Kqfyopgzu12i30zg51uw3wiq PDF

Application for Individual Life &
Disability Insurance (Part 1)

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A Personal Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
Complete this section for the Proposed Insured.
1. Full legal name )LUVW0,/DVW6XI¿[ TERESA FOSTER
2. *HQGHU (Select one): Male X Female
3. 'DWHRIELUWK(mm/dd/yyyy): 02/28/1971
4. 3ODFHRIELUWK(Country & State/Province): USA / NY
5. 7D[SD\HU,GHQWL¿FDWLRQ1XPEHU(SSN/ITIN): 107-70-9743
6. 5HVLGHQWLDODGGUHVV±do not use PO Box (Street, Apt. or Suite #, City & State or Country, ZIP/Postal Code):
4 LAWRENCE DRIVE
NESCONSET, NY, USA 11767
7. Mailing address – only if different than question 6 32%R[RU6WUHHW$SWRU6XLWH&LW\ 6WDWHRU&RXQWU\=,33RVWDO&RGH
8. 3UHIHUUHGSKRQHQXPEHU (516)477-1409
) - ([WHQVLRQ +RPH Work X Mobile
$OWHUQDWHSKRQHQXPEHU (516)728-8848
) - ([WHQVLRQ +RPH Work Mobile
%HVWWLPHWRFDOO 6 am X pm
9. (PDLODGGUHVV lilaserrn@gmail.com
10. U.S. Driver’s License (If actual age under 16, skip to question 11): X Yes 1R
If No (Select one): Passport 2WKHU(Specify):
a. ,GHQWL¿FDWLRQQXPEHU 267112190
E 6WDWHRU&RXQWU\RILVVXH NY
c. Expiration date (mm/dd/yyyy): Only required if Passport or Other
11. 7KH3URSRVHG,QVXUHGLVD(Select one):
X 5HVLGHQW86FLWL]HQ 1RQUHVLGHQW86FLWL]HQ 5HVLGHQWQRQ86FLWL]HQ 1RQUHVLGHQWQRQ86FLWL]HQ
If U.S. citizen, skip to section B – Personal History Information. If non-U.S. citizen, continue to question 11a and attach copy of visa.
a. &RXQWU\RIFLWL]HQVKLS
E 7\SHRIYLVD
c. 9LVDQXPEHU
d. Expiration date (mm/dd/yyyy):
A2000NY-US 0118 Application for Individual Life & Disability Insurance (Part 1) – v.2 page 1 of 11
B 3HUVRQDO+LVWRU\,QIRUPDWLRQ ::::::::::::::::::::::::::::::::::::::::::::::::
1. ,VWKH3URSRVHG,QVXUHGFXUUHQWO\GLVDEOHGRUDSSO\LQJIRUDQ\GLVDELOLW\EHQH¿WV"If Yes, provide details in section L . . Yes X 1R
2. ,VWKLVD/LIHFRQYHUVLRQRU/LIHLQVXUDELOLW\RSWLRQH[HUFLVH" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
If Yes, answer questions 3-5 and use the Conversion & Insurability Option Supplement. In addition, if Evidence of Insurability is
required, complete all questions below; otherwise, skip to section C – Life Product Information.
For questions 3-12, provide details for any Yes answers in section L – Additional Information.
3. +DYH\RXXVHGWREDFFRRURWKHUQLFRWLQHFRQWDLQLQJSURGXFWVH[FHSWFLJDUVHJFLJDUHWWHVHFLJDUHWWHVSLSHVVQXII
FKHZLQJWREDFFRRUQLFRWLQHGHOLYHU\GHYLFHVXFKDVJXPRUWKHSDWFK
a. :LWKLQWKHODVWPRQWKV" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
E :LWKLQWKHODVWPRQWKV" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
4. +DYH\RXXVHGFLJDUVZLWKLQWKHODVWPRQWKV" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
,I<HVSURYLGHQXPEHURIFLJDUVSHU\HDU
5. +DYH\RXXVHGDSUHVFULSWLRQPHGLFDWLRQWRDVVLVWZLWKVPRNLQJFHVVDWLRQRUDVDVXEVWLWXWHIRUVPRNLQJHJ&KDQWL[
:HOOEXWULQHWFZLWKLQWKHODVWPRQWKV" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
+DVWKH3URSRVHG,QVXUHG
6. (YHUEHHQFRQYLFWHGRIDIHORQ\RUFXUUHQWO\RQSDUROHRUSUREDWLRQ" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
7. %HHQFRQYLFWHGRIRSHUDWLQJDPRWRUYHKLFOHZKLOHXQGHUWKHLQÀXHQFHRIDOFRKRORUGUXJVZLWKLQWKHODVW\HDUV" . . . . . . Yes X 1R
8. %HHQLQDPRWRUYHKLFOHDFFLGHQWLQZKLFKWKH\ZHUHIRXQGWREHDWIDXOWFRQYLFWHGRIDPRYLQJYLRODWLRQRUUHFHLYHGD
GULYHU¶VOLFHQVHUHVWULFWLRQRUUHYRFDWLRQZLWKLQWKHODVW\HDUV" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
'RHVWKH3URSRVHG,QVXUHG
9. 3ODQWRWUDYHOWRDIRUHLJQFRXQWU\LQWKHQH[W\HDUV"If Yes, use Foreign Travel Supplement . . . . . . . . . . . . . . . . . . . . Yes X 1R
10. +DYHDZULWWHQDJUHHPHQWWREHFRPHRULVFXUUHQWO\DPHPEHURIWKH$UPHG)RUFHV"If Yes, use Military Supplement . . Yes X 1R
11. ([SHFWWREHFRPHZLWKLQWKHQH[W\HDUVRUEHHQLQWKHODVW\HDUVDSLORWDVWXGHQWSLORWRUFUHZPHPEHURIDQ\
DLUFUDIW"If Yes, use Aviation Supplement for Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
12. ,QWHQGWRWDNHSDUWLQWKHQH[W\HDUVRUKDYHWKH\WDNHQSDUWLQWKHODVW\HDUVLQWKHIROORZLQJ
a. +DQJJOLGLQJSDUDVDLOLQJSDUDNLWLQJSDUDFKXWLQJVN\GLYLQJXOWUDOLJKWVRDULQJRUEDOORRQLQJ". . . . . . . . . . . . . . . . . . Yes X 1R
E 8QGHUZDWHUGLYLQJEXQJHHMXPSLQJURFNRUPRXQWDLQFOLPELQJKHOLFRSWHUVNLLQJRURUJDQL]HGUDFLQJE\
DXWRPRELOHPRWRUF\FOHPRWRUERDWRUVQRZPRELOH" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
If Yes to 12a or 12b, use Avocation Supplement.
13. Primary physician/practice:
a. Full legal name (If no current, physician seen in last 5 years):
DR GAGANDEEP GILL
E %XVLQHVVDGGUHVV(Street, Suite #, City & State or Country, ZIP/Postal Code):
300 EAST MAIN STREET
SMITHTOWN, NY, USA 11787
c. 3KRQHQXPEHU (631)257-5290
( ) -
d. 'DWHODVWVHHQ 04/2019
14. &XUUHQWRFFXSDWLRQ Nurse RN
a. 'XWLHV NURSING
E Employer/business name (If self-employed, provide business name): MEMORIAL SLOAN KETTERING
c. Employer/business address 32%R[RU6WUHHW$SWRU6XLWH&LW\ 6WDWHRU&RXQWU\=,33RVWDO&RGH
650 COMMACK ROAD COMMACK, NY, USA 11725-1100
15. Earned income ,IEXVLQHVVRZQHULQFOXGHVKDUHRIEXVLQHVVSUR¿WORVVLQDGGLWLRQWRZDJHV
a. &XUUHQW\HDU x$ $140,000 E 3ULRU\HDU x$ $140,000
16. Unearned income HJLQWHUHVWGLYLGHQGVFDSLWDOJDLQVUHQWV
a. &XUUHQW\HDU x$ $0 E 3ULRU\HDU x$ $0
B 3HUVRQDO+LVWRU\,QIRUPDWLRQcontinued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
For Life, complete questions 17-19. For DI only, skip to section H – Disability Income Product Information.
17. 1HWZRUWK $x $1,000,000
18. ,IDVWXGHQWUHWLUHHKRPHPDNHUMXYHQLOHXQHPSOR\HGRUGLVDEOHG)RUTXHVWLRQGLQFOXGHLQIRUFHDQGDSSOLHGIRUFRYHUDJH
a. $QQXDOKRXVHKROGHDUQHGLQFRPH x$ c. +RXVHKROGQHWZRUWK x$
E $QQXDOKRXVHKROGXQHDUQHGLQFRPH x$ d. 2WKHUFRYHUDJHRQZRUNLQJVSRXVH x$
19. ,IMXYHQLOHOLVWDOOIDPLO\PHPEHUVLQFOXGLQJVLEOLQJVSDUHQWVDQGOHJDOJXDUGLDQVLQWKHWDEOHEHORZ)RUWKHFRYHUDJHFROXPQVSURYLGHWKHWR-
WDOOLIHLQVXUDQFHFXUUHQWO\DSSOLHGIRURUQRZLQIRUFHZLWK0DVV0XWXDORURWKHUFRPSDQLHV,IQRQHH[SODLQLQVHFWLRQ/±$GGLWLRQDO,QIRUPDWLRQ
)DPLO\0HPEHU *URXS&RYHUDJH 1RQ*URXS&RYHUDJH
5HODWLRQVKLS 1DPH Age $SSOLHG)RU In Force $SSOLHG)RU In Force
x$ x$ x$ x$
x$ x$ x$ x$
x$ x$ x$ x$
x$ x$ x$ x$
x$ x$ x$ x$
x$ x$ x$ x$
& Life Product Information ::::::::::::::::::::::::::::::::::::::::::::::::::::

