Pre-Effective Amendment to Registration Statement of a Unit Investment Trust · Form S-6
Filing Table of Contents
Document/Exhibit Description Pages Size
1: S-6/A Pre-Effective Amendment #1 to Form S-6 88 430K
2: EX-1.A.(10) Underwriting Agreement 14± 61K
3: EX-1.A.(11) Underwriting Agreement 20 82K
4: EX-2 Plan of Acquisition, Reorganization, Arrangement, 2 10K
Liquidation or Succession
5: EX-6 Opinion re: Discount on Capital Shares 1 7K
6: EX-7.(A) Opinion re: Liquidation Preference 1 5K
7: EX-7.(B) Opinion re: Liquidation Preference 1 6K
EX-1.A.(10) · Underwriting Agreement
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Exhibit 1.A.(10)
STATE FARM LIFE INSURANCE COMPANY, Bloomington, Illinois
VARIABLE UNIVERSAL LIFE INSURANCE APPLICATION PAGE 1
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1 If the application is for a change in a State Farm policy, give the number:
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2 PROPOSED INSURED 1 (Print name in full)
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Mr. [_] LAST NAME FIRST NAME MIDDLE INITIAL
a Ms. [_]
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MAILING ADDRESS
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CITY STATE ZIP CODE
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IN YES NO SOCIAL SECURITY OR TAX ID NUMBER DRIVERS LICENSE NUMBER STATE
CITY [_] [_]
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SEX BIRTH DATE MO-DAY-YR AGE MARITAL STATUS
c
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HEIGHT WEIGHT STATE OF BIRTH UNITED STATES OR YES NO
CANADIAN CITIZEN? [_] [_]
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d OCCUPATION (GIVE EXACT DUTIES)
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EMPLOYERS NAME AND ADDRESS
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3 PROPOSED INSURED 2 (Print name in full)
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Mr. [_] LAST NAME FIRST NAME MIDDLE INITIAL
a Ms. [_]
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SOCIAL SECURITY OR TAX ID NUMBER DRIVERS LICENSE NUMBER STATE
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SEX BIRTH DATE MO-DAY-YR AGE MARITAL STATUS
b
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HEIGHT WEIGHT STATE OF BIRTH UNITED STATES OR YES NO
CANADIAN CITIZEN? [_] [_]
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c OCCUPATION (GIVE EXACT DUTIES)
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EMPLOYERS NAME AND ADDRESS
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4 APPLICANT/OWNER (If not Proposed Insured 1, print name in full)
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a LAST NAME FIRST NAME MIDDLE INITIAL
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SOCIAL SECURITY OR TAX IDENTIFICATION NUMBER
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b MAILING ADDRESS CITY STATE ZIP CODE IN YES NO
CITY [_] [_]
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Successor Owner (Required unless Applicant/Owner is a TRUST or Corporation)
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c LAST NAME FIRST NAME MIDDLE INITIAL
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Complete: if Proposed a Is Proposed Insured 1 to be Yes No
Insured is under age 16 Owner at and after age 21 ? [_] [_]
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b Give amount of insurance in force on: (If none, so indicate)
Father $ Mother $
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5 Variable Universal life
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a Initial Basic Amount: $
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b Death Benefit: [_] Option 1- [_] Option 2 - Basic Amount
(COMPLETE FOR NEW Basic Amount plus Account Value
POLICY ONLY) If option not chosen, policy provisions determined option.
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c Riders/Benefits applied for: Waiver of Monthly Yes No
(Check Ratebook For Deduction(For Disability) [_] [_]
availability of riders.)
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[_] AD AMOUNT [_] GIO AMOUNT 1-COMPLETE 8 & 9
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[_] CTR/1/ UNITS [_] A1 2 TERM AMOUNT 2-COMPLETE QUESTIONS
FOR PROPOSED INSURED ?
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d Dividend Option: [_] Addition to Account Value [_] Cash Payment
If option not chosen, policy provisions determined option.
