Life Insurance Change Request Form Instructions

Transcription

1 Life Insurance Change Request Form Instructions This document provides instructions for completing the Life Insurance Change Request Form (L-AP-CHG-2014). The form facilitates a range of processes with different paperwork requirements. The table below indicates which sections on the Life Insurance Change Request Form are mandatory for your case (highlighted in bold font on gold background) as well as additional documents (marked with a plus sign) that may be required. All changes require the completion and submission of an Agent s Certification. Inforce Policy Changes + For ALL changes involving additional underwriting, such as a face amount increase, rider add, rating improvement, etc. Sections 1, 2, Signatures and Section 7, Authorization and any required medical Part II + For Plan Changes (during the first 90 days) Sections 5 and 9;p + For EsG Splits resulting in 2 new individual policies (Policy Split Option) Section 9; If the company s risk is increased, also complete: Section 7, Authorization and any required medical Part II In addition, a regular Part 1 App is required for each Insured. If requesting a non 50/50 split: Section 7, Authorization and any required medical Part II for the Insured receiving the larger policy + For all other Splits Section 5 (with details on the new policies) and Section 9 + In addition, please see paragraph on page 2 regarding Section 11 Illustration. Notes: Adding a rider may require the completion of a separate disclosure statement. Unpaid Changes Sections 1, 2, Signatures and + For Plan Changes Section 5 Contractual Conversions & Exchanges (including PAL, VUL, UL Exchanges) Sections 1, 3, 5, 9, Signatures and + If adding a rider (or for other conversions that require underwriting) Section 7, Authorization and any required medical Part II + If the new policy is to be paid for from an existing Guardian policy Section 8 + In addition, please see paragraph on page 2 regarding Section 11 Illustration. Notes: You may be able to use the Express Conversion application in lieu of the Change Form depending on your situation. The Express Conversion application (generic form L-AP-CONV-2008) provides details on when that form can/cannot be used. If the policy is being paid using funds from an existing Guardian policy, please also complete form V167 ADMIN. L-AP-CHG-2014 Instructions Page 1

2 Exercise of Guaranteed Purchase Option/Guaranteed Insurability Option Sections 1, 4, 8, 9, Signatures and + If original policy IS NOT a UL or VUL policy Sections 5 + If original policy IS a UL or VUL policy Section 6d, if needed + If new policy is to include riders Section 7, Authorization and any required medical Part II + In addition, please see paragraph on page 2 regarding Section 11 Illustration. Universal Life/Variable Universal Life Changes Sections 1, 6, Signatures and + If face amount increases (not due to exercise of GIO) Section 7, Authorization and any required medical Part II + If changing death benefit from Option 1 to Option 2 Section 7, Authorization and any required medical Part II (only required for certain products) Reinstatement Sections 1, 7, 9, 10, Signatures, Authorization and any required medical Part II Note: Each Insured to be covered under the reinstated policy must complete this section on a separate form (e.g., EstateGuard). Policy Changes that Require Underwriting (Section 7): All changes that result in a higher face amount (not due to exercise of GIO) Addition of riders and benefits Rating improvements Change of Death Benefit Option from Option 1 to Option 2, depending on the product Plan change, if the company s risk is increased, especially Whole Life to Term Addition of Dividend Option Q (can only be added to a 2001 CSO policy on or after 2 nd anniversary) All reinstatements Illustrations (Section 11) If the use of this form may result in a new policy being issued, then this section may be needed. We strongly encourage the use of a signed illustration when applicable to the product in question. However, if one is not used and the product is not a Variable Life or Level Term product, then this section would be needed. L-AP-CHG-2014 Instructions Page 2

