Registration of Securities by a Small-Business Issuer — Form SB-2
Filing Table of Contents
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1: SB-2 Registration of Securities by a Small-Business 81 493K
Issuer
2: EX-3.1 Articles of Incorporation/Organization or By-Laws 28 113K
3: EX-3.2 Articles of Incorporation/Organization or By-Laws 17 74K
4: EX-4.1 Instrument Defining the Rights of Security Holders 2 16K
5: EX-4.2 Instrument Defining the Rights of Security Holders 4± 22K
6: EX-10.1 Material Contract 3 18K
15: EX-10.10 Material Contract 6 34K
16: EX-10.11 Material Contract 6 33K
17: EX-10.12 Material Contract 11 42K
18: EX-10.13 Material Contract 4 21K
19: EX-10.14 Material Contract 10 44K
20: EX-10.15 Material Contract 4 22K
21: EX-10.16 Material Contract 10 43K
22: EX-10.17 Material Contract 3 20K
23: EX-10.18 Material Contract 9 41K
24: EX-10.19 Material Contract 2 15K
7: EX-10.2 Material Contract 2 17K
25: EX-10.20 Material Contract 8 35K
26: EX-10.21 Material Contract 17 62K
27: EX-10.22 Material Contract 2± 13K
28: EX-10.23 Material Contract 2 17K
29: EX-10.24 Material Contract 19 56K
30: EX-10.25 Material Contract 13 50K
31: EX-10.26 Material Contract 7 35K
32: EX-10.27 Material Contract 4 17K
33: EX-10.28 Material Contract 9 40K
34: EX-10.29 Material Contract 10 47K
8: EX-10.3 Material Contract 6 43K
35: EX-10.30 Material Contract 6 35K
36: EX-10.31 Material Contract 6 31K
37: EX-10.32 Material Contract 11 57K
38: EX-10.35 Material Contract 37 125K
39: EX-10.36 Material Contract 18 52K
9: EX-10.4 Material Contract 7 36K
10: EX-10.5 Material Contract 2± 14K
11: EX-10.6 Material Contract 3 21K
12: EX-10.7 Material Contract 4 20K
13: EX-10.8 Material Contract 1 12K
14: EX-10.9 Material Contract 1 14K
40: EX-21.1 Subsidiaries of the Registrant 1 10K
41: EX-23.1 Consent of Experts or Counsel 1 11K
42: EX-27.1 Financial Data Schedule (Pre-XBRL) 2 14K
EX-10.35 — Material Contract
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EXHIBIT 10.35
Mony Life Insurance Company of America will pay
the benefits provided in this Policy, subject to all
the policy provisions
Insured:
PAUL H BERGER
Policy Number: B6009-75-96 J
Policy Date: 8-15-1996
Initial Specified Amount: $500,000
Issue Age: 28
Date of Issue: 8-15-1996
Class:
Preferred Class - Nonsmoker
Brief Description
THIS IS A FLEXIBLE PREMIUM VARIABLE LIFE TO AGE 95 POLICY. Specified Amount may
be increased or decreased. Net premiums may be allocated to one or more
sub-accounts of the Variable Account or to the Guaranteed Interest Account
(GIA). If the values have been sufficient to continue the Policy in force: death
proceeds are payable in event of death before Age 95; surrender value is payable
if Insured is living at Age 95. Some benefits reflect investment results.
Flexible premiums until Age 95. Nonparticipating (no dividends payable).
Important Notice(s)
The amount or the duration of the Death Benefit (or both) may increase or
decrease depending on investment results. But the Death Benefit will never be
less than the Specified Amount in force less any debt. See Death Proceeds -
Death Benefit Options section to determine death proceeds.
The fund value in the Variable Account increases or decreases depending on
investment results. There is no guaranteed minimum fund value, cash value or
surrender value. See Fund Value, Cash Value, Surrender and Sub-Account Unit
Value sections.
Right to Return Policy - This Policy may be returned to us during a period that
starts with its delivery and ends on the latest of: (a) 10 days after its
delivery to the rightsholder; (b) 45 days after Part I of the application is
signed; and (c) 10 days after we mail or deliver a Notice of Withdrawal Right.
The Policy may be returned by delivery or mail, along with a written notice to
cancel it, to our Home Office, a local office of ours, or to the Agent who sold
it. We will then promptly refund any premiums
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paid. Notice given by mail and return of the Policy by mail are effective on
being postmarked, properly addressed and postage prepaid. The Policy will be
considered never to have been issued.
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Table of Contents
[Download Table]
Section
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1 Schedule of Benefits, Premiums and Charges
2 Guaranteed Monthly Insurance Rates
3 Variable Account, the Funds and Sub-Accounts
4 Will Pay
5 Definitions
6 Dates and Policy Periods
7 Death Proceeds - Death Benefit Options
8 Premiums
9 Grace Period
10 Reinstatement
11 Beneficiary
12 Rights
13 Optional Policy Changes
14 Transfers
15 The Variable Account
16 The GIA
17 Cash Value
18 Fund Value
19 Fund Charge
20 Sub-Account Unit Value
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[Download Table]
Section
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21 Monthly Deduction
22 Cost of Insurance
23 Insurance Rate
24 Continuation of Insurance
25 Basis of Calculation
26 Surrender
27 Partial Surrender
28 Loans
29 Loan Account
30 General Provisions
31 Settlement Options
- Endorsements, if any
- Riders, if any
- Application
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1. SCHEDULE OF BENEFITS, PREMIUMS AND CHARGES
FLEXIBLE PREMIUM VARIABLE LIFE POLICY
DEATH BENEFIT OPTION 2 IN EFFECT SPECIFIED AMOUNT IN FORCE - $500,000 -
INITIAL SPECIFIED AMOUNT (THE SPECIFIED AMOUNT IN FORCE MAY NEVER BE LESS
THAN $100,000) MONTHLY INSURANCE RATES FOR INITIAL SPECIFIED AMOUNT - SEE
SECTION 2
FIRST PREMIUM $650.00
SCHEDULED PREMIUMS - $650.00 AT POLICY MONTH INTERVALS MEASURED FROM 8-15-1996.
GUIDELINE PREMIUM LIMITATION AS OF POLICY DATE $50,169.75
GUARANTEED INTEREST ACCOUNT LIMITATION - (SEE PREMIUM SECTION) $250,000
NUMBER OF GUARANTEED FREE TRANSFERS DURING A POLICY YEAR - 4
CHARGE ON EXCESS TRANSFERS: CURRENT - $0 (SUBJECT TO CHANGE; SEE TRANSFERS
SECTION)
GUARANTEED MAXIMUM - $25
DAILY MORTALITY AND EXPENSE RISK CHARGE .002055% (0.75% ANNUALLY)
SALES CHARGE - 4% OF EACH PREMIUM RECEIVED DURING YEARS 1 THROUGH 10
2% OF EACH PREMIUM RECEIVED DURING YEARS 11 THROUGH 20
PREMIUM TAX CHARGE - 2% OF EACH PREMIUM RECEIVED SUBJECT TO CHANGE BASED UPON
CHANGES IN APPLICABLE STATE TAX LAWS OR COST TO THE COMPANY.
FEDERAL TAX CHARGE - 1.25% OF EACH PREMIUM RECEIVED SUBJECT TO CHANGE BASED UPON
CHANGES IN APPLICABLE FEDERAL TAX LAWS OR COST TO THE COMPANY.
ADMINISTRATIVE EXPENSE CHARGE - $25.00 PER MONTH DURING THE FIRST POLICY YEAR -
$0. PER MONTH ON AND AFTER THE FIRST POLICY ANNIVERSARY - BOTH AMOUNTS ARE
INCLUDED AS APPLICABLE IN THE MONTHLY DEDUCTION ON A MONTHLY ANNIVERSARY DAY.
MINIMUM MONTHLY PREMIUM - $282.08 (SEE SECTION 9. GRACE PERIOD FOR EXPLANATION
AND FOR EFFECT OF ANY INCREASE IN SPECIFIED AMOUNT.)
UNDER THE TERMS OF THE POLICY, THE SCHEDULED PREMIUM SHOWN ABOVE MAY NOT
CONTINUE THE POLICY IN FORCE TO AGE 95 EVEN IF THIS AMOUNT IS PAID AS SCHEDULED.
THE PERIOD FOR WHICH THE POLICY WILL CONTINUE WILL DEPEND ON: THE AMOUNT OF
PREMIUMS PAID; CHANGES IN SPECIFIED AMOUNT AND DEATH BENEFIT OPTIONS; CHANGES
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IN INTEREST CREDITED EXPENSES, FUND PERFORMANCE AND MORTALITY DEDUCTIONS;
DEDUCTIONS FOR RIDERS AND ANY BENEFITS AND PARTIAL SURRENDERS AND POLICY LOANS.
ELECTION OF THE GUARANTEED DEATH BENEFIT RIDER CAN PROVIDE FOR GUARANTEED
CONTINUATION OF THE POLICY AND SOME RIDERS IF CERTAIN REQUIREMENTS ARE MET.
IA FUND CHARGE
THE FUND CHARGE FOR THE INITIAL SPECIFIED AMOUNT IS THE APPLICABLE PERCENTAGE
(SHOWN IN THE TABLE BELOW) OF THE SUM OF A PLUS B AS FOLLOWS:
A. ADMINISTRATIVE FUND CHARGE: $2,000.00
B. SALES FUND CHARGE - DURING THE FIRST 5 POLICY YEARS A SALES FUND CHARGE IS
GENERATED BASED ON THE FOLLOWING:
DURING POLICY YEARS 1 AND 2 - LESSER OF AMOUNT DESCRIBED IN (i) AND (ii)
BELOW. DURING POLICY YEARS 3 THROUGH 5 - AMOUNT DESCRIBED IN (i) BELOW:
-(i) 75% OF EACH PREMIUM RECEIVED UNTIL THE TOTAL OF ALL PREMIUMS
RECEIVED EQUALS $3,385.00.