Complete for all Life Products. Only one Primary may be selected per Application.
1. 0D[LPXPIDFHDPRXQWEHLQJDSSOLHGIRURQWKLV$SSOLFDWLRQ $x $1,000,000
:KROH/LIH (Select one): Primary Alternate Additional For Survivorship, also use Additional Insured Supplement
2. 3ODQ E 3ODQQHG$/,5 $x

3. )DFHDPRXQW $x 1XPEHURI\HDUV x
4. $XWRPDWLF3UHPLXP/RDQ$3/ Yes 1R 3D\LQJDOOSDUWXVLQJIXQGV" Yes 1R
5. Loan rate (Select one): $GMXVWDEOH Fixed c. 8QVFKHGXOHG/XPS6XP x$
6. Dividend Option (Select one): Paid-up additions 3D\LQJDOOSDUWXVLQJIXQGV" Yes 1R
&DVK Supplemental Insurance Dividend/Flex d. Dividend Option (Select one):
Dividend Accumulations Same as base policy Paid-up Additions
Riders (Not all riders are available on all plans) 12. /LIH,QVXUDQFH6XSSOHPHQW5LGHU/,65
7. :DLYHURI3UHPLXPIRU'LVDELOLW\5LGHU a. )DFHDPRXQW $x
Insured 1 Insured 2 E 0RGDO3D\PHQW x$
8. $FFHOHUDWHG'HDWK%HQH¿WIRU/RQJ7HUP&DUH6HUYLFHV5LGHU c. 8QVFKHGXOHG/XPS6XP x$
/7&5 3D\LQJDOOSDUWXVLQJIXQGV" Yes 1R
Yes 1R If Yes, complete LTCR Application. d. 3UHPLXP3D\LQJ3HULRG years
9. *XDUDQWHHG,QVXUDELOLW\5LGHU x$ e. &URVVRYHU<HDU years
10. 5HQHZDEOH7HUP5LGHU x$ 13. (VWDWH3URWHFWLRQ5LGHU(Survivorship only): Yes 1R
11. $GGLWLRQDO/LIH,QVXUDQFH5LGHU$/,5 This Rider is also known as a Four Year Level Survivorship Term
a. 0RGDO3D\PHQW x$ Insurance Rider.
1XPEHURI\HDUV
3D\LQJDOOSDUWXVLQJIXQGV" Yes 1R
7KHDPRXQWLQGLFDWHGDERYHLVDQHVWLPDWHRIWKHH[FKDQJHSURFHHGVDQGZLOOEHFKDQJHGRQFHWKHDFWXDODPRXQWDYDLODEOHIURPWKH
H[FKDQJHLVGHWHUPLQHGDQGPRQH\LVUHFHLYHG
,IQRWFRPSOHWHGWKH3UHPLXP3D\LQJ3HULRGDQG&URVVRYHU<HDUZLOOEHVHWWRHTXDOWKHDPRXQWRI\HDUVXQWLO3URSRVHG,QVXUHGUHDFKHVDJH
& Life Product Information continued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
7HUP/LIH (Select one): X Primary Alternate Additional
14. 3ODQ Vantage Term 20 Riders (Not all riders are available on all plans)
15. )DFHDPRXQW x$ $1,000,000 16. :DLYHURI3UHPLXPIRU'LVDELOLW\5LGHU X Yes 1R
9DULDEOHRU8QLYHUVDO/LIH (Select one): Primary Alternate Additional Additional forms are required for these products
17. 3ODQ 24. 'H¿QLWLRQRI/LIH,QVXUDQFH(Select one):

18. )DFHDPRXQW x$ &DVK9DOXH$FFXPXODWLRQ7HVW
19. ,QLWLDO3UHPLXP $ *XLGHOLQH3UHPLXP7HVW
20. 3ODQQHG3UHPLXP x$ Riders (Not all riders are available on all plans)
21. 1RQXQVFKHGXOHGSUHPLXP $x 25. 5LGHURSWLRQV(Select one):
22. /RDQUDWH Fixed a. :DLYHURI0RQWKO\&KDUJHV'HGXFWLRQV Yes 1R
23. 'HDWK%HQH¿W2SWLRQ6HOHFWRQHQRWDOO'HDWK%HQH¿W2SWLRQV E 'LVDELOLW\%HQH¿W5LGHU $x
are available for all plans):
c. :DLYHURI6SHFL¿HG3UHPLXP5LGHU $x
Level
26. 2WKHU,QVXUHG5LGHU(Also use Additional Insured Supplement):
Increasing by Account Value
a. 2WKHU,QVXUHGQDPH
5HWXUQRI3UHPLXP
E 7\SHDQGDPRXQW
,QFUHDVLQJE\63$$FFRXQW%DODQFH
27. *XDUDQWHHG,QVXUDELOLW\5LGHU*,5 Yes 1R
2WKHU$OWHUQDWH$GGLWLRQDO(Select one): Alternate Additional
If Alternate is selected, the Owner is applying for either the policy indicated in questions 1-27 or the policy indicated below. If Addition-
al is selected, the Owner is applying for both the policy indicated in questions 1-27 and the policy indicated below.
28. Details/remarks (Plan, face amount, riders, dividend options, etc.):
D Life Purpose of Insurance : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :

1. :KDWLVWKHSXUSRVHRIWKHLQVXUDQFH"(Select all that apply):
a. 3HUVRQDO X Income for dependents Estate taxes Mortgage Future insurability 2WKHU
E %XVLQHVV(If any Business options are selected, use Business Life Insurance Supplement):
Key employee Stock redemption &URVVSXUFKDVH Loan guarantee coverage 2WKHU
c. 6SOLW'ROODU Assignment Endorsement
2. ,VWKLVSROLF\EHLQJSXUFKDVHGLQFRQQHFWLRQZLWKDQHPSOR\HUVSRQVRUHGSODQ" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
a. If Yes, provide type (Select one): 7D[TXDOL¿HG 1RQTXDOL¿HG
E ,I1RQTXDOL¿HGZLOOWKHSROLF\EHLVVXHGRQD8QLVH[EDVLV" Yes 1R
3. :LOOWKLVSROLF\EHFROODWHUDOO\DVVLJQHG" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
4. +DVWKH3URSRVHG,QVXUHGVDQGRUWKH3URSRVHG3ROLF\2ZQHUVEHHQRIIHUHGDQ\HFRQRPLFLQFHQWLYHVXFKDV
³IUHH´OLIHLQVXUDQFHRUPRQH\WRSXUFKDVHWKLVSROLF\RUHQWHUHGLQWRDQ\DUUDQJHPHQWWKDWHQWLWOHVDOHQGHURULQYHVWRU
WRDQ\SRUWLRQRIWKHGHDWKEHQH¿WEH\RQGDORDQUHSD\PHQW" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
5. 'RHVWKH3URSRVHG,QVXUHGVDQGRUWKH3URSRVHG3ROLF\2ZQHUVKDYHDFXUUHQWDJUHHPHQWRUFRPPLWPHQWWRVHOO
WUDQVIHUDVVLJQRUUHOHDVHWKLVSROLF\±RUDQ\EHQH¿FLDOLQWHUHVWRIWKLVSROLF\RULWVRZQHUVKLSVWUXFWXUH±WRDOLIH
VHWWOHPHQWFRPSDQ\YLDWLFDOFRPSDQ\EDQNLQYHVWRURUVHFRQGDU\PDUNHWSURYLGHU". . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
6. ,VWKLVSROLF\GLUHFWO\RULQGLUHFWO\RZQHGE\DFDSWLYHLQVXUDQFHFRPSDQ\" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
7. :LOOWKHVRXUFHRIDQ\SUHPLXPSD\PHQWVEHDVVHWVRIRUIURPFRQWULEXWLRQVWRDFDSWLYHLQVXUDQFHFRPSDQ\" . . . . . . . . . Yes X 1R
E /LIH2ZQHU %HQH¿FLDU\,QIRUPDWLRQ : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
1. 2ZQHUVKLSDUUDQJHPHQW(Select one):
X 3URSRVHG,QVXUHGLVWKHRQO\2ZQHU3URSRVHG,QVXUHGV(if survivorship)DUHWKHRQO\2ZQHUV
2WKHU(If selected, provide Proposed Owner name(s) below and use Owner Designation Form):
1DPHVRI3URSRVHG2ZQHUV
2. %HQH¿FLDU\DUUDQJHPHQW(Select one):
6ROH,QGLYLGXDO3ULPDU\6ROH,QGLYLGXDO6HFRQGDU\%HQH¿FLDU\(If selected, complete the table below)
X 2WKHULQFOXGLQJ870$8*0$,IVHOHFWHGXVH%HQH¿FLDU\'HVLJQDWLRQ)RUPDQGVNLSWRVHFWLRQ)
)XOOOHJDOQDPH
0DLOLQJDGGUHVV
3ULPDU\
3UHIHUUHGSKRQHQXPEHU x ) - ([W +RPH Work Mobile 8QNQRZQ

