Exercise FIO App - Premiums Payable Future Purchase Option _FPO_

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Exercise FIO App - Premiums Payable Future Purchase Option _FPO_ Powered By Docstoc
					             Berkshire Life Insurance Company of America
             700 South Street                                                          APPLICATION FOR EXERCISE OF FUTURE
             Pittsfield, Massachusetts 01201                                           PURCHASE OPTION, FUTURE INCREASE
             Berkshire Life Insurance Company of America is a subsidiary of            OPTION OR GROUP DISABILITY
             The Guardian Life Insurance Company of America, NY, NY                    REPLACEMENT OPTION – PENNSYLVANIA

1. Proposed Insured ___________________________________________ 2. Date of Birth ______________________
3. Social Security Number ______________________________________ 4. Marital Status _____________________
5. Primary Home Address____________________________________________________________________________
                                                                              Street, City, State and Zip Code


                                                                       Premiums Payable
                                                                          (Must Be Completed)

6a. s     Annually                              s Semiannually                      s Quarterly
    s     Monthly, by Automatic Payment Plan Premium
    s     Add to my existing monthly Automatic Payment Plan Service; number ______________________
    s     Monthly (for list billing only)
   b. If existing list bill, what is list billing number? ______________________
   c. If new list bill, name of business _______________________________ and common billing date _______________
   d. Premium Structure:                 s Level              s Graded             s Step-Rate (Disability Buy-Out only)
 7. Amount paid with application: $__________________
    Was receipt for amount paid with application delivered to you?                                  s Yes s No
 8. Premium notices on the new policy will be sent to the same person as under the Policy to which the FPO, FIO or GDR
    being exercised is attached, unless otherwise indicated below.
    Mail premium notices to: __________________________________________________________________________

                                                           Future Purchase Option (FPO)

9. From Policy Number ____________________________                                        10. Basic Plan/Policy Form No. ____________________
11. Amount of Future Purchase Option to be exercised:
    a. s Monthly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ ________________
    b. s Lump Sum (Disability Buy-Out only) . . . . . . . . . . . . . . . . . . . . . . . . . . .$ ________________
12. Total of New Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________________
                                                                                                                  ________________

13. Supplemental Benefits
    a. Continuation of Benefits – If your original policy has any of the following benefits, select those you want to
       continue on the new policy:
          Name of Benefit                                                                                Yes                          No
          COLA          _________%                                                                        s                           s
          Residual Disability                                                                             s                           s
          Lifetime Indemnity/Benefit Period                                                               s                           s
          Presumptive Permanent Disability (for Disability Buy-Out, monthly or down payment funding only) s                           s
          Other: _________________________________________________________                                s                           s

    b. Addition of Benefits – Do you want to add any of the following benefits to your new policy:
       Adding a benefit to the new policy will require underwriting. Complete Additional Information Questions on Page 4
       and Authorization on Page 6.

          Name of Benefit                                                                                Yes                            No
          COLA          _________%                                                                        s                             s
          Residual Disability (regular)                                                                   s                             s
          Residual Disability (2-year)                                                                    s                             s
          Lifetime Indemnity/Benefit Period                                                               s                             s
          Presumptive Permanent Disability (for Disability Buy-Out, monthly or down payment funding only) s                             s
          Other: _________________________________________________________                                s                             s

71-EXER PA (06/01)                                                            Page 1
                                             Future Increase Option (FIO)
14. From Policy Number ____________________________                   15. Policy Form No. _______________________
16. Total Amount of Future Increase Option to be exercised . . . . . . . . . . . . . . . . . . . . . . . .$ ________________
        Monthly Indemnity . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ ________________
        SIO/SIS Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ ________________
        Lump Sum (Disability Buy-Out only) . . . . . . . . . . . . . . .$ ________________

17. Supplemental Benefits
    a. Continuation of Benefits – If your original policy has any of the following benefits, select those you want to
       continue on the new policy:
          Name of Benefit                                                                                Yes                   No
          COLA          _________%                                                                        s                    s
          Residual Disability (regular)                                                                   s                    s
          Residual Disability (2-year)                                                                    s                    s
          Presumptive Permanent Disability (for Disability Buy-Out, monthly or down payment funding only) s                    s
          Other: _________________________________________________________                                s                    s

    b. Addition of Benefits – Do you want to add any of the following benefits to your new policy:
       Adding a benefit to the new policy will require underwriting. Complete Additional Information Questions on Page 4
       and Authorization on Page 6.

