EXHIBIT 1.(10)(a)
VARIABLE UNIVERSAL LIFE APPLICATION
(Known in some states as Flexible
Premium Variable Life)
ABOUT THIS BOOKLET
Here's the life insurance application you requested. Before you begin, please
take a moment to read the step-by-step instructions below. If you have
questions and would like to speak to an Account Representative, please call
toll free 1-800-292-8444 (in San Antonio call 456-9050).
1. This booklet contains an application for USAA Life Insurance Company's
Variable Universal Life insurance policy. Please complete the entire
application and sign where indicated. If additional space is needed to
answer any question, please attach an extra sheet of paper.
2. Use the Guide opposite the questions as a "road map" to completing the
application.
3. In some cases, medical tests will be required. USAA Life will arrange
and pay for the tests.
4. To take advantage of our Automatic Payment Plan for premium payments,
complete the authorization form enclosed in your packet and attach a
check marked "VOID" to the form.
5. RETURN THIS BOOKLET INTACT along with any required premium payment in
the enclosed postage-paid envelope. If the insurance you're applying
for, plus any other insurance you have with USAA Life, exceeds $500,000,
do NOT send the premium payment with your application. We will bill you
when your application is approved.
USAA
LIFE
INSURANCE
COMPANY [LOGO]
31345-0198
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VARIABLE UNIVERSAL LIFE - PART I - GUIDE
1 PROPOSED INSURED
Annual income is NOT required if the applicant is a dependent child.
2 POLICYOWNER
Only the Policyowner can exercise policy rights. If the Proposed Insured is a
minor, an adult must be named as the Policyowner. If a business is named as
the Policyowner, indicate the name of business.
After the policy is issued, a Business Authorization Form will be sent to you.
If the Policyowner is other than the Proposed Insured, we recommend that a
Successor Owner be named in Section 20, Special Requests, under Personal
Profile Part II.
Generally, it is advisable to name the Proposed Insured as the Successor Owner
unless federal estate tax is a consideration OR the Proposed Insured is a
minor.
3 PAYOR
If the premiums for the policy will be paid by someone other than the
Policyowner, please complete this section.
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VARIABLE UNIVERSAL LIFE ~ PART I ~ APPLICATION
1 PROPOSED INSURED (PLEASE PRINT OR TYPE)
NAME: FIRST MIDDLE LAST BIRTH DATE: MO DAY YR AGE
____________________________________________ ______________________ ____
BIRTHPLACE (STATE) SEX: [ ] M [ ] F
SOCIAL SECURITY NUMBER _____________________
USAA NUMBER (IF ANY) _______________________
DRIVER'S LICENSE NUMBER AND STATE OF ISSUE ________________________
EMPLOYER/SOURCE OF INCOME __________________
OCCUPATION / DUTIES ________________________
ANNUAL INCOME $___________________________
MILITARY STATUS:
[ ] ACTIVE DUTY [ ] RETIRED [ ] ACTIVE RESERVE [ ] INACTIVE RESERVE
[ ] SEPARATED [ ] PRECOMMISSIONED [ ] NONE
BRANCH OF SERVICE/GOVT AGENCY MILITARY RANK
_____________________________ _____________
RESIDENCE PHONE EXT. BUSINESS PHONE EXT.
(___)_______________ _______ (___)_______________ _______
RESIDENCE ADDRESS: NUMBER & STREET CITY STATE ZIP
____________________________________________________________________________
YEARS THERE
______________
BUSINESS ADDRESS: NUMBER & STREET CITY STATE ZIP
____________________________________________________________________________
YEARS EMPLOYED
______________________
HAVE YOU OR YOUR SPOUSE EVER BEEN AN OFFICER IN THE U.S. ARMED FORCES?
[ ] YES [ ] NO
HAVE EITHER OF YOUR PARENTS OR YOUR SPOUSE'S PARENTS EVER BEEN
AN OFFICER IN THE U.S. ARMED FORCES? [ ] YES [ ] NO
2 POLICYOWNER (COMPLETE ONLY IF THE POLICYOWNER IS OTHER THAN THE PROPOSED
INSURED OR IF THE PROPOSED INSURED IS UNDER AGE 15)
RANK/TITLE NAME: FIRST MIDDLE LAST
____________________________________________________________________________
RELATIONSHIP TO INSURED SSN/TAX ID NO.
____________________________________________________________________________
ADDRESS: NUMBER & STREET CITY STATE ZIP
____________________________________________________________________________
RESIDENCE PHONE EXT. BUSINESS PHONE EXT.
(___)_______________ _______ (___)_______________ _______
BIRTH MO DAY YR
DATE: __/__/__ USAA NUMBER (IF ANY) ____________
POLICY SENT TO POLICYOWNER UNLESS OTHERWISE REQUESTED.[ ] INSURED [ ] OTHER
IF OTHER, PLEASE COMPLETE THE FOLLOWING:
NAME: FIRST MIDDLE LAST
____________________________________________________________________________
ADDRESS: NUMBER & STREET CITY STATE ZIP
____________________________________________________________________________
YEARS THERE
_______________
3 PAYOR (COMPLETE ONLY IF PAYOR IS OTHER THAN POLICYOWNER)
NAME: FIRST MIDDLE LAST
____________________________________________________________________________
RELATIONSHIP TO INSURED
____________________________________________________________________________
SSN/TAX ID NO.
