Pre-Effective Amendment to Registration Statement of a Unit Investment Trust — Form S-6
Filing Table of Contents
Document/Exhibit Description Pages Size
1: S-6EL24/A Pre-Effective Amendment to Registration Statement 4± 24K
of a Unit Investment Trust
9: EX-27.ALGRMDP Financial Data Schedule (Pre-XBRL) 2± 18K
10: EX-27.ALGRSMCP Financial Data Schedule (Pre-XBRL) 2± 18K
11: EX-27.FIDASM Financial Data Schedule (Pre-XBRL) 2± 18K
13: EX-27.FIDGRWTH Financial Data Schedule (Pre-XBRL) 2± 18K
14: EX-27.FIDINDEX Financial Data Schedule (Pre-XBRL) 2± 18K
12: EX-27.FIDMONMT Financial Data Schedule (Pre-XBRL) 2± 18K
15: EX-27.FIDOVER Financial Data Schedule (Pre-XBRL) 2± 18K
19: EX-27.INVHGYD Financial Data Schedule (Pre-XBRL) 2± 18K
16: EX-27.INVINDL Financial Data Schedule (Pre-XBRL) 2± 18K
17: EX-27.INVTOT Financial Data Schedule (Pre-XBRL) 2± 18K
18: EX-27.INVUTIL Financial Data Schedule (Pre-XBRL) 2± 18K
22: EX-27.LIMMATBD Financial Data Schedule (Pre-XBRL) 2± 18K
20: EX-27.NBGOVTIN Financial Data Schedule (Pre-XBRL) 2± 18K
21: EX-27.NBGRWTH Financial Data Schedule (Pre-XBRL) 2± 18K
23: EX-27.NBPART Financial Data Schedule (Pre-XBRL) 2± 18K
24: EX-27.VEGOLD Financial Data Schedule (Pre-XBRL) 2± 18K
25: EX-27.VEWLDWD Financial Data Schedule (Pre-XBRL) 2± 18K
46: EX-99.2AOPINCOUNSEL Miscellaneous Exhibit 2± 17K
47: EX-99.2BOPINCOUNSEL Miscellaneous Exhibit 1 14K
3: EX-99.3A12-31-94CMPY Miscellaneous Exhibit 35± 156K
4: EX-99.3B12-31-94CMPY Miscellaneous Exhibit 27± 119K
5: EX-99.3C3-31-95CMPYS Miscellaneous Exhibit 13± 62K
6: EX-99.3D12-31-94SEPA Miscellaneous Exhibit 6± 34K
7: EX-99.3E3-31-95SEPAC Miscellaneous Exhibit 5± 51K
8: EX-99.3F3-31-95SEPAC Miscellaneous Exhibit 6± 33K
30: EX-99.A1ESTABLISHSEP Miscellaneous Exhibit 5± 34K
37: EX-99.A3A.1ADDENDUMT Miscellaneous Exhibit 1 15K
38: EX-99.A3A.2AMENDMENT Miscellaneous Exhibit 1 16K
39: EX-99.A3A.3AMENDMENT Miscellaneous Exhibit 7± 36K
40: EX-99.A3A.4AMENDMENT Miscellaneous Exhibit 2± 17K
41: EX-99.A3A.5AMENDMENT Miscellaneous Exhibit 5± 30K
42: EX-99.A3A.6AMENDMENT Miscellaneous Exhibit 2± 16K
31: EX-99.A3BCOMPENSATIO Miscellaneous Exhibit 4± 23K
32: EX-99.A3CCOMMISSIONS Miscellaneous Exhibit 1 14K
26: EX-99.A4.AUNDERTAKIN Miscellaneous Exhibit 4± 27K
27: EX-99.A4.BREGSTMTCON Miscellaneous Exhibit 3± 20K
28: EX-99.A4.CSIGNATUREP Miscellaneous Exhibit 2± 18K
29: EX-99.A4.DEXHIBITIND Miscellaneous Exhibit 2± 15K
43: EX-99.A4.ESERVICESAG Miscellaneous Exhibit 2± 18K
51: EX-99.A4.FNOTICEOFWI Miscellaneous Exhibit 2± 18K
52: EX-99.A4.G6E3-TREPRE Miscellaneous Exhibit 1 14K
53: EX-99.A4.HPOWERSOFAT Miscellaneous Exhibit 13± 62K
2: EX-99.A5APROSPECTUS Miscellaneous Exhibit 90± 396K
35: EX-99.A6.ARESTATEDAR Miscellaneous Exhibit 4± 27K
36: EX-99.A6.BBY-LAWS Miscellaneous Exhibit 15± 71K
33: EX-99.A7.ALIFECONTRA Miscellaneous Exhibit 36± 136K
34: EX-99.A7.BRIDERCONTR Miscellaneous Exhibit 3± 22K
44: EX-99.A9.AAPPLICATIO Miscellaneous Exhibit 24± 94K
45: EX-99.A9.BAPPLICATIO Miscellaneous Exhibit 12± 57K
50: EX-99.C1ACCTCONSNT Miscellaneous Exhibit 1 14K
48: EX-99.C6.AOTHEROPINA Miscellaneous Exhibit 2± 16K
49: EX-99.C6.BOTHEROPINA Miscellaneous Exhibit 1 16K
Q1155
Flexible Premium Variable Life Insuance Application
Security Life of Denver Insurance Company
P. O. Box 173763
Denver, CO 80217-3763
1-800-933-5858
Flexible Premium Variable LIFE INSURANCE APPLICATION INSTRUCTIONS
FOR ALL APPLICATIONS
Use dark ink to complete the application.
