DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint

8/9/2019 DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint

1/25

Fi

LED

STt f.IE

S t ~ L J l : ~ U l

ClfiCUIT

CUHi\

J / l . C l " \ s u : ~

C(,(1;.;'

1

Y

\

IN

THE CIRCUIT

COURT

OF

JACKSON COUNTY,

AllKANSAS

~ DIVISION

l U I ~

FEB 7

M

II: 36

D.T.

ALLEN CO.,

INC.

H E C O R O E ~ £ A I N T I F F

800: l_PAGE

s.

CASE

NO. V

dO 15-:JO

ALLIANZ LIFE INSURANCE

COMPANY OF

NORTH AMERICA

COMPLAINT

DEFENDANT

COMES NOW, Plaintiff, D.T. Allen Co., Inc., by and through its

attorneys,

Newland &

Associates,

PLLC,

and for its Complaint, states as follows:

PARTIES,

JUIUSDICTION,

AND

VENUE

1. D.T.

Allen Co.,

Inc. ( D.T. Allen or the Company ) is an Arkansas corporation

with its principal place ofbusiness in Jackson County, Arkansas.

2. Upon information and belief, Defendant Allianz Life Insurance Company of North

America ( Allianz ) is an

insurance

company organized under the laws of the State of Minnesota

and authorized to do business in Arkansas.

3. Jurisdiction and venue are appropriate

in

this Court pursuant to Ark. Code Ann. §

16-13-201 and Ark. Code Ann. §§ 23-79-204 and 16-55·213, respectively.

FACTS

4. On

or about April

17, 1991,

Allianz issued

life

insurance policy number xxx3871,

Insuring the life of Michael W. Allen, Sr.

C Mr.

Allen ) in the sum of 250,000.00 (the Policy ).

Mr.

Allen was designated as the owner of the Policy. A

copy

of

the

Policy is

attached

hereto

as

Exhibit

A

and incorporated

herein.

5.

At

the

time

of

the

Policy's

issuance,

Mr.

Allen

was

part

owner

ofD.T.

Allen.

6.

Since the

Policy's

issuance • D.T. Allen has

pald

all premiums

on

the Policy.

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 1 of 25


2/25

7.

On

or about May

20,

2002, Mi·. Allen transferred ownership o the Policy to D.T,

Allen

and

designated D.T. Allen as the sole beneficiary. A

copy

of

the

Service Request

signed

by

Mr. Allen is

attached

hereto as Exhibit B

and

incorporated

herein.

8. n

approximately

September 2007,

Mr. Allen

relinquished

all

of

his

ownership in

the Company. Thereafter, the Company continued

to

pay all premiums on the Policy.

9.

Michael

Allen Sr.

passed

away on

or about September

4,

2014.

10.

Pursuant to the Policy and Service Request, D.T.

Allen

is the owner and sole

beneficiary

under

the

Policy and

the

only

person able to make a rightful

claim.

ee Exhibits

A-B.

11.

Despite

repeated

demands, Allianz

has

refused

to

pay

D.T.

Allen

any

of the

proceeds ofthe Policy.

COUNT I:

BRE CH OF CONTR CT

12.

Plaintiff realleges

and

incorporates the allegations contained in the

.Il eceding

paragraphs as if set forth word for

word herein.

13. D.T. Allen sues for

breach

of contract for all death benefit proceeds owed to it

by

Allianz under

the

Pol

Icy.

14. Pursuant to the

insurance

contract, upon Mr. Allen's death, Allianz was required to

pay

all

insurance proceeds to the

designated beneficiary .

15, The

Policy identifies D.T.

Allen

as the beneficiary of

all

insurance benefits.

16. Despite demand, Allianz

has refused

to pay the insurance

benefits

due

to D.T.

Allen

under the Policy

based on the

unsubstantiated claim of a non-party to the insurance contract.

17.

Allianz

has breached

its contract

with

D.T. Allen

by

refusing to

pay

the

insurance

benefits

due to D.T.

Allen pursuant to the Policy.

2

-

~



3/25

18.

As

a

direct

and

proximate result

of

such breach,

D T.

Allen is

entitled to judgment

against Allianz

in the

arnoimt of

Two Hundred

Fifty

Thousand

Dollars

( 250,000.00),

plus

twelve

percent

(12%) damages and

its

reasonable

attorney s fees pursuant to Ark.

Code

Ann. § 23-79-

208.

19. Alternatively, Plaintiff is entitled to

recover

its costs and attorney s fees pursuant

to

Ark.

Code

Ann.

§16-22-308

for breach of contract.

RESERVATION OF RIGHTS

20. D.T. Allen specifically reserves the right to

bring

any additional

causes

o

action

against

the

Defendants,

or additional defendants,

and

to

amend

this

Complaint

as

necessary.

21. D.T.

Allen

r ~ u s t s

ajury trial on all matters

to

which it is entitled.

WHEREFORE,

Plaintiff, D.T. Allen Co.,

Inc.,

respectfully requests that the

Court

grant

the

above requested

relief,

for its costs and attorneys fees, and for all other just

and

proper relief

to which it may be entitled.

Respectfully submitted,

D.T. ALLEN CO., INC.

By

and

through:

NEWLAND ASSOCIATES, PLLC

2228 Cottondale Lane, Suite 200

Little

Rock, AR

72202

(501)

221-9393 telephone

(501) 221-7058

facsimile

3



4/25

Allianz Life

Insurance Company

of North America

PO

Box59060

Mlnneapolls, MN 55459-0060

800.950.1962

September

22 2014

D ALLEN ANDCO

INC

PO BOX459

NEWPORT

AR

72112

RE:

Policy number

aa

Dear D.T.

Allen

and CO lnc:

Per

your request, please find the enclosed

duplicate

policy.

llianz®

You

can access

current

policy

Information by going to our secure website at www.alllanzjlfe.com. If this Is

your

first

visit

to our website, cllck on register here

and

follow the Instructions to aeate

your

own account. Do you

have feedback about a product or our service? You

can submit

feedback by logging In

to

account

and

dicking

on

Contact

Us .

Thank

you for

the opportunity to

help you

reach your financial goals.

If

you

have any questions,

feel

tree to ciall us

at B00.950_.1962.

Polley

Administration

Allianz Life Insurance Company of

North

America

EXHI IT·

LPA-1390

Rev 04/08/2011

I

a ·



5/25

Allianz Life

Insurance

Company

or North

Amerfca

Allianz

P P o ~ s e o e o

MlnnoojlOll1,

MN

ll545D OOOO

TelophGno:

BDOIUl IHi&

72

June S,

2002

D.T. ALLBN AND CO. INC

POBOX 59

NBWPORT,AR 72112

RE: Allianz Policy Number: 3871

Insured: Michael W. Allen

Sr.

Dear Policy Owner:

We have received and recorded the request to change the ownership

designation

on

the

above-mentioned

contract(s),

h ~ a s o

keep

this acknowledgment with

your policy.

Please review

the

changes to

make sure they

are as

desired.

We appreciate

the opportunity to

provide service

to

you. fyou have further questions, please do not hesitate to oall

your

representative or me at 800-950-1962, extension 46247.

