Post-Effective Amendment
Filing Table of Contents
Document/Exhibit Description Pages Size
1: 485BPOS Registration Statement With Exhibits 6 32K
2: EX-99.A Exhibit A 2 18K
3: EX-99.B Exhibit B 2 13K
4: EX-99.C.(1) Exhibit C(1) 23 93K
5: EX-99.C.(2) Exhibit C(2) 23 92K
6: EX-99.C.(3) Exhibit C(3) 6 28K
13: EX-99.D(7) Exhibit D(7) 5 15K
7: EX-99.D.(1) Exhibit D(1) 7± 28K
8: EX-99.D.(2) Exhibit D(2) 4 24K
9: EX-99.D.(3) Exhibit D(3) 5 14K
10: EX-99.D.(4) Exhibit D(4) 3 12K
11: EX-99.D.(5) Exhibit D(5) 5 14K
12: EX-99.D.(6) Exhibit D(6) 2 10K
14: EX-99.E(1) Exhibit E(1) 6 27K
15: EX-99.E.(2) Exhibit E(2) 2 10K
16: EX-99.F Exhibit F 10± 36K
EX-99.E(1) — Exhibit E(1)
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EXHIBIT E(1)
Form of Life Insurance Application (24APP0396NY)
ASSURANCE COMPANY OF NEW YORK New York, NY 10005
LIFE INSURANCE APPLICATION
1. PROPOSED First Middle Last Date of Birth Age Sex Place of Birth
INSURED ______________________ _____________ ____ ___ ______________
mo. day yr.
Address City State Zip
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Social Security No. __________ Citizenship ____ U.S. Other (Country)_________
Telephone Occupation and Duties:______________________________
Home ( ) Employer: __________________
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Business ( ) Address: ________________________
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2. OWNER First Middle Last Social Security or Tax I.D. No.
(if other _____________________________________________________________________
than Address City State Zip
proposed _____________________________________________________________________
insured) If a contingent owner is desired, indicate in special
instructions below.
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3. BENEFICIARY Primary Relationship
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Contingent Relationship
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4. PLAN Plan _________________ Insurance Amount $ _________________
SELECTION $_________Waiver or Premium Accidental Death $ ___________ Waiver of
Specified Premium $ __________ Other _________________
Death Benefit Option:_____ Universal Life - Option A (increasing)
_____ Variable Life - Option I (level)
_____ Universal Life - Option B(level)
_____ Variable Life - Option II (enhanced)
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5. PREMIUM Premium Paid with Application $ _____ must be at least two months
premium for the plan and
insurance amount applied for)
Universal Life or Variable Life only:
Planned Initial Premium $ ___________ Planned Periodic Payment $ ________
Frequency:_____ Annual _____ Semi-Annual ______ Quarterly _____ Other ______
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6. OTHER Life Insurance now in force: Company Amount Plan Year Issued
IMPORTANT (if none, so state)
INFORMATION
YES or NO
a. Have you ever had a request for life or disability insurance
declined, postponed, rated, or restricted in any way, or are any
other applications for insurance pending or contemplated?
b. Will the policy applied for replace or change any existing life
insurance or annuity?
c. Within the past two years have you flown or taken instruction as
a pilot, or engaged in any kind of racing, scuba or sky diving,
hang gliding, or do you intend to?
d. Within the past five years have you used amphetamines, narcotics,
barbiturates, hallucinogens, cocaine, or marijuana, or received
treatment for drug or alcohol use?
e. Have you ever had your driver's license restricted or revoked?
Driver's License No._____ _____
f. Proposed Insured's Height _____ ft. ______ in. Weight ______ lbs.
Any weight loss in last year?
g. Within the past 12 months have you smoked cigarettes or used any
other tobacco products?
h. Do you intend to reside or travel outside the United States?
Give details to "YES" responses to questions 6a through 6h.
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HOME OFFICE AMENDMENTS AND CORRECTIONS SPECIAL INSTRUCTIONS (for home office use
only where permitted by state statute)
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7. Have you within the past 5 years: YES NO
a. Consulted a physician for any reason; had an electrocardiogram or
other diagnostic tests?
b. Been in a clinic, hospital, or medical facility for observation
or treatment?
c. Been advised to have any diagnostic test, hospitalization, or
surgery which was not done?