Print LEGIBLY to avoid issue errors.
Attach a complete illustration and all schedules associated with this
application to expedite policy issue process and ensure that
the policy is issued accordingly.
Incomplete applications may require an amendment to be signed upon delivery,
or may be returned, which will delay the issue process.
The issue state will be determined by the state in which the application was
signed.
SIGNATURES REQUIRED, Page 10:
The signature of all proposed insureds (parent or guardian of the proposed
insured if below age 15).
The signature(s) of the owner. If a corporation is the owner, one officer,
other than the proposed insured, should sign and
indicate name of corporation and title of signing officer.
The signature of the agent/registered
representative. (Page 10 and Registered Representative's Report.)
APPLICATION - PART I
SECTION A:
A-3: Exercise Right of Exchange Rider - complete
this box to identify policy to be exchanged and
return the policy along with the application
and medical information on the new proposed insured.
A-4: If the application is employer
sponsored, and the policy will be corporate
owned, this question should be answered "No".
SECTION B: Proposed Insured Information
B-1: The legal name of the insured will
appear on the policy as indicated in this space.
B-4 Insurance age is calculated as age nearest birthday.
SECTION C AND SECTION D: Owner and Beneficiary Designations
If you are designating more than one owner
and/or beneficiary, use Special Instructions,
Section O, and indicate the second owner's name
and/or percentage of the beneficiary split. For example:
John Doe, Husband, 70%
Mary Doe, Mother, 30%
If you are designating a trust as the owner
and/or beneficiary, include the name of the
Trustee, the name of the Trust and the date of the Trust. For example:
John Doe, Trustee, of the Revocable
Life Insurance Trust of James Doe, dated
November 1, 1991.
When you are designating more than one owner,
include the social security number or tax
identification number for each respective owner
in Special Instructions, Section O.
If you have children as owners or beneficiaries, please refer to the
brochure entitled "Your Minor Child."
SECTION F: Special Dating Requested
This section provides an option for
indicating a specific age and date on which
the policy applied for will be issued. This
date is the POLICY DATE only, and may differ from the INVESTMENT DATE.
SECTION I: Premium Information
I-1: Consult your Service Guide for List Bill and EFT guidelines.
I-2: Electronic Funds Transfer (EFT) is a premium
payment method which the payor may elect. If
selected, the premium will automatically be
drafted from the payor's checking account.
I-3: If any Authorized Withdrawal/EFT is collected
with this application, the required premium
amount as outlined in the prospectus must also
be collected along with the Binding Limited Life
Insurance Coverage form in order to bind coverage.
SECTION J: Fund Transfers
J-1: You must have at least $10,000 of
Accumulation Value in the Fidelity Investments
Money Market Division or the Neuberger & Berman
Limited Maturity Bond Division to exercise this
option. The minimum transfer amount each month
is $100. The maximum transfer amount is equal to
the Accumulation Value in the Division from
which the transfer originates when the election is made, divided by 12.
SECTION K: 1035 Exchange Information
K-4: For purposes of 1035 Exchanges, this information is required to carry
over the correct cost basis and loan amount.
SECTION O: Special Instructions
Used for any additional information (for
example, billing and mailing instructions) and
continuing your answers for owner and beneficiary designations.
If you are requesting child rider(s) and need
to request beneficiary(ies) other than shown in
Section D, please indicate here. Include name(s)
of beneficiary(ies) and relationship.
May be used to continue answers to question K-12, if necessary.
Payor, accepting rating on formal application only.
APPLICATION - PART II
Medical Information
This part of the application must be completed for each person proposed for
coverage unless the person is medically examined.
Application for Flexible Premium Variable
Life Insurance to Security Life of Denver Insurance Company
PART I
Please Print All Information Using Dark Ink
SECTION A - General Information (Complete for all cases)
A-1 (box) Check here if insurance is for PENSION or
similar tax qualified ERISA plan.
A-2 If above statement checked, list plan type (box)
(Example: Profit-Sharing; Defined Contribution; etc.)
A-3 (box) Exercise Right of Exchange Rider
Name of Insured under Policy to be Exchanged Policy Number
(box) (box)
A-4 Employer Sponsored Plans check one:
Employee Owned? (box) Yes (box) No
SECTION B - Proposed Insured (Complete for all cases. To apply for additional
insureds complete Section G)
B-1 Name (Print full name, include suffix)
(First, Middle, Last, Suffix)
(box)
B-2 Sex
(box) Male
(box) Female
B-3 Birthdate
Month Day Year
(box) (box) (box)
B-4 Insurance Age
(Age Nearest Birthday)
(box)
B-5 Birthplace
(State)
(box)
B-6 Social Security Number
(box)
B-7 Telephone Number
(box)
B-8 Height (box)
B-9 Weight (box)
B-10 Address
(Street, Apt. No.)
(box)
(City) (State) (Zip Code)
(box) (box) (box)
B-11 Occupation
(box)
B-12 Describe duties
(box)
B-13 Employer Name
(box)
B-14 Employment date:
Month Year
(box) (box)
SECTION C - Owner (Complete only if other than Proposed Insured)
C-1 Owner Name (Print full name, include suffix - if name to appear
differently on policy, indicate in Section O)
(First, Middle, Last, Suffix)
(box)
C-2 Relationship to Proposed Insured
(box)
C-3 Social Security Number or Tax I.D. No. (Include any hyphens)
(box)
C-4 Owner Address
(Street, Apt. No.)