-(ii) 26% OF EACH PREMIUM RECEIVED UNTIL THE TOTAL OF ALL PREMIUMS
RECEIVED EQUALS $8,776.25 PLUS 6% OF EACH PREMIUM RECEIVED IN EXCESS
OF THAT AMOUNT UNTIL THE TOTAL EXCESS RECEIVED EQUALS $17,552.50 PLUS
5% OF EACH PREMIUM RECEIVED IN EXCESS OF THAT AMOUNT.
AFTER THE 5TH POLICY ANNIVERSARY, NO ADDITIONAL SALES FUND CHARGE IS GENERATED
(THE ABOVE PERCENTAGES DO NOT APPLY TO PREMIUMS RECEIVED AFTER THAT ANNIVERSARY
EVEN IF THE TOTAL OF ALL PREMIUMS RECEIVED DOES NOT EQUAL THE AMOUNT SHOWN IN
(i) ABOVE). BEGINNING WITH THE 5TH POLICY ANNIVERSARY, THE AMOUNT OF THE SALES
FUND CHARGE GENERATED UP TO THAT DATE AND THE AMOUNT OF THE ADMINISTRATIVE FUND
CHARGE SHOWN ABOVE BOTH DECLINE EACH POLICY YEAR IN ACCORDANCE WITH THE TABLE
BELOW.
[Download Table]
POLICY YEAR APPLICABLE % POLICY YEAR APPLICABLE %
----------- ------------ ----------- ------------
1 100% 9 60%
2 100 10 50
3 100 11 40
4 100 12 30
5 100 13 20
6 90 14 10
7 80 15 AND LATER 0
8 70
SEE FUND CHARGE SECTION FOR THE EFFECT OF ANY CHANGE IN SPECIFIED AMOUNT.
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2. GUARANTEED MONTHLY INSURANCE RATES FOR INITIAL SPECIFIED AMOUNT. RATES ARE
PER $1,000 OF AMOUNT AT RISK - SEE COST OF INSURANCE SECTION.
[Download Table]
INSUREDS INSUREDS
ATTAINED ATTAINED
AGE RATE AGE RATE
-------- ------ --------- -----
28 .12 62 1.28
29 .12 63 1.43
30 .12 64 1.59
31 .12 65 1.77
32 .13 66 1.96
33 .13 67 2.17
34 .13 68 2.40
35 .14 69 2.64
36 .15 70 2.92
37 .16 71 3.29
38 .17 72 3.61
39 .18 73 4.02
40 .19 74 4.50
41 .21 75 5.02
42 .22 76 5.57
43 .24 77 6.15
44 .26 78 6.76
45 .28 79 7.41
46 .30 80 8.13
47 .32 81 8.93
48 .35 82 9.86
49 .38 83 10.91
50 .41 84 12.07
51 .45 85 13.32
52 .49 86 14.64
53 .54 87 16.01
54 .59 88 17.43
55 .65 89 18.89
56 .72 90 20.43
57 .79 91 22.08
58 .87 92 23.89
59 .96 93 25.96
60 1.06 94 28.66
61 1.17
3. Variable Account, Funds and Sub-Accounts (see Variable Account section for
further information)
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The Variable Account is MONY America Variable Account L and includes the
sub-accounts listed below.
The sub-accounts available for investment purposes, and the corresponding
portfolios of the applicable funds are:
[Download Table]
Sub-Account Applicable Fund
----------- ---------------
Intermediate Term Bond MONY Series Fund, Inc.
Long Term Bond MONY Series Fund, Inc.
Money Market MONY Series Fund, Inc.
Government Securities MONY Series Fund, Inc.
High Yield Bond Enterprise Accumulation Trust
International Growth Enterprise Accumulation Trust
Equity Enterprise Accumulation Trust
Small Cap Enterprise Accumulation Trust
Managed Enterprise Accumulation Trust
The MONY Series Fund, Inc. is organized under the laws of Maryland. The
Enterprise Accumulation Trust is organized under the laws of Massachusetts. Each
fund is registered with the Securities and Exchange Commission (SEC) as an open
end, diversified management investment company under the Investment Company Act
of 1940.
4. Will Pay
We will pay the death proceeds to the Beneficiary upon receipt of due proof
of the Insured's death before Age 95 and while this Policy is in force. We will
pay any surrender value to the Insured if living at Age 95. Payment in any case
will be subject to all the provisions of this Policy.
5. Definitions
"We", "us" and "our" refer to MONY Life Insurance Company of America.
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"Home Office" means our administrative office at 1740 Broadway, New York, N.Y.
10019. "Home Office" also includes our Operations Center at One MONY Plaza,
Syracuse, New York 13202.
"Specified Amount in force" is the Initial Specified Amount, adjusted for any
increases or decreases in Specified Amount.
"GIA" is the Guaranteed Interest Account (see the GIA section for additional
information).
"Monthly Anniversary Day" means the first day of each policy month. But, if that
day is not a Valuation Date for all sub-accounts, the Monthly Anniversary Day
will be deemed to be the next following Valuation Date.
"Unit" is the measure by which the value of this Policy's interest in a
sub-account is determined.
"Valuation Date" is each day that the New York Stock Exchange is open for
trading or any other day on which there is sufficient trading in the securities
of a portfolio of a Fund (see Section 3) to affect materially the Unit value of
that sub-account of the Variable Account.
"Attained age" during the first policy year means age at nearest birthday on the
Policy Date. During each succeeding policy year, "attained age" means age at
nearest birthday on the policy anniversary on which that policy year commenced.
"Age 95" means the policy anniversary nearest the Insured's 95th birthday.
6. Dates and Policy Periods
Where dates are shown, the numbers stand for month, day and year, in that order.
Months, years and anniversaries are measured from the Policy Date, if no other
method is stated. The Policy Date is shown on Page 1. Each policy month starts
on the same date in each calendar month as that specified in the Policy Date. If
the Policy Date is the 29th, 30th or 31st of a month, there will be some
calendar months when there is no same date. For those months the policy month
will start on the last day of the calendar month.
7. Death Proceeds-Death Benefit Options
Death Proceeds -The proceeds payable to the beneficiary upon our receipt of due
proof of the death of the Insured while this Policy is in force will be the sum
of:
- the Death Benefit; and
- any insurance provided by any additional benefit rider then in force on the
Insured's life on the date of death.
LESS:
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- any debt due us on this Policy reduced by any unearned loan interest; and
- if death occurs during any period for which a monthly deduction has not been
made, any monthly deduction that may apply to that period, including the
deduction for the month of death.
Interest will be paid on death proceeds paid in one sum. We will determine the
interest rate for each year, and this rate will not be less than 2 3/4%
annually. Interest will be paid from the date of the Insured's death to the date
of payment.
Death Benefit - (If a Waiver of Monthly Deduction Benefit rider is part of this
Policy, and if Death Benefit Option I is in effect, it will automatically change
to Death Benefit Option 2 under the terms and conditions set forth in the second
paragraph of that rider.)
If Death Benefit Option 1 is in effect on the date of death, the Death Benefit
is the greater of:
(a) the Specified Amount in force on the date of death, plus the increase, if
any, in the fund value since the last Monthly Anniversary Day; and
(b) the fund value on the date of death, plus the applicable percentage (see
below) of the fund value on the last Monthly Anniversary Day.
If Death Benefit Option 2 is in effect on the date of death, the Death Benefit
is the greater of:
(a) the Specified Amount in force on the date of death, plus the fund value on
the date of death;
and
(b) the fund value on the date of death, plus the applicable percentage (see
below) of the fund value on the last Monthly Anniversary Day.
The applicable percentage of the fund value used to determine the Death Benefit
payable is:
[Download Table]
Insured's Attained
Age Applicable Percentage
on Date of Death of Fund Value
------------------- ----------------------
40 or under 150%
41-45 150% less 7% for each year
over attained age 40
46-50 115% less 6% for each year
over attained age 45
51-55 85% less 7% for each year
over attained age 50
56-60 50% less 4% for each year
over attained age 55
61-65 30% less 2% for each year
over attained age 60
66-70 20% less 1% for each year
over attained age 65
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[Download Table]
Insured's Attained
Age Applicable Percentage
on Date of Death of Fund Value
------------------- ----------------------
71-74 15% less 2% for each year
over attained age 70
75-90 5%
91-94 5% less 1% for each year
over attained age 90
8. Premiums
Payment of Premiums - Premiums after the first are payable to us at our Home
Office or at any local office to a person authorized by us to accept them, but
only in exchange for a receipt signed by our Treasurer and by the person
receiving the payment. We shall accept premiums after the first (shown in
Section 1) subject to limitations as described below. But we shall not accept
any part of a payment as a premium if that part would result in the sum of
cumulative premiums paid, less any partial surrenders and their fees, being in
excess of the guideline premium limitation that then applies to the Policy.
We reserve the right to reject all or a portion of any scheduled or unscheduled
premium payment if part (b) of either Death Benefit Option 1 or Death Benefit
Option 2 is in effect or would be in effect if such a payment had been accepted
by us.