          Name of Benefit                                                                                Yes                   No
          COLA          _________%                                                                        s                    s
          Residual Disability (regular)                                                                   s                    s
          Residual Disability (2-year)                                                                    s                    s
          Presumptive Permanent Disability (for Disability Buy-Out, monthly or down payment funding only) s                    s
          Other: _________________________________________________________                                s                    s

                                   Group Disability Replacement Option (GDR)
18. From Policy Number ____________________________                   19. Policy Form No. _______________________
20. Date GLTD Coverage Terminated _______________________
21. Total Amount of Group Disability Replacement Option: . . . . . . . . . . . . . . . . . . . . . . . . .$ ________________
        Monthly Indemnity . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ ________________
        SIO/SIS Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ ________________

22. Supplemental Benefits
    a. Continuation of Benefits – If your original policy has any of the following benefits, select those you want to
       continue on the new policy:
          Name of Benefit                                                                                          Yes         No
          COLA             _________%                                                                               s          s
          Residual Disability (regular)                                                                             s          s
          Residual Disability (2-year)                                                                              s          s
          Partial Disability                                                                                        s          s
          Other: _________________________________________________________                                          s          s

    b. Addition of Benefits – Do you want to add any of the following benefits to your new policy:
       Adding a benefit to the new policy will require underwriting. Complete Additional Information Questions on Page 4
       and Authorization on Page 6.

          Name of Benefit                                                                                          Yes         No
          COLA             _________%                                                                               s          s
          Residual Disability (regular)                                                                             s          s
          Residual Disability (2-year)                                                                              s          s
          Partial Disability                                                                                        s          s
          Other: _________________________________________________________                                          s          s

71-EXER PA (06/01)                                          Page 2
                                               Employment Information
                                                     (Must Be Completed)

23a. Occupation(s) _____________________________ b. Exact duties _____________________________________
  c. Nature of Business ___________________________________________________________________________
  d. Insured’s annual earned income (net income before taxes) for last full tax year:               $_________________
  e. Other Income (investments, rents, etc.). Source_________________________                       $_________________
  f. Are you now disabled?       s Yes     s No                            g. Are you working full time?   s Yes     s No
  h. For Overhead Expense: Your share of covered expenses? $________________; and _____________% of total.


                                                   Existing Insurance
                                                     (Must Be Completed)

24. Existing Disability Income, Overhead Expense and Disability Buy-Out Insurance
      (Describe all coverage in force, including individual, franchise, association, group, or government plans and any
      disability insurance terminated within the last six months).

                              Monthly Policy Date Benefit              Other                     Terminated or
         Company              Benefit Mo/Day/Yr Period                Benefits                To be Terminated?
                              $                                                           s Yes, Date           s No
                              $                                                           s Yes, Date           s No
                              $                                                           s Yes, Date           s No



25.   Details and Special Requests
      (Include requests for any additional or alternate policies. Give details for YES answers to Questions pertaining to
      Aviation Travel and Avocation and Underwriting Information.)




71-EXER PA (06/01)                                         Page 3
                           Additional Information – Complete Questions 26, 27 and 28
                                   when adding any benefit to the new policy.

26a. Primary Home Address: _________________________________________________________________________
                                                                  Street, City, State and Zip Code

      b. Home Telephone Number _________________________                      c. How many years at this address? ______________
      d. Business Address: ____________________________________________________________________________
                                                                  Street, City, State and Zip Code

      e. Business Telephone Number _______________________                     f. How many years at this address? ______________
      g. Previous address of Proposed Insured if moved during past 3 years: s Residence or s Business
        from _______________________________________________________________________________________
        to _________________________________________________________________________________________
      h. Employer (if business) _________________________________________________________________________
      i. Address: ____________________________________________________________________________________
                                                                  Street, City, State and Zip Code


27.   Aviation Travel and Avocation
      a. Within the past three years (1) have you flown or (2) do you contemplate flying as a student
         pilot, pilot, crew member, or with any duties aboard an aircraft in flight?
         (Complete Aviation Supplement if answer is “Yes”.)                                                           s Yes       s No
      b. Do you contemplate a change in residence to or travel in a foreign country?                                  s Yes       s No
      c. Within the past three years, have you participated in or do you contemplate participating in:
         scuba diving; sky diving; hang gliding; any form of motor racing; or any other hazardous
         activities?                                                                                                  s Yes       s No

28.   Underwriting Information–give details of Yes answers in Details and Special Requests Section.
      Since the effective date of coverage for the insured:
      a. Has there been a change in occupation?                                                                       s Yes       s No
      b. Has there been any illness, injury or surgical operation?                                                    s Yes       s No
      c. Has a physician or any other practitioner been consulted; or has any lab, X-ray, or diagnostic
         testing been done?                                                                                           s Yes       s No
      d. Has an application for a policy or reinstatement of a life or health policy been declined,
         rated-up, postponed, or modified as to kind or amount?                                                       s Yes       s No
      e. Are you, the undersigned, aware of any impairment in health of the insured(s)?                               s Yes       s No
      f. Are you, the undersigned, aware of the use of tobacco in any form by the insured(s) in the
         last 12 months?                                                                            s Yes s No
      g. The name(s) and address(es) of the insured physician(s): _____________________________________________
                                                                                                        Name

      _____________________________________________________________________________________________________________________________________
                                                           Address (Street, City, State and Zip Code)

      h. This physician, or any other, was last consulted by the insured:
      Date_________________ Reason _____________________________ Results______________________________