(box)
(City) (State) (Zip Code)
(box) (box) (box)
SECTION D - Beneficiaries (Complete for all cases)
D-1 Primary Beneficiary(ies) (Print Full Names)
(box)
Relationship to Proposed Insured
(box)
Birthdate
(box)
Continent Beneficiary(ies) (Print Full Names)
(box)
Relationship to Proposed Insured
(box)
Birthdate
(box)
SECTION E - Plan Information (Complete for all cases)
E-1 Flexible Premium Variable Life Insurance Policy
a. Product Name
(box)
b. Stated Death Benefit (box)
c. Scheduled Periodic Premium $(box) (If premium varies from year to
year attach schedule)
d. (box) Option 1 (Stated Death Benefit. If no option selected,
Option 1 will apply.)
(box) Option 2 (Stated Death Benefit plus Account Value.)
(box) Option 3 (Stated Death Benefit plus Premiums Paid, less
partial withdrawals.)
e. (box) Guideline Premium Test
(box) Cash Value Accumulation Test
f. First Year Pour-In (if any) $(box)
g. Riders
(box) Adjustable Term Rider $(box)
(Attach Schedule of Target Death Benefits)
(box) Additional Insured $(box)
(Complete section G)
(box) Accidental Death $(box)
(box) Child's Insurance Rider (# of Units) (box)
(Complete section H)
(box) Right to Exchange
(box) Waiver of Cost of Insurance
(box) Guaranteed Insurability Rider
(box) Waiver of Specified Premium $(box)
(box) Other (box)
SECTION F - Special Dating Requested (If neither box checked below, policy
will be issued at age nearest birthday as of issue date.)
F-1 (box) Date to Save Age Specify Requested Age (box)
F-2 (box) Specific Date
Mo Day Year
(box) (box) (box)
SECTION G - Additional Insured Rider
G-1 Name of Proposed Additional Insured (If more than one additional
insured, specify details in special instructions, Section O)
(First, Middle, Last, Suffix)
(box)
G-2 Relationship to proposed insured (box)
G-3 Birthdate
Month Day Year
(box) (box) (box)
G-4 Social Security Number (box)
G-5 Height (box)
G-6 Weight (box)
G-7 Insurance Age (Age nearest birthday) (box)
G-8 Show beneficiary for additional insured if different from beneficiary
named in Section D.
Name: (box) Relationship (box) Birthdate: (box)
SECTION H - Child Rider
Birthdate Mo/Day/Yr Height Weight
H-1 Child (box) (box) (box) (box)
H-2 Child (box) (box) (box) (box)
H-3 Child (box) (box) (box) (box)
H-4 Child (box) (box) (box) (box)
SECTION I - Premium Information
I-1 Premium Mode (If no option selected - Premium mode will be quarterly)
(box) Annual
(box) Quarterly
(box) Semi-Annual
(box) Monthly (only available for List Bill and Authorized
Withdrawal/EFT)
I-2 Payment Method
(box) Direct Bill (not available for monthly)
(box) Single Premium
(box) List Bill Existing List Bill Number ____________
(box) Authorized Withdrawal (Complete Authorized Withdrawal/EFT Form)
I-3 Premium collected with application
NOTE: The agent is not authorized to collect any premium before delivering
a policy unless the Binding Limited Life Insurance Coverage form has been
completed and signed by the agent, applicant and proposed insured and a
copy given to the applicant. There is no coverage before delivery of the
policy except as provided by that form.
Yes No
(box) (box) a. Has agent collected any premium (including any
Authorized Withdrawal/EFT Form) with this
application? If any Authorized Withdrawal/EFT is
collected with this application, the required
premium amount as outlined in the prospectus must
be collected. If yes, total premium (including
any pour-in) collected $ (box)
(box) (box) b. If answer to (a) is "Yes," has agent complied with
the Binding Limited Life Insurance Coverage
requirements?
(box) (box) c. Has the applicant signed and received a Binding
Limited Life Insurance Coverage form in connection
with this application? Attach signed copy of
Binding Limited Life Insurance Coverage form.
I-4 Guaranteed Minimum Death Benefit Option
Guarantee Period (Select one, if option desired)
(box) Later of ten years or age 65 (box) Lifetime
Note: The Guarantee Period will terminate if your Account Value on any
Monthly Processing date is not diversified according to the
following rules. No more than 35% of your unborrowed Account Value may
be invested in any one division, and your unborrowed Account Value
must be invested in at least five divisions.
You can satisfy these diversification requirements if you participate
in the Automatic Rebalancing feature. You can also satisfy our
requirements for diversification if you elect Dollar Cost Averaging and
direct the resulting transfers into at least four other
Divisions with no more than 35% of any transfer being allocated to any
one division.
I-5 Initial Premium Allocation. Please allocate your Initial Premium to the
Guaranteed Interest Division and/or among the Variable Account
Divisions. Please use whole number percentages for each Division
elected. You must allocate at least 1% of your Premium
Allocation to each Division in which you elect to invest, provided that
the minimum allocation to each Division is at least $100. The total must
equal 100%.