Guideline Premium Limitation - The guideline premium limitation that applies to
the Policy at any time will never be more than as determined in accordance with
Section 7702 of the Internal Revenue Code of 1986 as now or later amended or any
further amendment of such Code superseding or modifying that section. The
guideline premium limitation that applies to the Policy on the Policy Date is
shown in Section 1. Changes in the Specified Amount in force, the Death Benefit
Option in effect or an additional benefit provided by rider will change the
guideline premium limitation. In the event of any such change we reserve the
right to reduce the Policy's cash value so that the guideline premium limitation
that applies to the Policy is not violated. The amount by which the cash value
is so reduced will be refunded in cash. The endorsement issued to reflect any
such change will include the revised guideline premium limitation that then
applies to the Policy.
Limit on Premium Payments Allocated to the GIA - We shall return to the
rightsholder any part of a premium payment requested for allocation to the GIA
if: (a) the fund value in the GIA equals or exceeds the GIA Limitation shown in
Section 1; or (b) acceptance of that part payment would cause the fund value in
the GIA to exceed such Limitation.
Net Premium - A net premium is the premium paid, less the sales charge, premium
tax charge and federal tax charge shown in Section 1.
Premiums Received Before or at Delivery of the Policy - The first full net
premium must be paid before or at delivery of the Policy and will be allocated
to the Money Market sub-account on the later of the Policy Date and the
Valuation Date that coincides with or next follows the Date the premium
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is received at our Operations Center. If the Policy is not accepted at delivery,
any premium paid will be returned without interest.
Allocation of Net Premiums Received After Delivery of the Policy - Any net
premium received after delivery of the Policy and before the end of the period
under the "Right to Return Policy" provision (see page 1) will be allocated to
the Money Market sub-account:
At the end of the "Right to Return Policy" period if the Policy has not been
returned under the terms of that provision, the fund value in the Money Market
sub-account will then be transferred to the sub-account or sub-accounts of the
Variable Account and/or the GIA in accordance with the most recent scheduled
premium allocation election on record, unless there is no allocation on record.
In that case the fund value will not then be transferred from the Money Market
sub-account.
After the "Right to Return Policy" period ends, any net premiums received will
be allocated either: (a) to one or more sub-accounts of the Variable Account
and/or the GIA in accordance with the scheduled premium allocation then in
effect for the Policy; or (b) if there is no such allocation in effect, to the
Money Market sub-account.
An unscheduled premium may be otherwise allocated, if a specific request is so
made for that premium (see Unscheduled Premiums below).
Net premiums are allocated on the Valuation Date that coincides with, or next
follows, the date the premium is received at our Operations Center. Allocations
must be made in whole percentages. If the GIA or a sub-account is to receive any
allocation, the allocation must be at least 10% of the net premium. The
allocation election on record may be changed by written notice to us at our
Operations Center. A change will take effect within 7 days after we receive that
notice.
Scheduled Premiums - We shall send reminder notices for the payment of the
scheduled premiums shown in Section 1. The amount and interval of payment of
scheduled premiums may be changed upon written request. But the new payment
interval must satisfy our rules in use at the time of the change.
Unscheduled Premiums - Additional premium payments of at least $250 may be made
at any time. We reserve the right to limit the total amount of unscheduled
premiums paid during any 12 consecutive calendar months to an amount that
assures that the sum of cumulative premiums paid, less any partial surrenders
and their fees, is not in excess of the guideline premium limitation that
applies to the Policy. An unscheduled premium may be allocated by amount as well
as by percentage. If a specific allocation is not requested or is requested
incorrectly, then the net premium will be allocated in accordance with the most
recent scheduled premium allocation on record, unless there is no allocation
election on record. In that case the unscheduled net premium will be allocated
to the Money Market sub-account. A specific allocation for an unscheduled
premium will not change the allocation on record for scheduled premiums.
9. Grace Period
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Minimum Monthly Premium - The Minimum Monthly Premium on the Policy Date is
shown in Section 1.
A. Applicable During the First 2 Policy Years the Policy is in Force - If the
sum of all premiums paid, less any partial surrenders (and their fees) and
less any debt, on the Monthly Anniversary Day is smaller than the sum of
each Minimum Monthly Premium times the number of in force policy months
during which that premium was applicable, we shall send notice of
insufficient premium. A grace period of 61 days from the date of that notice
will be allowed for payment of any balance needed on the Monthly Anniversary
Day to cover the Minimum Monthly Pre mium for the following month plus an
amount equal to 2 Minimum Monthly Premiums, or if greater, the number of
Minimum Monthly Premiums until the next scheduled premium due date.
B. Applicable after the Policy is in Force 2 or More Policy Years - If the cash
value, less any debt, on the Monthly Anniversary Day is not enough to cover
the monthly deduction (see Monthly Deduction section) for the following
month, we shall send notice of insufficient value. A grace period of 61 days
from the date of that notice will be allowed for payment of: (a) any balance
needed for the monthly deduction plus; (b) an amount equal to 2 monthly
deductions or, if greater, the number of monthly deductions until the next
scheduled premium due date.
If the payment described in A or B above, as applicable, is not received within
the grace period, the Policy will end at the end of the grace period and any
remaining surrender value will be refunded.
10. Reinstatement
If the Policy ends at the end of the grace period, the Policy may be reinstated.
But this may only be done within 5 years after the Monthly Anniversary Day
immediately before the start of the grace period. We shall need:
(a) evidence satisfactory to us that the Insured is insurable.
(b) payment of a premium large enough to cover:
(i) the balance needed as described in subsection A or B of Grace Period,
whichever is ap plicable (see Section 9 above); and
(ii) an amount sufficient to keep the Policy in force for at least 3 months
from the re instatement date.
(c) payment or reinstatement of any debt due us on the Policy, plus payment of
interest on any reinstated debt from the date of reinstatement to the next
policy anniversary at the rate which applies to policy loans on the date of
reinstatement.
(d) reinstatement of any fund charge that would have been outstanding on the
date of reinstatement had the Policy remained in force.
The reinstatement date will be the Monthly Anniversary Day that coincides with,
or immediately pre cedes, the date the application for reinstatement is approved
by us.
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11. Beneficiary
Determination of Beneficiary - The beneficiary is as set forth in the
application for this Policy unless otherwise provided by endorsement. Any
reference in any beneficiary designation to a beneficiary living or surviving
will, unless otherwise provided, mean living on the earlier of: (a) the day due
proof of the Insured's death is received by us at our Home Office: and (b) the
14th day after the Insured's death. The share of the death proceeds of any
beneficiary who is not living on that earlier day will be payable to the
remaining beneficiaries. Payment will be made in the manner provided for in that
designation. If no beneficiary is then living and unless otherwise provided, the
death proceeds will be payable to the Insured's executors or administrators.
Change of Beneficiary - Beneficiary changes may be made during the Insured's
lifetime by written notice to us at our Home Office. A change will take effect
as of the date the notice was signed. But we must first accept and record this
change at our Home Office. And this change will be subject to any payment made
by us or action taken by us before receipt of the notice at our Home Office. The
Policy need not be returned for us to endorse the change unless we ask for it.
12. Rights
During the Insured's lifetime, all rights under this Policy belong exclusively
as set forth in the application for this Policy unless otherwise provided by
endorsement. These rights include the right to change the beneficiary and to
assign. Also included are all other rights, benefits, options, and privileges
which are given by this Policy or allowed by us.
13. Optional Policy Changes
The following changes may be requested by writing to us at our Home Office. We
shall issue an endorsement to the Policy to reflect any such change.
Increasing the Specified Amount - (Increases are not available: (a) before the
second policy anniversary; (b) on or after the policy anniversary nearest the
Insured's 81st birthday; or (c) if the monthly deduction is being waived under
the terms of a waiver of Monthly Deduction Benefit rider). To increase the
Specified Amount in force, a supplemental application must be submitted, subject
to evidence satisfactory to us that the Insured is insurable. Any increase must
be at least $10,000. The increase will take effect on the Monthly Anniversary
Day that coincides with, or next follows, the date on which we approve it.
Any increase in Specified Amount may be cancelled on the latest of: (a) 10 days
after we deliver the endorsement reflecting that increase to the rightsholder;
(b) 45 days after part 1 of the application for that increase was signed; and
(c) 10 days after we mail or deliver a Notice of Withdrawal Right to the
rightsholder. The increase will be cancelled as of its effective date upon
receipt of written notice to cancel it at our Operations Center. We will issue
an endorsement to reflect the cancellation. Within 7 days after the notice is
received: (1) we will credit the Policy's fund value with the amount of any
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monthly deductions attributable to the increase; and (2) any outstanding fund
charge will be adjusted, if necessary, so that it will be as though the increase
had not occurred. The amount in (1) will be allocated among the sub-accounts as
if it were a scheduled premium (see Premiums section). But, upon written
request, such amount may instead be paid in cash.
At any time during the first 24 months after the date an increase in Specified
Amount in force takes effect, the amount of fund value in the sub-accounts may
be transferred to the GIA as described in the "Exchange Transfer to the GIA"
provision (see Transfers section).
Decreasing the Specified Amount - (Decreases are not available before the second
policy anniversary). Any decrease in the Specified Amount in force must be at
least $10,000. The decrease will take effect on the Monthly Anniversary Day that
coincides with, or next follows, the date on which we approve it. The decrease
will be applied as follows:
(a) first, to reduce the amount provided by the most recent increase in
Specified Amount;
(b) next, to reduce the next most recent increases successively;
(c) finally, to reduce the Initial Specified Amount.
We will reject any requested decrease if that decrease would result in a
Specified Amount which is less than the Specified Amount we then allow or if the
resulting Fund Value would be less than the product of: (a) the number of months
to the next policy anniversary, times (b) the monthly deduction. (See Fund
Charge Section for the effect of decrease on Fund Value.)