71-EXER PA (06/01)                                               Page 4
I (we) represent that the answers in this application to Berkshire Life Insurance Company of America are true and complete;
and that together with the statements of the Proposed Insured in any evidence of insurability furnished shall form the basis
and be a part of the contract of insurance, if issued. It is also understood and agreed that:
Insurance in the amount of the Option resulting from the exercise of the Future Purchase Option, Future Increase Option
or Group Disability Replacement Option shall take effect as provided in the agreement or provision providing the Option.
Insurance in excess of the Option, if any, and additional benefits desired, if any, shall not take effect until (1) insurance in
the amount of the Option takes effect, and (2) a policy including (in addition to insurance in the amount of Option) such
excess insurance and/or additional benefits is delivered to the Owner while the health and other conditions affecting
insurability of the Proposed Insured remains as described in the Application or in any evidence of insurability furnished with
this Application, and (3) the required premium has been paid.
The word “Option” refers to the Options to Purchase Additional Insurance provided in an agreement attached to the policy
indicated. By exercising the Option, the owner hereby elects, pursuant to said Option agreement, to purchase such
additional insurance for the Option amount indicated and on the Option date indicated.
No information acquired by any representative of the Company shall bind the Company unless it shall have been set out
in writing in this Application. Only the President, a Vice President, the Secretary or an Assistant Secretary may make,
modify, or discharge contracts or waive any of the Company’s requirements, and then only in writing.
I, the Proposed Insured, acknowledge receipt of: the Notice of Insurance Information Practices; the Fair Credit Reporting
Act Disclosure; and the Medical Information Bureau Pre-Notice.
Under the penalties of perjury, I, the Owner, certify: (1) that the Number shown on this application is my correct Taxpayer
Identification Number and (2) that I am not subject to backup withholding under the Internal Revenue Code either because:
(a) I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends;
or (b) the Internal Revenue Service has notified me that I am no longer subject to backup withholding.

Signed at ____________________________________                          Signed ____________________________________
            City, State                         Mo-Day-Yr                                      Proposed Insured


Witness _____________________________________                           Signed ____________________________________
                                                                                        Owner (if other than Proposed Insured)




                                                                        Consent of Assignee (Assignment to Continue)


                                                                        Signed ____________________________________
                                                                                                      Assignee



Any person who knowingly, and with intent to defraud any insurance company or other person, files an
application of insurance or statement of claim containing any materially false information or conceals, for the
purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act,
which is a crime, and subjects such person to criminal and civil penalties.




71-EXER PA (06/01)                                          Page 5
Authorization
I authorize any physician, medical practitioner, hospital, clinic, other medical or medically related facility, insurance or
reinsuring company, the Medical Information Bureau, Inc., consumer reporting agency, or employer having information
about me, to give to Berkshire Life Insurance Company of America at its home office in Pittsfield, Massachusetts, any and
all such information with respect to diagnosis, treatment and prognosis for any physical or mental condition and/or
treatment of me and any other non-medical information.
I understand the information obtained by use of this Authorization will be used by Berkshire Life Insurance Company of
America to determine eligibility for insurance. Any information obtained will not be released by Berkshire Life Insurance
Company of America to any person or organization except to: reinsuring companies; the Medical Information Bureau, Inc.;
or other persons or organizations performing business or legal services in connection with my application, or as may be
otherwise lawfully required or as I may further authorize.
I know that I may request to receive a copy of this Authorization.
I agree that a photographic copy of this Authorization shall be as valid as the original.
I agree this Authorization shall be valid for two and one half years from the date shown below.



Signed at ____________________________________                        Signed ____________________________________
                             City, State                                                    Proposed Insured



Date ________________________________________                         Witness ___________________________________


Any person who knowingly, and with intent to defraud any insurance company or other person, files an
application of insurance or statement of claim containing any materially false information or conceals, for the
purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act,
which is a crime, and subjects such person to criminal and civil penalties.




71-EXER PA (06/01)                                        Page 6
                                                                  Agent’s Statement

1a. Does this application involve a replacement as defined under applicable state law or
    Company procedure?                                                                                                    s Yes   s No
 b. If “Yes” did you deliver appropriate disclosure statement?                                                            s Yes   s No
2. Did you deliver to the Insured the Notice of Insurance Information Practices, the Fair
   Credit Reporting Act Disclosure and the Medical Information Bureau Pre-Notice?                                         s Yes   s No
3. Remarks by Agent or Broker: ____________________________________________________________________
I certify that I have truly and accurately recorded the information supplied on this application and all attachments thereto.
I have witnessed the signatures on the application, authorization, medical and all other documents.
___________________________________________________________________
Please Print Name of Licensed Agent or Broker Completing This Application




Signed _______________________________________
               Licensed Agent or Broker Completing This Application

This information will be used for the payment of commissions. If the information is inaccurate, processing of the
Application and payment of commissions will be delayed.


 Agent or Corporate Code                    Agent’s Surname or Corporate Name               1st Year                   Renewal %
                                                                                               %              (If different from 1st Yr.)




I have reviewed this application. I have determined that all the required answers and statements have been made.




   __________________                                                        _________________________________________________
          Agency Number                                                                      Agency Personnel Signature

Any person who knowingly, and with intent to defraud any insurance company or other person, files an
application of insurance or statement of claim containing any materially false information or conceals, for the
purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act,
which is a crime, and subjects such person to criminal and civil penalties.