Sincerely,

Brooke:

Wood

Polley Administration

Allianz Administrative Management

C:WYNTON C NORWOOD office

:5670

.OUPlJCATE



6/25

ACKNOWLEDGEMENT FOR CHANGB

To be attached and

made

part of:

Policy : lm3s

Insured: Micheal W. Allen

Sr.

The

policy

is hereby changed

to read: all

rights, title and interest in the policy are hereby

transferred

and vested

in:

Primacy

Ownership:

D.T. ALLEN AND CO. INC

POBOX459

NEWPORT, AR 72112

Primary Beneficiary:

D.T. ALLEN

AND CO.

INC

POBOX 59

NEWPORT,

AA 72112

Contingent Beneficiary:

ESTATE

OF INSURED

In evidence thereof, t he

Company has

caused the

Acknowledgement

to be executed at its

ome Office

and

put

into effect this

31st

day

of

May, 2002.

Allianz Life Insurance Company ofNorth America

Minneapolis, Minnesota



7/25

.

P1

lexible

Premium

djustable Life Policy

Death Benefit

payable

to

the

Beneficiary upon

death

of

the

Insured before

age

95.

Net

Cash Value, if any, paid

to the Owner

at

the

lnsured's age 95. Nonparticipating - No annual dividends.

Signed

for the Company

at

its Home

Office on

the

date of Issue.

Suzanne J

Pepin

Senior Vice President,

Secretary,

and

Chief

Legal Officer

YOUR 20 DAY RIGHT

TO

EXAMINE YOUR POLICY

Charles Kavltsky

President

You may

return

your pollcywlthln

20

days after receiVlng lt lf dissatisfied for

any

reason.

You may

return

It to the agent or

our

Home

Office. We will

void

the policy and

mall

a refund

of

any

premium you

paid

within

10 days of receipt.

This

ls

a egal

contract

between you

and

the Company.

READ

YOUR

POLICY

CAREFULLY

LifeUS • Insurance

Company

5701

Golden Hiiis Drive

Minneapolis,

MN 55416-1297

A

Stock

Company

- - ' ~ · - ·



8/25

POLICY SCHBDULB

NOTB: TIIB

MATURITY

DA'fB

ISTHJ,nOLICY

ANNIVBRSARY

FOLLOWINO

THB

INSURBD'S

95

111

BIRTHDAY. COVERAGE

MAY

EXPIRE

PRIOR.

TO Tiffi MATURITY DATB IFNO

.PREMIUMS

ARE

PAID

A[ITEll 'fHE

INITIAL PREMIUM

OR [(I

SUBSEQUBNT

PREMIUMS

ARE INSUFFICIENT TO CONTINUE

COVBitOB

l'O SUCH DATE. COVERAGE MAY

ALSO BE

AFFECTED

BY

A0-IANOB IN CURRENT VALUES. IF THB

POLICY DOES

CONTINUE

IN PORCE

TO

THE

MATURITY DA TB, IT IS POSSIBLE THA'l' "rnBltE MAY

BE

U1 l'LE OR

NO CASH SURRENDER

VALUE

AT

THAT TIME.

MONTHLYEXl'ENSE CB'.An.GES:

S?.SO l'ER

POLICY

PER

MONTH, ALL POLICY

YEARS

POLICY LOAN INTEREST RA1'E:

7.40% JN

ADV

ANCll

CONSISTENT PREMIUM

BASIS:

$1,212.00.

im GURANTEED INTEREST RATE

USBD

IN

CALCULATING

THB ACCUMULATION

VALUB

IS

0.32737% PER MONTH, COMPOUNDBD

MONTHLY.

THIS IS

EQUIV

ALBNT

TO

4.0%

PER

YEAR,

COMPOUNDED YBARLY.

DlJPL CATE:

INSURED: MICHAE ilV

ALLEN

SR

POLICY NUMBER:

lm3 7 AGE

ANDS.EX: 43

MALE

INITIAL

SPECIFIED

AMOUNT1 $250,000 PREMIUM RATE CLASS: NON.SMOKER

DEATH BENEFIT

OPTIONr

POLICY

DATE: APRIL 17,

J991

JNITV..L

PREMIUM: SIOl.00

MONTHLY

ANNIVERSARY DAY:l7

PLANNED

PREMIUM:

$101.00

MATURI'N

DATE1APRIL17,

2043

PLANNED EXCESS; PAYABLE: MONTHLY

OWNER

AND BENEFICJAD.Y: AS NAMBD IN APPLICATION

OR

AS LATBR CH NOBD•



9/25

•

(POLICY SCHEDULE

C O ~ T I N U E D

POLICY

NU1r1b ::R:

:St :71

OTHER COVERAGES:

NO O T H E ~ COVERAGES ? R E S e ~ T

SP :'.CIFIED

~ · l O O N T

SURR:NoeR CHARGES

EFFECTIVE

DATE

.

TERMINATION

DATE

THE FOLLOWING

S U R ~ e ~ D E R

C H A ~ ~ e s A ~ E a ~ s e o ON

THE

END OF THE POLICY YEAR:

POLICY YEAil

4\JOUNT

POLICY YEAR

AMOUNT

s6,500,JO

2

S6,S00.00

3

61500.00

4 ~ 6 5 0 0 . 0 0

S615DO.OO

6

S6 5QQ OO

7

~ 6 5 i l 0 . 0 0

8 S6,500.00

9

$0,soo.oo

10

S6,soo.oo

11

ss zoo.oo

2

53,900. 00

13

S21600.00

14

s1,:soo.oo

15'+

so.oo

THE S U R R c N D c ~ CHARGE WILL SE I N C R E ~ S E O O U ~ I N G THE FIRST 15

YEARS

SY

A ~ Y EXCESS

I ~ T E R E S T

CREDITED

o u q l ~ G

THE 12 M O ~ T H S PRECEDING THE

SURRcNiHR

3A

DUPllCf\TE



10/25

PE1003

MENDMENT ENDORSEMENT

This endorsement Is attached to the policy as of the

Polley

Date and amends

the

policy as

follows:

PAYMENT

OF THE DEATH BENEFIT (added):

Interest

on

Life Insurance Proceeds

w

We will pay Interest on the proceeds

of

any

benefit paid. under

this

policy more

than thirty

days after

the

Insured' death. We will

pay

interest for the period

after the date

of the lnsured's

death the

the

date

the

beneflt Is

paid. The interest

rate

wlll be equal to that

being used for

Settlement OpUon C, or

higher

If required by

aw.

In

all

other respects the provisions, condlUons,

exceptions

and llmllatlons contained

ln

the policy remain

unchanged and apply

to

this endorsement

LifeUS

InsuranceCompany

Suzanne

J,

Pepin

Senior

Vice President,

Secretary

and Chief Legal Officer

· :

·-



11/25

PE1034

MENDMENT ENDORSEMENT

This endorsement

Is

attached

to

the policy

as of the Policy Date and amends the policy as.follows:

DEFINITIONS (added):

The

Preferred Annuitlzatlon Amount

la equal to

the Accumulation Value

on the Preferred

Annultizatlon Date

plus

four limes the

sum

of the excess Interest credited to the

Accumutatlon

Value since

the Polley

Date.