Changing the Death Benefit Option - Any change in Death Benefit Option will take
effect on the Monthly Anniversary Day that coincides with, or next follows, the
date on which we approve the request to change the Option. If the change is from
Option 2 to Option 1, the Specified Amount in force will not be changed. If the
change if from Option 1 to Option 2, the Specified Amount in force will be
decreased by the amount of the fund value on the Monthly Anniversary Day on
which the change in Option takes effect. But, the Specified Amount in force
after the decrease cannot be less than the minimum Specified Amount we then
allow. We reserve the right to request evidence satisfactory to us that the
Insured is insurable for a change from Option 1 to Option 2.
14. Transfers
Transfers Among the Sub-Accounts and the GIA - After the "Right to Return
Policy" period has expired, fund value may be transferred among the sub-accounts
and/or to or from the GIA upon request.
Transfers to the GIA - We will reject any part of a transfer to the GIA if the
fund value in the GIA equals or exceeds the GIA Limitation shown in Section 1
or, if that part of the requested transfer would cause the fund value in the GIA
to exceed such Limitation. Any portion of a requested transfer which is rejected
will be retained in the sub-accounts in the same proportion as the transfer
amount allocated against each sub-account bears to the total transfer amount.
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Transfers from the GIA - A transfer of fund value from the GIA to any of the
sub-accounts may be made once each policy year. A request for such transfer must
be received by us at our Operations Center on or within 30 days after a policy
anniversary. We will reject any part of a requested transfer from the GIA if
that part would exceed the greater of: (a) 25% of the fund value held in the GIA
on the Date the transfer would take effect; or (b) $5,000.
A transfer transaction which does not move fund value from the GIA will take
effect on the Valuation Date that coincides with, or next follows the date the
request is received at our Operations Center. A transfer transaction which moves
fund value from the GIA will take effect on: (a) the policy anniver sary; or (b)
if later (subject to above provisions), the Valuation Date that coincides with
or next follows the date the request is received at our Operations Center.
Transfer Charge - All transfers included in a request are considered one
transaction. The number of guaranteed free transfers which may be made during a
policy year and the charge for transfers in excess of that number during that
year are shown in Section 1. We reserve the right to increase, decrease or
eliminate the charge but it will never be more than the guaranteed maximum shown
in Section 1.
Any applicable transfer charges are allocated against the GIA and/or the
sub-accounts from which the fund values are being transferred. The charge
allocated against the GIA or any sub-account will be in the same proportion that
the amount being transferred from the GIA or any sub-account bears to the total
amount being transferred. But, if there is insufficient fund value in the GIA or
any sub-account to provide for its proportionate share of the charge, then the
entire charge will be allocated against the GIA and/or each sub-account from
which funds are transferred in the same proportion that the fund value held in
the GIA and each sub-account bears to the fund value in the GIA and all
sub-accounts from which funds are transferred.
Exchange Transfer to the GIA - At any time during the first 24 months after the
date, of issue of the Policy or within 24 months after the effective date of an
increase in specified amount, the entire amount of fund value in the
sub-accounts may be transferred to the GIA. Election of this exchange transfer
will change this Policy to a policy which is not dependent upon the investment
results of a separate account.
There will be no transfer charge for an exchange transfer and the GIA limitation
will be waived. On the date an exchange transfer takes effect, the premium
allocation will be changed to the GIA only.
15. The Variable Account
The variable benefits under this Policy are provided through investments we make
in the Variable Ac count. This is an investment account established and
maintained by us, separate from our general account or other separate accounts.
It is used for our flexible premium variable life policies and, if permitted by
law, may be used for other policies or contracts.
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We own the assets in the Variable Account. Assets equal to the reserves and
other liabilities of the Variable Account will not be charged with liabilities
that arise from any other business we conduct. We may from time to time transfer
to our general account assets which exceed the reserves and other liabilities of
the Variable Account.
The Variable Account is registered with the Securities and Exchange Commission
(SEC) as a unit investment trust under the Investment Company Act of 1940. It is
also governed by the laws of the state of Arizona. We may, to the extent
permitted by applicable laws and regulations, make these changes: (a) the
Variable Account may be operated as a management company under the Investment
Company Act of 1940; or (b) the Variable Account may be deregistered under that
Act if registration is no longer required; or (c) the Variable Account may be
combined with any of our other separate accounts.
Sub-Accounts - We use the assets of each separate sub-account to buy shares in a
corresponding portfolio of the applicable fund. (See Section 3).
We reserve the right to establish new sub-accounts or eliminate one or more
sub-accounts if marketing needs, tax considerations or investment conditions
warrant. Any new sub-accounts may be made avail able to existing contracts on a
basis to be determined by us. If any of these changes are made, we may by
appropriate endorsement change the Contract to reflect the change.
Income and realized and unrealized gains or losses from assets of each
sub-account are credited to or charged against that sub-account without regard
to income, gains or losses in the other sub-accounts, our general account or any
other separate accounts. We reserve the right to credit or charge a sub-account
in a different manner if required, or appropriate, by reason of a change in the
law.
We will value the assets of each sub-account on each Valuation Date after the
assets in its corresponding fund portfolio have been valued on that Date.
Portfolio Changes - If, in our judgment, a portfolio no longer suits the
purposes of the Policy due to a change in its investment objectives or
restrictions, we may substitute shares of another portfolio that fund or shares
of another investment fund. But, we will notify the rightsholder before doing so
and, to the extent required by law, we will get prior approval from SEC and the
Arizona Insurance Department. Such approval process is on file with the Arizona
Insurance Department. We also will get any other required approvals.
16. The GIA
The GIA is an account which is part of our general account. The general account
consists of all of our assets except those held by the Variable Account and
other separate accounts maintained by us. The guaranteed annual interest rate
that applies in the calculation of the fund value in the GIA is 5% (0.013368%,
compounded daily). Interest in excess of the guaranteed rate may be applied in
the
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calculation of that fund value in a manner determined by us. We may use
different rates of interest for different portions of the fund value in the GIA.
After the 10th policy anniversary the annual interest rates that apply in the
calculation of the fund value in the GIA on a given date will be .5% higher than
the rate applicable to policies of the same type which have not yet reached
their 10th policy anniversary. This increase is based on current expectations as
to mortality, investment earnings, persistency and expenses and is not
guaranteed.
17. Cash Value
The cash value of this Policy at any time is the fund value, less the fund
charge.
18. Fund Value
1. The fund value of this Policy on the Policy Date is
(a) the net premiums received by us on or before the Policy Date; less
(b) the monthly deduction due on the Policy Date
Thereafter, fund value calculations are made on Valuation Dates. If a fund value
calculation has to be made for a day that is not a Valuation Date, then we shall
use the Valuation Date that next follows that day.
2. The fund value of this Policy on a Valuation Date is determined as follows:
(a) Determine the Policy's fund value in each sub-account on that Valuation Date
by multiplying the number of Units credit to the sub-account for the Policy
before the purchase or redemption of any Units on that Date by its Unit
value on that Date.
(b) Determine the amount of any refund by multiplying the fund value in each
sub-account by .04167% (.5% annually). This refund is determined and
allocated to each sub-account on each Monthly Anniversary Day after the 10th
policy anniversary. It is based on current expectations as to mortality,
investment earnings, persistency and expenses and is not guaranteed.
(c) Total the fund value in each sub-account on that Valuation Date.
(d) Add the fund value in the GIA on that Valuation Date; this is the
accumulated value with interest of net premiums allocated, and amounts
transferred, to the GIA before that Date, decreased by any allocations
against the GIA before that Date for (i) any amounts transferred to Loan
Account; (ii) any amounts transferred to the sub-accounts and applicable
transfer charge; (iii) any partial surrender and its fee; and (iv) any
monthly deductions.
(e) Add any amounts in Loan Account on that Date.
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(f) Add interest credit on the Date on the amounts in (e) since the last Monthly
Anniversary Day.
(g) Add any net premiums received on that Valuation Date.
(h) Deduct any partial surrender, and its fee, made on that Valuation Date.
(i) Deduct any monthly deduction to be made on that Valuation Date.
3. The fund value of this Policy on a Monthly Anniversary Day for the purpose of
determining the cost of insurance and the cost of any waiver of monthly
deduction rider on that Day is determined as follows:
(a) Determine the Policy's fund value on that Day as described in items (a)
through (h) in subsection 2 of this section.
(b) Deduct the monthly deduction (excluding the cost of insurance and cost of
any waiver of monthly deduction rider if applicable; see Monthly Deduction
section).
19. Fund Charge
The fund charge for the Initial Specified Amount is shown in Section 1A. A new
fund charge will be determined for each increase in Specified Amount and will be
provided in the endorsement issued to reflect that increase. The fund charge for
the Specified Amount in force reflects any charge attributable to the Initial
Specified Amount and to each increase in Specified Amount.
For purposes of calculating fund charges after an increase in Specified Amount,
premiums are allocated to the Initial Specified Amount and each increase in
Specified Amount in the same proportion that the annual guideline premium
increment for the Initial Specified Amount and each increase in Specified Amount
bears to the total annual guideline premium.
Any decrease in Specified Amount requested by the rightsholder or made by us as
a result of a partial surrender or change in Death Benefit Option, will result
in a portion of the outstanding fund charge (if any) being assessed against the
fund value. The amount of fund charge assessed will be the pro-rata portion of
the fund charge attributable to each part of the Specified Amount in force being
decreased. Any fund charge assessed will be allocated against the sub-accounts
and/or the GIA in the same manner as monthly deductions.
A full surrender will result in all of the outstanding fund charge (if any)
being assessed against the sur render proceeds.