____% Guaranteed Interest Division
Variable Account Divisions
Neuberger & Berman
____% Limited Maturity Bond
____% Growth Portfolio
____% Government Income
____% Partners Portfolio
Alger American
____% Small Capitalization
____% MidCap Growth
____% Growth
____% Leveraged AllCap
Fidelity Investments
____% Asset Manager
____% Growth Portfolio
____% Overseas
____% Money Market
____% Index 500
Van Eck
____% Worldwide Balanced
____% Gold and Natural Resources
Invesco
____% Industrial Income
____% High Yield
____% Utilities
____% Total Return
SECTION J - Fund Transfers
J-1 Dollar Cost Averaging
Please transfer $(box) from (check one only) my
(box) Fidelity Investments Money Market Division
(box) Neuberger & Berman Limited Maturity Bond Division
into the other Variable Account Division(s) selected below.
(Note: Please use whole number percentages for each
Division selected.) You must allocate a minimum of 1% to each
Division in which you elect to invest, provided that the minimum
allocation to each Division is at least $100. The total must equal
100%. You may specify a date for Dollar Cost Averaging to terminate.
You may also specify a dollar amount so that when the Account Value
reaches this dollar amount, Dollar Cost Averaging would terminate.
Neuberger & Berman
____% Limited Maturity Bond
____% Growth Portfolio
____% Government Income
____% Partners Portfolio
Alger American
____% Small Capitalization
____% MidCap Growth
____% Growth
____% Leveraged AllCap
Fidelity Investments
____% Asset Manager
____% Growth Portfolio
____% Overseas
____% Money Market
____% Index 500
Van Eck
____% Worldwide Balanced
____% Gold and Natural Resources
Invesco
____% Industrial Income
____% High Yield
____% Utilities
____% Total Return
J-2 Automatic Rebalancing
(box) Automatic Rebalancing
Note: If you elect this feature, each quarter we will transfer amounts
among the Variable Account Divisions and the Guaranteed Interest
Division so that the percentages of your unborrowed Account Value in
each Division match your most recent premium allocation. To
qualify for this feature you must allocate your
premium to at least five Divisions with no more
than 35% of the premium allocated to any one Division.
J-3 Telephone Transfer
(box) Telephone Transfer (Check if you wish to select this option.)
I/We hereby authorize and direct the Customer Service Center of Security
Life of Denver Insurance Company to accept telephone instructions from
either the Owner or _____ (insert name of your Registered Representative
if you wish the representative to have telephone transfer authority) to
reallocate my Accumulation Value among the Divisions available or
request a policy loan or partial withdrawal. I/We agree to hold
harmless and indemnify Security Life for any losses arising from such
instructions. I/We further authorize Security Life and its Customer
Service Center to record telephone conversations with me/us.
(Initials of Owner _______)
SECTION K - Personal Information
K-1 List life insurance policies on all persons proposed for coverage
(1) now in force or (2) applied for within the last 12 months, or
(3) pending now. If NONE, Check this box (box)
Name of Year A.D. Business or Indicate if Inforce,
Proposed Insured Company Issued Amount Amount Personal Applied for, or Pending
(box) (box) (box) (box) (box) (box) (box)
(box) (box) (box) (box) (box) (box) (box)
(box) (box) (box) (box) (box) (box) (box)
Yes No
K-2 Has any proposed insured ever been declined for insurance
(or reinstatement) or been offered insurance with
restricted benefits or at other than standard rates?
(If "Yes" give details in Section K-12) (box) (box)
K-3 Is this insurance to replace, or will it cause any change
in, any insurance or annuity on any person proposed for
coverage? (If "Yes" submit a completed replacement form
with this application.) (box) (box)
K-4 a. Is this insurance intended to be a tax free exchange -
1035 Exchange? (box) (box)
b. If "Yes" will any policy loan be carried over? (box) (box)
SECTION K - Personal Information (Continued)
Yes No
K-5 Has any person proposed for coverage:
a. ever smoked cigarettes? (If "Yes," give name and
details in section K-12) (box) (box)
b. ever used tobacco in any form other than cigarettes?
(If "Yes" give name and details in section K-12) (box) (box)
c. ever stopped smoking cigarettes? (If "Yes" give name
and date last smoked in section K-12) (box) (box)
d. ever stopped using tobacco in any form other than
cigarettes. (If "Yes" give name, type and date
last used in section K-12) (box) (box)
K-6 Within the last 3 years or within the next 12 months,
has any person proposed for coverage:
a. flown (or planned to fly) other than as a
passenger on a regularly scheduled airline?
(If "Yes" complete Aviation Supplement.) (box) (box)
b. had a drivers license denied, revoked, or suspended;
had three or more moving violations; been convicted
of an alcohol or drug related driving offense; been
involved in two or more auto accidents? (If "Yes"
give details in section K-12) (box) (box)
c. participated in (or intend to participate in) vehicle
racing (on land or water), ballooning, bobsledding,
hang gliding, ultralight aviation, horse racing,
mountaineering, rodeo, scuba/skin diving, skydiving/
parachuting, or bungee cord jumping? (If "Yes"
complete Avocation Supplement) (box) (box)
K-7 List Driver's License No. here (box) State (box)
K-8 Does any person proposed for coverage contemplate
traveling or residing outside the U.S.A. or Canada
within the next 12 months? (If "Yes" give details
in section K-12) (box) (box)
K-9 Has any person proposed for coverage been
convicted of a felony within the last 5
years? (If "Yes" give details in section K-12) (box) (box)
K-10 Has any person proposed for coverage:
a. ever had, or now have, any type of heart disease,
cancer, leukemia, or malignant tumor? (If "Yes"
give details in section K-12) (box) (box)
b. ever been diagnosed by a licensed member of
the medical profession as having Acquired Immune
Deficiency Syndrome (AIDS) or any immune
deficiency or disorder? (Do Not Answer This
Question If You Reside In Nevada.) (If
"Yes" give details in section K-12) (box) (box)
K-11 Does any person proposed for coverage now
participate in any regular physical exercise
program? (box) (box)
K-12 Details of "YES" Answers to Questions K-2 through K-11
(box)
SECTION L - Medical Exam Certificate (Complete when submitting medical
examination of another insurance company.)