'DWHRIELUWK(mm/dd/yyyy): 7,1 661 (,1 8QNQRZQ
5HODWLRQVKLSWR,QVXUHG 'LVWULEXWLRQ 100%
6HFRQGDU\&RQWLQJHQW
)XOOOHJDOQDPH
0DLOLQJDGGUHVV
3UHIHUUHGSKRQHQXPEHU x ) - ([W +RPH Work Mobile 8QNQRZQ
'DWHRIELUWK(mm/dd/yyyy): 7,1 661 (,1 8QNQRZQ
5HODWLRQVKLSWR,QVXUHG 'LVWULEXWLRQ 100%
F /LIH2WKHU&RYHUDJH5HSODFHPHQW,QIRUPDWLRQ : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
1. 7RWDODPRXQWRIQRQ*URXSOLIHLQVXUDQFHFXUUHQWO\DSSOLHGIRU ZLWK0DVV0XWXDORURWKHUFRPSDQLHV . . . . . . $x $1,000,000
2. 7RWDODPRXQWRIQRQ*URXSQHZLQVXUDQFHWKDWZLOOEHSODFHGLQDOOFRPSDQLHV . . . . . . . . . . . . . . . . . . . . . . . $x $1,000,000
3. 7RWDODPRXQWRIQRQ*URXSOLIHLQVXUDQFHFXUUHQWO\in forceZLWK0DVV0XWXDORURWKHUFRPSDQLHV
LQFOXGLQJDQ\SROLFLHVZKLFKPD\KDYHEHHQVROGWUDQVIHUUHGRUDVVLJQHG(If none, enter 0): . . . . . . . . . . . . . $x $0
4. 'RHVWKH3URSRVHG,QVXUHGKDYHQRQ*URXSOLIHLQVXUDQFHRUDQQXLW\FRQWUDFWVFXUUHQWO\LQIRUFH
pending, applied for, or conditionally issued ZLWKRWKHUFRPSDQLHVH[FOXGLQJ0DVV0XWXDOWKDW
are not intended to be replaced/FKDQJHG "If Yes, complete the table below. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
5. ,VWKLV$SSOLFDWLRQLQWHQGHGWRUHSODFHFKDQJH DQ\*URXSRUQRQ*URXSOLIHLQVXUDQFHRUDQQXLW\
contract in force ZLWK0DVV0XWXDORURWKHUFRPSDQLHV? If Yes, complete the table below and
use the state appropriate replacement form(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X 1R
5HSODFHFKDQJHPHDQVZLWKLQPRQWKVFDXVLQJDSROLF\FRQWUDFWWRODSVHVXUUHQGHULQZKROHRUSDUWIRUIHLWWHUPLQDWHFRQYHUWWRUHGXFHG
SDLGXSRUFRQWLQXHDVH[WHQGHGWHUPLQVXUDQFHUHGXFHLQYDOXHE\ERUURZLQJDJDLQVWLWFKDQJHWKHWHUPRUFRYHUDJHEHQH¿WV
3ROLF\1XPEHU &RPSDQ\ )DFH$PRXQW Product Issue Yr. Purpose Status 5HSODFH 1035x
$x %XVLQHVV Applied for Yes Yes

Personal In force 1R 1R



F /LIH2WKHU&RYHUDJH5HSODFHPHQW,QIRUPDWLRQcontinued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
For 1035 Exchanges, complete questions 6-8 and use applicable 1035 Exchange forms. Otherwise, skip to question 9.
6. $QWLFLSDWHGYDOXHRIH[FKDQJH $x $0
7. $SSO\([FKDQJHSURFHHGVWR(Select all that apply): Additional premium (UL or VL) $/,5 /,65 Initial premium
8. :LOODSROLF\ORDQEHFDUULHGRYHUWRWKHQHZSROLF\" Yes X 1R
For Internal Term to Term Replacements, complete question 9. Otherwise, skip to section G – Life Payment Information.
9. 'R\RXZLVKWRWHUPLQDWHDQH[LVWLQJLQWHUQDOWHUPSROLF\RUULGHU" Yes X 1R If Yes, use Term to Term Replacement Form.
G Life Payment Information :::::::::::::::::::::::::::::::::::::::::::::::::::

1. %LOOLQJW\SH(Select one): 3UH$XWKRUL]HG&KHFN(PAC; if selected, use applicable PAC form) X ,QGLYLGXDO'LUHFW%LOO
*URXS%LOOZLWK,QYRLFH)UDQFKLVHQXPEHU(Must be provided at the time of business submission):
2. Frequency (Select one): 0RQWKO\(PAC/Group only) Quarterly Semi-annual X Annual Single Premium (If available)
3. ,VLQLWLDOSUHPLXPEHLQJVXEPLWWHGZLWKWKLV$SSOLFDWLRQ" Yes X 1R If Yes, use Temporary Life Insurance Receipt
4. Save age ,I<HVSUHPLXPZLOOEHGXHIRUHDFKPRQWK3ROLF\LVEDFNGDWHGWRVDYHDJH Yes X 1R
5. Policy dating (Select one): X Date of issue 6SHFL¿FGDWH(Up to the 28th of each month):
6. Source of Premium (Select all that apply): X Earned Income Investment Income Investment/Savings
*LIWV,QKHULWDQFH Loan/Premium Financing 2WKHU(Specify):
7. Premium Payor (Select one): X Proposed Insured(s) 3URSRVHG2ZQHUV 2WKHU
If Other is selected, provide details in questions 7a-7b.
a. Full legal name )LUVW0,/DVW6XI¿[
E Mailing address 32%R[RU6WUHHW$SWRU6XLWH&LW\ 6WDWHRU&RXQWU\=LS3RVWDO&RGH
H Disability Income Product Information :::::::::::::::::::::::::::::::::::::::::

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Notice and Consent Form for AIDS Virus (HIV)
Antibody/Antigen Testing
(New York)
To determine your insurability, the Insurer named above (the Insurer) has requested that you provide a sample of your blood, oral fluid,
and/or urine for testing and analysis. All tests will be performed by a licensed laboratory.
Tests may be performed to determine the presence of antibodies to the Human Immunodeficiency Virus (HIV), also known as the AIDS
virus. The HIV antibody/antigen test that is performed is actually a series of tests done by a medically accepted procedure. These tests
are extremely reliable.
You may contact the New York Department of Health’s statewide toll free telephone number (1-800-541-AIDS) for further information
about AIDS, the meaning of HIV related test results, and the availability and location of HIV related counseling services.
Positive HIV antibody/antigen test results do not mean that you have AIDS, but that you are at significantly increased risk of developing
AIDS or AIDS-related conditions and you may wish to consider further independent testing. Federal authorities say that persons who are
HIV antibody/antigen positive should be considered infected with the AIDS virus and capable of infecting others.
Positive HIV antibody or antigen test results will mean that your application will be declined. In the event of any adverse underwriting
decision, the insurer will send the results to you, your physician or your designee. We recommend your personal physician be used so
that the results can be accurately conveyed and clearly explained. Please indicate the name and address of the person to whom the results
should be sent:
TERESA FOSTER
__________________________________________________ 4 LAWRENCE DRIVE NESCONSET, NY, USA 11767
_______________________________________________________
(Name) (Address)
All test results will be treated confidentially. They will be reported by the laboratory to the Insurer. When necessary for business reasons,
the Insurer may disclose test results to its affiliates, reinsurers or employees who have responsibility for making decisions regarding your
application or policy, or outside counsel. Test results may be reported to a medical information exchange using strict confidentiality
procedures including the use of general codes that are also used to report other diseases or conditions not related to AIDS. There will be
no other disclosure of test results except as may be required or permitted by law or as authorized by you.
I have read and understand this Notice of Consent for AIDS Virus (HIV) Antibody/Antigen Testing. I voluntarily consent to the
collection of blood, oral fluid and/or urine from me, the testing of that blood, oral fluid and/or urine, and the disclosure of the results as
described above. I understand that prior to the collection of blood, oral fluid and/or urine, the person who collects the specimen will
provide me with information regarding AIDS and the transmission of HIV infection.
No attempt to modify or amend this form will change its terms or in any way be binding upon the Insurer or any of its agents or
contractors. A copy of this form will be valid as the original.
X
_______________________________________________________ _____________________
Signature of Proposed Insured Date
Or Parent/Guardian
Massachusetts Mutual Life Insurance Company (MassMutual), 1295 State Street, Springfield, MA 01111-0001 and its subsidiaries: C.M. Life Insurance Company and MML Bay
State Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, Connecticut 06082-1981.
N201NY 1004
Beneficiary Designation Form
Not for use with Qualified Plan owned policies
Massachusetts Mutual Life Insurance Company