The

Preferred Annultlzatlon

Date

Is

the later

of

the pollcy anniversary after your age 65

or 15 years

from the

Policy Date.

The Preferred Annultlzatlon Elecllon Period

Is

the period of time

between the

Preferred

Annulllzallon Date

and the Preferred Annultlzation Expiration Date.

The Preferred Annultlzatlon Expiration Date ls

the later of

the policy anniversary after

your

age

70 or

15 years from the

Policy Date.

Excess Interest Is the monthly

accrued

Interest

credited

In excess of the monthly accrued

Interest credited at the guaranteed minimum Interest

rate

PAYMENT OF

THE

DEATH

BENEFIT (added):

Option

A: During

the

Preferred Annuitlzallon Electlon

Period,

the

Death Benefit will be the

greater of the Speclfled

Amount shown

on

the

Policy Schedule or the

Death BenefK

Factor

times

the Preferred

AnnuiUzation

Amount as

of

the date of

the

lnsured s

death.

Option

B: During the Preferred Annuitlzallon Election Period, the Death Benefit will e the

greater of the Specified

Amount shown

on the Policy Schedule plus

the

Accumulatlon

Value as of Iha

date

of

the

lnsured s

death or the

Death Benefit

Factor

times

the

Preferred

Annultlzation

Amount

es

of the

dale

o the lnsurecl s death.

l>UPllCATE



12/25

PE1034

CASH VALUE (added):

r e f e r ~ e d

Annultlzatlon Electlon •

During the Preferred

Annuitizatlon Eleotlon Period, the

Preferred

Annultlzatton

Amount will be

paid

t you

If

you

request

II to be paid over

your

life,

your

life

with

a period

certain r

under a oint end

survivor

option.

To

qualify for

the


Amount the followlng condition

must

be

met. At

the end of each five pollcy

years

beginning with the fifth and

at the Preferred Annu ltlzatlon

Date, the cumulative total to date of

any

renewal premiums paid must equal r exceed

the

number

Of

renewal

years since Issue times the Planned Periodic Premium.

We will tell

you

on

your Annual

Report

whether the quallncallon

for the

Preferred

Annulllzallon Amount

has

been met. You wlll have 60 days from the date of the Annual

Report

to

pay

a

premium large enough to meet the

qualification.

Wewlll notify

you at your last

known

address 60 days

prior

to

the


Expiration Date that the Preferred Annultlzatlon Election Period wlll end.

SETTLEMENT

PROVISIONS

(Option

A

and

Bare

deleted and

replaced

with the

following):

OPTION

A: Installments for

a Guaranteed Period We wltl

pay

equal

ln&tallments

for

a

guaranteed period of one to thirty years. If

installments

are paid over a

minlm1 111

of ten

years,

the

Death Benefit

will

be Increased

by 10%. Each Installment wlll consist

of part

benefH and part Interest.

We

wlll pay the Installments as requested

ellher

monthly,

quarterly, semi-annually

or

annually, See

Table

A.

OPTION B:

Installments for Life with a

Guaranteed

Period

We wlll pay equal monthly

Installments

as long

as

the

payee ls

living,

lt

we

wlll

not make payments

for

less

than

the

guaranteed

perlod

the payee chooses.

The Death

Benefit will be Increased

10% under

this

Option. We

wlll

pay the lnsteUments monthly. See Table

8.

In

all other respects the provisions, conditions, exceptions and

lfmlle lons contained In

the

policy

remain

unchanged

and

apply lo this

endorsement.

LifeUS Insurance ompany

Vice President and Secretary



13/25

APPLICATlON FOR

LIFE

INSURAN.

1· PART1

OJesi•anr

11hrour

,

2

1n1t io

0

l OllOllO

IOllJ/ld

lolldll l d'v•DUll pOllCy

0

Pwuud 1 1 1 1 1 1 1 1 ~ llflOll

fUYei

1

11y lltOGl'lt 5 • Monthl1 l11:111r1

CJ

Ole

l n 1 1 1 1 ~ 1 u 1 1

S •

1llax Paw ~ ' 1 ' 4 1 1 1 1 1 1

J

\;Gil

ol L•v·•g CL•nnJ Collslml 1 1 ~ 1

l•llax

12 DEATH BENEFIT OPTION 1c11oo"11t1e1

0 AtC1A11w111oq value

lnch>dto

Sp1d1ed 11ntun1

0 b ~ i : u . 1 1 1 ~ 1 1 1 1 1 1 1

Y;rl '

f'lr•ble 11111 Spoerl1ad Arioll I

13 PLANNED PERIODIC PREMIUMS

CJ Aarw11 CJ

m1-.\•Rlll'

0 1 1 - J r t ~ )

is:'.

Mo•lll')I

PAC

CJ

loll

Bid

GIWI

llo

J

GO'll Allo• [J 8 •171 ,..mun

MODAL

PAEMIUJd

AMOUNTS _ _ , _ / ' 0 . . . _ / , u . O Q ~ ; . _ . - - - - - -

b ADDITIONAL P ~ E M I U M lil'loLr1 t txms al pl>Aoed

PlllOdlC Pl•OlllrT·1 I -

INITIAL PREMIUM

h

plus

b I

s

_ _ tO i ~ o - - _

4MDUll•

SUSYITIEO W1111 ~ P r $

IEHO P L A H ~ E D PERIODIC PAYMENT ~ O l l C f l

0

YES

II V.S D ftoposd '""'«

0 App

1

1n111

I

Ovrnaf

0 01111

ifeU

Insurance Company

Bo' 5011bfl

\ l m n e n p o l J ~ \hnnr,ot

a :;15.1511.1•1Jhll

llJISl..., 11 ll1M.,.

Ill

relalt

10

CJ Spoun o11n1\lfld (

f.,l'1•r

"'""

IJIPl>ld

1

0

OIMI

P,opasad

ln11ttdl111spo1111

llllllr

DP111 111$\Sad R i d ~

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NAME

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lAST

2a

SOCIALSECURITYNUMBER

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RESIDENCE ADO

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TO

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COVERED UNDER

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•

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ad·•

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c <

.,.., ' ' ' ll l *"l

rtqlltll

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ol

llllG' ca11oof

CHILD

CHILO

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NAME SEX HEIGHT WEIGHT

BIRTHOATE

AGE

DUPliCATE

I

A11

i•l.'t11ny

th\ldr1•

•• 111'a11 """'II '

"OI boltg

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b ~ · • U-r11nr ch1\drc•

shown

1bo Who no rol '•n

11

h 1pphcr1t

D

Yet

[J No

IU 'YES , .... 11J111t 1'111111sar

1n

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l9e 11

~ ' ' '



14/25

14 BENEFICIARY· STATE

FULL

NAME AND

RELATIONSHIP

Pnmary lnsUfpd·s Benej1c1ary

_ jiut filth

fll/ :t_n 5 1 0 1 1 ~

Con11'418nt

Beneficiary

r

Other

lnsured/Spouses s

Beneficiary

Conlmgent Benehc1ary

BENEFICIARY FOR

CHILDREN

IS THE PRIMARY INSURED

15 OWN

ER 11 other

than the Person to be Insured)