L-1 The attached examination is on the life of: (box)
L-2 Name of insurance company for which examination was made and date of
examination:
Company (box) Date of Examination (box)
Yes No
L-3 To the best of the proposed insured's knowledge and
belief, are the statements in the examination true as
of today? (If "No," explain in "Remarks") (box) (box)
L-4 Has the proposed insured consulted a doctor or other
practitioner or received medical or surgical advice
since the date of the examination? (If "Yes," explain
in "Remarks") (box) (box)
Remarks to No. L-3 and L-4
(box)
SECTION M - Financial Information (Must be completed where the face amount
exceeds [1] $200,000 for business insurance, [2] $300,000 for an insured 65
and under, or [3] $100,000 for an insured over 65.)
M-1 What is the purpose of the insurance applied for? (box)
If the insurance applied for is personal, what is the proposed insured's:
Annual Earned Income $(box) Total Assets $(box)
Annual Interest & Other Income $(box) Total Liabilities $(box)
Total Net Worth $(box)
Yes No
M-2 If Business Insurance:
Last Year 2 Years Ago
a. Annual net profit (before taxes, past
two years) $(box) $(box)
b. Business reason for insurance (check at least one
box and furnish details)
(box) Key Person (box) Stock Redemption/Buy and Sell (box) Other (box)
c. If Key Person insurance: Yes No
(1) Are all partners or key people to be covered? (box) (box)
(If "No," explain)
(box)
(2) Does proposed insured have an ownership interest
in the business? (box) (box)
If "Yes," what is proposed insured's percent of
ownership? (box)%
(3) What is proposed insured's annual income? $(box)
d. If to fund stock redemption, is there a written
agreement? (box) Yes (box) No
(1) What is the book value of the business? $(box)
(2) What is the market value of the business? $(box)
(3) How was the value determined? (box)
Yes No
M-3 Is this insurance to guarantee a loan? (box) (box)
a. If "Yes," is the lender requiring this insurance? (box) (box)
b. Is the loan finalized? (box) (box)
c. What is the term of the loan? (Months) (box)
d. Name of lender: (box)
e. Amount of loan: (box)
f. Purpose of loan: (box)
g. Are others being insured for the same purpose? (box) (box)
If Yes, who and for what amount?
(box) Amount $(box)
(box) Amount $(box)
SECTION M - Financial Information (Continued) (Must be completed where the
face amount exceeds [1] $200,000 for business insurance, [2] $300,000 for an
insured 65 and under, or [3] $100,000 for an insured over 65.)
M-4 Additional remarks about purpose of the insurance and how the amount of
insurance was determined.
Remarks to Section M
(box)
SECTION N - Suitability
a. Have you, the Proposed Insured, and the Owner, if other than the Proposed
Insured, received a current Prospectus dated ______________________ for the
Variable Life Insurance policy applied for and current prospectus for each
of the Variable Account Divisions? (box) Yes (box) No
b. Do you understand that under the policy applied for the amount or duration
of the death benefit may vary under specified conditions; policy values may
increase or decrease in accordance with the investment experience of
investment divisions in a Separate Account, and may increase in accordance
with the interest credited in the Guaranteed Interest Division; and the
amount payable at the Final Policy Date is not guaranteed but is dependent
on the amount then in the Account Value? (box) Yes (box) No
c. Do you understand that any personalized illustrations received are based
on hypothetical interest assumptions which may not be indicative of actual
future investment experience of our Separate Account or of actual interest
credited in our Guaranteed Interest Division? (box) Yes (box) No
d. With this in mind, is the policy in accord with your insurance objectives
and your anticipated financial needs? (box) Yes (box) No
SECTION O - Special Instructions
(box)
PART II
Please Print All Information Using Dark Ink
Part II must be completed for each person proposed for coverage unless the
person is medically examined.
SECTION A - Personal Physicians
A-1 For each person proposed for coverage, give
the name and address of the personal physicians
and the date and reason the physician was last
seen.
If NONE, check here (box)
Proposed Insured's Name Name and Address of Physician Date and Reason Last Seen
(box) (box) (box)
(box) (box) (box)
(box) (box) (box)
SECTION B - Medical Information (Complete for
each person proposed for coverage.) (For all
of Section B, circle each specific condition
and give details of all "Yes" answers in the
Details Section following question B-11. Give
name of disease, symptoms, etc.; the date of
onset; the duration; number of attacks; and
name and addresses of medical professional or
hospital providing services.)