____________________________________________________________________________
ADDRESS: NUMBER & STREET CITY STATE ZIP
____________________________________________________________________________
YEARS THERE
____________
RESIDENCE PHONE EXT. BUSINESS PHONE EXT.
(___)_______________ _______ (___)_______________ _______
BIRTH MO DAY YR
DATE: __/__/__ USAA NUMBER (IF ANY) ____________
PREMIUM NOTICES SENT TO POLICYOWNER UNLESS OTHERWISE REQUESTED.
VULXXXXST 1-98
TURN TO NEXT PAGE.
USAA LIFE INSURANCE COMPANY
9800 FREDERICKSBURG ROAD
SAN ANTONIO, TEXAS 78288
31345-0198
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4 POLICY AMOUNT AND OPTIONAL BENEFITS
SELECT OPTION-Option A and/or Option B are mentioned in the enclosed
illustration. Be sure to write in the SPECIFIED AMOUNT OF INSURANCE. Then
decide which OPTIONAL BENEFITS you want. Each of the options carries an
additional premium.
WAIVER OF MONTHLY DEDUCTION - If you suffer an accident or illness that
results in a covered disability; this option guarantees that your cost of
insurance will be paid for you during the period of your disability. The
premium for this benefit varies based on the age of the Proposed Insured.
ACCIDENTAL DEATH BENEFIT (ADB) - If you die as a result of a covered accident,
this option will pay your beneficiary an ADDITIONAL amount above the face
amount you have selected for the policy. The selected ADB can be up to a
maximum of $200,000, or the face amount of the policy, whichever is less. The
premium for ADB is $.84 per $1,000 of coverage per year.
CHILD RIDER - An easy way to provide coverage for your child(ren), this rider
is available in $1,000 increments from $2,000 to a maximum of $25,000. The
cost for this rider is $6 per $1,000 of coverage per year. Premiums remain the
same, regardless of the number of children covered. The Proposed Insured under
the basic policy must be age 20 through 55 to select the Child Rider option.
If you select the Child Rider option, you must complete Sections 13-19 of the
Personal Profile.
5 PREMIUM AMOUNT AND METHOD OF PAYMENT
PREMIUM AMOUNT - Write in your Planned Periodic Premium for the amount of
insurance and Optional Benefits you selected in Section 4. (See the enclosed
illustration for the premiums.) If you select the Automatic Payment Plan,
enclose a check for two months' premium. If you select any other method of
payment, enclose one full payment for the payment interval selected. (Please
make checks payable to USAA Life Insurance Company.)
METHOD OF PAYMENT - Select the method by which you want to make your premium
payments.
AUTOMATIC PAYMENT PLAN. We suggest that you use our Automatic Payment Plan.
This is an efficient and economical monthly payment system that authorizes
USAA Life to automatically withdraw your premium payment on the date of your
choice from your bank account. Complete and return the authorization form
enclosed in your packet.
MONTHLY GOVERNMENT ALLOTMENT. If you are eligible, you may elect to pay your
premiums by Monthly Government Allotment. With this method, your contract
premium amount is deducted at the end of the month in which the salary is
earned. We'll provide additional instructions after your policy is issued.
DIRECT BILLING. If you choose this method, please also select a payment
frequency. You can choose between an annual, semi-annual or quarterly direct
premium payment plan.
SINGLE PREMIUM. Single Premium means you have no plans for future premium
payments.
NOTE: IF THE INSURANCE YOU'RE APPLYING FOR, PLUS ANY OTHER INSURANCE YOU NOW
HAVE WITH USAA LIFE, EXCEEDS $500,000, DO NOT SEND THE PREMIUM WITH YOUR
APPLICATION. WE WILL BILL YOU WHEN YOUR APPLICATION IS APPROVED.
1035 EXCHANGE If you intend to cancel an existing policy and transfer the cash
surrender value to the policy applied for in this application, then fill in
the amount of exchange and the company name of the policy. You should complete
a separate 1035 Exchange form and send it and your old policy with your
application.
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4 POLICY AMOUNT AND OPTIONAL BENEFITS
PLAN NAME: VARIABLE UNIVERSAL LIFE (KNOWN AS FLEXIBLE PREMIUM VARIABLE LIFE IN
GA, IL, IN, MD, PA, TN, VA, AND DC.) SPECIFIED AMOUNT OF INSURANCE ($100,000
MINIMUM) $_______________
SELECT OPTION
(CHECK ONLY ONE): [ ] OPTION A [ ] OPTION B
Provides fixed death Provides fixed
benefit protection insurance protection
plus your cash
value as total death benefit
OPTIONAL BENEFITS: CHECK THE BENEFITS YOU ARE REQUESTING AND
FILL IN AMOUNT IF APPLICABLE.