CJ lnd1v1dual

Full

Name

0 Corporation

Soc

Soc

, Tax or Employer ID

No

D Partnership Address

0 Trustee

B11 mg Address (if d1fteron11

16 OWNER OF POLICY ON

A

JUVENILE

a

II

the appllcanl 1dent11Jed Quest1ons

·8

on

page

1

s a uvemlo,

complele

lhe

owner

mlormahon

below

Ralat1onsh1p

to Proposed Insured

(Child)

other

than paren

I or

r a n ~ a r e n t

01thera

arent

or guardian musI

sign this

appl1callon in

addition to the Applicant

b

Parents

name

lnsinnce

m

orce

rather

Mother

c

Stele the total amount

of hlo insurance

on each

brother and

sister

of

the child

Name

Amount__

Name Amount__

If

more space required. answer

1n

REMARKS

17 COMPLETE IF

APPLYING

AS ANON·SMOKER

YES NO

a Has

any

person

to be insured

smoked

cigarettes in the

past year? O p....-

Name(s)

b

Is tobacco other than c1g1rettes used by any person to

be

covered?

0 V

Name(s)

Type/lrequency

18 DRIVINB

RECORD

.

oo

a What is your drivers license no

tale

rJ../S.._

Within the

pas I

three

years, has any

pe1 on

to be covered

been

convicted

or pleaded gu11ly to YES MO

b Three

or mora moving v1olat1ons an\\/or accidents?

o

0

c Onvmg under the

Influence

ol

alcohol

and/or

drugs?

Cl

Name

· · ··

Oela1ls

(give dates,

type of

v1olat1on)

•

19

FOREIGN

TRAVEL. AVIATION

ANO

MILITARY

YES

NO

a Except lor

vacation tnps doea

1ny person

to bci

covered Inland to travel outside

the US or

Canada

within

lhe

next

two

years?

0

µ

b

Does any

petson

to be covered intend to lly other than

as 1

passenger or

has he

or

she

flown

olher

thin

as a

P.Y"assenger dunno

the

post

two

years? 0

If "Yes' complete

Avratton Ouesllonna1re

c

Isany parson to

be

covered

a

member or does he

or

she

intend to become

a

member

of

the

anned rorces

nclud1ng

reserves?

D

If ·Yes",

give

details

in

REMARKS

20

AVOCATION AND SPORTS

YES O

Does any person to be

covered part1c1pate 1n

rocreatronal

acllv1t1es

mvolving

a Aeronautics (includinghang gliding, ultra

kght.

soaring,

cir,/

ky

d1vma.

ballooning)?

0

Frequency Equipment

Looa11on/area

Future

part1cipa11on

·b

Powered racing

or

compet111ve

vehicles (1nclud1ng

otorcycles, au1omob1les and motor boats)?

Cl

Type

of vehicle

Racmg

ctass1f1cation

Speeds

attained

Maximum

Average

I

Races

a•mually

"fype ol track

c

Recreational vehicles ovar

open terrain.

trails,

sand, snow or

ice (including

snowmobiles,

dirt

b1kea and dune buggtes)?

0

r

Type

of

vehicle

Where usod?

Frequency

Compet1bve

tac1ng?

II yes specify engine

sae

d

Skin

or

SCtJba d1v1ng, mountain clmbmg, rodeos,

compebtl\le

sk11ng?

D

f

Frequency

Locat1onfare11

DIVING

-

Typa

ol

equipment Frequency

Maximum

and

average depths

2.1 OTHER INSURANCE YES NO

a

Has

any

company

dllchnod

to

issue,

romstate. or

renew. rated mod111ed,

postponed

or canceled

any

hie

or health insurance on any person to be covered?

b Wiii insurance. mcludmo annuities, 1n

any

c;ompany

be

discontinued or changed If the

insurance

applied

for 1s

issued?

c

Is

any apphcauon for life

or

health insurance

on

any

a

person 10 be oovered pending in any

other company?

a

22 LIFE

INSURANCE

IN FORCE WITH

ALL

COMPANIES

Proposed

lnsurod

l..Jle

~ 3 9 )

Other

lnsUfed(s)

•

ADB

I

Dis Income

L

oo?>feu 1H

loopuifE.



15/25

_____

.•

...

~ ~ ~ P l E T E WITH RESPECT

TO ALL

PE NS TO BE COVERED, AS SHOWN

BELOW

NAM ; ANO ADDRESS OF YOUR FAMILY

PHYSICIAN

De, Paul H e r ~ e Y 1 1

Oeb.

/fJQC/q/h st AJgup t A

COMPLETE

OUESTIDllS

S·l CAREFULLY, GIVE DETAILS OF LL

YES

ANSWERS, lllCLUDIND llAME

Of PEllSllH

AFFECTED. All

DATES. lllAONOSES,

OU RATIONS,

OUTCOME

AND

THE

llAME3

ND

ADDNESSU

OF

LL

HOSPITALS ND

ATTEHDlllB

PHY&ICIAKS If ADDITIONAL SPACE

REQUIRED, MTACH SHEET

Of PAPEll. SIONEO. MTED AHO WITNESSED

3 IS ANY

PERSON

TO

BE COVERED

PRESENTLY

TAKING

MEDICATION?

4

WITHIN

THE

PAST FIVE YEARS HAS ANY PERSON

TO BE

COVERED

a Consulted, been exa1111ned or been

treated

by

any

phys1c1an or pracl11toner?

b

Had

an

x•ray. ileclrocatd1ogram

or any

laboratory test

r tudy?

c

Had

observation or

treatment

al acl1mc. hospital or sanitarium?

d Had or bean advised \o have a

surgical

operation? ·

e Had d1wness, shortness

of breath.

pain

or

pressuf" m

he

chest?

f Had

any

in1ury requiring treatment?

5

TO

THE

BES

TOF Y UR

ICNOWLEl>GE.

HAS ANY

PERSON

TO BE

COVERED

HAD

OR

BEEN TOLD HE OR SHE HAD\I

a

Epilepsy.

fainting spells. nervous or mental

condll1on,

neuritis. paralysis,

or any

d1smo or

abnorrnahty of the

brain or

nervous ayatem'

b Heart

allack,

murmur, palp1lat10n.

or

tugh blood pressure. anam1a, vancose

vems. or

any disease

or alJlormahlY of the heart.

blood

or blood

vessels

II

c l\Jben:utosis, asthm1, pleurlb)',

or

any disease

or abnormality ol

th11

lungs,

bronchial tubes, throat

or respiratory

system?

Ulcer.

ind1gest1on, coht1s,

gall stone,

hem111. or

any disease

orabncrmahty

of the

stomacn. intestines, rectum, gall

bladder or l1ver11

e Urinary 111Jgar, albumin or stone, syphilis,

menslrual

d1sorller, or disease or

abnormality ol the breas\s, kidneys.

prostate, unnary

or genital systems?

D1ab&tes . gout.

or

any dlS1Jas11 or

abnonnahty ol

Iha thyroid or other glands?