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8. Within the past 10 years, have you ever had or been treated for or had
indication of:
a. Cancer, stroke, or heart attack? _
b. Diabetes, glandular disorder, enlarged lymph nodes, epilepsy, or any other
mental or nervous disorder?
c. Chest pain, high blood pressure, heart murmur, or other circulatory or
blood disorder?
d. Kidney, urinary or reproductive disorder, or sexually transmitted disease?
e. Liver or gastro-intestinal disorder?
f. Asthma, emphysema, or other respiratory disorder?
g. Loss of vision, amputation, deformity, arthritis, or other musculo-skeletal
disorder?
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9. Any family history of diabetes or heart disease?
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10. FAMILY HISTORY AGE IF STATE OF AGE AT CAUSE OF
LIVING HEALTH DEATH DEATH
FATHER
MOTHER
BROTHERS & SISTERS
No. Living
No. Dead
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11. Have you ever had or been told you have:
a. "AIDS" (Acquired Immune Deficiency Syndrome)?
b. "AIDS" Related Complex (ARC)?
c. Tested positive for antibodies to the "AIDS"
(Human T-Cell Lymphotropic, Type III;
HTLV-III) Virus?
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12. Are you presently taking any medication?
INSTRUCTIONS: Give full details for all "YES" answers to questions 7 to 12. Give
dates, treatment, duration of illness, and names and addresses of all attending
physicians and medical facilities.
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13. Personal Physician: (If none, so state)
Name___________________________
Address_________________________
Date and Reason Last Seen__________
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I hereby represent all my statements and answers to the above questions to be
correct and true to the best of my knowledge and belief. This application and
any amendments shall be a part of any contract issued by the Company. No medical
examiner or agent can make or change a contract or waive any of the Company's
rights or requirements. Unless otherwise provided by the Receipt for Conditional
Temporary Insurance, if applicable, no policy will take effect unless and until
while the insured is living, the application is approved, the full initial
premium is paid, the policy is delivered and accepted by the owner, and answers
and statements in this application continue to be complete and true at the time
of such payment and acceptance. Acceptance of any policy issued based on this
application will be a ratification of any amendments or corrections noted by
American International Life Assurance Company of New York in the space headed
"Home Office Amendments and Corrections," except that if required by state
statute or regulation, any change in amount, age, plan of insurance, additional
benefits, or classification must be agreed to in writing.
I authorize any physician or medical professional, hospital, clinic or
medically-related facility, insurer or reinsurer, Veterans Administration
facility, the Medical Information Bureau, Inc., consumer reporting agency,
employer or person, to disclose to American International Life Assurance Company
of New York and its reinsurers, medical and other information pertaining to me
for use in determining insurability. I authorize all such sources, except the
MIB, Inc. to give such information to any insurance support organization
authorized by American International Life Assurance Company of New York to
collect and transmit such information. I agree that this authorization shall be
valid from the date signed for a period of 2 1/2 years. I agree that a photocopy
of this authorization shall be as valid as the original. I understand that a
copy is available to me upon request. I hereby acknowledge receipt of the Notice
to Applicant Part One and Part Two.
SIGNED AT ____________________________ ON _______________________________
(City, State)
(Signature of Proposed Insured
or Parent if a Minor)
________________________________________________
(Signature of Owner if other than Proposed Insured)
________________________________________________
(Printed Name of Agency) (Code No.)
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(Signature of Agent) (Address of Agency)
( ) ( )
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(Printed name of Agent) (Code No.) (Agent Phone Number) (Agency Phone
Number)
AGENT: Do you have any reason to believe the contract applied for is to replace
or change any existing annuities or life insurance on the life of the proposed
insured? _____YES_____NO
AMERICAN INTERNATIONAL LIFE 80 Pine Street
ASSURANCE COMPANY OF NEW YORK New York, NY 10005
RECEIPT FOR CONDITIONAL TEMPORARY INSURANCE
In exchange for the completion of the application and the payment of the
premium required by this receipt as shown below, American International Life
Assurance Company of New York ("Company") will provide insurance prior to the
issuance of the policy, upon the following terms:
No insurance will be provided under this receipt unless all Requirements shown
below are first fulfilled during the lifetime of the proposed insured, and
within 60 days from the date Conditional Temporary Insurance starts. If all
Requirements are not so met, or the proposed insured dies by suicide, the
liability of the Company shall be limited to a refund to the applicant of the
premium paid with this receipt. This receipt provides no insurance for riders or
additional benefits.