3 Customer Service Office THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA 3900 Burgess Place THE GUARDIAN INSURANCE & ANNUITY COMPANY, INC. Bethlehem, PA BERKSHIRE LIFE INSURANCE COMPANY OF AMERICA (Please check appropriate company. In this form, the Company is the insurer checked above.) LIFE INSURANCE CHANGE REQUEST FORM Please print. (Page 1 of 5) 1. General Information (Complete in ALL Cases.) Name of Insured: Policy Owner s Name: Agency Name/Code: _ Please complete Agent s Certification to provide Agent information and other information. 2. Changes to an Inforce Policy Insured s Date of Birth: Please indicate Policy Number(s) of the policy to which the requested change applies. Plan change* to: Redate* to: Add rider/benefit* Cancel rider/benefit Rating improvement request* Exercise Simplified Insurability Option* Increase Coverage* to: Reduce Coverage to: (For reductions in face amount, include instruction on how any release of cash value is to be handled. If not specific, release of cash value will be used to purchase Paid-Up Additions.) Correction of Age (Provide birth certificate.) Change Premium Mode Change Dividend Option* to: (Effective on next anniversary.) Place Policy on Nonforfeiture Option Other* (Explain below.) * Some policy changes may involve additional underwriting. Please complete Section 7 Personal History of the Insured, the Authorization and any required medical Part II for those changes. A detailed list of requests that require underwriting is provided on the instructions. 3. Conversions & Exchanges (a) Is the Insured currently totally disabled as defined in the Waiver of Premium Rider included in the policy? Yes No (If Yes, give details in Section 12 Remarks.) (b) Policies/Riders to be converted/exchanged: Description of Original Coverage Policy Number Full/Partial * Amount remaining in force (for partial conversion only) Full Partial Full Partial Full Partial Full Partial * If a partial exchange of a VUL or PAL policy is being requested, the Owner agrees that the Company may split the policy into 2 policies. One of the new policies will be exchanged in accordance with the Owner s request and the other policy will remain in force as a new VUL or PAL policy (depending on whether the original policy was VUL or PAL.) (c) Effective date of Conversion or Exchange: L-AP-CHG-2014 MI

4 LIFE INSURANCE CHANGE REQUEST FORM (Continued) (Page 2 of 5) 4. Guaranteed Purchase Option/Guaranteed Insurability Option Policy Number(s) Type of Option Date Amount Exercised Regular Alternate * Regular Alternate * Regular Alternate * * For Alternate Option Date, please indicate date of applicable event: and reason: Marriage Birth of Child(ren) Adoption of Child(ren) Other (Please identify.) 5. New Policy Information (for Conversions, Exchanges, GIO, etc.) When making a conversion, exchange, exercising a GIO option, or any other situation where a new policy is to be issued, use this Section to provide details about the new policy. New Policy Plan Face Amount Riders (Give type and, if applicable, amount. Also, complete any required Disclosure Statement.) Dividend Option Premium Mode * APL? Yes No (Default is Yes.) Death Benefit Option Planned Premium (UL/VUL) 7702 Test Owner Beneficiary Other Information * If adding this policy to an existing Bank Draft Authorization (GOM) arrangement, please provide existing policy number in Other information. 6. Universal Life/Variable Universal Life Changes (a) Face Amount Changes Policy Number Type of Change Amount of Face Change (Do not enter resulting face amount.) Increase Decrease $ Increase Decrease $ (b) Is the Insured currently totally disabled as defined in a disability Waiver benefit included in the policy? Yes No (If Yes, give details in Section 12 Remarks. Indicate the type of Waiver rider, e.g. Waiver of Monthly Deductions, Disability Benefit Rider, or both.) (c) If increasing the face amount, are you also requesting an increase in the Specified Amount under a Disability Benefit Rider? Yes Amount of Increase $ No (d) Change in Planned Premium (Can be done in conjunction with a face amount change, or separately.) New Planned Premium: New Premium Mode, if applicable: (e) Change in Death Benefit Option Change From: Option To: Option L-AP-CHG-2014 MI