71-EXER PA (06/01)                                                          Page 7
Notice of Information Practices
Thank you for your interest in insurance with Berkshire Life Insurance Company of America. Your application will be
evaluated as promptly as possible. Since underwriting and administering your insurance coverage will include the
collection of a certain amount of personal information by the Company and your authorized representative, this notice is
intended to tell you more about our information practices.
Collection of Information
Notice of Insurance Information Practices: To issue an insurance policy we need to obtain information about you and
any other persons proposed for insurance. Some of that information will come from you and some will come from other
sources. That information and any subsequent information collected by us may in certain circumstances be disclosed to
third parties without your specific authorization. You have a right of access and correction with respect to the information
collected about you except information which relates to a claim or civil or criminal proceeding.
If you wish to have a more detailed explanation of our information practices, make a written request to Berkshire Life
Insurance Company of America, Underwriting Department, 700 South Street, Pittsfield, Massachusetts 01201.
Fair Credit Reporting Act Disclosure: In making this application it is understood that an investigative consumer report
may be made whereby information is obtained through interviews with third parties. This inquiry includes information as to
your character, general reputation, personal characteristics, and mode of living. You have the right to make a written
request to Berkshire Life Insurance Company of America, Underwriting Department, 700 South Street, Pittsfield,
Massachusetts 01201, within a reasonable period of time for additional information concerning the nature and scope of the
investigation.
Medical Information Bureau Pre-Notice: Information regarding your insurability will be treated as confidential. Berkshire
Life Insurance Company of America may, however, make a brief report thereon to the Medical Information Bureau, a non-
profit membership organization of life insurance companies, which operates an information exchange on behalf of its
members. If you apply to another Bureau member company for life or health insurance coverage, or a claim for benefits is
submitted to such a company, the Bureau, upon request, will supply such company with the information in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you
question the accuracy of information in the Bureau’s file, you may contact the Bureau and seek a correction in accordance
with the procedures set forth in the Federal Fair Credit Reporting Act. The address of the Bureau’s information office is
Post Office Box 105, Essex Station, Boston, Massachusetts 02112, telephone number (617) 426-3660.
Berkshire Life Insurance Company of America may also release information in its file to reinsurers and to other life
insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted.




                                            (Give this form to the applicant)

71-EXER PA (06/01)                                       Page 8
                                              Additional Billing Information
Multi-life or list bill plans
Indicate if the policy applied for is part of any of the following plans:

Check all that apply

   Type of Plan:
   s Qualified Sick Pay Plan (QSPP) - (Only the proposed Insured may be an owner or loss payee in a QSPP)
   s    Voluntary Income Protection (VIP)
   s    Employer Sponsored Plan - multi-life (2 or more)
   s    Association
        s New Association case                                ___________________________________________________
                                                                                    Association Name and Case #



                                                              ___________________________________________________
                                                                                              Address



        s Add to Association case                             ___________________________________________________
                                                                                    Association Name and Case #



   s    List bill plan - All policies must have a common billing date and premium mode.
        s New list bill plan - You must request the same list bill date for all policies.


                                                              ___________________________________________________
                                                                                            List Bill Name



                                                              ___________________________________________________
                                                                                              Address



                                                              ___________________________________________________
                                                                                            List Bill Date



        s Add to list bill plan - Show the list bill date (the next premium due date) of the existing plan.


                                                              ___________________________________________________
                                                                                      List Bill Name and Number



                                                              ___________________________________________________
                                                                                            List Bill Date



SPECIAL INSTRUCTIONS: Use this section to request special underwriting or issue considerations.


Name of other insureds whose application should be handled concurrently:
________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________




 71-EXER PA (06/01)                                             Page 9
            Berkshire Life Insurance Company of America
            700 South Street
            Pittsfield, Massachusetts 01201                                  PART 1–FINANCIAL SUPPLEMENT
            Berkshire Life Insurance Company of America is a subsidiary of
            The Guardian Life Insurance Company of America, NY, NY



Full Name of Proposed Insured                                                                                           Date of Birth
(Print–First Name, Middle Initial, Last Name–Leave space between names)                                                 Mo Day   Year




A. Income. Fill in amounts requested for last year and two years ago using the Proposed Insured’s individual and/or business
income tax returns and supporting schedules. Note: Do not list income that is not reported to the IRS. Explain in Section C any
significant fluctuations between years. Describe any changes since the end of the most recent calendar year. Put loss amounts
in parentheses.


                                                                                                         Actual Last     Actual 2 Calendar
                                                                                           Actual*      Calendar Year        Years Ago
                                      Earned Income                                      Year to Date      ______             _______

1. Non-owner/employee’s salary and bonus from Form W-2


2. Owner/employee’s salary and bonus from Form W-2

3. Amount of after-tax corporate earnings, excluding salary and/or bonus,
   taxable as personal income.
4. Sole proprietor net income or loss (after expenses) from Form 1040
   Schedule C. If spouse has duties, explain in Section C.
5. Share of partnership net income or loss (after expenses) shown on the
   Proposed Insured’s Schedule K-1.
6. Pension plan contributions or other amounts that the Proposed Insured had
   the option to receive as salary and would cease if the Insured were disabled.