Arthritis, rheumalic fever. back trouble, or any disease or abnormality of the

1omts, muscle& or bonas?

h Any disease or

abnormality

of the eyus, ears

or

skm?

1

Cancer

or tumor?

1 Any physical deformity or

defect?

k

AAY

immune def1c1llllcy

disorders, Acquired

Immune

Oef1c1ency

Syndrome

(AIDS), or AIDS Related Complex (ARC), or test retults md1ca•1ng

eicposura

to the AIDS

virus?

6 WITHIN THE PAST TEN YEARS, HAS ANY PERSON TO BE COVERED REGULA

a

Amphotam1nes. barbiturates

orsedauves, except as p11scnbed by a

physician?

b Cocaine,

heroin,

morphin1, LSD, mar11uana.

PCP, oranyotherhalluc1nogenicor

narcotic d1Jg >

7 a

Have

any close relative&

of any person

to

be ooverad aver

had

cancer,

diabetes,

heart disease, or a nervous or mental abnormahty\I

Has eny person to be covered everroceiv11d

treatment or

101ned

an organization

for alcoholism or

dru11

addlc11on?

G Is any person to be covered now pregnant"

REMARKS

HOME OFFICE CHANGES IN THIS

APPLICATION.

0 utd¥µ1}

D U P L ~ C T E

.

I

I



16/25

·

' l ~ I I ' ' · ~ .

·Li feU• n s u r ~ c e Company

PART II

OF application

for

Insurance to

PROPOSED ,

INSURED:

\'f\,

t_1 a

e

(\\\f. ?

First Name ln1t1al Last

Name

Date

of

Birth

a

Name end address

of your personal

phys1c1an? _ ; ~ b . \ o c .

b Date and reason last c o ~ s u f l e d ? - q

d What med1ca11ons are

YoU

presenU

taking?

2

WITHIN THE

PAST FIVE YEARS

HAVE

YOU

a Con1:1ultecl

been

examined or

been

treated by ny

phys1e1en

or?

b

Had an X-ray, EKG or

anyJab9£aloJ:®I

or study?

c

Had obsarvahon or treatment at

a clinic, hospital

or

san1tanum?

d Had or been advised lo have a surgical operation?

a

Had dizziness, shortness of breath,

pain

or pre&sure

in

Iha chest?

3

HAVE

YOU

EVER BEEN

TOLD

YOU

HAD

a Epilepsy,

fainting spells,

nervous or mental

cond1 1on,

paralysis.

or

any disease

or

abnormality

of the

brain or

nervous system?

b Heart attack.

m u r m u r ~ .

anemia,

or

any disease

or abnormality of

the

heart, blood

or blood vessels?

c Tuberculosis, asthma. pleurisy, or

any

d1Bease or

abnormality al the

lungs. or respiratory

eystam?

.

d Ulcer,

1nd1gest1on,

colrtis.hern1a orany

disease

or abnormality of the

stomach,

mtestrnea, rectum, gall

bladder or

fiver?

e Urinary sugar, albumin

or

stone,

syphll1a.

or disease or abnormahty

of the

breasts. kidneys, prostate. urinary or genital systems?

Diabetes. gout, or any disease or abnormality of

the

thyroid or

other

glands?

g

Arthnha,

rheumatic fever, back

trouble,

or any disease or ebnormeltty

of

the

Joints.

muscles

or

bones?

h

Any

disease

or abnormality of h e ~ r s or skin?

1 Cancer or tumor?

J

Any

physical deformity

or delect?

k

An

immune

de 1c1ency

disorder,

Acquired

Immune

oer1c1ency

Syndrome (AIDS), Aids

Releled Complex (ARC),

or

test results

1nd1oating

exposure

to the

AIDS virus?

4 a

W1th1

ii

the past ten

yea

rs.

have

you used amphetamines, barbiturates,

cocaine. heroin.

morphine.

LSD. manruana,

PCP,

or

any

other

hallucmogen1c or

narcot10

drug?

b

Have

you ever received treatment

or rorned an

organizabon for

alcoholism or

drug addiction?

c Has your weight changed more than 15

pounds

m

he past year?

5

· Family History

Diabetes,

· high

blood

pressure, heart or

kidney

disease.

nervous or mental rffneas or su1c1de?

If Living Age at If Deceased

Stale of Health Death Cause of Death

Father

Mother

Brothers

& Sisters 0

Bo 69000

· \ l l 1 1 1 1 c u p o l 1 ~ . \fmnesot1t 5'5459·0000

~ M a l e

{a

~ L

ff

Female

Day

ear

I

DECLARE

that,

to

the best

of my

knowledge

and

belief.

the

statements

end

answers m

Part II

of this Appltcatronare lull,

complete, and true These statements and answers are

to

be tons1dered

as

the basis for

any insuranc& wrttten

hereon

JAUTHORIZE

any licensed phys1c1an, medical

prectt11oner.

hospital, oltmc or other medical

or

medically related

fac1lrty

insurance company.

the Medical

lnlormal1on Bureau or other organ1zalion. 1nst1tullon or person. that has ny

reoorda

or

knowledge of me or

my

health, to give to the Company .any such information This

authonzabon

11 good for

SO

months

from

the

apphca1lon date · ·

To fac1htate rapid aubm1ss1on of such mformat1on. I authorize all

said

sources. except the Medical lnform.allon Bureau, lo

give such

records or

knowledge to ~ n y

egenoy employed by

the

insurance com pany lo collect

and

transmitsuch mformatton

A photographic copy of this authorization shall be es vahd as

the

ortg1nal · ·

··

· · · : . .

~ e d _ a t

( C 1 l y S t ~ ) ~ j } A ) s

< f \ t l . _ o . . ~ , . , ) . On . .

.

1 ~ - 2 : _

s : : s \ , ~ ; i k s ±

l \ ) q . . s ~ Q , € ,

.-/ ~ · ... ,.... ·:.:.

Signature of Witness

1

' ) ~ \ l e ; )

Signature of

PROPOSED INSURED

..

hJR M r

•? l tQ

•.

_ .• • ' ; • •



17/25

•.

lllelJS

( the Co(11plnt}

•=

· · · · .

3fJ?/

:

..

,.,._.

·· I-Rf

PRESENT thal the

statements and

answers given hrs Apphcatron are

lrve complete,

and correctly

recorded to the

bes Iof 1ny

(our) knowledge and

bel1el

I AGREE Iha 1) This Appl1cation shall consrst

of

Par I

and

Parl II 11 apphcable) and

shalt

be

the

basrs

lor

any poltcy issued

on this

Application (2.)