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e Planned Premium: Agents Employees
Existing Payroll Payroll Salary
Annual SFPP Life PAC Deduction Deduction Allotment
Mode: [_] [_] [_] [_] [_] [_]
(Check one)
------------------------
Existing Special Monthly
Account Number:
------------------------
--------------------
Amount to be billed each payment date $
--------------------
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f Increase in Basic Amount:
(DO NOT COMPLETE FOR NEW POLICY) $
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g Initial Account and Payment Allocation: COMPLETE FOR NEW POLICY ONLY
(During the free look period, all net premiums %
will be allocated to the Fixed Account.) (Must Be Whole %
with 1% Minimum)
[_] Large Cap Equity Index Subaccount
[_] Small Cap Equity Index Subaccount ---------------
[_] International Equity Index Subaccount ---------------
[_] Stock and Bond Index Subaccount ---------------
[_] Bond Subaccount ---------------
[_] Money Market Subaccount ---------------
[_] Fixed Account ---------------
---------------
TOTAL = 100%
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h Check the appropriate box if you wish to have:
Only one may be in effect at one time.
[_] Dollar Cost Averaging -OR- [_] Portfolio Rebalancing
Complete separate form if either checked.
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i Premium submitted with application $
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6 Beneficiary Designation - Proposed Insured 1
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Completion of this section will replace all previous rider and policy
designations for this policy. If a Change of Plan, this will replace previous
designations.
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PRIMARY BENEFICIARY - FULL NAME AGE RELATIONSHIP
[_] Interest Option or [_] One Sum or [_] Other-Explain*
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SUCCESSOR BENEFICIARY - FULL NAME AGE RELATIONSHIP
[_] Interest Option or [_] One Sum or [_] Other-Explain*
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FULL BENEFICIARY - FULL NAME AGE RELATIONSHIP
One Sum Settlement Only
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* If additional space is needed, use the explanation section on Page 2.
If a beneficiary survives the Insured, any payment to successor will be one
sum, unless changed.
================================================================================
7 Beneficiary Designation - Proposed Insured 2
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(Complete for Additional Insured's rider only if Beneficiary provision in the
rider is NOT desired.) If a Change of Plan this will replace previous
designations. If this section is completed, the Payment of Benefit Provisions
of the policy will control rather than the Beneficiary provision of such
rider. "Additional Insured" would be used in place of "Insured."
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PRIMARY BENEFICIARY - FULL NAME AGE RELATIONSHIP
[_] Interest Option or [_] One Sum or [_] Other-Explain*
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SUCCESSOR BENEFICIARY - FULL NAME AGE RELATIONSHIP
[_] Interest Option or [_] One Sum or [_] Other-Explain*
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FULL BENEFICIARY - FULL NAME AGE RELATIONSHIP
One Sum Settlement Only
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* If additional space is needed, use the explanation section on Page 2.
If a beneficiary survives the Additional Insured, any payment to successor
will be one sum, unless changed.
================================================================================
VARIABLE UNIVERSAL LIFE INSURANCE APPLICATION PAGE 2
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CHILDREN'S TERM RIDER JUVENILE APPLICATIONS (AGES 0-15)
Complete 8 & 9 OR Complete 9 & 10
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8 List children under age 18; (only if CTR applied for) (If None, so state)
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LAST NAME, FIRST NAME, MI RELATIONSHIP TO BIRTH DATE AMOUNT NOW
(LAST NAME DIFFERENT EXPLAIN) PROPOSED INSURED 1 ------------ INSURED FOR
MO DAY YR.
------------
$
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ALL Applications Complete 10
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Proposed Insured
1 2
YES NO YES NO
10a Do you have personal and business life insurance
of more than $200,000? (If yes, give amounts and details) [_] [_] [_] [_]
b Do you have any accidental death insurance
excluding group? (If yes, and AD applied for, [_] [_] [_] [_]
give amount )
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c Will this policy replace or change insurance or
annuities you now have? (If yes, explain) [_] [_] [_] [_]
d Are you now applying for life or health insurance
with any other company? (If yes, state companies and amount)[_] [_] [_] [_]
e Do you plan to leave or travel from the United
States or Canada in the next 6 months? (If yes, explain) [_] [_] [_] [_]
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Applications (Ages 16 & Up):
If NO Medical Exam required
complete 10-16
If Medical Exam required
completed 11, 12, 14a, & 14e.