7. Other earned income (explain source in Section C).


8. Total earned income – add amounts above.

9. Unearned income. This includes capital gains, interest, dividends, tax exempt
   unearned income, income from other investments, net rental income, pensions,
   annuities, and alimony. If none, so state.

                                                                                                                         *Do Not Estimate.

10.   Have there been any changes in your job or business which are likely to result              Yes              No
      in a significant difference between current years earnings and the last calendar
      year? (If Yes, describe in Section C).                                                       s               s

11.   Estimate your Net Worth (gross worth less any mortgage loans and other debts):              $______________________
      (Give details in Section C).
                       Cash, Savings, Stocks, Bonds, Cash Value of Life Insurance                 $______________________
                       Interest in your business (excluding goodwill)                             $______________________
                       Personal Property                                                          $______________________
                       Real Estate Residential Only                                               $______________________
                       Other Real Estate                                                          $______________________
                       Other (give details in Section C)                                          $______________________



71-FS (06/01)                                                                Page 1
12.   Has the Proposed Insured or any business owned in whole or in part by the Proposed                 Yes             No
      Insured ever been (a) in bankruptcy or (b) named as debtor by a creditors’ committee,
      or (c) entered into a composition agreement with creditors, or (d) named in a receiver-               s             s
      ship action? (If Yes, give details in Section C).

      Date Discharged:________________________ Where:____________________________________________________
                              Month/Day/Year                                 City                      County          State
B.    Business Insurance – complete when the beneficiary, owner or payor is the business
      (Overhead and Disability Buy-Out Insurance).
      The following questions apply to _______________________________________________________________________
                                                                             Name of Business

1.    Give names of all officers, key persons or partners. (If there are any on whom business
      insurance is not carried or proposed, explain in Section C.)
                                                                                         Business Ins.              Business Ins.
                  Name                               Title                   % Owned       in Force                  Proposed
                                                                                             $                  $




2.    Has the business ever been (a) in bankruptcy or (b) named as debtor by a                         Yes             No
      creditors’ committee, or (c) entered into a composition agreement with creditors,
      or (d) named in a receivership action? (If Yes, give details in Section C.)                       s               s

      Date Discharged:_________________________ Where:___________________________________________________
                               Month/Day/Year                                City                      County          State
3.    If to cover a business loan, give loan amount, purpose, and repayment schedule:



4.    Business Financial                                                                           Actual Last   Actual 2 Calendar
                                                                                      Actual*      Calendar Year    Years Ago
                                                                                    Year to Date      ______         _______
      a. Total Assets                                d. Gross Annual Sales
      b. Total Liabilities                           e. Net Profit after Taxes
      c. Business Net Worth (a – b)

5.    Estimated Fair Market Value $_____________________
C.    Remarks (Show any details to your answers here)

       *Do not estimate.
It is understood and agreed as follows:
The statements and answers made above are true and complete and correctly recorded. The Company may rely on them to
determine the amount, if any, of insurance it will issue, and they shall form a part of the contract of insurance if issued.
If no written buy-sell agreement is in place, one must be executed before a disability occurs which would qualify for benefits under
the policy. Otherwise, Berkshire will have no liability. We will require a written assurance within one year of the policy date that
an agreement is in place. If no assurance is received, the policy will be voided and the premiums refunded.

Signed at_____________________________________________________________ Date_____________________,______

Witness___________________________________________                 Proposed Insured___________________________________
                                                                   Officer of Corporation
Witness___________________________________________
                                                                   or Business Principal ________________________________
                                                                   (If Section B Required)

Any person who knowingly, and with intent to defraud any insurance company or other person, files an application of
insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and may also
be subject to civil penalties.
71-FS (06/01)                                            Page 2
                     Berkshire Life Insurance Company of America
                     700 South Street
                     Pittsfield, Massachusetts 01201                                      AUTOMATIC PAYMENT
                     Berkshire Life Insurance Company of America is a subsidiary of       PLAN AUTHORIZATION
                     The Guardian Life Insurance Company of America, NY, NY




 Berkshire Life Insurance Company of America is hereby requested and authorized to draw checks or electronic fund transfers
 monthly against the checking or savings account listed below.
                                                                       Name of
         Name of Bank___________________________________________Branch (if any)______________________________
Print
or
Type
         }   Address of Bank___________________________________________________________________________________
             Account in Name of______________________________________ Account Number ____________________________
             Type of Account: s Checking                          s Savings
             s For collection of premiums on the policies shown below.                                 Bank Transit No. ____________________________
                                                                                                                       For Agency or Home Office Use Only
             s For repayment of loans at $___________ per month on                                                     Agency Code
               the policies shown below.
                                                                                                                       APP Code
             ATTACH VOIDED CHECK/SAVINGS DEPOSIT SLIP HERE
 For Payment of           Policy Number
                            or New                                                                                                                   Month Paid
  Policy Policy            Application                                                     Name of Insured                                            by First
 Premium Loans*              Dated                                                                                                                   Withdrawal

     s           s

     s           s

     s           s

     s           s

     s           s

 *Policy premium must be paid by automatic payment plan in order to repay a loan by automatic payment plan.