Except as

otherwise provided the cond1t1onal

receipt, issued

any

policy issued on this

Apphcat1on

shall

not

lake e1f1ct unless all ol the follo1Vmg

cond1t1011s

aro met

(a)

The

ltrst

run

pramnrn

is

paid,

(b)

Tho

policy

1s

delivered lo tho

ownor dunno

tna

hlohme of

the

person(s)

t

be

cover11d

by

such

policy, and (c) AU ol tho stalements and

answers

given in thtS Appl1cahon to the hostol my

(our)

knowledge and

belier

conhnue Io be lrueandcomplete as

or

the date of delivery

ol

lho policy. (3)

No

agont

or

medical exernmermaywa1ve or

alter a

provision

ol

any pohty

and

nowaiver

ormod1l1cat1on

ol any

pohey issued on

lh1a Apphcahon

shall be binding

upon lhe

Comp11nyunless tn

wn11ng

and signed by lhe Presiden\ ora Vice Pres 1denl

and lhe

Sucretaiyor

an Ass1stanl Secretary (4J Tlla

Company may md1catechanges m

ha

SPlJCC

for

Home

OH1ce Changes

m ho

Application

foradmuwstrallve purposes only

f\rrt o1her changes rn this Appl1cauon shall be sub1ec1 to wntten consent by the owner

I

AUTHORIZE any phys1c1an modrcal pract1t1oner

hospital

cllnrc, medically

rel

t e ~

lacilrty.

mstranoe compuny, the Medical lnforrnat1on Bureau

(MIBI

or

other oruamzahon uuhtutmn orpnrson that has any mlormatlon

in 111

records on

me

ormy children to give the

Company

us legal

represenlal1vos and

its

re1nsurers any such

information

10 use (or underwntrno rnsurance and for delerm1nmg eltgibll11y

lorbenaflls

The Company may release mf

0


18/25

.

DEFINITIONS

We,

our,

us

or The Company

means

LlfeUSA Insurance

Company.

You and your means the

owner

of

this

policy named In the

application, unless later changed.

The owner may

be other

than the peraon(s) Insured. The owner s

solely

entitled to

exercise all policy rights.

Insured means the person or persons whose life

is

Insured

lft lderthls

Policy.

Accumulation

Value

is the policy s

total value.

It

Is

describoo

In the

AccumulaUon

Values

section.

Age

means the

lnsured s

age

on the

last

birthday.

The Beneficiary Is the person or entity to whom we will

pay

the

Death Benefit if

the Insured

dies.

Cash Value means

the Accumulation

Value

less any

surrender penalty,

Lapse

means

termination

of the

pollcy

due

lo Insufficient

premium

payment

as

described in the Grace Period

section.

A

Polley

Loan

Is

the Indebtedness

to

us

for

a

loan

secured

by this

policy.

The Maturity

Date

Is

the policy anniversary

followlng the

lnsured s 95th

birthday.

The Maximum Loan Value Is

the IEM gest amount

you may

borrow under the

loan

provision.

·

The Net Cash

Value

Is the Cash Value less any remaining

loan balance.

The Net Premium Is 100 of any premium

you

pay.

Reinstate

means to

restore

coverage

after

the policy

has

lapsed.

A Rider

Is

en

attachment to the policy

that

provides

an

additional

benefit.

The Polley Date Is shown In the Policy Schedule and

detennlnes

the monthly anniversary

day,

policy

anniversaries, end policy

years.

Insurance Is effective as

shONll

on

the Application.

GUIDE TO POLICY PROVISIONS

Accumulation Values ..................................................

6

Ownership Definition ..................................................

2

Application ................................................................10

Payment of

Cash

Values and

Loans

...........................7

Beneficiary s Rights ...................................................

4

Payment of Death Benefit... .......................................4

Cash Value .................................................................

7

Polley Changes ..........................................................

6

Change of Beneficiary ................................................4

Polley Loans ...............................................................

7

Consistent

Premium

Payment Provislon .....................

5

Polley Schedule ..........................................................3

Death Benefit ............................................................ 4

Premlums ...................................................................

5

Definitions ..................................................................2

Reinstatement

of Lapsed Policy .................................5

General

Provlslons ...................................................

10

Settlement Provisions ................................................. B

Guaranteed Values ....................................................

6

Surrender

Option

........................................................ 7

Grace Period

..............................................................5

Table of Guaranteed Mortallty Rates ........................

11

Misstatement of Age .................................................10

Table of Surrender Charges .................................... 3A

2

O U P L \ t ~ f E

...

-- · - · - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -



19/25

THE BENEFICIARY

Who

Receives the

Death

Benefit

·We

will

pay the Death

Benefit to the

Beneficiary

when the Insured dies. The

Beneficiary

Is the person

or

entity

named

In

the application

unless changed,

Protection

of

the

Death

Benefit·

To

the

extent permitted

by law, the Death Benefit will not

be

subject

to

the claims of

tie

Beneficiary s

creditors.

If the Beneficiary Dies ~ I f any Beneficiary

dies before

the

Insured,

that

Beneflclarv s

Interest

In the Death

Benefit

will

end.

If any Beneficiary dies et

the

same time as the Insured,

or within 30 days after the Insured that Beneficiary s

Interest In the

Death

Benefit

will

end.

If he

Interest of all

named

beneficiaries

has ended

when

the Insured dies,

we

will

pay

the

Death

Benefit

to

you.

If you are not living

at

the

time, we

will ray the

Death Benefit

to the executor or

a


20/25

PREMIUMS

Subject to the

Preml

Limlta lon provision

and

the

followlng

condltlons, we wlll accept

any

payment you send

to us while this policy ls In force.

1.

You

may

pay the first premium to our

authorized

representative. You may send subsequent premiums

to our Home Office

oryou

may pay them to an agent or

cashier

we authorize.

We will

give you a receipt

If

you

ask

for

one.

2. You may

pay premiums

at any time,

but

only If each

premium Is at least 25.

Premiums

paid by payroll

deduction are accepted.

3. To quallfy for the Consistent

Premium Payment

Pro-

vision, you must submit the Consistent Premium

Payment Basis stated In the Polley Schedule.

You

must

abide

strictly

by the

conditions

In the

Consistent

Premium Payment Provision

section.

Premium

Limitation · ny

premium received di.ling

a

policy year which

Is more than

three tlmes

the

total of

the

Monthly

Deductlons

for

the last year

may

be

refunded.

We

may also refund

any

unscheduled premlums that exceed

25,000 In any twelve month

period.

We

will not refund any

amouri lf

doing so would cause

your

policy to lapse

before the

next

monthly anniversary day,

We

will apply any

refund

first

toward reduction of any

outstanding

loan If you

give

us wrllten Instructions

lo

apply

the

refund

In

this

manner.

We

wlll remove

the excess premium

at the

end

of any policy

year

If

he

premiums

paid

exceed

the

amount allowable

for

the Death Benefit to qualify for federal income tax exclusion.

Interest

wlll

be

paid on the amount removed to the end of

that policy year. We will refund this excess amount

(Including

Interest)

within 60

days

after the end

of

that policy

year.

Continuation of

Insurance

•

Subject to

the

Grace Period

provision, your policy

will

continue between premium

payments

at the same

face

amount plus additional benefits

pro\'ided by Rider, Refer to the

Monthly

Deduction section

for further explanation.

Grace

Period

· grace period Is

a period

of

61 days

after

which either of

the

following has

occurred:

1.

The

Accumulation

Value minus any

loan

is less than

the

Monthly

Deduction

due.

2.