B-1 Has any person proposed for coverage ever
been treated for, or been told by a member of
the medical profession that the person has:
Yes No
a. pain, pressure, or discomfort in the chest or arms;
high blood pressure; heart murmur; irregular heartbeat;
or any other disease or disorder of the heart? (box) (box)
b. anemia; leukemia; or any other disorder of the blood,
veins or arteries? (box) (box)
c. asthma; bronchitis; pneumonia; tuberculosis; emphysema;
shortness of breath; chronic cough, or any other disorder
of the lungs or respiratory system? (box) (box)
d. mental or emotional disorder, nervous breakdown; epilepsy;
convulsions; chronic fatigue; fainting spells; paralysis;
stroke; or any other disorder of the brain or nervous
system? (box) (box)
e. significant weight loss; ulcer; colitis; diverticulitis;
hepatitis; cirrhosis; persistent diarrhea; or
other disease of the liver, gall bladder,
pancreas, stomach or intestines? (box) (box)
f. diabetes; thyroid; recurrent enlarged glands; or other
glandular disease or disorder? (box) (box)
g. arthritis; gout; or any bone, joint, muscle, or skin
disorder? (box) (box)
h. polyp, tumor, or cancer? (box) (box)
i. disorder of the urinary tract or kidneys; urethritis;
cystitis; sugar, albumin, or blood in the urine? (box) (box)
j. prostate or testicular disease; venereal disease; herpes;
or disease of the uterus, ovaries or breasts? (box) (box)
k. any disorder of the eyes; ears; nose; or throat? (box) (box)
l. any other health impairment or medically or surgically
treated condition within the last 5 years not mentioned
above? (box) (box)
Yes No
B-2 Has any person proposed for coverage ever
been treated for or been told by a licensed
member of the medical profession that the
person has Acquired Immune Deficiency Syndrome
(AIDS) or any disorder or deficiency of the
Immune System? (Do Not Answer This Question If
You Reside In Nevada.) (box) (box)
B-3 Within the past 10 years, has any person
proposed for coverage:
a. tested positive in a test to detect antibodies to the
AIDS virus (Human T-Cell Lymphotrophic virus type III;
HTLV-III, Human Immunodeficiency Virus [HIV])? (Do Not
Answer This Question If You Reside in Connecticut or
Maine.) (box) (box)
b. had a blood transfusion? (box) (box)
B-4 Within the past 5 years, has any person
proposed for coverage been a patient in or had
treatment at a hospital, clinic, sanitarium or other
medical facility? (box) (box)
B-5 Is any person proposed for coverage now
under regular medical observation by, or taking
treatment from, a member of the medical
profession? (box) (box)
B-6 Other than as stated in the answers above,
has any person proposed for coverage, within
the last 5 years:
a. had a checkup or consultation with a
member of the medical profession? (box) (box)
b. had an electrocardiogram, x-ray, blood test or other test? (box) (box)
c. been advised by a member of the medical profession to have
any diagnostic test, hospitalization, or surgery which was
not completed? (box) (box)
B-7 Does any person proposed for coverage have a deformity
or an amputation? (box) (box)
B-8 Does any person proposed for coverage now
take any medicine prescribed by a member
of the medical profession? (box) (box)
B-9 Except as legally prescribed by a physician,
has any person proposed for coverage ever
used narcotics, cocaine, marijuana, or any
hallucinatory or mind altering substances in
the past 10 years? (box) (box)
B-10 In the last 5 years, has any person proposed
for coverage received treatment for or
joined an organization because of the
alcoholism or drug addiction of that
person? (box) (box)
B-11 Has any parent, brother, or sister of any
person proposed for coverage ever had
cancer; diabetes; high blood pressure; heart or kidney
disease; nervous or mental disorder;
tuberculosis; or hereditary disorder? (box) (box)
Details of "Yes" answers to questions B-1 through B-11
Ques. Name of
No. Proposed Insured Complete Details
(box) (box) (box)
(box) (box) (box)
(box) (box) (box)
(box) (box) (box)
(box) (box) (box)
(box) (box) (box)
SECTION C - Family History
Living Deceased
Family Member Age State of Health Age at Death/Cause
Father (box) (box) (box)
Mother (box) (box) (box)
Brothers (box) (box) (box)
(box) (box) (box)
Sisters (box) (box) (box)
(box) (box) (box)
AGREEMENTS
All statements and answers in this
application (which includes Part I, Part II,
and supplements and amendments) are true and
complete to the best of my knowledge and
belief. I also agree that:
1. The statements and answers in this
application will be relied upon and form the
basis of any insurance.
2. No information will be considered as
having been given to Security Life unless it is
written in this application. (This paragraph
does not apply in the states of Maine,
Missouri, Oregon, South Carolina, and South
Dakota.)
3. No agent or any other unauthorized person can
make or change any insurance contract or give
up any of Security Life's rights or
requirements. Any change must be in writing and
signed by an officer of Security Life.
4. Security Life may amend this application by
an appropriate notation in the space designated
"Home Office Corrections" in order to correct
errors or omissions or to conform the
application with any policy that may be issued.
The acceptance of the policy constitutes a
ratification of such amendments.
In those states, including Maryland,
where change in amount, classification, plan,
premium, or benefit requires the written
consent of the applicant, no change may be
ratified except by a written acceptance. We
reserve the right to make any changes required
by law.
5. Insurance Under Policy Applied For - Except
as may be provided in any Binding Limited Life
Insurance Coverage, no policy of insurance will
be in force until (1) the first policy premium
is paid and (2) the policy is delivered while
the facts and health condition of the proposed
insured(s) are as represented in this
application. When these conditions are
satisfied, the policy as delivered will then
take effect.
6. Binding Limited Life Insurance Coverage - Any
pre-delivery insurance coverage is provided in
the Binding Limited Life Insurance Coverage
form. That coverage is available only if: a
premium is accepted by the agent; the agent has
authority to accept premium as set out in that
form; and the form is completed and signed by
the agent, applicant, and proposed insured.
7. If the contract applied for is for a pension,
profit-sharing, HR10, or other tax qualified
plan, any policy issued shall not be
transferable other than to the Insurer, except
as directed by the Plan Administrator. Other
applicable provisions may be added to the
contract.