[ ] WAIVER OF MONTHLY DEDUCTION (Not available if Proposed Insured is under
age 15 or over age 55: not available in New York).
[ ] ACCIDENTAL DEATH BENEFIT (ADB) (Not available if Proposed Insured is
under age 10 or over age 60) $___________
[ ] CHILD RIDER (Only available if Proposed Insured is age 20 through 55 and
child is age 17 or under; not available for residents of Hawaii)
$____________
[ ] OTHER _________________________________
5 PREMIUM AMOUNT AND METHOD OF PAYMENT
INITIAL PREMIUM PAYMENT AMOUNT $__________
PLANNED PERIODIC PREMIUMS $_________
METHOD OF PAYMENT
(SELECT ONLY ONE)
[ ] AUTOMATIC PAYMENT PLAN (MONTHLY) $ ______________ You must complete and
return the enclosed authorization form with this application. Please
include a voided check from your financial institution.
[ ] MONTHLY GOVERNMENT ALLOTMENT $ ______________
[ ] DIRECT BILLING $ ______________
[ ] ANNUALLY $ ______________
[ ] SEMI-ANNUALLY $ ______________
[ ] QUARTERLY $ ______________
[ ] SINGLE PREMIUM $ ______________
PLEASE ENCLOSE A CHECK
FOR THE INITIAL PREMIUM PAYMENT AMOUNT
WITH YOUR COMPLETED APPLICATION.
If the amount of insurance you're applying for, plus any other life
insurance you have with USAA Life, exceeds $500,000, do NOT send the
premium.
1035 EXCHANGE $____________ FROM
________________________
(NAME OF COMPANY)
VULXXXXST 1-98
USAA LIFE INSURANCE COMPANY
9800 FREDERICKSBURG ROAD
SAN ANTONIO, TEXAS 78288
31345-0198
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6 INVESTMENT ALLOCATION
Provide the desired percent allocation of the initial premium payment you
request next to your selected accounts. If you are allocating your premium
payment to variable fund accounts other than the Money Market Variable Fund
Account, that portion of your premium payment will be allocated to the Money
Market Variable Fund Account for a period equal to the FREE LOOK PERIOD stated
in your policy plus five days. At the end of the period, the premium payments
will be allocated as directed in this application and as explained in more
detail in the prospectus. If you decide to return the policy within the FREE
LOOK PERIOD, USAA Life will refund your money as explained in the policy.
7 INVESTMENT SUITABILITY INFORMATION
These questions are intended to help you determine your Investment Objectives
and Risk Tolerance. This information helps us determine the suitability of
this policy for your needs.
Please complete all of this information to the best of your ability. Enter a
number from 1-4 in the space provided (with 1 as the highest) to rate the
priority of your Investment Objectives and Risk Tolerance. Below this,
complete the information based on the Policyowner's income and net worth.
8 TOBACCO USE
Please answer questions regarding your tobacco use.
NOTE: TOBACCO USE QUESTION A SHOULD BE ANSWERED "YES" IF THE PROPOSED
INSURED HAS USED ANY TOBACCO PRODUCTS OR NICOTINE SUBSTITUTES (E.G.,
NICOTINE PATCH OR GUM) IN THE PAST 12 MONTHS.
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6 INVESTMENT ALLOCATION
You may allocate your premium payment to as many of the variable fund
accounts as you like, in amounts no smaller than one tenth of a percent, as
long as the total equals 100%.
USAA LIFE:
_____ % Growth & Income
_____ % World Growth
_____ % Aggressive Growth
_____ % Diversified Assets
_____ % International
_____ % Income
_____ % Money Market
_____ % Alger American Growth
_____ % Scudder VLIF Capital Growth
_____ % Bankers Trust Equity 500 Index
_____ % Bankers Trust Small Cap Index
_____ % Bankers Trust EAFE (R) Index
100% TOTAL
7 INVESTMENT SUITABILITY INFORMATION (TO BE COMPLETED BY POLICYOWNER)
INVESTMENT OBJECTIVES Enter a priority rating from 1-4 (with 1 as highest).
_____ Long-term gain
_____ Short-term gain
_____ Income
_____ Tax advantaged
RISK TOLERANCE
Check one.
______ Aggressive
______ Moderate
______ Conservative
INVESTMENT TIME HORIZON
[ ] 1-10 years [ ] 10-20 years [ ] 20+ years
Annual income from occupation $_______
Annual income from other sources $_______
Projected income for next 12 months $_______
Estimated net worth (excluding home) $_______
Tax bracket _____
List sources of income ________________
8 TOBACCO USE (PLEASE LIST DETAILS FOR EACH "YES" ANSWER IN THE SPACE
PROVIDED BELOW)
A. Has the Proposed Insured smoked one or more cigarettes in the last 12
months? [ ] Yes [ ] No
B. Has the Proposed Insured used any other form of tobacco or tobacco
surrogate in the last 12 months? [ ]Yes [ ] No
C. Has the Proposed Insured ever used any form of tobacco? [ ]Yes [ ]No
TYPE AVERAGE DAILY USAGE DATE LAST USED
________ ___________________ _______________
TYPE AVERAGE DAILY USAGE DATE LAST USED
________ ___________________ _______________
TYPE AVERAGE DAILY USAGE DATE LAST USED
________ ___________________ _______________
TYPE AVERAGE DAILY USAGE DATE LAST USED
________ ___________________ _______________
NOW, COMPLETE THE PERSONAL PROFILE SECTION.