20. Sub-Account Unit Value
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The unit value of each sub-account on its first Valuation Date was set at $10.
The unit value of each sub-account on any subsequent Valuation Date is obtained
by subtracting (b) from (a) and dividing the result by (c), where:
(a) is. The per share net asset value on the Valuation Date of the applicable
fund portfolio in which the sub-account invests times the number of
such shares held in the sub-account before the purchase or redemption
of any shares on that Date.
(b) is. The mortality/expense risk charge accrued as of that Valuation Date.
The daily mortality/expense risk charge is a percentage (shown in
Section 1) of the sub-account's net asset value on the previous
Valuation Date. (If the previous day was not a Valuation Date, then
the daily mortality/expense risk charge accrued is the percentage
shown in Section 1 times the number of days since the last Valuation
Date times the sub-account's net asset value on that last Valuation
Date.)
(c) is. The total number of Units held in the sub-account on the Valuation Date
before the purchase or redemption of any Units on that Date.
21. Monthly Deduction
The monthly deduction on a Monthly Anniversary Day for the following policy
month is (a), plus (b), plus (c), where:
(a) is the cost of insurance (see Cost of Insurance section below).
(b) is the cost of any additional benefits provided by rider.
(c) is the administrative charge (as shown in Section 1).
Any monthly deduction to be made before the end of the "Right to Return Policy"
period (see page 1) will be allocated against the Money Market sub-account.
Monthly deductions made after the end of the "Right to Return Policy" period
will be allocated against the GIA and/or each sub-account on the same basis that
scheduled premiums are then allocated. However, if on any Monthly Anniversary
Day there is insufficient fund value in the GIA and/or a sub-account to provide
for its share of the monthly deduction, the monthly deduction will be allocated
against the GIA and/or each sub-account in the same proportion that the Policy's
fund value held in the GIA and/or each sub-account bears to the Policy's fund
value in the GIA and all sub-accounts on that Day.
22. Cost of Insurance
The cost of insurance is determined on a monthly basis on a Monthly Anniversary
Day. It is determined separately for each of the following, in the order shown:
(a) the Initial Specified Amount; and
(b) each increase in Specified Amount, successively, in the order in which it
took effect; and
(c) either (i) or (ii) below, depending upon the Death Benefit Option in effect
on the Monthly Anniversary Day:
(i) if Death Benefit Option I is in effect and if the Death Benefit that
would have been payable in the event of the Insured's death on that Day
is greater than the Specified
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Amount then in force, the difference between that Death Benefit and
that Specified Amount;
(ii) if Death Benefit Option 2 is in effect and if the Death Benefit that
would have been payable in the event of the Insured's death on that Day
is the fund value plus the applicable percentage of that value, the
difference between that Death Benefit less the fund value on that Day
and the Specified Amount then in force. (The applicable per centage of
the fund value is defined in Death Proceeds - Death Benefit Options
section.)
The cost of insurance on a Monthly Anniversary Day for each of (a), (b), (c)(i)
and (c)(ii) above is calculated by multiplying its insurance rate (see Insurance
Rate section below) by its Amount At Risk (defined below). The insurance rate
that applies to (c)(i) and (c)(ii) is same as the rate that applies to the most
recent increase in Specified Amount. (If there has been no increase, the rate
for the Initial Specified Amount applies.)
The "Amount At Risk" on the Monthly Anniversary Day is the difference between
(1) and (2), where: (1) is the Death Benefit that would have been payable in
the event of the Insured's death on that Day; and (2) is the fund value on
that Day determined as described in subsection 3 of the Fund Value section.
The Policy's fund value on the Monthly Anniversary Day is applied in the
order shown to (a), (b) and, if applicable, (c)(i) or (c)(ii) above, to
determine the Amount At Risk for each. If the fund value when so applied
equals or exceeds the Initial Specified Amount, there is no Amount At Risk
for that Initial Specified Amount and no cost of insurance for it. If the
fund value when so applied equals or exceeds the Initial Specified Amount
plus any increase in Specified Amount, there is no Amount At Risk for that
increase and no cost of insurance for it.
23. Insurance Rate
The insurance rate is based on the Insured's sex, age on the Policy Date, number
of years since the Policy Date, and class of risk. "Class of risk" for the
Initial Specified Amount is the class of risk to which the Insured belonged on
the Policy Date and is shown on Page 1.
The insurance rate for any optional increase in Specified Amount will be based
on the Insured's sex, age on the effective date of the increase number of years
since that date and "Class of Risk" on that date.
Each year we shall review the monthly insurance rates to determine if any change
should be made Monthly insurance rates will be based on our expectations as to
future; (a) mortality; (b) investment earnings; (c) expenses, and (d)
persistency. But, we guarantee that the insurance rates for the Initial
Specified Amount will never be more than the rates shown in the Guaranteed
Monthly Insurance Rates for Initial Specified Amount table in Section 2. And,
insurance rate for any optional increase in Specified Amount will never be more
than the guaranteed rates provided by us at the time the increase takes effect.
21
All guaranteed rates are based on the 1980 Commissioners Standard Ordinary
Smoker of Non-Smoker Mortality Tables as applicable (for issue ages under 18,
there is no smoker/nonsmoker adjustment), with interest at the rate of 5% a year
(0.013368%, compounded daily) with appropriate increase for rated risk. Any
change in insurance rates will be on a uniform basis for insureds of the same
class. Changes in rates and the way in which they are determined will be filed
with the insurance supervisory official of the state in which the Policy is
delivered.
24. Continuation of Insurance
If premium payments are not continued, the Policy will be continued only as long
as stated in (a) or (b) below, as applicable: (a) during the first 2 policy
years, as long as the sum of all premiums paid less any partial surrenders (and
their fees) and less any debt is equal to or greater than that sum of each
Minimum Monthly Premium times the number of in force policy months during which
that premium was applicable; or (b) after the Policy is in force 2 or more
policy years, as long as the cash value less any debt is sufficient to cover any
monthly deductions (See Section 9 Grace Period.)
This Continuation of Insurance provision will not continue the Policy beyond Age
95. Nor will it continue any additional benefit rider beyond its date for
termination.
25. Basis of Calculation
The method of determining cash value, fund charge and sales charge has been
filed with the insurance supervisory official of the state in which this Policy
is delivered. Cash values are not less than the minimum values required by the
law of the state in which the Policy is delivered.
26. Surrender
The Policy may be surrendered at any time during the Insured's lifetime for its
surrender value, which is its cash value, less any debt reduced by any unearned
loan interest.
27. Partial Surrender
A partial surrender of this Policy may be made after the second policy
anniversary for any amount of at least $500 which, with its fee (see below), is
less than the Policy's surrender value on the date of the partial surrender. A
partial result may not result in a Specified Amount in force less than the
minimum we then allow. Nor may it result in a remaining surrender value of less
than $500. We reserve the right to limit the number of partial surrenders to 12
during a policy year.
A partial surrender fee equal to the lesser of: (a) $25; and (b) 2% of the
amount of the partial surrender will apply to each partial surrender. The amount
of a partial surrender, plus its fee, will be deducted from the fund value of
the Policy on the date of the partial surrender. The fee will be retained by us.
22
Allocation of Partial Surrenders - Any partial surrenders (and their fees) will
be allocated against: (a) one or more sub-accounts; (b) the GIA and one or more
sub-accounts; or (c) if there is no cash value in any sub-account, the GIA.
Partial surrender amounts allocated against the subaccounts in accordance with
(a) or (b) above, will be as requested by written notice to us at our Operations
Center. Allocations against the GIA in accor dance with (b) above will be
subject to a maximum amount which bears the same proportion to the total amount
being surrendered as the amount of fund value held in the GIA bears to the fund
value in the GIA and all sub-accounts on the date of the partial surrender.
Allocations will take effect on the Valu ation Date that coincides with, or next
follows, the date the request is received at our Operations Center.
Partial surrender allocations may be by either amount or percentage. Allocations
by percentage must be in whole percentages (totaling 100%) and at least 10% of
the partial surrender must be allocated against the GIA or any sub-account
included in an allocation. We shall not accept an allocation request if that
request is incorrect or if there is insufficient fund value in the GIA or any
sub-account to provide for the requested allocation against it. But, if an
allocation is not requested then the entire amount of the partial surrender will
be allocated against the GIA and each sub-account in the same proportion that
the fund value held in the GIA and each sub-account bears to the fund value in
the GIA and all sub-accounts.
Any partial surrender fee will be allocated against the GIA and/or any
sub-accounts in the same proportion as the amount of the partial surrender
allocated against the GIA and each sub-account bears to the total amount
surrendered. But if there is insufficient fund value in the GIA or any
sub-account to provide for its proportionate share of the fee, then the entire
fee will be allocated against the GIA and each subaccount from which fund value
is being surrendered in the same proportion that the fund value held in the GIA
and each sub-account bears to the fund value in the GIA and all sub-accounts
from which fund value is being surrendered.
If Death Benefit Option 1 is in effect on the day on which a partial surrender
is made, we shall then reduce the amount of the Death Benefit payable on that
day by the amount of the partial surrender, plus its applicable fee. If the
amount of that reduced Death Benefit is less than the Specified Amount in force
on that day, then the Specified Amount in force on that day will be decreased as
of that day to equal the amount of that reduced Death Benefit. But the amount of
partial surrender cannot result in a Specified Amount in force less than the
minimum Specified Amount we then allow.
Preferred partial surrender amount - After the second policy anniversary, one or
more partial sur renders may be made during each policy year without application
of a fund charge (see Fund Charge section), up to a total surrender amount for
that year of: 10% of the Policy's cash value on the date of the first surrender
made during that year. Partial surrenders may be made only to the extent
surrender value is available. We reserve the right ht to limit the number of
partial surrenders made. under this Preferred partial surrender amount provision
to 12 during any policy year.