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11 Have you used tobacco in any form in the
last 12 months? [_] [_] [_] [_]
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12 Have you, in the last 3 years: (If yes, explain)
a flown as a pilot, crew member, or a student pilot in
aircraft such as an airplane, helicopter, glider, or
ultralight? Or, is any such activity planned in the
next 6 months? [_] [_] [_] [_]
b engaged in avocations such as mountain or rock
climbing, auto, motorcycle, or powerboat racing,
scuba or sky diving, hang gliding, or ballooning?
Or, is any such activity planned in the next 6
months? [_] [_] [_] [_]
c had your driver's license suspended or revoked,
had any moving violations, had 2 or more
accidents, or been charged with driving under the
influence of alcohol or drugs? [_] [_] [_] [_]
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9 Has juvenile or have any children named in question 8:
(If yes, explain)
YES NO
a had a birth defect, mental disorder, or impairment of sight,
hearing, or speech? [_] [_]
b had asthma, seizure, diabetes, or kidney disease? [_] [_]
c had heart murmur, anemia, leukemia, or cancer? [_] [_]
d in the last 3 years, for any reason not previously explained,
been a patient in a hospital, clinic, or emergency room? [_] [_]
e in the last 10 years, had or been treated for Acquired
Immune Deficiency Syndrome (AIDS)? [_] [_]
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Proposed Insured
1 2
13 Have you ever: (If yes, explain) YES NO YES NO
a applied for or received disability benefits? [_] [_] [_] [_]
b had an impairment or loss of sight or hearing, or an
impairment of neck, back, or limb? [_] [_] [_] [_]
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14 Have you, in the last 10 years, had or been treated
for: (If yes, circle and explain)
*a high blood pressure, stroke, heart murmur, chest
pain, heart attack, tumor, cancer, or lymph gland
disorder? [_] [_] [_] [_]
b mental, nervous, or convulsive disorder; or epilepsy? [_] [_] [_] [_]
c pneumonia, emphysema, asthma; ulcer, colitis,
liver, or intestinal disorder; anemia or blood disorder? [_] [_] [_] [_]
d diabetes, arthritis, sexually transmitted disease, or
kidney disease? [_] [_] [_] [_]
*e Acquired Immune Deficiency Syndrome (AIDS)? [_] [_] [_] [_]
f chronic diarrhea, unexplained weight loss, recurrent
fever, fatigue, or night sweats? [_] [_] [_] [_]
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15 Have you, in the last 5 years: (If yes, explain)
a used cocaine, marijuana, hallucinogenic drugs, or
narcotics not prescribed by a physician? [_] [_] [_] [_]
b been treated or counseled, or advised to seek
treatment or counsel, for alcohol or drug use? [_] [_] [_] [_]
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16 Have you, in the last 5 years, for any reason not
previously explained: (If yes, explain)
a had treatment or a test in any medical facility such
as a lab, clinic, emergency room, or hospital? [_] [_] [_] [_]
b had treatment or advice from any physician or
psychologist? [_] [_] [_] [_]
c taken prescribed medication? (If yes, list & explain) [_] [_] [_] [_]
d had surgery or been told surgery was necessary? [_] [_] [_] [_]
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* AGENT - If yes, it may be advisable not to collect money or give a Binding
Receipt - Consult Agents Service for specific instructions.
VARIABLE UNIVERSAL LIFE INSURANCE APPLICATION PAGE 3
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17 SUITABILITY INFORMATION
Complete for new policy, an increase in Basic Amount, or addition of an
Additional Insured's level term rider.
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Applicants are urged to supply information in order that the agent may make an
informed judgment as to the suitability of a particular purchase of a Variable
Universal Life Policy. If the Applicant chooses not to, the agent must complete
the following items to the best of his/her knowledge.