On a

monthly

anniversary date

there

Is Insufficient Net

Cash Value

to cover tile

next Monthly

Deductron

and

the

sum of the premllm paid lo date

ts

less than one-

lwelrth

of

the Planned Periodic Premium on an

annual

basis limes the

n ber

of months since Issue.

At

least

30

days

prior

to termination,

we

will

give you written

nollce at your laet

known address that

the grace period has

begun. You

must

then pay

a

premium large

enough to keep

the policy In

force.

If

you

do not pay enough

premium,

your

policy

will

lapse.

We will subtract the premium necessary to provide cover-

age

to the date

of

death If the Insured dies during

the

grace

period.

Reinstatement

of

Lapsed

Polley

w Unless this policy was

surrendered,

it may

be reinstated after lapse. To reinstate

the

policy, you

must meet

the following conditions.

1. You must request reinstatement In writing within three

years from the date of lapse and before the lnsured's

age 95.

2.

The

Insured

must

still

be Insurable

by

our standards.

3. If any loans

existed

when

the

policy lapsed, you must

repay

or reinstate them together w

th· interest

'Milch

had

accrued

to

the dale

of

lapse,

4.

You

must pay a premium

large

enough

to

cover

the

two

Monthly

Deductions due when the policy lapsed

and

three Monthly Deductions

due when

the

poftcy

le

reinstated.

The Accumulation

Value of the reinstated policy

will

be any

loan repaid,

plus 100%

of any premium you pay

at

reinstatement, minus the

Monthly Deductions due

at the

time

of

lapse.

Consistent Premium Payment Provision ·The

Consistent

Premium Payment Provision Is an Increase to the

Accumulallon

Value of 30%

of

the

Consistent

Premium

Payment Basis on each

poBcy

anniversary

from

the

eleventh

through

the

twentieth.

These Increases wl I be

credited

to

your Accumulallon

Value if the following condition Is met:

1.

Al the e ld of each of the policy years beginning

with

lhe

eleventh

and

ending

with

the

twentieth,

the cumulallve

total to date of any renewal premiums paid

must

equal

or

exceed

the

number of

renewal

years

since Issue

times the Consistent Premium Payment Basis on the

Policy Schedule.

These

Increases

will

terminate when the

policy terminates.

5

DUPLICATE



21/25

POLICY

CHANGES

Changes In Specified Amount ·Subject to

the following

conditions, you may request

a

change In the lnsured's

Specified

Amount

after the

first policy anniversary.

1. Specified Amount Decreases

Any decrease will become

effective

on the monthly

anniversary

day that

falls

on

or next

foUows

receipt of

request. Any such decrease

will reduce Insurance In

the

following order:

(a)

Insurance

provided by

the most

recent inaease;

(b) the

next most

recent

inaeases

successively; and

(c)

Insurance provided

under the original application.

2.

Specffled Amount Increases

Any

request

for an

Increase must be

applied

for on

a

supplemental

appllcatfon. such increase sh.all be

subject lo evidence

of insurabllity

satisfactory to

us.

No

Increase

Is

allowed

unless the Net Cash

Value

Is

sufficient to cover the

next

Monthly

Deduction.

Change In Death

Benefit Option ·You

may request

a

hqe

In

the

death benefit

option In

effect after the first

policy anniversary. The request must

be In

a

written

form

acceptable

to us.

Subject

to the following,

he effective

date

of

the

change wlll

be

the monthly anniversary day that fells

on

or next

follows the

date we receive

your requesl

1 If

the change Is

from Option A toOption 8

the

Specified

Amount after

such

change

shall be equal

to

the

lnsured's Specified Amount before sueh change less

the

Accumulation

Value

on

the

date

of

change.

2.

If

the change

la

from Option

8

to

Option

A,

the lnsured's

Spedfied

Amount

after such

change

shall be

e q u ~

to

the lnsured's Death Benefit before such change.

GUARANTEED VALUES

Accumulation Values ·The Accumulation

Value

on any

specified

date ls equal to:

1. The Accumula6on Value

on

the last monthly

an

nlversary day

plus accrued Interest from that

date

to the specified

date.

plus 2.

All

net premiums paid since the last monthly

anniversary day

plus

accrued interest from the

date

of receipt

to the specified date Iese any

refunds since

the last

monthly anniversary day.

minus

3-

Any partial

surrenders since the last monthly

anniversary

day.

At

the end of each policy month, the

Monthly

Deduction

wRI

be subtracted from

the Accumulatlon

Value.

Interest

Rates

•

The

guaranteed

minimum Interest rate

for

all polk::y years Is 4%.

We

may

declare a higher lnlerest

rate than the guaranteed

minimum

rate at any time. We may

change

this higher rate

at

our

option.

We

will never declare

a

rate lower than the

guaranteed minimum Interest

rate.

We will pay Interest on any part of the Accumulatlon Value

securing

a

Polley

Loan.

The excess rate may

be

lower than

the rate

credited to

the

unborrowed portion

of

the

Accumulatlon Value.

Monthly Mortality Charge - We

will determine the Monthly

Mortality Cost Charge for each policy year at the beginning

of

that

year. We

will use

the lnsured's age as of that

policy

year.

A

Table of

Guaranteed Maximum

Monthly Mortality

Cost

Charges

Is shown on

page

11.

We

may use rates

lower

than

these monthly

deduction

rates. We will

never use

higher

rates.

A

reduction In

the guaranteed

Monthly Mortality Cost

Charges for this policy

will also

apply

to all

other policies

Issued

on the same plan

and

to the same class

of

Insured.

The

reduced rate

will not

be affected

by

any

change In the

lnsured's health

or

occupation.

Monthly Deduction • We will take

the

Monthly Deduction

for the prior month from the Accumulation Value at the end

of

that

policy month.

The Monthly Deduction is equal to

{a the Monthly

Mortallty

Cost Charge times

the

difference between

the Death

Benefit and

the

Accumulation Value at the beglMing

of the

month,

plus (b)

the

Monthly Deduction for any Riders,

plus (c) the monthly

expense

charge

as

shown

In

the

Polley

Schedule.

·

... ~ D U P L ~ C A T E



22/25

BASIS

OF

COMPUTATION

The

Cash Values of

the

policy will not be less than the

minimum

values required by the Stale

where

the pafcy

Is

dellvered. Tue gunnteed Monthly

Deduclicn rates and

the

guaranteed Interest rate are

the

basis

fa

the Cash Values.

Calcufetfon

a minimum

Cash Value and ncnforfelture

benefits

Is based

en

the Commissioners 1980 Standard

Ordinary

Smoker/Nonsmdcer

Ultlmale Mortality Tables

for

males and

females, age last

birthday

and

4%

Interest

Death Is assumed lo occur t the end

of the poUcy

year.

We have flied the method we used to compute minimum

Cash

Values and nonforfeiture benefits

with

the Supervisory

Official

a the

Shte of policy

delivery.

SETILEMENT

PROVISIONS

·When the Insured dies, we will pay the Death

Benefit

In

a

lump sum unless you or

the

Beneficiary

choose a

settlement option.

You may

choose a settlement

option

while

the

Insured Is llvlng. The Benellclary may choose

a

settlement option after the Insured

has

died.