5 LIFE INSURANCE CHANGE REQUEST FORM (Continued) (Page 3 of 5) 7. Personal History of the Insured Note that for requests that require underwriting on policies covering more than one person, a separate form is needed for each insured. 1. Please indicate the name(s) and address(es) of your physician(s). If none, so state. Name Address 2. Please provide information regarding the last time you consulted with each of the listed physicians. (a) Date and reason last consulted (b) What treatment or medication was given or recommended? 3. Height: ft. in. Weight: lbs. Weight change in the last 12 month Gain Loss lbs. Reason for change: If Yes to any of the following questions 4 through 18, give details in Section 12 Remarks unless a separate Supplement or Questionnaire is required. Yes No 4. Within the last 10 years, have you had, been treated for or received a consultation or counseling for: (a) Heart disease, stroke, chest pain, elevated blood pressure, heart murmur or any other disease or disorder of the heart or blood vessels?... (b) Respiratory disorder, kidney disorder, diabetes, mental or emotional problems, disorder of the liver or other gastrointestinal organs, cancer or tumor of any kind, anemia or other disorder of the blood, disorder of the nervous systems or disorder of the reproductive organs?... (c) Any condition not covered in (a) or (b) that required hospitalization or medical care? Are you currently receiving medical care or taking medication? Have you been advised within the last 5 years to have any diagnostic test, hospitalization, or surgery which has not been completed? Within the last 10 years, have you been diagnosed by or received treatment from a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS)? Within the last 10 years, have you used drugs other than as prescribed by a physician or had or been advised to have counseling or treatment for alcohol or drug use? (If Yes, complete ADU Supplement.) Has the proposed insured ever had life, disability, accident or medical insurance declined, postponed, modified, rated, cancelled or withdrawn a pending application, or had a renewal or reinstatement refused? Are you currently receiving, or within the last 10 years have you received or applied for, any disability benefits, including Worker s Compensation, Social Security Disability Insurance or any other form of disability insurance? Do you intend to reside outside of the U.S.? (If Yes, complete Foreign Travel and Residence Questionnaire.) Do you intend to travel outside of the U.S.? Within the last 10 years, have you had your driver s license suspended or revoked, or been convicted of DUI or DWI, or within the last 5 years, have you been charged with and/or convicted of any motor vehicle moving violations? (If Yes, details must include date of violation, description of violation and penalty.) Within the last 10 years, have you been convicted of, or pled guilty or no contest to, a felony, or is such a charge pending against you? Within the last 3 years have you flown as a licensed pilot, student pilot, or crew member in any type of aircraft, or do you intend to do so in the future? (If Yes, complete Aviation Supplement.) Within the last 3 years, have you participated in, or do you intend to participate in, any of the following activities: mountain climbing, rock climbing, scuba diving, hang gliding, parachuting, skydiving, or motor vehicle racing? (If Yes, complete Avocation Supplement.) Are you, or do you intend to become, a member of the armed forces, including the Reserves, or are you on alert? (If Yes, complete Military Status Questionnaire.) Have you ever used tobacco or any other nicotine product such as cigarettes, cigars, pipe, chewing tobacco, snuff, nicotine gum, nicotine patch, or electronic nicotine delivery device? (If Yes, complete chart below.)... Product Type(s) Date Last Used Frequency of Use 19. How much life insurance is in force or applied for on your life (not including this policy)? L-AP-CHG-2014 MI

6 LIFE INSURANCE CHANGE REQUEST FORM (Continued) (Page 4 of 5) 8. Replacement As a result of the proposed purchase of life insurance, have you (the Owner) done any of the following, or are you considering doing any of the following to any existing life insurance policy or annuity contract that you own: (a) Lapse, partial lapse, surrender, forfeit, assignment to an insurer, or termination of existing insurance? Yes No (b) Taking loans, withdrawals, or any other use of funds from your existing insurance (including a stoppage or reduction in premium payments) to pay the premiums on the new life insurance policy? Yes No IMPORTANT: If Yes to either of these questions, please complete the appropriate state replacement form(s). In addition, you must fully complete the information below for all policies for which you answered yes. Policy Number Issuing Company Name of Insured 9. Change of Ownership 1. Is there an intention that any group of investors will obtain any right, title, or interest in any policy issued on the life of the proposed insured as a result of this application? Yes No 2. Will you (the owner/applicant) borrow money to pay the premiums for this policy or have someone else pay these premiums in return for an assignment of policy values back to them? Yes No (If Yes to either of these questions, complete Statement of Owner Intent form.) 10. Reinstatement Note that for policies covering more than one person, a separate form is needed for each insured. Reinstatement of policy number which lapsed for non-payment of premium due on. The following amount is enclosed in payment of the costs to reinstate the policy. $. If Policy Owner answers Yes, give details in Section 12 Remarks. Has any person died who was ever insured under this policy or any rider attached to this policy? Remarks For remarks exceeding the space in this section, use Supplement to Application for Insurance form. Yes No L-AP-CHG-2014 MI

