company; I can ask to be
interviewed with respect to any investigative consumer report;
and I can ask for a copy of any such report. A photocopy of this
authorization is as valid as the original. This authorization is
valid for 30 months from the date it is signed. I have received
a Notice of Information Practices; this Notice gives a more
detailed description of the information practices of the
Company.
--------------------------------------------------------------------------------
------------------------- ------------------------
Signatures Signed at Date
------------------------- ------------------------
city state month day year
--------------------------------------------------------
Proposed
Insured
--------------------------------------------------------
-----------------------------------------------
Applicant if Other
than Proposed
Insured
-----------------------------------------------
-----------------------------------------------
Agent
-----------------------------------------------
--------------------------------------------------------------------------------
-----------------------------
Owner's Owner's Social Security or Taxpayer
Identification Number:
-----------------------------
Certification
(in lieu [_] I am [_] I am not subject to backup withholding under
of W9) Section 3406(a)(l)(c) of the Internal Revenue Code. Under
penalties of perjury, I certify that the information in this
section is true, correct and complete.
-------------------------- -----------------------
Signature Date
of Owner
-------------------------- -----------------------
month day year
--------------------------------------------------------------------------------
Agent
Certificate
(Completion required in every case.)
-----------------------------------------------------------------------------------------------------------
Questions 1. Did you see the Proposed Insured on the date the [_] YES [_] NO
application was signed? If NO, explain in REMARKS.
2. Is the Proposed Insured a citizen of the USA?
---------------- -----------------------------
If NO, specify: Date of entry Type of visa
---------------- -----------------------------
mo day yr
3. If Proposed Insured's name has been changed in the past 10 years, give former name(s).
----------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------
4. Provide phone number where Proposed Insured can be contacted.
--------------
Preferred calling time AM PM
------ ------
5. If Proposed Insured is a juvenile (ages 0 through 14);
a. Give name and relation of person responsible for support.
----------------------------------------------------------------------
----------------------------------------------------------------------------------------
b. Give Life Insurance in force on above person's life.
---------------------------
c. Are there any other children insured for less than this child? [_] YES [_] NO
If YES, provide details in REMARKS.
6. Has a nonmedical been submitted based on expanded nonmedical limit? [_] YES [_] NO
If YES:
------------- ----------------------------------------
Date of Physician's Who completed
Exam detailed in APS the exam?
------------- ---------------------------------------
mo day year Physician's name and address
7. Do you have knowledge or reason to believe that any insurance
or annuity in this or any other company has been or will be
replaced as a result of this Application for
insurance? [_] YES [_] NO
8. Is this Business Insurance? [_] YES [_] NO
If YES, complete the following:
a. Describe purpose of insurance.
[_] Key Employee [_] Buy-Sell [_] Deferred Compensation
[_] Salary Continuation [_] Split Dollar [_] Section 162 Bonus
[_] Other (Describe in REMARKS.)
b. Are other key individuals insured or being
insured for similar amounts? [_] YES [_] NO
If NO, state why not.
------------------
c. What percentage of business does the applicant own or control? %
------------------
Give names and amount of business coverage in force and/or applied for for all key
associates, plus the percentage of ownership in each:
Name Amount % Name Amount %
----------------------------------------------------------------------------------------
$ $
----------------------------------------------------------------------------------------
$ $
----------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------
Agent
Certificate
Continued
(Completion required in every case.)
--------------------------------------------------------------------------------------------
----------
d. Year Business was established.
----------
e. For the Business, provide approximate amount of:
Assets Liabilities Net Worth Net Income
-------------------------------------------------------------------------
$ $ $ $
-------------------------------------------------------------------------
9. If Paid Up Additions Rider or FTR was requested, submit copy
of Illustration to the home office with Application.
10. State Source of Funds if $10,000 or greater.
--------------------------------------------------------------------------------------------
Complete questions 11 and 12 for Variable Life Only:
11. Is policyowner associated with a member firm of the NASD? (If
YES, give name and address of firm.)
-----------
12. Tax Bracket (%)
-----------
--------------------------------------------------------------------------------------------
Remarks
--------------------------------------------------------------------------------------------
Signature To the best of my knowledge, I have presented the Company all pertinent facts
regarding the Proposed Insured and regarding this Application.
------------------------------ --------------------
Signature Date
of Agent --------------------
------------------------------ month day year
--------------------------------------------------------------------------------------------
--------------------------
General If agent of another company, give name of company.
Agent --------------------------
Certificate Is agent licensed where Application is written? [_] YES [_] NO
--------------------------------------- ---------------------
Signature Date
of General ---------------------
Agent month day year
---------------------------------------
--------------------------------------------------------------------------------------------
------------------------------------------------------------------------------
Commission Split
Agent Agent Agency -----------------------
Identification Agent Name Number Number First Renewal
------------------------------------------------------------------------------
------------------------------------------------------------------------------
------------------------------------------------------------------------------
------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------
--------------------------------------- -------------------
For Variable Accepted for Date
Life Only the Company -------------------
--------------------------------------- month day year
--------------------------------------------------------------------------------------------
COMPLETE ABOVE DATA IN ALL CASES FOR PROPER CREDITING OF COMMISSIONS