(MassMutual) 1295 State Street, Springfield, Massachusetts 01111-0001
____________________________________________________________________________________________________________________________________________
Indicate usage below:

X At time of application, use this form to designate Beneficiaries
 After issue, use this form to change the Beneficiary on existing MassMutual policies/contracts
A Personal Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
1. TERESA FOSTER
Insured full legal name (First, MI, Last, Suffix): _______________________________________________________________________
2 02/28/1971
Insured date of birth (mm/dd/yyyy): _________________________________________________________________________________
3. Policy Number (After issue): _____________________________________________________________________________________
4. TERESA FOSTER
Owner full legal name (First, MI, Last, Suffix): _________________________________________________________________________
__________ ) __________ – _____________ Extension: __________________  Home  Work 
5. Owner phone number: ((516)477-1409 X Mobile
lilaserrn@gmail.com
6. Owner email: ____________________________________________________  After issue, check to have confirmation sent by email.
B Beneficiary Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
X Primary  Secondary  Tertiary
1a. Class (Select one): 
X Named Individual  Trust  Trust under Insured’s Will  Estate of Insured  Other Entity
Type (Select one): 
Class of children (If selected, name living children below):
 Any lawful children of the Insured  Any children born of the marriage of and/or legally adopted by the Insured and (list other
parent full legal name): ____________________________________________________________________________________
DOUGLAS FOSTER
Full legal name: _______________________________________________________________________________________________
4 LAWRENCE DRIVE NESCONSET, NY, USA 11767
Mailing address: _______________________________________________________________________________________________
Phone number: (x__________ ) ____________ – ______________ Extension: ________  Home  Work  Mobile  Unknown
01/26/1969
Date of birth/Trust (mm/dd/yyyy): __________________________ TIN: 133-60-6533 X SSN  EIN  Unknown
________________________ 
Husband
Relationship to Insured: __________________________________ $1,000,000
Distribution (If not equal shares): x%/$ ______________________
X No
Issue per stirpes?  Yes 
1b. Class (Select one):  Primary  Secondary  Tertiary
Type (Select one):  Named Individual  Trust  Trust under Insured’s Will  Estate of Insured  Other Entity
Full legal name: ________________________________________________________________________________________________
Mailing address: _______________________________________________________________________________________________
Date of birth/Trust (mm/dd/yyyy): __________________________ TIN: ________________________  SSN  EIN  Unknown
Relationship to Insured: __________________________________ x ______________________
Distribution (If not equal shares): %/$
Issue per stirpes?  Yes  No
F5159NY-US Beneficiary Designation Form – 0413 page 1 of 3

B Beneficiary Information continued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
To name additional beneficiaries, copy this page.
1c. Class (Select one):  Primary  Secondary  Tertiary

Full legal name: ________________________________________________________________________________________________
Mailing address: _______________________________________________________________________________________________
1d. Class (Select one):  Primary  Secondary  Tertiary
Full legal name: ________________________________________________________________________________________________
Mailing address: _______________________________________________________________________________________________
1e. Class (Select one):  Primary  Secondary  Tertiary
Full legal name: ________________________________________________________________________________________________
Mailing address: _______________________________________________________________________________________________
C UTMA/UGMA : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
1. UTMA/UGMA refer to a state’s law that governs the transfer of title to life insurance proceeds to a Custodian to manage for a minor until
the minor reaches an age permitted by law. Under the UTMA/UGMA of the state designated in 1b, the person designated in 1a will be
Custodian for the child(ren) named in Section B. These custodial arrangements may only be used in states where permitted by applicable
law. This is not applicable to the Issue per stirpes, if selected.
a. Custodian’s full legal name (First, MI, Last, Suffix): _________________________________________________________________
b. Custodial state: ____________________________________________________

D Disclosures : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
Beneficiary. Unless otherwise requested, proceeds shall be paid • For Other Entities, it includes the successors or assigns of
equally and in one sum as follows: the designated Entity.
• If there is no living or existing beneficiary, the proceeds will
be paid to the owner or the owner’s estate. Definitions:
• If there is no living or existing beneficiary, and the owner is an • “Lawful child(ren)”, “issue” and “children” of a person mean
entity, the proceeds will be paid to the entity. only the lawful children born to or adopted by that person.
• For survivorship policies, if both insureds are owners and • “Issue per stirpes” means that if a beneficiary dies before the
there is no living or existing beneficiary, the proceeds will be Insured, any amount that would have been paid to that
paid to the estate of the last to die of the insureds. beneficiary, will be paid in one sum and in equal shares to the
surviving children of that beneficiary, if any, before any other
• If Distribution Amounts/Percentages are designated, and a
contingent beneficiary.
beneficiary predeceases the Insured, no longer exists or is no
longer entitled to payment, that amount/percentage will be General Provisions:
distributed to the surviving beneficiaries in that class as per • The Company is only responsible to perform according to the
the ratio designated. terms of the policy, and is not responsible for carrying out the
• If dollar amounts are designated, and the proceeds at the terms of any trust or any trust agreement outside of this policy.
death of the Insured are greater or less than the total amount • If no custodian is designated, any money payable to a minor
designated, then the proceeds payable to each beneficiary will be paid to the court appointed guardian of the estate of
will be adjusted so that the relative ratio between and among the minor. Only the legal guardian of the minor can exercise
the beneficiaries remains the same. any rights given to a minor.
• If a revocable trust is the owner, and the trust is not in effect • When the Owner of the contract is not the Insured and the
at the death of the Insured, and there is no living or existing Owner is not the beneficiary, there may be unintended
beneficiary, the proceeds shall be paid to the designated income and gift tax consequences. The Owner should seek
grantor(s) equally, otherwise to the estate of whichever said advice from personal legal or tax advisors.
grantors is the last to die.
• If a Trust under the Insured’s Will is designated, then
proceeds will be paid only if the Will is probated and if there is
a trust in effect.
E Signatures : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
At time of Application. I, the undersigned, have read the Application including all supplements and all statements and answers, and affirm that
these statements and answers are true, complete and correctly recorded to the best of my knowledge and belief. To the best of my knowledge
and belief, all statements made in the Part 1 are true, complete and correctly recorded. I hereby adopt all statements made in the Application
and agree to be bound by them.
After issue. I, the undersigned, agree the information provided on this form is true, complete and correctly recorded to the best of my
knowledge and belief.
 Signature of Owner: _____________________________________________________________________________________________

Printed name: TERESA FOSTER
___________________________________________________________________ Date: ______________________
Title (Required when applicable): _____________________________________________________________________  Sole Officer
Printed name of Corporation/Partnership/Trust (If applicable): ____________________________________________________________
 Signature of Owner 2 (If applicable): ________________________________________________________________________________

Printed name: ___________________________________________________________________ Date: ______________________
Title (Required when applicable): __________________________________________________________________________________
Printed name of Corporation/Partnership/Trust (If applicable): ____________________________________________________________
Witness Signature Section

A witness is a disinterested party (anyone other than the Owner, Insured or Beneficiary). Not for use with new applications. Use only for
change of beneficiaries post issue. See instructions for requirements.
 Signature of Witness: ___________________________________________________________________________________________

Printed name: _____________________________________________________________________ Date: ____________________