8. I certify, under penalty of perjury, that my
social security/tax identification number(s) is
shown and is correct and that I am not subject
to back up withholding.
AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION
Security Life of Denver Insurance Company ("Security Life") may obtain
information about me or my minor children from:
any physicians; medical practitioner; hospital,
clinic or other medical facility; employer;
other insurance companies or institutions;
consumer reporting agency; or Medical
Information Bureau, Inc. (MIB, Inc.). The
purpose is to evaluate my application for
insurance or benefits. Security Life may obtain
an investigative consumer report and any
records or other information available as to
diagnosis, treatment and prognosis of any
physical or mental condition.
Security Life may obtain any drug, physical and mental health,
and alcohol-related information which may be
protected by federal or state laws and
regulations. As it pertains to alcohol and drug
information covered by federal regulation, this
authorization may be revoked at any time by
written notice to Security Life. But any action
taken before my written revocation is received
by Security Life will not be affected.
Security Life may make a brief report about me
or my children to MIB, Inc. Security Life may
disclose information to: its reinsurers; those
who perform services for Security Life on my
application for insurance or benefits: or those
companies to which I have applied or may apply
for life or health insurance or benefits.
Disclosure may be made when required or
permitted by law.
This is valid for two and one-half years from
the date below. An original or copy may be used
by Security Life or its authorized
representatives to obtain information. I have
read and received a copy of this authorization.
I also have a copy of the Notice of Information
Procedures. It includes the MIB, Inc. and Fair
Credit Reporting Notices.
NOTICE: Any person who knowingly and with
intent to injure, defraud, or deceive any
insurance company, files an application,
statement or claim containing any false,
incomplete, or misleading information is guilty
of insurance fraud.
Signature of
Proposed Insured (box) Date (box)
(If below age 15, signature of parent or guardian)
Signed at City (box) State (box)
Signature of Spouse/ (box)
Additional Insured(s) (If proposed for coverage) (box)
Owner Signature (If other than proposed insured) OR (If applicable) Corporate
Owner Signature (box)
(If a firm or corporation is to be owner, the signature and title of an
officer other than the proposed insured is required.)
Except for any medical exam form, I certify
that I have asked and recorded completely and
accurately the answers to all questions on this
application. I know of nothing else affecting
the risk.
Signature of Agent/Registered Rep. (box) Reg. Rep. Number (box)
(box) (box)
Name of Broker/Dealer/Branch Address of Broker/Dealer/Branch
HOME OFFICE CORRECTIONS (FOR HOME OFFICE USE ONLY)
(Not applicable in West Virginia)
(box)
Registered Representative's Report
(Must be completed and signed for every application)
Yes No
1) Do you have knowledge or reason to
believe that replacement of existing
insurance or annuity may be involved? (box) (box)
If Yes, explain:______________________
2) How long have you known the proposed insured? ______ Years
Are you related? (box) (box)
If so, how? _________________________
3) Does the proposed insured speak English? (box) (box)
Was the application interpreted for
and understood by the proposed insured? (box) (box)
Are all persons proposed for
coverage U.S. citizens? (box) (box)
If not, how long in U.S.? ____Mos. ____Yrs.
4) Did proposed insured approach you for this insurance? (box) (box)
Yes No
5) What is the amount of insurance in force
on the spouse of the proposed insured?
$______________
6) If any proposed insured is a minor, what
is the amount of insurance on:
Father $___________ Mother $__________
Brothers $___________ Sisters $__________
7) Will the applicant accept this policy if it
is a "Modified Endowment" at issue? (box) (box)
8) If a medical exam is required, has it been ordred? (box) (box)
9) What is the source of the first premium payment:
(box) Applicant check
(box) Other (specify):__________________
10) Writing Registered Representative (Print) (box)
Writing Registered Representative (Sign) (box)
Date (box) Registered Representative Number: (box)
Production Credit Split
Agent Number Percent
____________ _______
____________ _______
____________ _______
11) What was the Primary purpose of the insurance?
PERSONAL PLANNING
A (box) Estate/Death Tax
B (box) Family Protection
C (box) Mortgage Protection
D (box) College Funding
E (box) Gift/Charitable
F (box) Retirement Maximizer
G (box) IRP/PPP/PRO
H (box) Savings
I (box) Other _____________________________
BUSINESS PLANNING
J (box) Executive Bonus
K (box) Qualified Plan
L (box) Deferred Compensation
M (box) Buy-Sell
N (box) Key Executive
O (box) Employee Benefit
P (box) Other _____________________________
12) Who was the Primary decision-maker involved?
PERSONAL PLANNING
A (box) Insured
B (box) Insured and Spouse
C (box) Parent
D (box) Grandparent
E (box) Child(ren)
F (box) Other _______________________________
BUSINESS PLANNING
G (box) Businessowner
H (box) Attorney
I (box) Accountant
J (box) Board of Directors
K (box) Trustee
L (box) Other ________________________________
13) Did the Home Office or Regional Staff assist you? (box) Yes (box) No
(If yes, check all that apply.)
A (box) Illustration
B (box) Case design
C (box) Sample Documents
D (box) Template design
E (box) Estate Analysis
F (box) Business Analysis
G (box) Family Asset Review
H (box) Competition Services
I (box) Legal Consultation
J (box) Other ________________________________
(Detach and give to Applicant)
AGREEMENTS
All statements and answers in this
application (which includes Part I, Part
II, and supplements and amendments) are
true and complete to the best of my
knowledge and belief. I also agree that:
1. The statements and answers in this
application will be relied upon and form
the basis of any insurance.