7 LIFE INSURANCE CHANGE REQUEST FORM (Continued) (Page 5 of 5) 12. Clarifications and Corrections (for Home Office or Customer Service Office Use Only) 13. Representations (Complete in ALL Cases) Those parties who sign below, agree that: 1. Approval by the Company of the changes requested shall be based upon this Life Insurance Change Request form, and on the statements and representations made herein and in any required Part II or other supplement forms, all of which shall be attached to the policy. 2. All of the statements that are part of the application are correctly recorded, and are complete and true to the best of the knowledge and belief of those persons who made them. 3. For any new insurance: any misrepresentation or omission, if found to be material, may adversely affect acceptance of the risk, claims payment or may lead to rescission of any policy or new coverage that is issued based on this application. 4. No agent, broker or medical examiner has any right to accept risks, make or change contracts, or to waive or modify any of the Company's rights or requirements. No information acquired by any Representative of the Company shall bind the Company unless it shall have been set out in writing in this application. 5. Changes or corrections made by the Company and noted in Section 13 of this form are ratified by the undersigned upon acceptance of the new policy or policy change. In those states where written consent is required by statute or State Insurance Department regulation for amendments as to plan, amount, classification, age at issue, or benefits, such changes will be made only with the Owner s written consent. 6. When a new policy is to be issued as a result of the requested policy change and no underwriting is required for the transaction, the new policy will take effect on the later of the policy date of the new policy or the date the first premium is paid. If the transaction does involve underwriting, then the portion of the new policy that was subject to underwriting will not take effect until the later of the policy date or the date the first premium is paid during the lifetime and prior to any change in health of the Proposed Insured. The policy date is the date from which premiums are calculated and become due. 7. For any new policy issued as a result of the requested change, by paying premiums on a basis more frequently than annually, the total premium payable during one year s time will be greater than if the premium were paid annually. That is, the cost of paying annualized periodic premiums will be more than the cost of paying one annual premium. 8. In the case of reinstatement: (a) that the reinstatement, if approved by the Company, shall be contestable to the same extent and for the same period of time as was the original policy, beginning from the effective date of this reinstatement; (b) that no reinstatement shall take effect unless and until this application is approved by the Company and payment of any overdue premiums have been made during the lifetime of any insureds covered under the reinstated policy; (c) that any payment taken in connection with this application shall be collected at the risk of and for the account of the payor. Any payment made shall remain the payor s property until the Company approves this application. If it is not approved, any payment made shall be returned to and accepted by the payor, without interest; and (d) upon reinstatement, no benefit shall be paid if the death of any insured occurred between the date of default of this policy and the effective date of reinstatement. Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and may also be subject to civil penalties. Signed by Owner at: on City and State mm/dd/yyyy Signature of Proposed Insured Signature of Additional Owner Witness (for applications taken by mail) L-AP-CHG-2014 MI Signature of Applicant/Owner if Other than Proposed Insured Signature of Assignee (if applicable) Check here if this form was taken by mail. If application is taken by mail, the signature of the agent does not attest to the signature of the Proposed Insured or Owner if Other than the Proposed Insured. Check here if this form was taken in person. I certify that I have taken this application in the presence of the Proposed Insured and Owner (if Other than the Proposed Insured), and that I have truly and accurately recorded on this application the information supplied by the Proposed Insured and Owner (if Other than the Proposed Insured). Signature of Licensed Agent Agent s Name License Number(s) State(s) where licensed