Coverage and Premium
Payment Information
Insurance Coverage Taking Effect Disclosure Statement About Our Policy’s Premium
Thank you for applying for a MassMutual life insurance policy. This Payment Options
disclosure is intended to provide you important information about how Please Read This Information Carefully
policy charges accrue in relation to the date insurance coverage takes As a policyholder of MassMutual, you have the right to choose among
effect under the terms of your policy. Please read the disclosure and four payment plan options for paying your annual premium. Each
discuss it with your MassMutual representative. payment option, other than annual, costs more money. Among our
policyholders, the additional cost varies depending upon the type of
What is my Policy Date? policy and its original issue date.
It is important to understand some important dates. These dates may A generic description of the payment options and range of costs, expressed
be defined further in your policy. as dollars and as annual percentage rates, are described below.
• Policy Date. The Policy Date is the date on which policy charges Premium Payment Options
(premiums) begin to accrue. Clients may choose a specific Policy Date. You may pay premiums once a year (annually), twice a year (semi-
Otherwise, the Policy Date will be set to the Issue Date. annually), or four times a year (quarterly) or twelve times a year (monthly).
• Issue Date. The Issue Date is the date the Company issues the policy. If you pay your annual premium by installments, there will be an
• Delivery Date. The Delivery Date is the date the policy is delivered to additional charge.
you for acceptance. a. If you pay semi-annually, the additional charge equals an annual
When does Insurance Coverage Begin? percentage rate (APR) in the range of 8.2% to 18%. This would
amount to an additional annual charge in the range of $20 to $43
The date insurance coverage under the policy begins varies from on an annual premium of $1,000.
policy to policy according to the specific policy issued and any b. If you pay quarterly, the additional charge equals an annual
insurability changes during the underwriting process. Generally, percentage rate (APR) in the range of 2.4% to 23.7%. This would
except as otherwise provided in the terms of any temporary insurance amount to an additional annual charge in the range of $9 to $88 on
agreement, or the Part 1 Application for Life Insurance, insurance an annual premium of $1,000.
coverage under the policy takes effect when the policy is delivered c. If you pay monthly, the additional charge equals an annual
and the initial premium is paid, provided that on that date the insured(s) percentage rate (APR) in the range of 4.3% to 22.1%. This would
amount to an additional annual charge in the range of $20 to $103
is alive, all answers on the application, including any amendments to on an annual premium of $1,000.
the application presented to you on the Delivery Date, are still true and
There may be other premium payment options available on certain
complete and there have been no changes in the insured(s) health or products. Please contact MassMutual at 1-800-272-2216 for more
insurability. If a future Policy Date is selected at the time of application, information.
coverage does not begin prior to that date. If you would like to know the exact dollar amount of the additional
How does the date Insurance Coverage Begins compare to the Date charge or the Annual Percentage Rate that you are paying because
Policy Charges Begin? you pay your annual premium in installments, you may access our
“Modal Charge Disclosure and Annual Percentage Calculator” link
The Policy Date, the date the charges begin, may occur before at www.massmutual.com/calculators and follow the simple
insurance under the policy takes effect, such as when coverage takes instructions. Alternatively, you may call this toll free number
effect on the Delivery Date. If your Policy Date occurs before 1-800-272-2216 and we will provide you with the information.
insurance takes effect, you will be charged for premiums for a period How To Change Your Premium Payment Option*
during which no insurance was in force. To reduce the likelihood of You also have the right to change this option during the lifetime of your
paying such premiums, the Policy Owner may purchase a Temporary policy. In order to make a change, you must either:
Life Insurance Receipt, if eligible, or ask the Company to issue the • Inform your MassMutual agent that you wish to change the
policy with a future Policy Date. premium payment frequency for your policy; or
• Notify MassMutual in writing via regular mail (MassMutual
How does Future Dating or Redating Affect my Policy? Customer Service Hub at 1295 State Street, Springfield, MA 01111-
You may specify a policy date or ask the Company to reissue your 0001) or contact us at www.massmutual.com that you wish to
policy with a new Policy Date matching the date insurance coverage change the premium payment frequency for your policy’s premium.
To request a change in your policy’s premium payment frequency,
begins. Requesting a new Policy Date may cause your age for be sure to include the policy number in your correspondence; or
insurance purposes to change and the cost of insurance rates to
• Contact a MassMutual Customer Service Representative at
increase. Further, the Policy Date is used to determine the date on
1-800-272-2216 and inform the representative that you wish to
which the suicide, contestability and surrender charge periods begin
change the premium payment frequency for your policy.
to run. There will be no coverage under the policy before the new
* If your premium is paid through a payroll deduction, there may be limitations
Policy Date. on your ability to change the payment option. Contact your MassMutual
Please review your policy and consult your MassMutual representative if you agent to determine if your premium payment option can be changed.
have questions about policy charges or policy dating. This notice does not change any of the terms of your MassMutual policy.
Massachusetts Mutual Life Insurance Company (MassMutual), 1295 State Street, Springfield, MA 01111-0001 and its subsidiaries: C.M. Life Insurance Company and MML
Bay State Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, Connecticut 06082-1981.
COR4628
Important Privacy, Compensation &
Consumer Information
6WDWH6WUHHW6SULQJ¿HOG0$ For use in New York
At Massachusetts Mutual Life Insurance Company (“MassMutual”), we recognize that our relationships with you
are based on integrity and trust. As part of that trust relationship, we want you to understand that in order to
provide our products and services to you, we must collect, use and share personal information about you. This
Privacy Notice describes policies and practices about how we protect, collect and share personal information
related to the products and services you receive from us, including life insurance, disability income insurance,
long-term care insurance, and individual annuities. It also describes how you can limit some of that sharing.
Disclosures : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
Privacy Notice Credit bureaus; and
We protect your personal information by: 2WKHU¿QDQFLDOLQVWLWXWLRQVZLWKZKRPZHPD\MRLQWO\PDUNHWSURG-
ucts, if permitted in your state.
Using security measures that include physical, electronic and
procedural safeguards to protect your personal information from In addition, we may share certain of your personal information with
unauthorized access or use in accordance with state and federal \RXU0DVV0XWXDO¿QDQFLDOSURIHVVLRQDOLIKHRUVKHLVDFDUHHUDJHQW
requirements. RI RXUV ZKR WHUPLQDWHV WKHLU UHODWLRQVKLS ZLWK XV WR MRLQ DQRWKHU ¿-
QDQFLDO LQVWLWXWLRQ ZKRP ZH FDOO D ³GHSDUWLQJ 0DVV0XWXDO ¿QDQFLDO
Training employees to safeguard personal information and restrict-
professional”) so that he or she can continue to work with you at his
ing access to personal information to those employees who need it
or her new company.
to perform their job functions.
Please note that any personal information consisting of medical or
Contractually requiring business partners with whom we share your
health information is only shared with third parties to perform busi-
personal information to safeguard it and use it exclusively for the
ness, professional or insurance functions on our behalf or as autho-
purpose for which it was shared.
rized by you.
Personal information we may collect. The types of personal infor-
Important privacy choices. MassMutual respects your privacy
mation we may collect depend on the type of product or service you
FKRLFHV,I\RXKDYHDUHODWLRQVKLSZLWKDGHSDUWLQJ0DVV0XWXDO¿-
have with us and may include:
nancial professional, as described above, and you prefer that we do
Information that you provide to us on applications or forms, during not share your personal information, such as information about your
conversations with us or our representatives, or when you visit our insurance policies or contracts held with us, with him or her under
website (for example, your name, address, Social Security num- these circumstances, you can opt out of this sharing by directing us
EHUGDWHRIELUWKLQFRPHDQGDVVHWVEHQH¿FLDULHVDQGPHGLFDORU not to do so. If you wish to opt out of the sharing of your personal
health information). LQIRUPDWLRQ ZLWK \RXU GHSDUWLQJ 0DVV0XWXDO ¿QDQFLDO SURIHVVLRQDO
,QIRUPDWLRQ DERXW \RXU WUDQVDFWLRQV ZLWK XV DQG RXU DI¿OLDWHV LQ- you may:
cluding your policy coverages, premiums, and payment history. Call us at (800) 272-2216.
Information from third parties such as consumer or other reporting You may make this privacy choice and contact us at any time, how-
agencies and medical or health care providers. ever, if we do not hear from you we may share your information with
We may share all of the personal information we collect, as de- \RXUGHSDUWLQJ0DVV0XWXDO¿QDQFLDOSURIHVVLRQDODVGHVFULEHGDERYH
scribed above, with: If this is a joint account, if one joint owner tells us not to share infor-
mation that choice will apply to the other owner or owners. If you have
Agents, brokers and others who provide our products and services already told us your choice, there is no need to do so again.
to you;
If you have not purchased a product or service through a MassMutual
2XUDI¿OLDWHGFRPSDQLHVVXFKDVLQVXUDQFHRULQYHVWPHQWFRPSD- ¿QDQFLDOSURIHVVLRQDORU\RXGRQRWKDYHDUHODWLRQVKLSZLWKD0DVV-
nies, insurance agencies or broker-dealers that market our products 0XWXDO¿QDQFLDOSURIHVVLRQDODVGHVFULEHGDERYH\RXGRQRWQHHGWR
and services to you; contact us as we will not share your personal information other than
Companies that perform marketing or administrative services for us; as described in this notice.
1RQDI¿OLDWHGFRPSDQLHVLQRUGHUWRSHUIRUPVWDQGDUGEXVLQHVVIXQF- Other than as described above, we will only share your personal in-
tions on our behalf including those related to processing transac- formation as permitted by law and, if the law requires us to obtain
tions you request or authorize, or maintaining your policy or contract; your consent or give you the opportunity to opt out of some types of
sharing, we will do so before sharing the information.
Courts and government agencies in response to court orders or
legal investigations;
page 1 of 2 Important Privacy, Compensation & Consumer Information – 0515 N2010-US