YES NO
Did the applicant provide the suitability information? [_] [_] (If no, explain)
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a. Annual Income from Occupation $ f. Tax Bracket: g. Score from Risk Profiler:
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b. Annual Income from other sources $ [_] Death Benefit
Indicate other sources: h. Purpose for [_] Personal Retirement Planning
Purchasing Years to Retirement: ________________
this Policy:
---------------------------------------------------- [_] Other (specify) ____________________________
c. Projected Income for next 12 months $ -------------------------------------------------------------------------------
---------------------------------------------------- i. Which best approximates your experience with the following
d. Estimated Net Worth (excluding home) $ ________ types of investments:
Liquid Assets included in Net Worth $ ________ NONE UP TO 5 YRS 5 YRS OR MORE
----------------------------------------------------
e. No. and Age of Dependent Children: Mutual Funds [_] [_] [_]
(If none, so state) Individual Common Stocks [_] [_] [_]
Annuities [_] [_] [_]
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18 TELEPHONE AUTHORIZATION
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The owner may make certain requests under the Policy by telephone if we have a
written telephone authorization on file. These include requests for transfers,
withdrawals, changes in premium allocation instructions, dollar-cost averaging
changes, and changes in portfolio rebalancing program. Our Home Office will
employ reasonable procedures to confirm that instructions communicated by
telephone are genuine. Such procedures may include, among others, requiring some
other form of personal identification prior to acting upon instructions received
by telephone, providing written confirmation of such transactions and/or tape
recording of telephone instructions. Your request for telephone transactions
authorizes us to record telephone calls. If reasonable procedures are not
employed, we may be liable for any losses due to unauthorized or fraudulent
instructions. If reasonable procedures are employed, we will not be liable for
any losses due to unauthorized or fraudulent instructions.
This authorization will continue in force until the earlier of a) the date we
receive a revocation request from the Owner, b) the date we restrict or
discontinue all Telephone Authorizations, or c) the date we receive an ownership
change.
YES NO
Do you elect to have telephone authorization? [_] [_]
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If space is insufficient, use additional sheets, which will be part of this application. Sheets must
19 EXPLANATIONS be signed & dated by Proposed Insured(s), and/or Applicant, and witnessed by Agent.
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QUESTION NAME OF PERSON NATURE AND SEVERITY OF CONDITION DATES NAMES & ADDRESSES OF
NUMBER FREQUENCY OF ATTACKS - TREATMENT RECEIVED ONSET RECOVERY MEDICAL ATTENDANTS AND HOSPITALS
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MO. YR. MO. YR.
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VARIABLE UNIVERSAL LIFE INSURANCE APPLICATION PAGE 4
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20 AGREEMENTS AND ACKNOWLEDGMENTS
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YES NO
a. Do you believe that this policy will meet your needs and financial [_] [_]
objectives?
b. Do you understand that the amount and duration of the death
benefit may vary, depending on the investment performance of the
variable accounts in the separate account? [_] [_]
c. Do you understand that the policy values may increase or
decrease, depending on the investment experience of the
separate account? [_] [_]
d. Did you receive the separate account prospectus and the
fund prospectus for the policy applied for? If yes, give
date shown on the prospectus: ________________________________ [_] [_]
e. Are you associated with an NASD member broker dealer? [_] [_]
Coverage will be effective as of the policy date if the following conditions
are met: the first premium is paid when the policy is delivered; the Proposed
Insureds are living on the delivery date; and, on that delivery date, the
information given to State Farm Life is true and complete without material
changes.
For changes in Basic Amount, the change will be effective on the deduction
date on or next following acceptance of the change by State Farm Life if on such
deduction date the following conditions are met; there is enough cash surrender
value to make the required deduction; the Proposed Insureds are all living; and
the information given to State Farm Life is true and complete without material
changes.
However, if a binding receipt has been given and is in effect, its terms
apply.
All Proposed Insureds and the Applicant state that the information in this
application and any medical history is true and complete. It is agreed that
State Farm Life can investigate the truth and completeness of such information
while the policy is contestable.
By accepting the policy, the Owner agrees to the beneficiaries named,
method of payment, and corrections made. No change in plan, amount, benefits, or
age at issue may be made on the application unless the Owner agrees in writing.