   If more than one policy is under the Automatic Payment Plan                               premiums due prior to the end of the calendar month of this authorization.
Authorization, the Company will combine the monthly premiums in one                              The Company is authorized to deposit monthly checks or process
monthly charge. Policy loan payments will apply to only one policy at a                      electronic fund transfers for payments at any time during the month they
time, in the order in which they are listed above. This authorization when                   fall due. It is the Company’s present intention to deposit such checks or
approved on behalf of the Company by its Secretary or an Assistant                           transfers on or about the 15th of the month.
Secretary shall be in effect on a policy only when and if such policy is                         The provisions stated below are agreed to.
issued and delivered and in full force; and with payment in cash of all


Signed at X_________________________________ this X_________________________ day of X_________________________________________

X___________________________________________________________                                X_________________________________________________________
               Signature of Depositor (if other than owner)                                                      Signature of Policyowner


                                                                              Provisions Applicable To

PREMIUM PAYMENTS                                                                            to reduce the loan on only one policy at a time in the sequence indicated
   Under this Authorization, if and when approved, the premium on the                       on the face page.
policy(ies) shall be payable monthly. The due dates of monthly premiums
are based on the anniversary date of the policy.                                            GENERAL PROVISIONS
   If the Authorization is no longer effective, premiums shall be payable                       The word “policy” as used herein shall include “Annuity Contract” if
on the most frequent mode available under Company practice.                                 appropriate.
   If the option to apply dividends in reduction of premiums has been pre-                      No payment or portion thereof toward any premium shall be deemed
viously elected, the Policyowner hereby elects that dividends be used to                    to have been paid unless or until Berkshire Life Insurance Company of
purchase Paid-Up Additions (except for Term Policies or Annuities, on                       America receives actual payment at its Home Office and no check or
which dividends will accumulate at interest).                                               electronic fund transfer drawn by the Company constitutes a receipt
   If the option to apply dividends to purchase one year term insurance                     unless it is honored. The Company shall incur no liability as the result of
with any balance to apply in reduction of premiums has been previously                      the dishonor of any charge under the Authorization.
elected, the Policyowner hereby elects that any balance be paid in cash.                        Any Authorization of the Company to draw checks or electronic fund
                                                                                            transfers may be terminated by thirty days’ written notice to the Company
LOAN PAYMENTS                                                                               at its Home Office by the Policyholder or by the Depositor. The Company
   Under this Authorization, if and when approved, policy loan payments                     may terminate immediately by notice in the event any check or electronic
shall be applied to interest and principal. Loan repayment shall be applied                 fund transfer is dishonored.

71-APP (06/01)                                                                        Page 1
                 Berkshire Life Insurance Company of America
                 700 South Street
                 Pittsfield, Massachusetts 01201                                    AUTHORIZATION TO HONOR CHARGES
                 Berkshire Life Insurance Company of America is a subsidiary of     ORDERED BY AND PAYABLE TO
                 The Guardian Life Insurance Company of America, NY, NY             BERKSHIRE LIFE INSURANCE COMPANY OF AMERICA




                                                                                              Print or type

                                                                                       {      name and address
                                                                                              of bank and
                                                                                              branch (if any)




Account in name of_______________________________________________________________________________________________________________

Account No. _________________________________________________ Bank Transit No. ____________________________________________________




The undersigned requests and authorizes you to pay and charge to the above            or employee of Berkshire Life Insurance Company of America to sign such
account of the undersigned, checks or electronic fund transfers drawn on said         checks. This authority is to remain in effect until revoked by me in writing and
account by and payable to the order of Berkshire Life Insurance Company of            until you receive such notice. I agree that you shall be fully protected in honor-
America, Pittsfield, Massachusetts, provided there are sufficient collected funds     ing any such charges. It is further agreed that if any such charge be dishonored,
in said account to pay the same upon presentation. Your rights with respect to        whether with or without cause and whether intentionally or inadvertently, you
any checks or electronic fund transfers so drawn shall be the same as if it were      shall be under no liability whatsoever even though such dishonor results in the
a check drawn by you and signed by me. It will not be necessary for any officer       forfeiture of insurance.

__________________________________                                                   X_______________________________________________________________
Date                                                                                                         Bank Signature of Depositor

                                                                                     X_______________________________________________________________
                                                                                                             Bank Signature of Depositor



TO THE BANK NAMED ABOVE:
   In consideration of your participation in the arrangement authorized by             omission of your bank in connection with any check or electronic funds
your Depositor, whereby amounts payable to this Company are collected                  drawn or transferred, or purporting to be drawn or transferred by
by checks or electronic fund transfers drawn by this Company on the                    Berkshire Life Insurance Company of America pursuant to the
account of the Depositor, Berkshire Life Insurance Company of America                  Authorization, whether or not such loss results from an intentional or
hereby agrees:                                                                         inadvertent dishonor of any such charge or transfer or involves the forfei-
   To indemnify and hold you harmless from any loss, including the cost                ture of insurance.
of defending any legal action, you may suffer as a result of any act or
                                                                                           BERKSHIRE LIFE INSURANCE COMPANY OF AMERICA