VULXXXXST 1-98
USAA LIFE INSURANCE COMPANY
9800 FREDERICKSBURG ROAD
SAN ANTONIO, TEXAS 78288
31345-0198
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PERSONAL PROFILE - PART I - GUIDE
9 PURPOSE OF INSURANCE
Please check the appropriate box for Purpose of Insurance. Purpose of
Insurance includes two broad areas -- personal and business.
PERSONAL INSURANCE INCLUDES: FAMILY PROTECTION, which protects against the
loss of your future income; ESTATE LIQUIDITY, which protects against the
forced sale of your estate to pay estate taxes; DEBT PROTECTION, to pay
specific debt balances.
BUSINESS INSURANCE INCLUDES: KEY PERSON, which protects a business from loss
of revenue due to the death of a key person; BUY/SELL AGREEMENT, which
provides funding to settle a deceased partner's business interest.
IF THE PURPOSE FOR THIS INSURANCE IS NOT LISTED, please check "Other" and
indicate the purpose in the space provided.
10 BENEFICIARY DESIGNATION
Please write in the full name and address of each beneficiary. If you wish to
name a trust as beneficiary, please indicate whether it is an intervivos
(living) trust or a testamentary trust established by your will. If it is an
intervivos trust, please include the date it was written, grantor's name, and
the name and address of the trustee.
PRIMARY BENEFICIARY - This is the person, persons, or trust to receive the
proceeds from the policy at the insured's death.
CONTINGENT BENEFICIARY - The person, persons, or trust to receive the proceeds
if the primary beneficiary does not survive the insured. If more than one
person is named as primary or contingent beneficiary, the proceeds will be
divided equally unless otherwise directed.
NOTE: WHEN YOU NAME A BENEFICIARY, PLEASE INCLUDE NAME, ADDRESS, RELATIONSHIP,
AND SOCIAL SECURITY OR TAX IDENTIFICATION NUMBER INFORMATION.
11 LIFE INSURANCE NOW IN FORCE (OR APPLIED FOR ON THE LIFE OF PROPOSED
INSURED NAMED IN PART I)
COMPLETE NAME OF COMPANY - Please list all policies currently in force or
applied for on the life of the individual to be insured. If none, so indicate.
TYPE OF PLAN AND COVERAGE - Please indicate type of plan and coverage type
(e.g., personal, business, group) for each policy listed.
ACCIDENTAL DEATH BENEFIT - If any of these policies have an Accidental Death
Benefit, fill in the dollar amount.
12 REPLACEMENT
If you are replacing a policy, please provide the following information:. name
of company, amount of policy, effective date of policy, and policy number.
NOTE: IF YOU ARE REPLACING A POLICY THAT HAS SUBSTANTIAL CASH AVAILABLE, YOU
MAY BE CREATING A TAXABLE SITUATION. TAX RULES MAY ALLOW YOU TO DEFER THIS
TAXABLE GAIN WHEN BUYING ANOTHER POLICY. SPECIAL FORMS ARE REQUIRED IN SUCH
SITUATIONS, SO PLEASE CALL FOR ASSISTANCE.
HAWAII RESIDENTS: IF YOU CHECK "YES" FOR REPLACEMENT, state law requires that
you send your policy to USAA Life Insurance Company for comparison.
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PERSONAL PROFILE ~ PART I
9 PURPOSE OF INSURANCE
[ ] FAMILY PROTECTION [ ] KEY PERSON
[ ] ESTATE LIQUIDITY [ ] BUY/SELL AGREEMENT
[ ] DEBT PROTECTION [ ] OTHER
10 BENEFICIARY DESIGNATION (ATTACH A SEPARATE SHEET IF MORE SPACE IS
REQUIRED)
NAME OF PRIMARY BENEFICIARY(IES): FIRST MIDDLE LAST
_____________________________________________________________________________
RELATIONSHIP TO INSURED BIRTH DATE: MO DAY YR SSN / TAX ID NUMBER
_________________________________________/___/_______________________________
ADDRESS: NUMBER & STREET CITY STATE ZIP
____________________________________________________________________________
NAME OF CONTINGENT BENEFICIARY(IES): FIRST MIDDLE LAST
_____________________________________________________________________________
RELATIONSHIP TO INSURED BIRTH DATE: MO DAY YR SSN / TAX ID NUMBER
_________________________________________/___/____________________________
ADDRESS: NUMBER & STREET CITY STATE ZIP
____________________________________________________________________________
IF THERE ARE NO SURVIVING BENEFICIARIES, THE PROCEEDS ARE PAID TO THE OWNER
OR, IF THE OWNER IS DECEASED, TO THE OWNER'S ESTATE. IF A BENEFICIARY
DESIGNATED IS A TRUST PLEASE PROVIDE THE TRUST NAME, GRANTOR'S NAME, TRUST
DATE, TRUSTEE INFORMATION AND TRUST TAX IDENTIFICATION NUMBER.