Only an authorized company officer may change the policy provisions. Neither the
agent nor a medical examiner may pass on insurability.
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Social Security or Tax Identification Number (TIN) Certification - By
signing this application, I certify under penalties of perjury that (1) the TIN
shown above is correct, and (2) that I am not subject to backup withholding
either because I have not been notified that I am subject to backup withholding
as a result of a failure to report all interest or dividends, or the Internal
Revenue Service has notified me that I am no longer subject to backup
withholding. (If you are subject to backup withholding, cross out item 2.) The
Internal Revenue Service does not require your consent to any provision of this
document other than the certifications required to avoid backup withholding.
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Any policy issued on this application will be owned by Proposed Insured 1 or
the Applicant, if other than Proposed Insured 1.
DATED ON________Month_______Day________YEAR______
Signature of Proposed Insured 1 X
---
NOT REQUIRED IF PROPOSED INSURED IS UNDER AGE 16
AT_________CITY________________STATE_____________
Signature of Proposed Insured 2 X
------------------------------------------
Signature of Agent as
Witness to all Signatures X
------------------------------------------------
Signature of Applicant X
---------------------------------------------------
Not required unless applicant is other than Proposed Insured 1. If a firm or
corporation is to be the owner, give its name and signature of authorized
officer.
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[LOGO OF STATE FARM LIFE INSURANCE COMPANY APPEARS HERE]
ACKNOWLEDGMENT
I have received the Notices and the Acknowledgment and Authorization.
AUTHORIZATION
I authorize any source having information about me or my children to give to
State Farm Life, its reinsurers, or its representatives all such information as
to health history, diagnosis, treatment, or prognosis with respect to any
physical or mental condition, and as to other non-medical information. "Source"
includes any doctor, hospital, clinic, U.S. Veterans Administration Hospital,
mental health facility, or any other medically related facility, MIB, Inc.,
insurance company, or consumer reporting agency. Any information obtained will
be used to determine eligibility for insurance. This information may be released
to another insurance company or MIB, Inc.; however, no MIB, Inc. information
will be released to a consumer reporting agency. This authorization is valid for
2 years. A photocopy is as valid as the original.
I elect to be interviewed if an investigative consumer report is prepared and
indicate this preference by a "checkmark" in the following box. [_]
DATE SIGNED
-----------------------------------
SIGNATURE OF
PROPOSED INSURED 1 X
----------------------------------------------------------
(PARENTS OR GUARDIAN SIGNATURE IF JUVENILE APPLICATION)
SIGNATURE OF
PROPOSED INSURED 2 X
----------------------------------------------------------
Maiden or Former Name
---------------------------------------------
Maiden or Former Name
---------------------------------------------
AGENT'S STATEMENT
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YES NO
1 Do you know the Proposed Insureds? [_] [_]
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2 Who is to pay premiums? (Full name and relationship
if other than Proposed Insureds)
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YES NO
3 Was a Binding Receipt issued? [_] [_]
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4 Indicate other State Farm insurance in family.
[_] Auto [_] Life [_] Fire [_] Health
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5 Is this policy a replacement or change of existing YES NO
insurance or annuities? (If yes, explain) [_] [_]
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6 Is State Farm Health YES NO
Insurance being applied for? [_] [_]
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7 Did you give Proposed Insureds the Notices YES NO
and the Acknowledgement and Authorization? [_] [_]
--------------------------------------------------------------------------------
8 Personal History Interview Telephone Information
DAYTIME
PHONE NO. ( ) -
-------------------------------
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9 If applicable, has an oral specimen YES NO
test been completed or an exam been [_] [_]
scheduled? (show date and physician or
paramedical facility)
--------------------------------------------------------------------------------
Agent's Code Stamp
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[LOGO OF STATE FARM LIFE BINDING RECEIPT
INSURANCE COMPANY APPEARS
HERE]
State Farm Life has received $___________. This money is part of the
application for life insurance on ___________________________ (Proposed Insured
1) and any others named in the application. Any check received must be honored
for payment when presented. Otherwise this Receipt is void.