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28. Loans
Loans for not less than the minimum amount of $250 may be obtained at any time
while this Policy has a loan value. A proper assignment of this Policy to us
will be needed. The loan value is up to 90% of the cash value less any debt on
the date of the loan.
Loan Interest - Loan interest at an annual rate of 5.4% will be charged in
advance on new or outstand ing loans, including a loan continued after any
reinstatement of the Policy. Loan interest will accrue from day to day between
policy anniversaries and will be payable in advance on the date of the loan and
on each policy anniversary. Any interest not paid when due will be added to the
loan and bear interest at the 5.4% annual rate.
Miscellaneous Provisions - The Policy will be the sole security for any policy
loan. But it need not be given to us for endorsement unless we ask for it.
Any reference to debt means total loan principal under this Policy plus any loan
interest due and unpaid on a policy anniversary.
If ever the debt exceeds the cash value, this Policy will end. But we must first
give at least 61 days notice of insufficient value.
Any debt may be repaid in whole or part before the Insured's death.
Any notice referred to in this "Loans" section will be mailed to the last known
address of the rightsholder and any assignee of record.
Any debt may be allocated against: (a) one or more of the sub-accounts; or (b)
the GIA and one or more of the sub-accounts; or (c) if there is no fund value in
any sub-account, the GIA.
Allocations of debt against the sub-accounts in accordance with (a) or (b) above
may be as requested in a notice satisfactory to us. Allocations against the GIA
in accordance with (b) above will be subject to a maximum amount which bears the
same proportion to the total amount of the loan as the amount of fund value held
in the GIA bears to the fund value in the GIA and all sub-accounts on the date
of the loan. Allocations will take effect on the Valuation Date that coincides
with, or next follows, the date the request for the loan is received at our
Operations Center.
Allocations may be by either amount or percentage. Allocations by percentage
must be in whole percentages (totaling 100%) and at least 10% of the loan amount
must be allocated against the GIA or any sub-account included in an allocation.
We shall not accept an allocation request if that request is incorrect or if
there is insufficient fund value in the GIA or any sub-account to provide for
the requested allocation against it. But, if an allocation is not requested then
the entire amount of the loan will be allocated against the GIA and each
sub-account in the same proportion that the fund value held in the GIA and each
sub-account bears to the fund value in the GIA and all sub-accounts.
24
Any debt repayment and any applicable unearned loan interest will be allocated
to the GIA and/or the sub-accounts in accordance with the scheduled premium
allocation then in effect (see Premiums section).
29. Loan Account
The loan account is a portion of the Policy's fund value which was transferred
from the GIA or the sub- accounts to secure any outstanding debt plus any
interest on such portion. On each Monthly Anniversary Day we credit interest on
the Loan Account. The loan account will earn interest at a rate not less than 5%
per year.
After the 10th policy anniversary the annual interest rate applicable to the
Loan Account will be .5% higher than the rate applicable to policies of the same
type which have not yet reached their 10th anniversary. This increase is based
on current expectations as to mortality, investment earnings, persistency and
expenses and is not guaranteed.
If the entire debt is repaid on a date which is not a Monthly Anniversary Day,
we determine the interest earned on the Loan Account from the preceding Monthly
Anniversary Day to the date that payment was received by us at our Operations
Center. This interest will be allocated on the date of repayment among the GIA
and/or the sub-accounts in accordance with the most recent scheduled premium
allocation on record (see Premium section).
30. General Provisions
The Contract -- This Policy has been issued in consideration of the application
and of the payment of the first premium shown in Section I. The application
(copy attached) is a part of the Policy. The Policy and the application (and any
supplemental applications for optional increases in Specified Amount) are the
entire contract.
Statements in Application -- All statements made in the application will be
considered to be representations. They are not warranties. No statement may be
used to make this Policy invalid or to deny a claim under it, unless the
statement is contained in the written application. And, a copy of the
application for this Policy must have been attached to it as issue.
Incontestability -- This Policy will be incontestable after it has been in force
during the lifetime of the Insured for 2 years from its date of issue, except as
to any provision for benefits in case of total disability. But, any optional
interest in Specific Amounts or any reinstatement will be incontestable only
after the increase or reinstatement has been in force during the lifetime of the
Insured for 2 years from the date it took effect.
Misstatement of Age or Sex -- If the Insured's age or sex has been misstated,
the amount of any Death Benefit will be sum of (a) and (b), where:
25
(a) is the fund value on the date of death;
(b) is the Amount At Risk on the last Monthly Anniversary Day, multiplied by the
ratio of the insurance rate on the last Monthly Anniversary Day based on the
incorrect age or sex to the insurance rate that would have applied on that
Day based on the correct age or sex.
Suicide Exclusion -- In case of the suicide of the Insured, sane or insane,
within 2 years of the date of the issue of the Policy, or within 2 years of the
date of any restatement, the amount payable by us will be limited to the amount
of the premiums paid less: (a) any debt; and (b) any partial surrenders and
their fees.
But, in the case of suicide of the Insured, sane or insane, within 2 years of
the date any optional increase in Specified Amount took effect the amount
payable by us with respect to that increase will be limited to its cost.
Assignment - We shall not be charged with notice of assignment of any interest
in this Policy until the assignment (or a copy) is received at our Home Office.
We are not responsible as to the validity or effect of any assignment. We may
rely solely on the statement of the assignment as to the amount of his or her
interest. All assignments will be subject to any debt on this Policy. The
interest of any beneficiary or other person will be subordinate to any
assignment, whenever made. The assignee will receive any sum payable to the
extent of his or her interest.
Policy Payment - In any settlement of this Policy, by reason of death,
surrender, or otherwise, we may require the return of the Policy. Also, any debt
on this Policy will be deducted when we determine the proceeds.
Due proof of death or total disability must be submitted to us at our Operations
Center on forms furnished by us. These forms can be obtained from any local
office of ours, or from our Operations Center.
Relationships - Relationships used in any beneficiary or other designation will
refer to the Insured unless the wording indicates otherwise.
Authority - No change in this Policy will be valid until it is approved by one
of our executive officers. This approval must be endorsed on or attached to this
Policy. No agent or other person has authority to accept representations or
information not in the written application. Nor may that person change this
Policy or waive any of its provisions.
Postponement of Certain Payments or Transfers - We will usually pay any amount
payable on surrender, partial surrender or loan within 7 days after we receive
written request for the payment at our Operations Center. We will usually pay
any death proceeds within 7 days after we receive due proof of death. But, any
payment involving a determination of fund value may be postponed in any case
whenever:
26
(a) the New York Stock Exchange is closed (except for customary weekend and
holiday closings), or trading on the New York Stock Exchange is restricted
as determined by the Securities and Exchange Commission (SEC);
(b) the SEC by order permits postponement for the protection of policyholders;
or
(c) the SEC determines that a state of emergency exists, so that valuation of
the assets of the Variable Account or disposal of securities is not
reasonably practicable.
Transfers among sub-accounts, and allocations to and against sub-accounts also
may be postponed under the circumstances described in (a), (b) and (c) above.
Reports - We will send a report at least annually to the rightsholder showing
the then current status of the Policy. It will show since the last report:
premiums received; expense charges (including any transfer charges); cost of
insurance and any riders; interest earned on any debt; interest on fund value in
GIA; and any partial surrenders (and fees).
It will also show as of the current and prior report dates: Death Benefit;
Specified Amount; cash value; fund value; sub-account Unit values; fund value in
GIA; outstanding fund charge; any debt; interest earned on Loan Account; and any
other information required by state law or regulation.
We will also send to the rightsholder any reports required by the Investment
Company Act of 1940.
Projection of Benefits and Values - We shall provide a projection of
illustrative future benefits and values at any time after the first policy
anniversary upon: (a) written request; and (b) payment of a service fee. The fee
will be the one then in effect for this service. The illustration will be based
on: (a) requested assumptions as to Specified Amount, Death Benefit Option and
scheduled premiums; and (b) any other assumptions that are needed and that we
agree to.
Nonparticipation - We pay no dividends on this Policy.
31. Settlement Options
Instead of being paid in one sum, any death or surrender proceeds payable under
this Policy to a natural person in his or her own right may be settled under one
of the options below. But the payments under the option chosen must be made to
that person (the payee). And, the amount of death or surrender proceeds must be
at least $1,000.
Options Available -
1. Interest Income - Interest on the proceeds held by us at the rate set by us
for each year. This rate will not be less than 2.3/4% a year.
2. Income for Specified Period - Income for the number of years chosen, based
on the table below. This table shows the monthly income for each $1,000 of
proceeds. Payments may be increased by additional interest as we may
determine for each year.
27
Option 2 Table
[Enlarge/Download Table]
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Years 1 2 3 4 5 6 7 8 9 10
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Amount $84.37 42.76 28.89 21.96 17.80 15.03 13.06 11.58 10.42 9.50
--------------------------------------------------------------------------------------------------------------------------------
Years 11 12 13 14 15 16 17 18 19 20
--------------------------------------------------------------------------------------------------------------------------------
Amount $8.75 8.13 7.60 7.15 6.76 6.41 6.11 5.85 5.61 5.39
--------------------------------------------------------------------------------------------------------------------------------
3. Single Life Income -- Income for a period certain and during the balance of
the payee's lifetime. The period certain chosen may be: (a) 0, 10 or 20 years;
or (b) the period required for the total income payments to equal the proceeds
(refund period certain). The amount of income will be figured by us on the date
the proceeds become payable. This amount will be at least as much as the
applicable amount based on the Option 3 table at the end of the Settlement
Options section. The minimum income amounts shown in that table are based on the
1983 Table a (discrete functions, without projections for future mortality) with
3 1/2% interest.