2. No information will be considered as having
been given to Security Life unless it is
written in this application. (This paragraph
does not apply in the states of Maine,
Missouri, Oregon, South Carolina, and South
Dakota.)
3. No agent or any other unauthorized person can
make or change any insurance contract or give
up any of Security Life's rights or
requirements. Any change must be in writing and
signed by an officer of Security Life.
4. Security Life may amend this application by
an appropriate notation in the space designated
"Home Office Corrections" in order to correct
errors or omissions or to conform the
application with any policy that may be issued.
The acceptance of the policy constitutes a ratification of such
amendments. In those states, including Maryland, where
change in amount, classification, plan,
premium, or benefit requires the written
consent of the applicant, no change may be
ratified except by a written acceptance. We
reserve the right to make any changes required
by law.
5. Insurance Under Policy Applied For - Except
as may be provided in any Binding Limited Life
Insurance Coverage, no policy of insurance will
be in force until (1) the first policy premium
is paid and (2) the policy is delivered while
the facts and health condition of the proposed
insured(s) are as represented in this
application. When these conditions are
satisfied, the policy as delivered will then
take effect.
6. Binding Limited Life Insurance Coverage - Any
pre-delivery insurance coverage is provided in
the Binding Limited Life Insurance Coverage
form. That coverage is available only if: a
premium is accepted by the agent; the agent has
authority to accept premium as set out in that
form; and the form is completed and signed by
the agent, applicant, and proposed insured.
7. If the contract applied for is for a pension,
profit-sharing, HR10, or other tax qualified
plan, any policy issued shall not be
transferable other than to the Insurer, except
as directed by the Plan Administrator. Other
applicable provisions may be added to the
contract.
8. I certify, under penalty of perjury, that my
social security/tax identification number(s) is
shown and is correct and that I am not subject
to back up withholding.
NOTICE OF INFORMATION PROCEDURES
OUR UNDERWRITING PROCESS
This process is an evaluation of information
about you. It is to see if you qualify for the
insurance requested. The information we review
may vary with the insurance applied for. We
look at information about you such as: your
age; occupation; health; mode of living; avocation;
and other personal information.
Answers on the application are the principal source of
information. We may contact other people or
institutions personally, by phone, or by
letter. The purpose is to confirm or add to
information you have provided. For example, we
may obtain information from your doctor,
clinic, hospital, or other insurers. In some
cases, your Security Life agent may obtain
information on our behalf. A medical
examination or laboratory tests may be
requested.
NOTICE
Any person who knowingly and with intent to
injure, defraud, or deceive any insurance
company, files an application, statement or
claim containing any false, incomplete, or misleading information is
guilty of insurance fraud.
MIB, INC.
Medical Information Bureau, Inc. ("MIB, Inc.")
may provide Security Life with a brief report
about you. This is a nonprofit organization of
life insurance companies which has an
information exchange for its members.
Information that is sent to MIB, Inc. by one
member may be given to their member companies who
have a business need for it.
Upon your written request, MIB, Inc. will
arrange for disclosure of any information it
may have in your file. If you question the
accuracy of MIB's information, you may request
a correction according to the procedures in the
Federal Fair Credit Reporting Act. MIB's
address is: P.O. Box 105, Essex Station,
Boston, Massachusetts 02112, telephone 617/426-
3660.
CONSUMER REPORTS
In some cases, a Security Life representative
may prepare a consumer report or investigative
consumer report about you or, Security Life may
ask an independent agency to prepare a consumer
report or an investigative consumer report
about you. These reports may include
information on your character; general
reputation; personal characteristics such as
health, finances, and job, and mode of living
except as may be related directly or indirectly
to your sexual orientation. Any information
obtained by the agency may be kept in its file
and later given to others who have a business
need for it.
If an investigative consumer report is ordered by Security Life, the report
will include information obtained through
interviews with your neighbors, friends, or
others you know. You may request a personal
interview. The agency will make a reasonable
attempt to talk to you. It will include that
information in its report. The Federal Fair
Credit Reporting Act gives you the right to
make a written request within a reasonable
period of time, to receive additional
information from Security Life about the nature
and scope of an investigation, if one is made.
We will provide the name, address, and phone
number of any agency we ask to prepare such a
report. You may contact the agency directly to
learn about the contents of the report.
DISCLOSURE OF INFORMATION
Information we obtain about you is
confidential. As permitted by law, we may
disclose information without further
authorization to others such as: consumer
reporting agencies hired to prepare
investigative reports; insurance companies to
which you have applied for coverage or
benefits; those providing services for us;
those conducting bona fide actuarial,
marketing, or scientific studies or audits; and
your attending doctor.
Upon written request, we will give you more information about these
procedures.
YOUR RIGHT TO REVIEW INFORMATION
These are procedures by which you can make a
written request to review personal information
in our policy file. However, Security Life will
not disclose information to you that was
prepared for any anticipated claim or any civil
or criminal proceeding. We also have procedures by which
you may request correction, amendment, or deletion
of any information in our files which you
believe to be inaccurate or irrelevant. Upon
written request, we will provide you with
further information about these procedures.
We hope this notice helps explain our underwriting process. If you have any
additional questions, discuss them with your agent or contact us directly.
Security Life of Denver Insurance Company
P. O. Box 173763
Denver, CO 80217-3763
1-800-933-5858
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