As of the application date, life insurance and any additional benefits will be
payable according to the terms of the application and the policy applied for,
subject to the terms of this Receipt. No benefits are provided by this Receipt
unless Death or Total Disability results from an accident that occurs or an
illness that first manifests itself after the application date. THE TOTAL
INSURANCE BENEFIT FOR A PROPOSED INSURED UNDER THIS OR ANY OTHER RECEIPTS AND
APPLICATIONS WILL NOT EXCEED $300,000. IF THAT PROPOSED INSURED IS UNDER THE AGE
OF 15 DAYS AT DEATH, THE TOTAL INSURANCE BENEFIT WILL NOT EXCEED $3,000.
Coverage under this Receipt will end when the first of the following occurs:
(a) The application is approved; (b) Notice of disapproval of the application is
given; (c) 60 days have expired starting with the application date.
State Farm Life reserves the right to disapprove the application by (a)
offering to issue a policy other than as applied for, or (b) declining to issue
a policy. If the application is disapproved, the notice of disapproval will be
given to Proposed Insured 1 or to the Applicant, if other than Proposed Insured
1. The notice will be given either (a) in person to, or (b) by mailing it to the
last known address of Proposed Insured 1 or the Applicant. If mailed, coverage
will end upon mailing of that notice.
The money received will be refunded if (a) the policy is not accepted, or (b)
State Farm Life declines to issue a policy, or (c) the 60-day period has
expired.
There is no coverage under this Receipt if the application contains any
material misrepresentation.
NO AGENT OR COMPANY REPRESENTATIVE MAY WAIVE OR CHANGE THE ANSWER TO ANY
QUESTION IN THE APPLICATION OR CHANGE THE TERMS OF THIS RECEIPT.
· Enlarge/Download Table
DATE OF APPLICATION SIGNATURE OF AGENT X
-------------------------------- ----------------------------------
Note: Do not use this Receipt for a change on a Variable Universal Life policy.
---
See reverse side.
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[LOGO OF STATE FARM LIFE Detach and leave with Proposed Insured
INSURANCE COMPANY APPEARS HERE] when Application is written:
NOTICES
Notice of Information Practices
The life insurance application requests personal information about the persons
proposed for coverage. Occasionally, we may need to collect additional personal
information from other sources. All such personal information is treated as
confidential. In certain cases, however, that information might be disclosed to
others without authorization. A right of access and correction exists as to the
personal information we may collect. A more detailed notice, including a
description of our information practices and your rights, is available upon
request.
MIB, Inc. (Medical Information Bureau) Notice
Information regarding your insurability will be treated as confidential. State
Farm Life or its reinsurers may, however, make a brief report to MIB, Inc. This
is a non-profit membership organization of life insurance companies which
operates an information exchange on behalf of its members. If you apply to
another MIB, Inc., member company for life or health insurance coverage, or a
claim for benefits is submitted to such a company, MIB, Inc., upon request, will
supply such a company with the information it may have in its file.
Upon receipt of a request from you, MIB, Inc. will arrange disclosure of any
information it may have in your file. If you question the accuracy of
information in the MIB, Inc. file, you may contact MIB, Inc. and seek a
correction in accordance with the procedures set forth in the federal Fair
Credit Reporting Act. The address of the MIB, Inc. information office is Post
Office Box 105, Essex Station, Boston, Massachusetts 02112, telephone number
(617) 426-3660.
State Farm Life or its reinsurers, may also release information in its file to
other life insurance companies to whom you may apply for life or health
insurance, or to whom a claim for benefits may be submitted.
| EX-1.A.(10) | Last "Page" of 7 | TOC | 1st | Previous | Next | Bottom | Just 7th |
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BINDING RECEIPT
(USE ONLY FOR A CHANGE. "CHANGE" INCLUDES AN INCREASE IN BASIC AMOUNT OR THE
ADDITION OF AN ADDITIONAL INSURED'S LEVEL TERM RIDER, A CHILDREN'S TERM RIDER,
OR AN ACCIDENTAL DEATH BENEFIT RIDER.)