11 LIFE INSURANCE NOW IN FORCE (OR APPLIED FOR ON THE LIFE OF PROPOSED
INSURED NAMED IN PART I)
1. NAME OF COMPANY POLICY NUMBER YR ISSUED TYPE PLAN
___________________________________________________________________
COVERAGE TYPE AMOUNT ACCIDENTAL DEATH BENEFIT
___________________________________________________________________
2. NAME OF COMPANY POLICY NUMBER YR ISSUED TYPE PLAN
___________________________________________________________________
COVERAGE TYPE AMOUNT ACCIDENTAL DEATH BENEFIT
___________________________________________________________________
3. NAME OF COMPANY POLICY NUMBER YR ISSUED TYPE PLAN
___________________________________________________________________
COVERAGE TYPE AMOUNT ACCIDENTAL DEATH BENEFIT
___________________________________________________________________
12 REPLACEMENT
Is this application for insurance intended to replace or modify any life
insurance now in force on the life of any Proposed Insured? (This
information is required by state regulations.) [ ] Yes [ ]No
IF YES, PLEASE LIST EACH POLICY TO BE REPLACED.
_____________________________________________________________________________
COMPANY AMOUNT ISSUE DATE POLICY NUMBER
_____________________________________________________________________________
COMPANY AMOUNT ISSUE DATE POLICY NUMBER
TURN TO NEXT PAGE
VULXXXXST 1-98
USAA LIFE INSURANCE COMPANY
9800 FREDERICKSBURG ROAD
SAN ANTONIO, TEXAS 78288
31345-0198
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13 CHILD RIDER (AVAILABLE FOR CHILDREN AGE 17 AND UNDER; NOT AVAILABLE IN
HAWAII)
Complete this section if you are requesting Child Rider coverage on your
policy. Complete questions about children in Section 18 of Part II,
Statement of Health. Family members who are not listed will not be covered.
NOTE: UNLESS OTHERWISE DESIGNATED UNDER SECTION 20, SPECIAL REQUESTS, THE
BENEFICIARY FOR THIS INSURANCE WILL BE THE PROPOSED INSURED UNDER THE BASIC
POLICY.
14 AVOCATION
Complete this section for all persons to be covered under the basic policy
and Child Rider.
Please give details regarding the type of activity and frequency of
participation.
15 FOREIGN RESIDENCE / TRAVEL
Complete this section for all persons to be covered under the basic policy
and Child Rider.
This question applies to active duty personnel as well as to civilians. Do
not include vacation travel of 30 days or less to Europe, Canada, Mexico, or
Japan.
16 AVIATION
Complete this section for all persons to be covered under the basic policy
and Child Rider.
Please give details regarding type of aircraft, FAA certificate type(s), and
hours flown.
17 DRIVING HISTORY
Complete this section for all persons to be covered under the basic policy
and Child Rider.
Please provide details regarding driving history for the past five years.
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13 CHILD RIDER (ATTACH A SEPARATE SHEET IF MORE SPACE IS REQUIRED)
IF COVERAGE IS NOT REQUIRED, PROCEED TO THE NEXT QUESTION.
1. CHILD'S NAME SEX: [ ]M [ ]F BIRTH DATE: MO DAY YR
_________________________________________________________________
SOCIAL SECURITY NUMBER HEIGHT (FT/IN) WEIGHT (LBS)
_________________________________________________________________
AMOUNT OF LIFE INSURANCE NOW IN FORCE
_________________________________________________________________
2. CHILD'S NAME SEX: [ ]M [ ]F BIRTH DATE: MO DAY YR
_________________________________________________________________
SOCIAL SECURITY NUMBER HEIGHT (FT/IN) WEIGHT (LBS)
_________________________________________________________________
AMOUNT OF LIFE INSURANCE NOW IN FORCE
_________________________________________________________________
3. CHILD'S NAME SEX: [ ]M [ ]F BIRTH DATE: MO DAY YR
_________________________________________________________________
SOCIAL SECURITY NUMBER HEIGHT (FT/IN) WEIGHT (LBS)
_________________________________________________________________
AMOUNT OF LIFE INSURANCE NOW IN FORCE
_________________________________________________________________
14 AVOCATION
Has any Proposed Insured ever participated in or does any Proposed Insured
plan to participate in (within the next 12 months) any of the following:
[ ] Yes [ ] No
IF YES, CHECK ALL THAT APPLY AND PROVIDE DETAILS BELOW.