You may

also choose one of these

opllons as

a method

receiving the surrender

or

maturity

proceeds

if any

ll e

available

under

this

policy. if

the

BeneHciary Is no

an

Individual, Home

Office approval ts required.

When we receive

a

satisfactory wrlllen r q u s ~ we

will

apply the benefit according

to

one of these options:

OPTION A: Installments for a Guaranteed Period • We

wfll

i:>ay

equal

Installments

for

a guaranteed

period

of

one

to thirty years. Each Installment will consist of

part benefit

and

part Interest. We ·win pay the Installments as

requested either monthly, quarterly, semi-annually or

ainually.

See Table A.

OPTION B: Installments for Life with a Guaranteed

Period

· e

will pay equal monthly installments as long

as

the payee Is living, but we Will

not

make payments for

less

than the guaranteed period

the

payee chooses. The

guaranteed

period

may be either ten or twenty years. We

will pay

the Installments monthly. See Table B.

OPTION C:

Benefit Deposited with Interest

· e

wlll

hold the

benefit

on deposll.

It

will earn Interest

at

such

Interest rates as we declare, but

not less

than 4%

annually.

We will

pay

the earned interest

as requested

either

monthly,

quarterly, semi-annually or annually.

The

payee may

withdraw part

or

all

of

the benefit and earned

Interest

t

any time.

.

OPTION D:

Installments of a

Selected

Amount.

We will

pay

Installments

of

a

selected amount untll we have paid

the

entire benefit

and

accumulated

Interest.

OPTION

E:

Annuity -We

wlll use

the

benefit as

a single

premium

to

buy an annuity.

The

annuity may be payable

to one or

two

payees. It may

be

payable as

requested

for

life with

or wltliout a guaranteed

period. The

annully

payment wlll

not

be

less

than

our current amulty contracts

are then paying.

The payee may

arrange

af Y

other

method

of settlement

as

long as we agree to

It.

The payee must be an Individual

receiving payment In

his or

her

own

right.

There must

be

at

least 1,000

avallable

for

an

optlon

and each

installment to each

payee

must be

Et least $26.

If the

benefit ls not enough to meet these

requirements,

we will

pay the benefit In

a

lump sum.

We

will

pay the ftrst lnstaHment

under

any

option

as

of

the

date of death,

maturity, or

surrender. Any

unpaid

balance

we hold under

Option

A, 8 or D will earn Interest at the

rate we are 1>aying at the time

of

the

settle1mr1l

We wlll

not

pay

less

than

4% annual Interest.

If the payee does

not

live to

receive ll guaranteed

payments under Oi:>tlon

A, B,

D

or

E or

any amount

deposited under

Option

C,

plus any accumulated

interest,

we will pay

the

remaining benefit

to

the

payee's

estate.

The

payee

may

name

and

change a

successor

payee for

any amount

we would otherwise

pay the payee's

estate.

a ·

D U P l ~ C T E



23/25

TABLE A

INSTALLMENTS

FOR

EACH 1000 PAYABLE UNDER

OPTION

A

GuaranlH

Monthly

Gueranloa

Monthly Guarantee

Monlhly

Porlod

1n1lallm1nt1

Period

ln•tallm111t1

Period

lnmlallm1nla

1

$84.84

11

$1.31 21

11.111

2


24/25

·•

GENERAL

PROVISIONS

Annual

Report·

We wHI

send

you

a

report

at least

once

a year which shows the premium payments,

expense

charges, Interest· credited,

mortality

charges, and

partial

surrenders

since lhe

last report. It

will also

show any

a.itstand(ng

loans,

the

current

Accumulation Value, and

current Net Cash

Value.

Projection

of

Benefits· If you

send us

a

written request,

we wll

furnish

you a

report which

shows

future

benefits

and values, The report will assume your Speclrled

Amount, type of Death

Benefit option,

Interest rate

and

future premium

payments. We

may

specify other

assumptions

a

necessary. You may request

one

report

free each

year.

Addltlonal reports will

not

cost

more

than

25 each.

lncontcstablllty

of

the Polley ·This

policy wlll be

lncontes able after It has been In force during

the

lnsured's nfetime

for two years from

the

Policy Date. This

provision does not apply to any Rider providing benents

speclflcally for

disability

or

death

by accident.

Amount

We Pay Is

limited

In

the Event of Suicide

We wlll

be

Hable only for

the

premiums paid, less any

particular surrenders, if

the

Insured dies by suicide whlle

sane or Insane w ithin one year from the Polley Dale.

Misstatement of

Age

or

Sex In the

Appllcation If

there Is a

misstatement

of the

lnsured's age

or sex

In

the

pol cy, we will adjust the excess of the Death Benefit ova."

the

Accumulatlon Value to

that which the most

recent

Monthly

Deduction

would purchase at

the

correct age or

sex.

The

Contract Consists of

the Polley and the

Appllcatlon

We

have Issued

this pollcy In consideration

of

the

application

and

Initial premium.

A

copy of the

application Is attached

and

Is

a

part of this

policy.

The

policy and the

application

together are the

entire contract. All statements

made by or for the Insured are considered representations

m

not warranties.

No

statements other

than

those

contained

In

the application wlll be used

lo

void

the pollcy

or defend

a

clalm.

Who Can Make

Changes

In

the Polley ·Only

our

Presldent or a Vice

President

together with our Secretary

have the

authority

to

make any changes ln this pollcy. Any

change must be

In

writing.

Assignment of the Polley

You may assign

or transfer all

or specific rights of

your

poUcy. No assignment wlll be

effective unlll you

notify

us In

writing. We

will

record

your

assignment. We wlll not be responsible

for

Its

valldlty

or

effect.

Death of the Owner

If

you die before the Insured, your

rights

will pass

to the executor

of your estate unless

ownership has been otherwise assigned.

Termination of Insurance ·This

policy

ill terminate m

lhe earliest of:

a the date

of surrender;

b. the poOcy anniversary following the lnsured's age

9 ;

or

c. the date of lapse.

No

Dividends

are

Payable

This Is nonparticipating

Insurance. It does not participate In our profits or surplus.

We do

not

distribute past surplus or recover past

losses by

changing the Monthly Deduction rates.

Notice •

Any

notice given

under

the provisions of this pollcy

will be sent to your last knCM'n address

and to

any assignee

of

record

10



25/25

GUARANTEED

MAXIMUM MONTHLY

MORTALITY COST CHARGES

PER DOLLAR NET AMOUNT AT RISK

AGE

1

2

3

4

G

7

II

9

10

11

12

13

14

Hi

111

17

18

19

20

21

22

23

2'4

25

28

27

211

211

30

31

32

33

34

35

36

37

38

39

'40

41

42

43

44

45

46

NONSMOKER

MALE FEMALE

0.000219215 0.00011i6691

o.ooooao641 0.000010005

0.000092507 0.000006611

0.0000110040

0.000065004

0.000077606 0.000064171

0.000073339 0.000062604

0.0000611171

0.0000601137

O.OOOOBB004 0.0000811170

0.000082604 0.000068337

0.000061670 0.000057503

o.ooooe2s

Date post:	01-Jun-2018
Category:	Documents
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DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint

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