8 The Guardian Life Insurance Company of America The Guardian Insurance and Annuity Company, Inc. Administrative Office: 3900 Burgess Place Bethlehem, PA SUPPLEMENTAL IDENTIFICATION INFORMATION FOR OWNER, BENEFICIARY AND INSURED Please read these instructions carefully. Due to regulatory requirements, we request the following supplemental identification information for the beneficiary, owner and/or insured. The information we are requesting depends on which application type was used, as follows: If you completed the Regular Life Insurance Application (form L-AP-2011, or state variation thereof), please provide the address and phone number for each named beneficiary. Please ensure that you completed all other requested information on the application itself. If you completed the Juvenile Life Insurance Application (form JUV-AP-2006, or state variation thereof), please provide the address, phone number, Social Security Number and Date of Birth for each named beneficiary, as well as the phone number for the proposed insured. If you completed the Simplified Issue/Guaranteed Issue Life Insurance Application (form L-AP-SIGI-2008, or state variation thereof), please provide the address, phone number and Social Security Number for each named beneficiary. Also, if the policy is to be owned by an individual other than the proposed insured, please provide this individual s date of birth. If you completed the Pension Trust Life Insurance Application (form PT-AP-2011, or state variation thereof), please provide the address, phone number and Social Security Number for each named beneficiary. However, if the Trust is to be the beneficiary of the policy, you do not need this form. If you completed the Life Insurance Change Request Form (form L-AP-CHG-2005, or state variation thereof), and you are requesting a conversion or an exchange or you are exercising a GIO rider, please provide the address, phone number, Social Security Number and Date of Birth of each named beneficiary and also the Owner. If the Change form was completed for any other reason, you do not need this form. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ADDITIONAL INFORMATION FOR BENEFICIARIES (Please complete appropriate sections as described above) BENEFICIARY NAME ADDRESS PHONE NUMBER SSN DATE OF BIRTH SUPP ID INFO

9 ADDITIONAL INFORMATION FOR OWNER (Please complete appropriate sections as described on page 1) OWNER NAME ADDRESS PHONE NUMBER SSN DATE OF BIRTH ADDITIONAL INFORMATION FOR INSURED Please indicate phone number for Proposed Insured if Juvenile Application was completed SUPP ID INFO

10 Life Customer Service Office Disability Customer Service Office 3900 Burgess Place 700 South Street Bethlehem, PA Pittsfield, MA THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA THE GUARDIAN INSURANCE & ANNUITY COMPANY, INC. BERKSHIRE LIFE INSURANCE COMPANY OF AMERICA (Please check appropriate company(ies). Any insurer checked above is herein referred to as the Company. ) Authorization to Obtain and Release Information Name of Proposed Insured Date of Birth Address of Proposed Insured This Authorization Is Designed To Comply With The HIPAA Privacy Rule This Authorization applies to the Proposed Insured named above. It can only be signed by the Proposed Insured, or the parent or legal guardian of the Proposed Insured in the case of a minor under the age of 18. Investigative consumer report. I authorize the Company or its legal representatives to obtain or have prepared an investigative consumer report as described in the notice given to me. Medical Records and other information. I authorize any physician, medical or mental health professional, practitioner, hospital, clinic, other health facility, pharmacy, pharmacy benefit manager, consumer reporting agency, the Social Security Administration, MIB, Inc., insurance or reinsurance company, or employer or other organization, institution or person that has any records or knowledge of the Proposed Insured or his/her health to release any and all medical and non-medical information in its possession about the Proposed Insured, to the Company or its legal representatives. Medical information means all information in the possession of or derived from providers of health care regarding the medical history, pharmaceutical history, mental or physical condition, or treatment of the Proposed Insured. I understand that the information released could contain reference to or results of HIV Antibody (AIDS) testing, and may relate to the symptoms, evaluation, diagnosis, examination, treatment or prognosis of any mental or physical condition, including psychiatric, and psychological conditions, and drug or alcohol abuse. I agree that this authorization shall be valid for two years from the date shown below and that a copy of the authorization shall be as valid as the original. I agree that if I sign this authorization electronically, that it will be equally as effective and valid as if I signed the form through traditional means. I understand, however, that I am under no obligation to sign this document electronically. I know that I may revoke this authorization in writing, at any time, by sending a written request for revocation to the Guardian Corporate Secretary at 7 Hanover Square, New York, NY , or the Berkshire Corporate Secretary at 700 South Street, Pittsfield, MA I understand that a revocation is not effective to the extent that the Company and/or any of the entities listed above has already relied on this authorization, or to the extent that the Company has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that the Company or its legal representatives will use the information obtained by this authorization to determine eligibility for insurance or eligibility for benefits under an existing policy. I further understand that if I refuse to sign this authorization, the Company may not be able to process my application, or pay a claim in the case of coverage which is already in force. The Company or its legal representatives will not release any information obtained to any person or organization except to reinsurance companies, MIB, Inc., Innovative Underwriters Services (a subsidiary of The Guardian Life Insurance Company of America), or other persons or organizations performing business or legal services in connection with an application, claim, or as may be lawfully permitted or required, or as I may further authorize. I understand that any information disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal regulations governing privacy (such as the HIPAA Privacy Rule). I authorize the Company or its legal representatives to make a brief report of my personal health information to the MIB, Inc. I acknowledge that I have been given a copy of this authorization and also acknowledge receipt of the Notice of Insurance Information Practices, which includes the Fair Credit Reporting Act Pre-Notice, the Medical Information Bureau Pre-Notice, and Medical Records. Signed at this day of,. City and State Day Month Year Signature of Proposed Insured or Parent/Legal Guardian C-AUTH-2013 Witness Signature *IMNB *