[ ] AUTOMOBILE RACING
[ ] SKYDIVING
[ ] ROCK OR MOUNTAIN CLIMBING
[ ] POWERBOAT RACING
[ ] ULTRALIGHT FLYING
[ ] MOTORCYCLE RACING
[ ] HANG GLIDING
[ ] SCUBA DIVING
[ ] BALLOONING
PROPOSED INSURED AVOCATION TIMES PER MONTH
___________________________________________________
DETAILS (SPEEDS ATTAINED, DEPTHS/HEIGHTS REACHED, ETC.)
________________________________________________________
PROPOSED INSURED AVOCATION TIMES PER MONTH
___________________________________________________
DETAILS (SPEEDS ATTAINED, DEPTHS/HEIGHTS REACHED, ETC.)
________________________________________________________
15 FOREIGN RESIDENCE / TRAVEL
Do any of the Proposed Insureds plan to travel to or reside in a foreign
country within the next 12 months? [ ] Yes [ ] No
IF YES, PROVIDE DETAILS AS INDICATED BELOW.
_____________________________________________________________________________
PROPOSED INSURED COUNTRY NAME PURPOSE OF VISIT LENGTH OF STAY
_____________________________________________________________________________
PROPOSED INSURED COUNTRY NAME PURPOSE OF VISIT LENGTH OF STAY
16. AVIATION
Has any Proposed Insured ever flown or does any Proposed Insured plan to fly
in the next 24 months as a pilot, crew member, student, or in any capacity
other than as a passenger? [ ] Yes [ ] No
IF YES, COMPLETE THE FOLLOWING.
ACTIVE DUTY OR RESERVE BRANCH OF SERVICE MAJOR COMMAND (AMC,
ACC, etc.)
____________________________________________________________________________
TYPE(S) OF AIRCRAFT [ ] PILOT [ ] CREW MEMBER
____________________________________________________________________________
HOURS FLOWN: NEXT 12 MOS. LAST 12 MOS. 13-24 MOS. AGO
____________________________________________________________________________
COMMERCIAL
____________________________________________________________________________
TYPE(S) OF AIRCRAFT [ ] PILOT [ ] CREW MEMBER
____________________________________________________________________________
HOURS FLOWN: NEXT 12 MOS. LAST 12 MOS. 13-24 MOS. AGO
____________________________________________________________________________
CIVILIAN PLEASURE
____________________________________________________________________________
TYPE(S) OF AIRCRAFT [ ] PILOT [ ] CREW MEMBER
____________________________________________________________________________
HOURS FLOWN: NEXT 12 MOS. LAST 12 MOS. 13-24 MOS. AGO
____________________________________________________________________________
TOTAL HOURS FLOWN WHILE IN CHARGE OF AN AIRCRAFT: _____ MILITARY _____CIVILIAN
If aviation participation requires a restriction for the base policy, which do
you prefer?
[ ] Pay additional premium [ ] Have policy contain an Aviation Exclusion
except when traveling as a passenger
NOTE: THE ABOVE OPTIONS DO NOT APPLY TO THE ACCIDENTAL DEATH BENEFIT. THE
AVIATION EXCLUSION FOR THAT BENEFIT CANNOT BE WAIVED.
17 DRIVING HISTORY
Within the last five years, has any Proposed Insured been convicted of
Driving While Intoxicated, Driving Under the Influence, two or more moving
violations, or had a driver's license suspended or revoked? [ ] Yes [ ] No
IF YES, PROVIDE DETAILS AS INDICATED BELOW.
____________________________________________________________________________
PROPOSED INSURED DATE VIOLATION TYPE DETAILS (SPEED, LENGTH OF
SUSPENSION/REVOCATION, ETC.)
____________________________________________________________________________
PROPOSED INSURED DATE VIOLATION TYPE DETAILS (SPEED, LENGTH OF
SUSPENSION/REVOCATION, ETC.)
TURN TO NEXT PAGE.
VULXXXXST 1-98
USAA LIFE INSURANCE COMPANY
9800 FREDERICKSBURG ROAD
SAN ANTONIO, TEXAS 78288
31345-0198
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PERSONAL PROFILE - PART II GUIDE
18 STATEMENT OF HEALTH
Complete this section for all persons to be covered under the basic policy and
Child Rider.
Depending upon your age, the amount of coverage for which you are applying,
and your health history, certain medical tests will need to be performed to
underwrite your insurance. USAA Life will have a paramedical service contact
you to schedule the appointment.
We will pay for anything we request. If you would like to expedite the
process, please call your Account Representative.
ATTENTION APO/FPO:
You will not be contacted by a paramedical service. If tests or exams are
indicated, please have a physician complete the enclosed Medical Examiner's
Report.
19 MEDICAL DETAILS
Please list details to questions answered "YES" in the Statement of Health.
Attach a separate sheet if more space is required.