Disclosures continued
Certain state laws may provide residents with additional protections &RQVXPHU1RWLÀFDWLRQ
for personal information. If you are a resident of one of the following This notice is to inform you that a consumer report or an investigative
states, we will not share your personal information with your depart- consumer report may be obtained from a consumer reporting agency
LQJ 0DVV0XWXDO ¿QDQFLDO SURIHVVLRQDO XQOHVV ZH UHFHLYH \RXU H[- for the purpose of evaluating your insurance application. The report
press consent: may contain information bearing on your credit worthiness, cred-
Arizona Massachusetts North Carolina it standing, credit capacity, character, general reputation, personal
characteristics or mode of living, which has been obtained from public
California Minnesota North Dakota record sources or through interviews with you, your family, neighbors,
Connecticut Montana Ohio friends or associates. Upon written request, we will inform you whether
or not an investigative consumer report requested along with the name
Georgia Nevada Oregon and address of the consumer reporting agency to whom the request
was made. You have a right to receive a copy of the investigative con-
Illinois New Jersey Vermont
sumer report from the consumer reporting agency that conducts the
Maine New Mexico Virginia investigation.
Medical Information Bureau Notice
If you are no longer our customer, we may continue to share your
personal information as described in this Privacy Notice. ,QIRUPDWLRQUHJDUGLQJ\RXULQVXUDELOLW\ZLOOEHWUHDWHGDVFRQ¿GHQWLDO
We or our reinsurers may, however, make a brief report thereon to
If you have any questions or concerns about this Privacy Notice,
the MIB Inc., formerly known as Medical Information Bureau, a not-
please contact us at (800) 272-2216.
IRUSUR¿W PHPEHUVKLS RUJDQL]DWLRQ RI LQVXUDQFH FRPSDQLHV ZKLFK
MassMutual Financial Group is a marketing name for Massachusetts operates an information exchange on behalf of its members. If you
0XWXDO/LIH,QVXUDQFH&RPSDQ\0DVV0XWXDODQGLWVDI¿OLDWHGFRP- apply to another MIB member company for life or health insurance
panies and sales representatives. This Privacy Notice is being provid- FRYHUDJHRUDFODLPIRUEHQH¿WVLVVXEPLWWHGWRVXFKDFRPSDQ\0,%
ed on behalf of the following insurance companies in the MassMutual XSRQUHTXHVWZLOOVXSSO\VXFKFRPSDQ\ZLWKWKHLQIRUPDWLRQLQLWV¿OH
Financial Group with regard to their individual insurance business:
Upon receipt of a request from you, MIB will arrange disclosure of any
Massachusetts Mutual Life Insurance Company, C.M. Life Insurance
LQIRUPDWLRQLWPD\KDYHLQ\RXU¿OH3OHDVHFRQWDFW0,%DW
Company, and MML Bay State Life Insurance Company.
77<LI\RXTXHVWLRQWKHDFFXUDF\RILQIRUPDWLRQ
Compensation LQ0,%¶V¿OH<RXPD\FRQWDFW0,%DQGVHHNDFRUUHFWLRQLQDFFRUGDQFH
The producer who is selling you the insurance policy or annuity con- with the procedures set forth in the Fair Credit Reporting Act. The ad-
tract for which you are applying is an insurance producer licensed by GUHVVRI0,%¶VLQIRUPDWLRQRI¿FHLV%UDLQWUHH+LOO3DUN6XLWH
the state of New York and has been authorized by Massachusetts Mu- %UDLQWUHH0DVVDFKXVHWWV
WXDO/LIH,QVXUDQFH&RPSDQ\RULIDSSOLFDEOHRQHRUPRUHRILWVDI¿OL- :HRURXUUHLQVXUHUVPD\DOVRUHOHDVHLQIRUPDWLRQLQRXU¿OHWRRWKHU
ated insurance companies (MassMutual) to sell such product(s). The insurance companies to whom you may apply for life or health insur-
role of the insurance producer in this transaction involves conferring DQFHRUWRZKRPDFODLPIRUEHQH¿WVPD\EHVXEPLWWHG,QIRUPDWLRQIRU
ZLWK\RXDERXWWKHEHQH¿WVWHUPVDQGFRQGLWLRQVRIWKH0DVV0XWXDO consumers about MIB may be obtained on its website at www.mib.com.
insurance policy or contract you are considering; offering advice about
The purpose of the bureau is to protect its member companies and
WKHVXEVWDQWLYHEHQH¿WVRIWKHSDUWLFXODULQVXUDQFHSROLF\RUFRQWUDFW
their policyholders from the costs created by people who try to hide
and selling and placing the insurance.
facts about their insurability. Information furnished by the bureau
Compensation will be paid to the producer by MassMutual based in FDQQRWEHXVHGDVDEDVLVIRUHYDOXDWLQJULVNV+RZHYHULWPD\EH
whole or in part on the insurance policy or contract you purchase. The XVHGWRDOHUWXVWRWKHSRVVLEOHQHHGIRUIXUWKHULQYHVWLJDWLRQ7+(%8-
compensation may vary depending on a number of factors, including, 5($8'2(6127+$9(0(',&$/5(32576)520+263,7$/6
but not limited to, the insurance policy or contract you purchase, the $1' '2&7256 7+( ,1)250$7,21 ,1 ,76 ),/(6 '2(6 127
premium amount, and the volume of business the producer provides 6+2::+(7+(5$1,1685$1&($33/,&$7,21:$6$&&(37-
for MassMutual. In addition, compensation that is paid to producers is ('3/$&(',1$1,1&5($6('35(0,80&/$6625'(&/,1('
generally limited by New York law and producers are prohibited by law (This notice is only valid where permitted by law.)
from rebating compensation, or otherwise providing an inducement, to
Our Purpose
an insured in order to make a sale. Note that compensation received
for various sales may not be readily comparable due to differences in Part of our basic Company purpose is to provide insurance at the
insurers’ distribution systems and compensation structures. lowest possible cost. The underwriting process is necessary both to
assure this low cost and to make sure that each policyholder contrib-
Please contact your producer if you would like more information about
utes his or her fair share of the cost. The procedures described above
the compensation the producer expects to receive in connection with
EHQH¿W\RXDVDSROLF\KROGHUEHFDXVHWKH\DVVLVWXVLQSURYLGLQJ\RXU
the policy or contract you purchase and about compensation he or
insurance at the lowest possible cost.
she would have received on any alternative quote(s) presented to you.
page 2 of 2 Important Privacy, Compensation & Consumer Information – 0515 N2010-US

Life Insurance Buyer's Guide
NAIC Model reprinted by Massachusetts Mutual Life Insurance Company.

This guide can help you shop for life insurance. It discusses how to:
• Find a policy that meets your needs and fits your budget
• Decide how much insurance you need
• Make informed decisions when you buy a policy.
Prepared by the National Association of Insurance Commissioners.
The National Association of Insurance Commissioners is an association of state insurance regulatory officials. This association helps the
various insurance departments to coordinate insurance laws for the benefit of all consumers.
©2006 National Association of Insurance Commissioners
This guide does not endorse any company or policy.
Important things to consider

1. Review your own insurance needs and circumstances. Choose the kind of policy that has benefits that most closely fit your needs. Ask an
agent or company to help you.
2. Be sure that you can handle premium payments. Can you afford the initial premium? If the premium increases later and you still need
insurance, can you still afford it?
3. Don’t sign an insurance application until you review it carefully to be sure all the answers are complete and accurate.
4. Don’t buy life insurance unless you intend to stick with your plan. It may be very costly if you quit during the early years of the policy.
5. Don’t drop one policy and buy another without a thorough study of the new policy and the one you have now. Replacing your insurance may
be costly.
6. Read your policy carefully. Ask your agent or company about anything that is not clear to you.
7. Review your life insurance program with your agent or company every few years to keep up with changes in your income and your needs.
Buying life insurance

When you buy life insurance, you want coverage that fits your needs.
First, decide how much you need – and for how long – and what you can afford to pay. Keep in mind the major reason you buy life insurance
is to cover the financial effects of unexpected or untimely death. Life insurance can also be one of many ways you plan for the future.
Next, learn what kinds of policies will meet your needs and pick the one that best suits you.
Then, choose the combination of policy premium and benefits that emphasizes protection in case of early death, or benefits in case of long life,
or a combination of both.
It makes good sense to ask a life insurance agent or company to help you. An agent can help you review your insurance needs and give you
information about the available policies. If one kind of policy doesn’t seem to fit your needs, ask about others.
This guide provides only basic information. You can get more facts from a life insurance agent or company or from your public library.
What about the policy you have now?

