Life Conversion Checklist Template (Page 4 of 4) in pdf

B. SUITABILITY (Complete only if applying for Variable Life Insurance and submit allocation form(s) with this Application.)

1. Have you, the Proposed Insured(s) and the Owner, if other than the Proposed Insured(s), received a current

Prospectus for the policy applied for and have you had sufficient time to review it?

h Y h N

2. Do you understand that the amount and duration of the death benefit may increase or decrease depending on the

h Y h N

investment performance of funds in the Separate Account?

3. Do you understand that the cash values may increase or decrease depending on the investment performance of the

funds held in the Separate Account?

h Y h N

4. With this in mind, do you believe that the policy applied for is in accord with your insurance objective and your

h Y h N

anticipated financial needs?

CASH VALUES MAY INCREASE OR DECREASE IN ACCORDANCE WITH THE EXPERIENCE OF THE SEPARATE

ACCOUNT. THE DEATH BENEFIT MAY BE VARIABLE OR FIXED UNDER SPECIFIED CONDITIONS.

SERVICE OFFICE ENDORSEMENTS (For Company Use Only. We will attach additional documentation as needed.)

AGREEMENT AND ACKNOWLEDGEMENT

I, the Owner, certify my TIN or SSN as provided by me is correct. I also certify that I am not subject to backup withholding.

Each of the Undersigned declares that:

1. This Application consists of: a) Application for Conversion of Group Life Insurance; b) any amendments to the application(s) attached

thereto; and d) any supplements, all of which are required by the Company for the plan, amount and benefits applied for.

2. No agent, broker or medical examiner has the authority to make or modify any Company contract or to waive any of the Company’s requirements.

3. I HAVE READ, or have had read to me, the completed Application for Conversion of Group Life Insurance before signing below.

All statements and answers in this application are correctly recorded, and are full, complete and true. I confirm that upon receipt of

the contract I will review the answers recorded on the application. I will notify the Company immediately if any information in the

application is incorrect. Caution: If your answers on this application are incorrect or untrue, the Company may have the right to deny

benefits or rescind coverage under the policy and any riders attached to it.

4. I agree that with the acceptance of any policy issued on the life of the Proposed Insured, all rights under the Group Policy for such

person are relinquished.

5. Corrections, additions or changes to this application may be made by the Company. Any such changes will be shown under “Service

Office Endorsements”. Acceptance of a policy issued with such changes will constitute acceptance of the changes. No change will

be made in classification (including age at issue), plan, amount, or benefits unless agreed to in writing by the Applicant.

STATE DISCLOSURE AND SIGNATURE

Any person who, with intent to defraud or knowing that he/she is facilitating fraud against an insurer, submits an application or files a

claim containing a false or deceptive statement is guilty of insurance fraud.

To the best of my knowledge and belief, the answers given above are true and complete. I agree that: (a) this application, a copy of which

will be attached to the policy when issued, will be a part of the policy; (b) by acceptance of any policy issued on the life of the Proposed

Insured, all rights under the Group Policy for such person are relinquished; and (c) only an officer of the Company can make or alter a

contract of insurance or bind the Company in any way.

WHEN INSURANCE TAKES EFFECT. The Insurance applied for on any person to be insured will take effect on the 1st day of the

month following the termination of the group coverage if the first pre mium is paid during the conversion period and the lifetime of the

Proposed Insured. Upon timely receipt by the Company of the conversion application and first premium, coverage will be available to

the Owner(s) and/or any beneficiaries either under the group policy or the Company’s new policy/certificate, but not under both.

Signed in _________________________________________, this ___________ day of _______________________________

___________

(state)

(month)

(year)

Signature of Proposed Insured

Signature of Owner

(Parent or Guardian if under 14 years of age)

(If other than the Proposed Insured)

Signature of Licensed Agent, Broker or Registered Rep.

Printed Name of Licensed Agent, Broker or Registered Rep.

APPLICABLE TO VARIABLE LIFE ONLY: I have reviewed the Application, Supplements, New Account Form and allocation forms

and find the transaction suitable.

Signature of Registered Principal or Broker/Dealer

Printed Name of Registered Principal or Broker/Dealer

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Life Conversion Checklist Template Page 4

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