PERSONAL PROFILE - PART II
18 STATEMENT OF HEALTH
(COMPLETE THIS SECTION FOR ALL PROPOSED INSUREDS INCLUDING ANY PERSON TO BE
COVERED BY THE CHILD RIDER)
Give full details of any "YES" answers to questions #3 or #4. Include dates,
name of Proposed Insured, name and address of physician consulted, reason
for visit, type of treatment, and any medication prescribed in the MEDICAL
DETAILS section listed below.
1. Height and weight of Proposed Insured. ___ Feet ___ Inches ___ Lbs.
2. Has there been any change in weight during the last 12 months?
[ ] Yes [ ] No If yes, indicate gain or loss. Gain ___ Lbs.
Loss ___ Lbs.
3. Has any Proposed Insured under the basic policy or under the
Child Rider ever: YES NO
A. Had a life or health insurance application declined,
postponed, modified or rated? [ ] [ ]
B. Had or been treated by a physician or consulted with a
health advisor for any of the following:
1. Disorder of eyes, ears, nose or throat? [ ] [ ]
2. High blood pressure, chest pain, heart attack,
or other cardiovascular disorder? [ ] [ ]
3. Disorder of the kidney, genitourinary tract, or
reproductive system? [ ] [ ]
4. Diabetes, hyperthyroidism, or other endocrine gland
disorder? [ ] [ ]
5. Ulcers, hepatitis, disorder of pancreas, liver, or
intestines? [ ] [ ]
6. Cancer, tumors, arthritis, disorder of the bones or
joints, or connective tissue disease? [ ] [ ]
7. Disorder of the blood, lymph glands, or respiratory
system? [ ] [ ]
8. Mental, nervous system, or brain disorder? [ ] [ ]
9. Alcoholism or advised to reduce or discontinue the use
of alcohol for health reasons? [ ] [ ]
C. Consulted for any other reason a physician or other
physical or mental health advisor within the last five
years? [ ] [ ]
D. Used marijuana, cocaine, heroin, barbiturates,
hallucinogens, or amphetamines unless on the advice of a
physician? [ ] [ ]
E. Been diagnosed or treated by a physician for Acquired
Immune Deficiency Syndrome (AIDS), AIDS-related complex
(ARC), or AIDS-related condition? [ ] [ ]
F. Been diagnosed or treated by a physician for any other
sexually transmitted disease (other than AIDS/ARC)?
4. Did mother or father of any Proposed Insured die before age
60 of cardiovascular disease or cancer? [ ] [ ]
19 MEDICAL DETAILS (ATTACH A SEPARATE SHEET IF MORE SPACE IS REQUIRED)
QUESTION # PROPOSED INSURED VISIT DATE VISIT REASON
_____________________________________________________________________________
DOCTOR'S NAME/ADDRESS TREATMENT MEDICATION
_____________________________________________________________________________
QUESTION # PROPOSED INSURED VISIT DATE VISIT REASON
_____________________________________________________________________________
DOCTOR'S NAME/ADDRESS TREATMENT MEDICATION
_____________________________________________________________________________
QUESTION # PROPOSED INSURED VISIT DATE VISIT REASON
_____________________________________________________________________________
DOCTOR'S NAME/ADDRESS TREATMENT MEDICATION
_____________________________________________________________________________
QUESTION # PROPOSED INSURED VISIT DATE VISIT REASON
_____________________________________________________________________________
DOCTOR'S NAME/ADDRESS TREATMENT MEDICATION
_____________________________________________________________________________
QUESTION # PROPOSED INSURED VISIT DATE VISIT REASON
_____________________________________________________________________________
DOCTOR'S NAME/ADDRESS TREATMENT MEDICATION
_____________________________________________________________________________
QUESTION # PROPOSED INSURED VISIT DATE VISIT REASON
_____________________________________________________________________________
DOCTOR'S NAME/ADDRESS TREATMENT MEDICATION
_____________________________________________________________________________
QUESTION # PROPOSED INSURED VISIT DATE VISIT REASON
_____________________________________________________________________________
DOCTOR'S NAME/ADDRESS TREATMENT MEDICATION
_____________________________________________________________________________
20 SPECIAL REQUESTS (WRITE IN ANY SPECIAL INSTRUCTIONS HERE)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
NOW READ AND SIGN AUTHORIZATION IN PART III. SEE NEXT PAGE.
VULXXXXST 1-98
USAA LIFE INSURANCE COMPANY
9800 FREDERICKSBURG ROAD
SAN ANTONIO, TEXAS 78288
XXXXX-0198
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PART III - AUTHORIZATION
HOME OFFICE ADDITIONS AND CORRECTIONS (DO NOT WRITE IN THIS SPACE)
No change in age at issue, plan of insurance, amount, risk classification,
or benefits shall be effective unless agreed to in writing by the Proposed
Insured and the Applicant if other than the Proposed Insured.
TELEPHONE PRIVILEGES
You may change premium payment allocation, request partial surrenders,
request loans, and request transfers between variable fund accounts by
telephone. If you want to decline the right to conduct this type of business
by telephone, please check this box.