State Farm Life has received funds as part of the application for life
insurance on _____________ (Proposed Insured 1) and any others named in the
application. "Funds" means (a) the receipt of money or (b) collection of a
deduction on the application date, as applicable. If the application date is a
deduction date, the required deduction will be made as of that date. If the
application date is not the deduction date, the required deduction will be
prorated from the application date to the next deduction date. There must be
enough cash surrender value to make the required deduction and any check
received must be honored for payment when presented. Otherwise this Receipt is
void.
As of the application date, life insurance and any additional benefits will
be payable according to the terms of the application and the policy applied for,
subject to the terms of this Receipt. No benefits are provided by this Receipt
unless Death or Total Disability results from an accident that occurs or an
illness that first manifests itself after the application date. THE TOTAL
INSURANCE BENEFIT FOR A PROPOSED INSURED UNDER THIS OR ANY OTHER RECEIPTS AND
APPLICATIONS WILL NOT EXCEED $300,000. IF THAT PROPOSED INSURED IS UNDER THE AGE
OF 15 DAYS AT DEATH, THE TOTAL INSURANCE BENEFIT WILL NOT EXCEED $3,000.
Coverage under this Receipt will end when the first of the following occurs:
(a) The application is approved; (b) Notice of disapproval of the application is
given; (c) 60 days have expired starting with the application date.
State Farm Life reserves the right to disapprove the application by (a)
offering to approve a change other than as applied for, or (b) declining to
approve a change applied for. If the application is disapproved, the notice of
disapproval will be given to Proposed Insured 1 or to the Applicant, if other
than Proposed Insured 1. The notice will be given either (a) in person to, or
(b) by mailing it to the last known address of Proposed Insured 1 or the
Applicant. If mailed, coverage will end upon mailing of that notice.
The funds will be refunded or recredited if (a) the change offered is not
accepted, or (b) State Farm Life declines to approve the change, or (c) the 60-
day period has expired.
There is no coverage under this Receipt if the application contains any
material misrepresentation.
NO AGENT OR COMPANY REPRESENTATIVE MAY WAIVE OR CHANGE THE ANSWER TO ANY
QUESTION IN THE APPLICATION OR CHANGE THE TERMS OF THIS RECEIPT.
· Enlarge/Download Table
Funds Received (If applicable): $ DATE OF APPLICATION SIGNATURE OF AGENT X
------------ ----------------- -------------------------
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Pre-Notice of Investigative Consumer Report
In accordance with the provisions of the federal Fair Credit Reporting Act, this
is to inform you that as a part of our procedure for processing your application
for life insurance, 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, except as may be related directly or indirectly to your
sexual orientation. You have the right to make a written request within a
reasonable period of time to receive additional detailed information about the
nature and scope of this investigation. You may also request to be interviewed
during the preparation of such a report and if an investigative consumer report
is prepared, you are entitled to request and receive a copy of the report.
ACKNOWLEDGMENT AND AUTHORIZATION
In connection with the application to State Farm Life for life insurance on your
life, you have signed the following Acknowledgment and Authorization.
Acknowledgment. I have received the Notices and the Acknowledgment and
Authorization.
Authorization. I authorize any source having information about me or my children
to give to State Farm Life, its reinsurers, or its representatives all such
information as to health history, diagnosis, treatment, or prognosis with
respect to any physical or mental condition, and as to other non-medical
information. "Source" includes any doctor, hospital, clinic, U.S. Veterans
Administration Hospital, mental health facility, or any other medically related
facility, MIB, Inc., insurance company, or consumer reporting agency. Any
information obtained will be used to determine eligibility for insurance. This
information may be released to another insurance company or MIB, Inc.; however,
no MIB, Inc. information will be released to a consumer reporting agency. This
authorization is valid for 2 years. A photocopy is as valid as the original.
Filing Submission - Alternative Formats (Word / Rich Text, HTML, Plain Text, SGML, XML, et al.)
Copyright © 2009 Fran Finnegan & Company. All Rights Reserved.
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