71-APP (06/01)                                                                    Page 2
          Berkshire Life Insurance Company of America
          700 South Street
          Pittsfield, Massachusetts 01201
          Berkshire Life Insurance Company of America is a subsidiary of               CONDITIONAL RECEIPT FOR
          The Guardian Life Insurance Company of America, NY, NY                       DISABILITY INSURANCE

When used in this receipt, the words “we,” “us,” “our,” and “the company” mean the Berkshire Life Insurance Company of America
of Pittsfield, Massachusetts.
This receipt does not create any temporary or interim insurance. It does, however, set the date and conditions under
which the insurance being applied for will go into effect. Unless all of the conditions in paragraph 2 below are met in full,
no insurance will become effective. No agent of the company and no broker is authorized to alter or waive any of our
requirements. If questions 9d or 9e on the accompanying Part 1 Application(s) for Insurance are left blank or are answered
“Yes,” no prepayment should be taken and no Conditional Receipt issued.
1. Effective Date   As used herein, “Effective Date” means the latest of (i) the date of the Application(s) for Insurance (Part 1(s)),
                    (ii) the date of the Application for Insurance (Part 2(s)) (or the date of the latest Part 2(s) if more than one is
                    required), (iii) the date of this receipt, (iv) the date of the latest completion of any medical examinations, tests,
                    x-rays and electrocardiograms which we require, or (v) the Policy Date, if any, requested in the Application(s).
2. Conditions Under The insurance in the amount and for the plan applied for will, subject to the provisions in paragraph 4, be-
   Which Insurance come effective as of the Effective Date only if all of the following conditions are met:
   May Become       (a) you have made an initial premium payment as acknowledged below, and if you have paid by check, draft
   Effective              or money order, you have made it payable to Berkshire Life Insurance Company of America (do not make
                          check payable to the agent or leave payee blank.)
                    (b) on the Effective Date the Proposed Insured(s) is (are), in the opinion of our authorized officers, insurable
                          and acceptable risk(s) under our rules and practices for the proposed insurance exactly as applied for
                          without modification;
                    (c) on the date of this receipt, all answers and statements in any part of the application(s) having an earlier
                          date are complete and true as though given on the date of this receipt.
                    If any one of these conditions is not met, there shall be no liability on our part except to return the
                    payment accompanying this receipt in the form of our check upon surrender of this receipt.
                    This receipt shall not apply to any alternate policy(ies) requested.
3. Amendment of     If we do not approve the application(s) as applied for, we may offer insurance other than as applied for. Such
  Application       insurance shall not be effective until:
                    (a) an amendment of application(s) to adjust the provisions of the contract shall be signed by the Proposed
                          Insured(s), the applicant, and the owner; while
                    (b) the health and other conditions affecting the insurability of the Proposed Insured(s) shall remain the same
                          as described in the application(s).
4. Maximum Limits If the disability of the Proposed Insured occurs prior to our approval; and the Proposed Insured(s) satisfy(ies)
                    the conditions set forth in paragraph 2 above, our liability shall not be greater than the total amount of insur-
                    ance (for the plan applied for) set forth in the schedule below. This amount shall be inclusive of all of the insur-
                    ance on the Proposed Insured(s) under conditional receipt pending and insurance in force with us.
                                         Disability          Total Disability             Disability Overhead
                       Age*           Income Limits          Buy-Out Limits                  Expense Limits
                    under 56            $5,000/mo.                $500,000                    $5,000/mo.
                      56-60              4,000/mo.                  400,000                    4,000/mo.
                      61-64                   0/mo.                     ***00                      ***000
                                    **Age means age of Proposed Insured at birthday nearest date of Conditional Receipt.   ***Products not available.
5. Acknowledgement We have received from________________________________________________________(Applicant):
   of Payment      (a) the sum of $___________to pay all or part of the first premium for the proposed disability income
                                                  insurance policy;
                   (b) the sum of $___________to pay all or part of the first premium for the proposed disability buy-out
                                                  insurance policy;
                   (c) the sum of $___________to pay all or part of the first premium for the proposed overhead expense
                                                  insurance policy;
                   on_________________________________________________(Proposed Insured(s)) in accordance with
                   Part 1 of the Application(s) for insurance.
6. Period of                  If less than the first full premium has been paid according to the mode of payment selected for the plan and
   Coverage                   the amount of insurance applied for, any insurance effective under paragraphs 2 and 3 above shall be in force
                              only for the pro rata portion of the policy year for which the premium has been paid. This portion of the pol-
                              icy year begins on the Effective Date and does not include any grace period.

I have read this receipt and have received a copy signed by the agent. I understand that insurance becomes effective only
if all the conditions of paragraph 2 are met and then only from the Effective Date, and not more than the limitations in
paragraph 4. I understand that if a policy date is requested in the application which is later than the date of either Part 1
or Part 2, I am waiving some rights under this receipt.