If you are thinking about dropping a life insurance policy, here are some things you should consider:
• If you decide to replace your policy, don’t cancel your old policy until you have received the new one. You then have a minimum period to
review your new policy and decide if it is what you wanted.
• It may be costly to replace a policy. Much of what you paid in the early years of the policy you have now, paid for the company’s cost of
selling and issuing the policy. You may pay this type of cost again if you buy a new policy.
• Ask your tax advisor if dropping your policy could affect your income taxes.
• If you are older or your health has changed, premiums for the new policy will often be higher. You will not be able to buy a new policy if you
are not insurable.
• You may have valuable rights and benefits in the policy you now have that are not in the new one.
• If the policy you have now no longer meets your needs, you may not have to replace it. You might be able to change your policy or add to it
to get the coverage or benefits you now want.
• At least in the beginning, a policy may pay no benefits for some causes of death covered in the policy you have now.
NB1000 409
In all cases, if you are thinking of buying a new policy, check with the agent or company that issued you the one you have now. When you
bought your old policy, you may have seen an illustration of the benefits of your policy. Before replacing your policy, ask your agent or
company for an updated illustration. Check to see how the policy has performed and what you might expect in the future, based on the
amounts the company is paying now.
How much do you need?

Here are some questions to ask yourself:
• How much of the family income do I provide? If I were to die early, how would my survivors, especially my children, get by? Does anyone
else depend on me financially, such as a parent, grandparent, brother or sister?
• Do I have children for whom I’d like to set aside money to finish their education in the event of my death?
• How will my family pay final expenses and repay debts after my death?
• Do I have family members or organizations to whom I would like to leave money?
• Will there be estate taxes to pay after my death?
• How will inflation affect future needs?
As you figure out what you have to meet these needs, count the life insurance you have now, including any group insurance where you work or
veteran’s insurance. Don’t forget Social Security and pension plan survivor’s benefits. Add other assets you have: savings, investments, real
estate and personal property. Which assets would your family sell or cash in to pay expenses after your death?
What is the right kind of life insurance?

All policies are not the same. Some give coverage for your lifetime and others cover you for a specific number of years. Some build up cash
values and others do not.
Some policies combine different kinds of insurance, and others let you change from one kind of insurance to another. Some policies may offer
other benefits while you are still living. Your choice should be based on your needs and what you can afford.
There are two basic types of life insurance: term insurance and cash value insurance. Term insurance generally has lower premiums in
the early years, but does not build up cash values that you can use in the future. You may combine cash value life insurance with term
insurance for the period of your greatest need for life insurance to replace income.
Term insurance covers you for a term of one or more years. It pays a death benefit only if you die in that term. Term insurance generally
offers the largest insurance protection for your premium dollar. It generally does not build up cash value.
You can renew most term insurance policies for one or more terms even if your health has changed. Each time you renew the policy for a new
term, premiums may be higher. Ask what the premiums will be if you continue to renew the policy. Also ask if you will lose the right to renew
the policy at some age. For a higher premium, some companies will give you the right to keep the policy in force for a guaranteed period at
the same price each year. At the end of that time you may need to pass a physical examination to continue coverage, and premiums may
increase.
You may be able to trade many term insurance policies for a cash value policy during a conversion period – even if you are not in good
health. Premiums for the new policy will be higher than you have been paying for the term insurance.
Cash value life insurance is a type of insurance where the premiums charged are higher at the beginning than they would be for the same
amount of term insurance. The part of the premium that is not used for the cost of insurance is invested by the company and builds up a cash
value that may be used in a variety of ways. You may borrow against a policy’s cash value by taking a policy loan. If you don’t pay back the
loan and the interest on it, the amount you owe will be subtracted from the benefits when you die, or from the cash value if you stop paying
premiums and take out the remaining cash value. You can also use your cash value to keep insurance protection for a limited time or to buy a
reduced amount without having to pay more premiums. You also can use the cash value to increase your income in retirement or to help pay
for needs such as a child’s tuition without cancelling the policy. However, to build up this cash value, you must pay higher premiums in the
earlier years of the policy. Cash value life insurance may be one of several types: whole life, universal life and variable life are all types of cash
value insurance.
Whole life insurance covers you for as long as you live if your premiums are paid. You generally pay the same amount in premiums for as
long as you live. When you first take out the policy, premiums can be several times higher than you would pay initially for the same amount of
term insurance. But they are smaller than the premiums you would eventually pay if you were to keep renewing a term policy until your later
years.
Some whole life policies let you pay premiums for a shorter period such as 20 years, or until age 65. Premiums for these policies are higher
since the premium payments are made during a shorter period.
Universal life insurance is a kind of flexible policy that lets you vary your premium payments. You can also adjust the face amount of your
coverage. Increases may require proof that you qualify for the new death benefit. The premiums you pay (less expense charges) go into a
policy account that earns interest. Charges are deducted from the account. If your yearly premium payment plus the interest your account
earns is less than the charges, your account value will become lower. If it keeps dropping, eventually your coverage will end. To prevent that,
you may need to start making premium payments, or increase your premium payments, or lower your death benefits. Even if there is enough
in your account to pay the premiums, continuing to pay premiums yourself means that you build up more cash value.
NB1000 409
Variable life insurance is a kind of insurance where the death benefits and cash values depend on the investment performance of one or more
separate accounts, which may be invested in mutual funds or other investments allowed under the policy. Be sure to get the prospectus from
the company when buying this kind of policy and study it carefully. You will have higher death benefits and cash value if the underlying
investments do well. Your benefits and cash value will be lower or may disappear if the investments you chose didn’t do as well as you
expected. You may pay an extra premium for a guaranteed death benefit.
Life insurance illustrations

You may be thinking of buying a policy where cash values, death benefits, dividends or premiums may vary based on events or situations the
company does not guarantee (such as interest rates). If so, you may get an illustration from the agent or company that helps explain how the
policy works. The illustration will show how the benefits that are not guaranteed will change as interest rates and other factors change. The
illustration will show you what the company guarantees. It will also show you what could happen in the future. Remember that nobody knows
what will happen in the future. You should be ready to adjust your financial plans if the cash value doesn’t increase as quickly as shown in the
illustration. You will be asked to sign a statement that says you understand that some of the numbers in the illustration are not guaranteed.
Finding a good value in life insurance

After you have decided which kind of life insurance is best for you, compare similar policies from different companies to find which one is likely
to give you the best value for your money. A simple comparison of the premiums is not enough. There are other things to consider. For
example:
• Do premiums or benefits vary from year to year?
• How much do the benefits build up in the policy?
• What part of the premiums or benefits is not guaranteed?
• What is the effect of interest on money paid and received at different times on the policy?
Remember that no one company offers the lowest cost at all ages for all kinds and amounts of insurance.
You should also consider other factors:
• How quickly does the cash value grow? Some policies have low cash values in the early years that build quickly later on. Other policies
have a more level cash value buildup. A year-by-year display of values and benefits can be very helpful. (The agent or company will give
you a policy summary or an illustration that will show benefits and premiums for selected years.)
• Are there special policy features that particularly suit your needs?
• How are nonguaranteed values calculated? For example, interest rates are important in determining policy returns. In some companies,
increases reflect the average interest earnings on all of that company’s policies regardless of when issued. In others, the return for policies
issued in a recent year, or a group of years, reflects the interest earnings on that group of policies; in this case, amounts paid are likely to
change more rapidly when interest rates change.
NB1000 409
DEPARTMENT OF FINANCIAL SERVICES OF THE STATE OF NEW YORK
DEFINITION OF REPLACEMENT
IN ORDER TO DETERMINE WHETHER YOU ARE REPLACING OR OTHERWISE CHANGING THE STATUS OF
EXISTING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS, AND IN ORDER TO RECEIVE THE VALUABLE
INFORMATION NECESSARY TO MAKE A CAREFUL COMPARISON IF YOU ARE CONTEMPLATING REPLACEMENT,
THE AGENT OR BROKER IS REQUIRED TO ASK YOU THE FOLLOWING QUESTIONS AND EXPLAIN ANY ITEMS
THAT YOU DO NOT UNDERSTAND.
AS PART OF YOUR PURCHASE OF A NEW LIFE INSURANCE POLICY OR A NEW ANNUITY CONTRACT, HAS
EXISTING COVERAGE BEEN, OR IS IT LIKELY TO BE:
(1) LAPSED, SURRENDERED, PARTIALLY SURRENDERED, FORFEITED, ASSIGNED TO THE INSURER
REPLACING THE LIFE INSURANCE POLICY OR ANNUITY CONTRACT, OR OTHERWISE TERMINATED?
X
YES_____ NO _____
(2) CHANGED OR MODIFIED INTO PAID-UP INSURANCE; CONTINUED AS EXTENDED TERM INSURANCE OR
UNDER ANOTHER FORM OF NONFORFEITURE BENEFIT; OR OTHERWISE REDUCED IN VALUE BY THE
USE OF NONFORFEITURE BENEFITS, DIVIDEND ACCUMULATIONS, DIVIDEND CASH VALUES OR OTHER
CASH VALUES?
X
YES _____ NO _____
(3) CHANGED OR MODIFIED SO AS TO EFFECT A REDUCTION EITHER IN THE AMOUNT OF THE EXISTING
LIFE INSURANCE OR ANNUITY BENEFIT OR IN THE PERIOD OF TIME THE EXISTING LIFE INSURANCE OR
ANNUITY BENEFIT WILL CONTINUE IN FORCE?
X
YES _____ NO _____
(4) REISSUED WITH A REDUCTION IN AMOUNT SUCH THAT ANY CASH VALUES ARE RELEASED, INCLUDING
ALL TRANSACTIONS WHEREIN AN AMOUNT OF DIVIDEND ACCUMULATIONS OR PAID-UP ADDITIONS IS
TO BE RELEASED ON ONE OR MORE OF THE EXISTING POLICIES?
X
YES _____ NO _____
(5) ASSIGNED AS COLLATERAL FOR A LOAN OR MADE SUBJECT TO BORROWING OR WITHDRAWAL OF ANY
PORTION OF THE LOAN VALUE, INCLUDING ALL TRANSACTIONS WHEREIN ANY AMOUNT OF DIVIDEND
ACCUMULATIONS OR PAID-UP ADDITIONS IS TO BE BORROWED OR WITHDRAWN ON ONE OR MORE
EXISTING POLICIES?
X
YES _____ NO _____
(6) CONTINUED WITH A STOPPAGE OF PREMIUM PAYMENTS OR REDUCTION IN THE AMOUNT OF PREMIUM
PAID?
X
YES _____ NO _____
IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, A REPLACEMENT AS DEFINED BY NEW
YORK INSURANCE REGULATION 60 HAS OCCURRED OR IS LIKELY TO OCCUR AND YOUR AGENT OR BROKER IS
REQUIRED TO PROVIDE YOU WITH THE IMPORTANT NOTICE REGARDING REPLACEMENT OR CHANGE OF LIFE
INSURANCE POLICIES OR ANNUITY CONTRACTS. YOU WILL ALSO RECEIVE A COMPLETED DISCLOSURE
STATEMENT NO LATER THAN THE TIME YOUR NEW POLICY OR NEW CONTRACT IS DELIVERED.
Date: _______________Signature of Applicant: ______________________________________________