If the income based on the period certain elected is the same as the income
provided by another available longer period or periods certain, we will deem an
election to have been made on the longest period certain.
3A. Joint Life Income -- Income during the joint lifetime of the payee and
another person. Income will continue during the balance of the survivor's
lifetime. The type of income chosen may give a survivor's income equal to: (a)
the income amount payable during the joint lifetime; or (b) two-thirds of that
income amount.
The amount of income payable during the joint lifetime will be figured by us on
the date the proceeds become payable. This amount will be at least as much as
the applicable amount based on the Option 3A table at the end of the Settlement
Options section. The minimum income amounts shown in that table are based on the
1983 Table a (discrete functions, without projections for future mortality) with
3 1/2% interest. If a person for whom option 3A is chosen dies before the first
income amount is payable, the survivor will receive settlement instead under
Option 3 with 10 years certain.
4. Income of Specified Amount -- Income, of the amount chosen, for as long as
the proceeds and interest last. But, the amount chosen may not be less each year
then 10% of the proceeds. Interest will be credited annually on the balance of
the proceeds at the rate for each year set by us. This rate will not be less
than 2 3/4% a year.
Other Settlement Options -- The proceeds may be settled under any other option
agreed to by us.
Choice of Settlement -- During the Insured's lifetime, one of the above options
may be chosen for proceeds payable by reason of his or her death. Or, a prior
choice may be changed. The choice or
28
change will be subject to the same conditions and will take effect in the same
way as a change of beneficiary.
The payee of any proceeds payable in one sum but not yet paid may instead choose
one of the options. This must be done by written notice to us at our Home Office
not more than 1 month after the proceeds become payable.
Payment Provisions -- A supplementary contract will be issued when the proceeds
are settled under one of these options. The contract will set forth the terms of
the settlement. The contract date will be the date of the Insured's death if:
(a) the proceeds settled are death proceeds; and (b) the settlement was chosen
during the Insured's lifetime. In all other cases the contract will bear the
date the proceeds become payable.
Payment will be made monthly unless quarterly, semi-annual or annual payments
are asked for when the option is chosen. But, if payments of the chosen
frequency would be less than $25 each, we may use a less frequent payment basis.
[Enlarge/Download Table]
-------------------------------------------------------------------------------------------------------------------
To obtain the amount of other than monthly payments,
multiply the monthly payment by the appropriate factor. Ann. Semi-Ann. Quarterly
-------------------------------------------------------------------------------------------------------------------
OPTION 2 11.85 5.97 2.99
-------------------------------------------------------------------------------------------------------------------
OPTION 3 - 0 Years Certain 11.68 5.90 2.97
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OPTION 3 - 20 Years Certain, or Refund Period Certain 11.80 5.95 2.99
-------------------------------------------------------------------------------------------------------------------
OPTION 3 - 10 Years Certain, or OPTION 3A 11.74 5.92 2.97
-------------------------------------------------------------------------------------------------------------------
The first payment under Option 2, 3, 3A, or 4 will be due as of the contract
date. The first payment under Option 1 will be due 1, 3, 6, or 12 months after
that date, depending on the frequency of payment.
Before we pay under Option 3 or 3A, we shall need proof of age which satisfies
us. After the contract date, unless otherwise provided in the settlement
approved by us at the time it was chosen, any settlement under Option 1, 2, 3,
or 4 will end at the payee's death. The amount stated below for that option will
then be paid in one sum to the payee's executors or administrators.
Option 1 or 4 -- Any unpaid proceeds and interest to the date of death.
Option 2 or 3 -- The amount which, with compound annual interest, would have
provided any future income payments for: (a) the specified period (Option 2); or
(b) the specified period certain (Option 3). This interest will be at the rate
or rates we assumed in computing the amount of income.
Option 3 - Minimum Monthly Income Per $1,000 of Proceeds
29
The life income shown is based on the payee's age at nearest birthday on the due
date of the first income payment.
[Enlarge/Download Table]
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10 Years Certain 20 Years Certain 10 Years Certain 20 Years Certain 10 Years Certain
Male Female AGE Male Female Male Female AGE Male Female Male Female AGE
AGE Female
---------------------------------------------------------------------------------------------------------------
$3.21 $3.14 10* $3.20 $3.13 $3.74 $3.56 35 $3.71 $3.55 $5.42 $4.93 60
---------------------------------------------------------------------------------------------------------------
3.22 3.15 11 3.21 3.14 3.78 3.59 36 3.75 3.58 5.54 5.04 61
---------------------------------------------------------------------------------------------------------------
3.23 3.16 12 3.23 3.15 3.82 3.62 37 3.78 3.61 5.67 5.14 62
---------------------------------------------------------------------------------------------------------------
3.24 3.17 13 3.24 3.17 3.86 3.65 38 3.82 3.64 5.80 5.25 63
---------------------------------------------------------------------------------------------------------------
3.26 3.18 14 3.25 3.18 3.90 3.69 39 3.85 3.67 5.94 5.37 64
---------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------
3.27 3.19 15 3.27 3.19 3.94 3.72 40 3.89 3.70 6.08 5.50 65
---------------------------------------------------------------------------------------------------------------
3.29 3.20 16 3.28 3.20 3.99 3.76 41 3.93 3.73 6.23 5.63 66
---------------------------------------------------------------------------------------------------------------
3.30 3.22 17 3.30 3.21 4.04 3.80 42 3.98 3.77 6.38 5.77 67
---------------------------------------------------------------------------------------------------------------
3.32 3.23 18 3.31 3.23 4.09 3.84 43 4.02 3.81 6.54 5.92 68
---------------------------------------------------------------------------------------------------------------
3.34 3.24 19 3.33 3.24 4.14 3.88 44 4.06 3.84 6.71 6.07 69
---------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------
3.36 3.26 20 3.35 3.25 4.20 3.92 45 4.11 3.88 6.88 6.23 70
---------------------------------------------------------------------------------------------------------------
3.37 3.27 21 3.37 3.28 4.25 3.97 46 4.16 3.93 7.05 6.40 71
---------------------------------------------------------------------------------------------------------------
3.39 3.29 22 3.38 3.28 4.31 4.02 47 4.21 3.97 7.22 6.58 72
---------------------------------------------------------------------------------------------------------------
3.41 3.30 23 3.40 3.30 4.38 4.07 48 4.26 4.01 7.40 6.76 73
---------------------------------------------------------------------------------------------------------------
3.43 3.32 24 3.42 3.32 4.44 4.12 49 4.31 4.06 7.57 6.95 74
---------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------
3.46 3.34 25 3.45 3.33 4.51 4.18 50 4.37 4.11 7.75 7.15 75
---------------------------------------------------------------------------------------------------------------
3.48 3.36 26 3.47 3.35 4.58 4.24 51 4.42 4.16 7.92 7.34 76
---------------------------------------------------------------------------------------------------------------
3.50 3.38 27 3.49 3.37 4.66 4.30 52 4.48 4.21 8.09 7.54 77
---------------------------------------------------------------------------------------------------------------
3.53 3.40 28 3.52 3.39 4.74 4.36 53 4.54 4.27 8.26 7.74 78
---------------------------------------------------------------------------------------------------------------
3.56 3.42 29 3.54 3.41 4.82 4.43 54 4.60 4.32 8.42 7.94 79
---------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------
3.58 3.44 30 3.57 3.43 4.91 4.51 55 4.66 4.38 8.57 8.14 80+
---------------------------------------------------------------------------------------------------------------
3.61 3.46 31 3.59 3.45 5.00 4.58 56 4.72 4.44
---------------------------------------------------------------------------------------------------------------
3.64 3.49 32 3.62 3.48 5.10 4.66 57 4.78 4.51
---------------------------------------------------------------------------------------------------------------
3.67 3.51 33 3.65 3.50 5.20 4.75 58 4.85 4.57
---------------------------------------------------------------------------------------------------------------
3.71 3.54 34 3.68 3.52 5.31 4.84 59 4.91 4.64
---------------------------------------------------------------------------------------------------------------
* and under
[Download Table]
20 Years Certain 0 Years Certain
Male Female Female Male
-------------------------------------------
$4.97 $4.71 $3.46 25 $3.34
-------------------------------------------
5.04 4.77 3.59 30 3.44
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5.10 4.84 3.75 35 3.57
-------------------------------------------
5.16 4.91 3.96 40 3.73
-------------------------------------------
5.22 4.98 4.22 45 3.93
-------------------------------------------
-------------------------------------------
5.28 5.05 4.56 50 4.20
-------------------------------------------
5.33 5.12 4.99 55 4.54
-------------------------------------------
5.38 5.19 5.57 60 5.00
-------------------------------------------
5.43 5.25 6.39 65 5.64
-------------------------------------------
5.48 5.32 7.53 70 6.53
-------------------------------------------
5.52 5.38
-------------------------------------------
5.55 5.43
-------------------------------------------
5.59 5.48
-------------------------------------------
5.62 5.53 Refund Period
5.64 5.57 Certain
Male AGE Female
-------------------------------------------
5.66 5.60 $3.44 25 $3.33
-------------------------------------------
5.68 5.63 3.56 30 3.42
-------------------------------------------
5.70 5.66 3.70 35 3.54
-------------------------------------------
5.71 5.68 3.88 40 3.69
-------------------------------------------
5.72 5.70 4.11 45 3.87
-------------------------------------------
-------------------------------------------
5.73 5.71 4.38 50 4.1
-------------------------------------------
4.73 55 4.40
-------------------------------------------
5.18 60 4.78
-------------------------------------------
5.76 65 5.28
-------------------------------------------
6.52 70 5.94
-------------------------------------------
* and under
30
+ and over
The minimum income for any age not shown in the 0 Years Certain and Refund
Period Certain columns is calculated on the same mortality and interest
assumptions as the minimum income for the ages shown and will be quoted on
request.