Requirements. The following must all be fulfilled before insurance will start:
(1) All questions in the application(s) have been fully answered with no
material misrepresentation; (2) Question No 8a is answered "NO"; (3) A first
premium equal to the greater of (a) the full modal premium or (b) at least two
months premium for the plan and insurance amount applied for has been received
by the Company; (4) All medical examination and tests required by the Company's
published underwriting rules according to the age and insurance amount applied
for have been completed; (5) The proposed insured is acceptable to the Company
under its rules and practices for the plan and insurance amount applied for, at
the rate class applied for or a lesser premium, as of the date the Company
receives all of its medical requirements.
When Conditional Temporary Insurance Starts. If the Requirements have been
fulfilled, this Receipt will provide insurance beginning with the later of (1)
the date of the application; or (2) the date all medical examination and tests
have been completed.
Death Benefit Amount Limit. The total amount of insurance provided by this
receipt, and the total in the aggregate of this and all other similar receipts
on the life of the proposed insured pending with the Company, is limited to the
lesser of: (1) the initial death benefit of the insurance applied for in the
application; or (2) $500,000. The death benefit will be paid to the beneficiary
named in the application.
When Conditional Temporary Insurance Ends. Insurance provided by this receipt
ends on the earliest of the following: (1) The date of the policy applied for is
issued as applied for (2) The date the Company mails to the applicant at the
address on the application, a notice that the application has been declined; (3)
60 days after the date Conditional Temporary Insurance starts under this
receipt; (4) The date the applicant receives an offer from the Company to issue
the policy other than as applied for. If the insurance coverage ends under (2),
(3) or (4) above, the premium paid with this receipt will be refunded. In no
event will insurance be in effect under both this receipt and any policy issued
on the basis of the application.
Payment Terms. The required premium will not be considered paid unless any
check, draft, money order or other form of payment is paid in accordance with
its terms. All premium checks must be made payable to the Company. Do not leave
the payee blank.
No agent may alter or waive any part of this receipt.
Receipt of $ _______ is hereby acknowledged this _____ day of ________, 19___
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(Signature of Agent)
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NOTICE TO APPLICANT - PART ONE
In order to properly underwrite and administer your insurance program, American
International Life Assurance Company of New York, (we, our) and our reinsurers
will rely heavily on information provided by you. We may also ask for medical or
other information about you from others, such as medical professionals who have
treated you and the Medical Information Bureau, Inc. In some situations, and in
compliance with applicable law, we may disclose necessary items of information
to third parties without your specific authorization. Upon written request, you
may have access to the information in your life. You also have the right to seek
correction of information you believe to be inaccurate.
In making this application for insurance, it is understood that an investigative
consumer report may be prepared whereby information is obtained through personal
interviews with your neighbors, friends, or others with whom you are acquainted.
This inquiry includes information as to your character, general reputation,
personal characteristics, and mode of living. You have the right to make a
written within a reasonable period of time to receive additional information
about the nature and scope of this investigation. You also have the right to
request to be interviewed in connection with the preparation of such report. You
may receive a copy of the report upon written request.
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NOTICE TO APPLICANT - PART TWO
Information regarding your insurability will be treated as confidential. We may,
however, make a brief report thereon to the Medical Information Bureau, Inc., a
non-profit membership organization of life insurance companies, which operates
an information exchange on behalf of its members. If you apply to another Bureau
member company for life or health insurance coverage, or a claim for benefits is
submitted to such a company, the Bureau, upon request, will supply such company
with information in its file. We or our reinsurers may also release information
in our files to other insurance companies to which you may apply for life or
health insurance or to which a claim for benefits may be submitted.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your file. If you question the accuracy of
information in the Bureau's file, you may contact the Bureau and seek correction
in accordance with the procedures set forth in the Federal Fair Credit Reporting
Act. The address of the Bureau's information office is: P.O. Box 105, Essex
Station, Boston, MA 02112, telephone number (617) 426-3660. If you would like to
receive a more detailed explanation of our procedures and your rights, please
send your request to: The Director of Underwriting, American International Life
Assurance Company of New York, 80 Pine Street, New York, NY 10005.
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