Date: _______________Signature of Applicant: ______________________________________________
X
TO THE BEST OF MY KNOWLEDGE, A REPLACEMENT IS INVOLVED IN THIS TRANSACTION: YES ____ NO ____
Date: _______________Signature of Agent or Broker: ________________________________________
Massachusetts Mutual Life Insurance Company (MassMutual), 1295 State Street, Springfield, MA 01111-0001 and its subsidiaries: C.M. Life Insurance Company and MML Bay
State Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, Connecticut 06082-1981.
F6484 0815
Disclosure Statement for Accelerated
Death Benefit For Terminal Illness Rider
For use only with an individual whole life insurance policy in New York
Leave with Client

(MassMutual) 1295 State Street, Springfield, Massachusetts 01111-0001
The policy you are applying for may have an Accelerated Death Benefit For Terminal Illness Rider (ABR) automat-
ically attached to it. For details on the availability of this rider, consult with your MassMutual representative. This
disclosure only applies to the ABR For Terminal Illness. It does not apply to any Accelerated Death Benefit for
Long Term Care Services Rider that may be attached to your policy. This is a disclosure statement only. Detailed
information is contained in the contract issued. The terms of the contract take precedence over the information
in this disclosure statement.
Terms & Conditions ��

Condition for acceleration. Subject to the terms of the rider, an ac- Payment option available. The accelerated benefit is payable in a
celerated death benefit payment will be paid if the Insured (or surviv- lump sum subject to a maximum limit. The maximum amount to be
ing Insured on a second-to-die policy) has a terminal illness. accelerated is equal to the lesser of:
A terminal illness is a medical condition that: • 75% of the Eligible Amount; and
• Is diagnosed by a legally qualified physician. For some products, • A dollar amount that varies by policy type and will be either
this diagnosis must first be made after the effective date of the $250,000 or $500,000. Depending on the policy type, the amount
policy; and available may also be further reduced by the amount accelerated
under all other policies on the life of the Insured(s) by MassMutual
• With reasonable medical certainty, will result in the death of the In-
and any of its affiliates.
sured (or surviving Insured on a second-to-die policy) within twelve
(12) months after the date the legally qualified physician certifies The amount of payment under this rider will be equal to the portion of
the diagnosis; and the Eligible Amount requested for acceleration less:
• Is not curable by any means available to the medical profession. • A fee of not more than $250; and
Limitations of the Accelerated Death Benefit • Twelve (12) months interest on the amount accelerated at the an-
nual interest rate MassMutual has declared for benefits under this
• Receipt of accelerated death benefits may be taxable. Receipt of
rider. This rate will not exceed the greater of:
accelerated death benefits in periodic payments may be treated dif-
ferently than receipt in a lump sum. Prior to applying for such bene- • The effective annual yield on ninety (90) day U.S. Treasury Bills
fits, the Owner should seek assistance from a qualified tax advisor. as of the date the Owner applies for acceleration of the death
benefit; or
• Receipt of accelerated death benefits may affect eligibility for pub-
lic assistance programs such as medical assistance (Medicaid) Aid • The maximum adjustable policy loan interest rate in effect on
to Families with Dependent Children and Supplemental Security the date the Owner applies for acceleration of the death benefit,
Income. Receipt of accelerated death benefits in periodic pay- as allowed by law.
ments may be treated differently than receipt in a lump sum. Prior Administrative Expense Charge. In computing the amount of
to applying for accelerated death benefits, the Owner should con- the accelerated death benefit payment, an administrative expense
sult with the appropriate social services agency concerning how charge, or a fee of not more than $250, will be deducted.
receipt will affect the eligibility of the recipient and/or the recipient’s
spouse or dependents. Effect on Policy. Policy Values, loan values, and the amount of insur-
ance will be reduced if you receive an accelerated death benefit pay-
• An accelerated death benefit payment will not be allowed if the ment. The effect on your policy can be accurately determined only at
Owner is required to request the payment by any third party (in- the time of claim. At that time, the amounts illustrated for the sample
cluding any creditor, governmental agency, trustee in bankruptcy, policy below will be determined for your policy and supplied to you.
or any other person) or as the result of a court order.
For the base policy and any riders or agreements included in deter-
• No health care facility as defined in Section 20 of the Public Health mining the Eligible Amount, the amounts of insurance and all values
Law can require any person to accelerate payment of a death ben- will be reduced by the ratio of the Amount To Be Accelerated to the
efit as a condition of admission to such health care facility or pro- Eligible Amount. Any amount of policy loans and loan interest will be
viding any care in such facility. reduced by the same ratio.
Premium for Accelerated Death Benefit. No premium is charged An ILLUSTRATION of the effect of an accelerated benefit payment on
for the Accelerated Death Benefit Rider. a sample policy can be seen on the next page:
page 1 of 2 Disclosure Statement for Accelerated Death Benefit For Terminal Illness Rider – 0615F7011NY-LI
Terms & Conditions continued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
The sample policy below details a Male Issue Age 45, Acceleration in Year 10:
Before Acceleration
Face Amount $80,000
Death benefit* $100,000
Cash surrender value $12,194
Policy debt $5,000
Premium $1,246
Acceleration Payment
Eligible amount $100,000
Amount to be accelerated
Maximum $75,000
Requested $37,500
Interest rate used 8%
Loan repayment $1,875
Amount of payment $32,597
After Acceleration
Face Amount $50,000
Death benefit* $62,500
Cash surrender value $7,621
Policy debt $3,125
Premium $779
*Before being reduced by policy debt.
page 2 of 2 Disclosure Statement for Accelerated Death Benefit For Terminal Illness Rider – 0615F7011NY-LI

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Application for Individual Life &

Disability Insurance (Part 1)

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Massachusetts Mutual Life Insurance Company

Indicate usage below:

F5159NY-US Beneficiary Designation Form – 0413 page 1 of 3

1c. Class (Select one):  Primary  Secondary  Tertiary

F5159NY-US Beneficiary Designation Form – 0413 page 2 of 3

 Signature of Owner: _____________________________________________________________________________________________

 Signature of Owner 2 (If applicable): ________________________________________________________________________________

Witness Signature Section

 Signature of Witness: ___________________________________________________________________________________________

F5159NY-US Beneficiary Designation Form – 0413 page 3 of 3

page 1 of 2 Important Privacy, Compensation & Consumer Information – 0515 N2010-US

page 2 of 2 Important Privacy, Compensation & Consumer Information – 0515 N2010-US

NAIC Model reprinted by Massachusetts Mutual Life Insurance Company.

Important things to consider

Buying life insurance

What about the policy you have now?

How much do you need?

What is the right kind of life insurance?

Life insurance illustrations

Finding a good value in life insurance

Date: _______________Signature of Applicant: ______________________________________________

Massachusetts Mutual Life Insurance Company

Вам также может понравиться

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Date: _Signature of Applicant: ________________________________