Signed______________________________________________________(Applicant) Date____________________(Mo-Day-Yr)

Signed_________________________________________________(Agent or Broker) Date____________________(Mo-Day-Yr)

71-CR (06/01)                                                              Page 1–APPLICANT COPY
          Berkshire Life Insurance Company of America
          700 South Street
          Pittsfield, Massachusetts 01201
          Berkshire Life Insurance Company of America is a subsidiary of               CONDITIONAL RECEIPT FOR
          The Guardian Life Insurance Company of America, NY, NY                       DISABILITY INSURANCE

When used in this receipt, the words “we,” “us,” “our,” and “the company” mean the Berkshire Life Insurance Company of America
of Pittsfield, Massachusetts.
This receipt does not create any temporary or interim insurance. It does, however, set the date and conditions under
which the insurance being applied for will go into effect. Unless all of the conditions in paragraph 2 below are met in full,
no insurance will become effective. No agent of the company and no broker is authorized to alter or waive any of our
requirements. If questions 9d or 9e on the accompanying Part 1 Application(s) for Insurance are left blank or are answered
“Yes,” no prepayment should be taken and no Conditional Receipt issued.
1. Effective Date   As used herein, “Effective Date” means the latest of (i) the date of the Application(s) for Insurance (Part 1(s)),
                    (ii) the date of the Application for Insurance (Part 2(s)) (or the date of the latest Part 2(s) if more than one is
                    required), (iii) the date of this receipt, (iv) the date of the latest completion of any medical examinations, tests,
                    x-rays and electrocardiograms which we require, or (v) the Policy Date, if any, requested in the Application(s).
2. Conditions Under The insurance in the amount and for the plan applied for will, subject to the provisions in paragraph 4, be-
   Which Insurance come effective as of the Effective Date only if all of the following conditions are met:
   May Become       (a) you have made an initial premium payment as acknowledged below, and if you have paid by check, draft
   Effective              or money order, you have made it payable to Berkshire Life Insurance Company of America (do not make
                          check payable to the agent or leave payee blank.)
                    (b) on the Effective Date the Proposed Insured(s) is (are), in the opinion of our authorized officers, insurable
                          and acceptable risk(s) under our rules and practices for the proposed insurance exactly as applied for
                          without modification;
                    (c) on the date of this receipt, all answers and statements in any part of the application(s) having an earlier
                          date are complete and true as though given on the date of this receipt.
                    If any one of these conditions is not met, there shall be no liability on our part except to return the
                    payment accompanying this receipt in the form of our check upon surrender of this receipt.
                    This receipt shall not apply to any alternate policy(ies) requested.
3. Amendment of     If we do not approve the application(s) as applied for, we may offer insurance other than as applied for. Such
  Application       insurance shall not be effective until:
                    (a) an amendment of application(s) to adjust the provisions of the contract shall be signed by the Proposed
                          Insured(s), the applicant, and the owner; while
                    (b) the health and other conditions affecting the insurability of the Proposed Insured(s) shall remain the same
                          as described in the application(s).
4. Maximum Limits If the disability of the Proposed Insured occurs prior to our approval; and the Proposed Insured(s) satisfy(ies)
                    the conditions set forth in paragraph 2 above, our liability shall not be greater than the total amount of insur-
                    ance (for the plan applied for) set forth in the schedule below. This amount shall be inclusive of all of the insur-
                    ance on the Proposed Insured(s) under conditional receipt pending and insurance in force with us.
                                         Disability          Total Disability             Disability Overhead
                       Age*           Income Limits          Buy-Out Limits                  Expense Limits
                    under 56            $5,000/mo.                $500,000                    $5,000/mo.
                      56-60              4,000/mo.                  400,000                    4,000/mo.
                      61-64                   0/mo.                     ***00                      ***000
                                    **Age means age of Proposed Insured at birthday nearest date of Conditional Receipt.   ***Products not available.
5. Acknowledgement We have received from________________________________________________________(Applicant):
   of Payment      (a) the sum of $___________to pay all or part of the first premium for the proposed disability income
                                                  insurance policy;
                   (b) the sum of $___________to pay all or part of the first premium for the proposed disability buy-out
                                                  insurance policy;
                   (c) the sum of $___________to pay all or part of the first premium for the proposed overhead expense
                                                  insurance policy;
                   on_________________________________________________(Proposed Insured(s)) in accordance with
                   Part 1 of the Application(s) for insurance.
6. Period of                  If less than the first full premium has been paid according to the mode of payment selected for the plan and
   Coverage                   the amount of insurance applied for, any insurance effective under paragraphs 2 and 3 above shall be in force
                              only for the pro rata portion of the policy year for which the premium has been paid. This portion of the pol-
                              icy year begins on the Effective Date and does not include any grace period.

I have read this receipt and have received a copy signed by the agent. I understand that insurance becomes effective only
if all the conditions of paragraph 2 are met and then only from the Effective Date, and not more than the limitations in
paragraph 4. I understand that if a policy date is requested in the application which is later than the date of either Part 1
or Part 2, I am waiving some rights under this receipt.

Signed______________________________________________________(Applicant) Date____________________(Mo-Day-Yr)

Signed_________________________________________________(Agent or Broker) Date____________________(Mo-Day-Yr)

71-CR (06/01)                                                          Page 2–HOME OFFICE COPY

				
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