____ DECLINE
CONDITIONS RELATING TO THIS APPLICATION / NOTICES
The Proposed Insured and the Applicant, if other than the Proposed Insured,
represent that all statements and answers contained in this application are
complete and true and are offered as consideration for the insurance applied
for. It is expressly agreed that:
1. The company is authorized to amend this application by an appropriate
notation in the space designated HOME OFFICE ADDITIONS AND CORRECTIONS in
order to correct any apparent errors or omissions. However, no change in age
at issue, plan of insurance, amount, risk classification, or benefits shall
be effective unless agreed to in writing by the Proposed Insured and the
Applicant if other than the Proposed Insured. The acceptance of any policy
issued as a result of this application shall constitute an acceptance of
such amendments as well as the acceptance of the beneficiary designation,
ownership, and method of payment of the proceeds of such policy.
2. The initial premium payment is held by the Company in its general account
while your application is being considered. During this time no earnings are
credited to an Account for you. If your application is accepted, the premium
will be transferred to the Variable Fund Accounts as provided in the policy.
3. The company shall incur no liability under this application prior to
delivery of the policy unless and until all conditions expressed hereafter
are met:
(a) an amount equal to the first full premium for the method of payment you
selected is received by the company, and
(b) all underwriting requirements, including any medical examinations
required by the company's rules, are complete.
If the Proposed Insured is an acceptable risk for insurance exactly as
applied for without modification of plan, premium rate, or amount of
insurance under the company's rules and practices, then the insurance under
the policy applied for shall become effective on the latest of: the date the
company receives the application, the date of completion of all underwriting
requirements, or any date of issue requested in the application. If any of
the above conditions are not met, the liability of the company shall be
limited to the return of the premium submitted. PRIOR TO DELIVERY OF THE
POLICY, THE COMPANY 5 MAXIMUM LIABILITY UNDER THIS APPLICATION SHALL NOT
EXCEED $200,000, INCLUDING ACCIDENTAL DEATH BENEFIT.
VULXXXXST 1-98
USAA LIFE INSURANCE COMPANY
9800 FREDERICKSBURG ROAD
SAN ANTONIO, TEXAS 78288
XXXXX-0198
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PART III AUTHORIZATION
I hereby authorize any licensed physician, medical practitioner, hospital,
clinic, or medically related facility, insurance company, Medical Information
Bureau, or any other organization, institution, or person that has any records
or knowledge of me or my health or that of any child to be insured, to provide
USAA Life Insurance Company any such information, including information about
AIDS, HIV, drugs, alcoholism, or mental illness. I further authorize USAA Life
Insurance Company to release any information obtained by this authorization to
its reinsurers, to the Medical Information Bureau, and other insurance
companies with which I have policies or to which I may apply or to which a
claim for benefits may be submitted, and to other persons or organizations
performing business or legal services in connection with my application or
claim. I agree that this authorization will remain in force for 2 1/2 years
from its date and that a reproduction shall be as valid as the original.
I authorize the company to obtain an investigative consumer report on me or
any child to be insured and elect the opportunity to be interviewed if such a
report is prepared.
I have read and understand the above authorization. I also acknowledge receipt
and review of the Notice of Privacy and Disclosure practices attached to the
application envelope.
I have received and read the prospectus for this Variable Universal Life
contract including the prospectuses for the underlying Funds. I understand the
objectives of the Variable Universal Life accounts as explained in the
prospectus and have determined that my allocations are suitable investments
based upon my needs and financial situation.
I understand that the premium payment value allocated to the Variable Fund
Accounts may increase or decrease and is not guaranteed as to a dollar amount.
NOTE: The following certification is required by the Internal Revenue Service
(IRS), and does not affect your insurability.
CERTIFICATION - Under penalties of perjury I certify that:
1.The number shown on this form is my correct taxpayer identification number
(or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding either because I have not been
notified by the Internal Revenue Service (IRS) that I am subject to backup
withholding as a result of failure to report all interest or dividends, or 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 contributions to an individual retirement
arrangement (IRA), and payments other than interest and dividends).
CERTIFICATION INSTRUCTIONS - You must cross out item (2) above if you have
been notified by the IRS that you are currently subject to backup withholding
because of underreporting interest or dividends on your tax return. The IRS
does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding.
DATED AT _________________________ THIS ______ DAY OF _________________, 19____
CITY STATE
____________________________________________
SIGNATURE OF PROPOSED INSURED OF BASIC POLICY
(PARENT IF UNDER 15)
____________________________________________
SIGNATURE OF POLICYOWNER IF OTHER THAN
PROPOSED INSURED
____________________________________________
SIGNATURE OF WITNESS (A NOTARY IS NOT
REQUIRED)
USAA LIFE USE ONLY
____________________________________________
SIGNATURE OF AGENT
____________________________________________ _____________
SIGNATURE OF REGISTERED PRINCIPAL DATE
VULXXXXST 1-98
USAA LIFE INSURANCE COMPANY
9800 FREDERICKSBURG ROAD
SAN ANTONIO, TEXAS 78288
XXXXX-0198
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19714-0896
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