Option 3A - Minimum Monthly Income Per $1,000 of Proceeds
The income shown is based on the ages (at nearest birthday on the due date of
the first income payment) of the 2 persons during whose joint lifetime payments
are to be made.
Same Income Continued to Survivor Two-Thirds of Income Continued to Survivor
[Enlarge/Download Table]
------------------------------------------------------------------------------------------------------
AGE AGE
OF AGE OF MALE OF AGE OF MALE
FEMALE 50 55 60 65 70 FEMALE 50 55 60 65 70
------------------------------------------------------------------------------------------------------
50 $3.89 $3.98 $4.04 $4.09 $4.13 50 $4.20 $4.35 $4.51 4.69 $4.89
------------------------------------------------------------------------------------------------------
55 4.03 4.16 4.27 4.36 4.42 55 4.36 4.54 4.73 4.95 5.18
------------------------------------------------------------------------------------------------------
60 4.16 4.34 4.51 4.66 4.78 60 4.55 4.76 4.99 5.25 5.53
------------------------------------------------------------------------------------------------------
65 4.27 4.51 4.76 4.99 5.20 65 4.76 5.01 5.29 5.62 5.97
------------------------------------------------------------------------------------------------------
70 4.37 4.66 4.99 5.34 5.67 70 4.99 5.28 5.63 6.04 6.49
------------------------------------------------------------------------------------------------------
The minimum income for any other combination of ages or for 2 persons of the
same sex are calculated on the same mortality and interest assumptions as the
minimum income for the combinations of ages shown and will be quoted on request.
Endorsements
(Endorsements may be made only by us. Any on this page were made when this
Policy was issued, if we do not state otherwise.)
SOME DEFINITIONS AND PROVISIONS FOR BENEFICIARY AND RIGHTS
DESIGNATIONS
A. Wherever used in any Beneficiary or Rights designation the following terms
shall mean:
1. "Estate" means the court appointed fiduciary (executor, administrator
or personal representative) for the decedent's estate.
2. "Will" means the instrument probated as the last will and testament.
3. "Children Per Stirpes" means that if a designated child dies leaving
children, such of said children as shall be living shall take the share
of such deceased child, divided equally.
31
4. "Trust" means an agreement of trust made by and between a settlor (or
grantor) and a trustee, under a specific date.
5. "Guardian" means that person appointed by a court of competent
jurisdiction to administer and manage the property (estate) of another
person ("ward," often an infant).
6. "Equal Rights" or "Equally in Rights" means "as shall be living,
jointly".
7. "Issue" or "Heirs" is deemed to mean "Children Per Stirpes." As stated
in number 3 above.
8. "And/or" or "Or" means "as shall be living, equally".
B. The Flexible Plan Settlement is not available as a settlement option.
/s/ David S. Waldman
-------------------------------
Secretary
89504
32
Rider attached to and forming a part of Policy (or Contract) issued by MONY Life
Insurance Company of America B6009-75-96
Endorsements
(Endorsements may be made only by us. Any on this page were made when this
Policy was issued, if we do not state otherwise.)
BENEFICIARY
The beneficiary is:
Hippo Inc., or its successors as said Corporation interest may appear. The
balance, if any, or the entire death proceeds if said Corporation, or its
successors shall have no interest shall be payable to sister, Johanna Gordon, if
living, if not, mother, Sandra Berger, if living. The Company may rely solely on
the statement of said Corporation, or its successors as to the amount of said
Corporation's interest.
MONY LIFE INSURANCE COMPANY OF AMERICA
/s/ David S. Waldman
------------------------------
Secretary
RIGHTS: During the Insured's lifetime, all rights belong exclusively to Hippo
Inc., or its successors except that the rights so far as concern the interest of
any beneficiary other than said Corporation, or its successors to change the
beneficiary, to elect a settlement option subject to the provisions of the
policy, and to change or revoke such an election belong exclusively to the
Insured and the right to assign and the right to change this designation of
rights belong exclusively to the Insured jointly with said Corporation, or its
successors. The interest of any beneficiary other than said Corporation, or its
successors shall be subordinate to the interest of said Corporation, or its
successors.
No agreement between the Insured and Corporation shall vary the terms of this
Contract or be otherwise binding on The Company. The Company shall be fully
protected and discharged in any dealing or settlement, in accordance with the
policy provisions, with any person designated as rightsholder without regard to
the terms or validity of the agreement,
MONY LIFE INSURANCE COMPANY OF AMERICA
57521
/s/ David S. Waldman
------------------------------
33
Secretary
34
I represent the statements and answers in this application to be true and
complete to the best of my knowledge and belief. I offer them to the appropriate
MONY Company to induce it to issue the policy or policies and to accept the
payment of premiums thereunder.
I agree that: (1) Payment of the first premium, if after the application date
below, will mean that I represent that such statements and answers would be the
same if made at the time of such payment; (2) no one but an Executive Officer of
the Company may change any contract or waive any of its provisions; (3) when
coverage takes effect: if a policy is issued exactly as applied for and required
cost has been received, the policy will take effect on the date we authorize its
delivery or on any later requested Policy Date. If a policy is issued either (a)
other than as applied for, or (b) exactly as applied for but any required cost
remains unpaid, the policy will take effect on the date it is delivered,
provided its delivery and payment of any required cost are made while each
person to be insured is living. But, in any case, a policy will not take effect
for any of these situations before the date indicated: (a) for a Purchase Option
election (Question 19), the Option Date; (b) for the exercise of a Term
Conversion (Question 21); (c) for a Government Allotment authorization, its
Policy Date, "Required Cost" in the case of a Purchase Option election or a Term
Conversion is the full first premium. In any other case, "required cost" is the
amount necessary to put the policy in force; (4) acceptance of any policy issued
will ratify any correction in or amendment to the application noted by the
Company in the space provided "FOR HOME OFFICE USE ONLY," in Section E of the
application. A copy of the application attached to the policy will be sufficient
notice of the change made. If the laws where the application is made so require,
any change of amount, class of risk, age at issue, plan of insurance or benefits
must be ratified in writing.
Under the penalties of perjury, I certify that:
- The number shown under Question 1 or 14 on Part 1 of the application is the
correct taxpayer identification number of the rightsholder (or the
rightsholder is waiting for a number to be issued).
- I am not subject to backup withholding because: (a) I am exempt from backup
withholding, or (b) I have not been notified by the Internal Revenue Service
(IRS) that I am subject to backup withholding as a result of a failure to
report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding (does not apply to real estate
transactions, mortgage interest paid, the acquisition or abandonment of
secured property, contribution to an individual retirement arrangement
(IRA), and payments other than interest and dividends).
For Underwriting and claim purposes, I permit:
- Any physician or other medical practitioner, hospital, clinic, other
medically related facility, consumer reporting agency, or the Medical
Information Bureau (MIB) to give medical record information regarding me to
the Company or any of its reinsurers. The data includes findings on medical
care; psychiatric or psychological care or examinations; or surgery. Also,
any insurer or reinsurer may give the company medical data described above
and data about current or pending insurance I may have.
35
- The Company to get consumer reports; and motor vehicle reports about me.
- Any employer, business associate, financial institution, insurer,
government unit or MIB, Inc. to give the Company any data that they may
have about my occupation, avocations, driving record, finances, insurance
coverage, general reputation and aviation activities (i.e., "personal
information").
I understand that:
- A photocopy or facsimile transmission copy of this form will be as valid as
the original. My consent to get medical record information and personal
information about me will end two years from the date shown below. I may at
any time, however, revoke my permission to get any data protected by 42 CFR
Part 2 or any other Federal or State law or regulation which provides for
such revocation. Any action taken before revocation, however, will be
valid.
- I have been given a copy of "MONY's Information Practices and The
Underwriting Process," including notices regarding consumer reports, and
MIB, Inc. I know that I have a right to get a copy of this form.
- My records are protected under federal and state law and cannot be disclosed
without my written consent unless otherwise provided by law. I further
understand that the specific types of information to be disclosed may, if
applicable, include: diagnosis, prognosis, and treatment for physical and/or
emotional illness, including treatment of alcohol or substance abuse for any
admissions; diagnosis, prognosis, and treatment of HIV infection, including
HIV test results; and diagnosis, prognosis and treatment for any
communicable disease or serious communicable disease or infection, including
sexually transmitted diseases.
- All or part of the data which the Company gets may be sent to MIB. It may
also be disclosed to and used by any Company reinsurer, employee or
contractor who performs any business service on any insurance I may have
applied for or have with the Company.
Signed at (City and State): on , 19 .
------------------------ --------------- ---
X X
--------------------------- --------------------------------------
Signature of Insured Signature of Spouse - if to be Insured
Signature of Applicant (if other than Insured), who agrees to be bound by the
representations and agreements in this and in any other part of this
application. In the case of the exercise of a purchase option election or a
conversion privilege, applicant means the owner of such right (other than the
Insured).
X
--------------------------- --------------------------------------
Signature of: Applicant
--- --------------------------------------
Owner (Rightsholder) Address
---
X
-------------------------------------
Signature of Parent or Legal Guardian
36
(if Insured is under age 15)
37
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