11 AGENT S CERTIFICATION (Please Print) This Agent s Certification is to be used with the application for life insurance on the life of (Proposed Insured) for the application dated. Proposed Insured s Date of Birth:. 1. Is the sale of this product being made in conjunction with a specific corporate marketing initiative? Please check one of the following (select the most appropriate): No Marketing Initiative Business Resource Center Take Advantage/Rapid App CPA Referral DI to Life Program Other 2. a. Is there a current individual Disability Income or Long-Term Care application pending with Berkshire? Yes No b. Has an individual Disability Income or Long-Term Care application been submitted to Berkshire within the past 6 months? Yes No For a yes answer to either question, please provide the policy number and other details in the Remarks section. 3. How long have you known the Proposed Insured? Years; the Proposed Owner? Years 4. If Proposed Insured is not gainfully employed, indicate amount of insurance on premium payor s life and relationship to Proposed Insured. 5. If beneficiary is estate, explain in Remarks why, and who will ultimately receive the proceeds of the policy? 6. Do you have knowledge of any existing life insurance policy or annuity contract in force on the Proposed Insured? Yes No 7. Do you have knowledge or reason to believe that replacement of an existing life insurance policy or annuity may be involved by reason of this transaction? Yes No 8. Will the sale of this policy involve the use of Premium Financing? Yes No (If yes, please provide the name of the lending institution and other details in the Remarks section.) 9. a. Did every person signing this application communicate in English well enough to understand and answer each question in English? Yes No (If no, please answer questions 9b, 9c, and 9d) b. Who acted as interpreter? c. If English was not used as the primary language, which language and/or dialect(s) was the sales interview conducted in? d. For the purpose of completing any Personal Information Telephone Interview, the proposed insured can converse comfortably in: 10. Was a preliminary inquiry previously submitted to Underwriting in connection with this application? Yes No If yes, please indicate application (policy) number: 11. Is the premium for this policy to be paid by a person or entity other than the policyowner? Yes No If yes, please provide a letter of authorization (with all required signatures) and also indicate payor s Tax ID number. 12. Was this application signed and dated in a state other than the state in which the policyowner lives or works? Yes No (if yes, please provide details in Remarks) *IMNB * L-AP-AC-2004

12 13. Complete if Medical Examination necessary. Medical Requirements being submitted: Chest X-ray EKG Stress EKG Full Blood Saliva Urine Paramedical Exam Medical Exam Other 14. Remarks (and additional instructions): 15. Commissions Producer s Name Producer s Code Servicing Agent (Check 1) Producer s Social Security Number Percentage % % % % % % Unless this application was taken by mail as indicated in the Representations section, I certify that I have taken this application in the presence of the Proposed Insured (and Owner, if Other than the Proposed Insured, for Variable Life) and that I have truly and accurately recorded on this application the information supplied by the Proposed Insured. For all applications: The answers to all questions on this application are full, complete and true to the best of my knowledge and belief. I represent that, to the best of my knowledge and belief, the insurance being applied for is suitable for the Owner s insurance needs and financial objectives. I know nothing unfavorable about this risk which is not fully set forth in these papers. The writing agent or broker is duly appointed and licensed in the state in which this application was signed and for the product(s) proposed. Signed at: City and State on mm/dd/yyyy Type or print Agent s/dealer s name Signature of Soliciting Agent Signature of Approved Registered Principal (For Variable Life Only) Signature of General Agent