8/9/2019 DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint
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Fi
LED
STt f.IE
S t ~ L J l : ~ U l
ClfiCUIT
CUHi\
J / l . C l " \ s u : ~
C(,(1;.;'
1
Y
\
IN
THE CIRCUIT
COURT
OF
JACKSON COUNTY,
AllKANSAS
~ DIVISION
l U I ~
FEB 7
M
II: 36
D.T.
ALLEN CO.,
INC.
H E C O R O E ~ £ A I N T I F F
800: l_PAGE
s.
CASE
NO. V
dO 15-:JO
ALLIANZ LIFE INSURANCE
COMPANY OF
NORTH AMERICA
COMPLAINT
DEFENDANT
COMES NOW, Plaintiff, D.T. Allen Co., Inc., by and through its
attorneys,
Newland &
Associates,
PLLC,
and for its Complaint, states as follows:
PARTIES,
JUIUSDICTION,
AND
VENUE
1. D.T.
Allen Co.,
Inc. ( D.T. Allen or the Company ) is an Arkansas corporation
with its principal place ofbusiness in Jackson County, Arkansas.
2. Upon information and belief, Defendant Allianz Life Insurance Company of North
America ( Allianz ) is an
insurance
company organized under the laws of the State of Minnesota
and authorized to do business in Arkansas.
3. Jurisdiction and venue are appropriate
in
this Court pursuant to Ark. Code Ann. §
16-13-201 and Ark. Code Ann. §§ 23-79-204 and 16-55·213, respectively.
FACTS
4. On
or about April
17, 1991,
Allianz issued
life
insurance policy number xxx3871,
Insuring the life of Michael W. Allen, Sr.
C Mr.
Allen ) in the sum of 250,000.00 (the Policy ).
Mr.
Allen was designated as the owner of the Policy. A
copy
of
the
Policy is
attached
hereto
as
Exhibit
A
and incorporated
herein.
5.
At
the
time
of
the
Policy's
issuance,
Mr.
Allen
was
part
owner
ofD.T.
Allen.
6.
Since the
Policy's
issuance • D.T. Allen has
pald
all premiums
on
the Policy.
Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 1 of 25
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7.
On
or about May
20,
2002, Mi·. Allen transferred ownership o the Policy to D.T,
Allen
and
designated D.T. Allen as the sole beneficiary. A
copy
of
the
Service Request
signed
by
Mr. Allen is
attached
hereto as Exhibit B
and
incorporated
herein.
8. n
approximately
September 2007,
Mr. Allen
relinquished
all
of
his
ownership in
the Company. Thereafter, the Company continued
to
pay all premiums on the Policy.
9.
Michael
Allen Sr.
passed
away on
or about September
4,
2014.
10.
Pursuant to the Policy and Service Request, D.T.
Allen
is the owner and sole
beneficiary
under
the
Policy and
the
only
person able to make a rightful
claim.
ee Exhibits
A-B.
11.
Despite
repeated
demands, Allianz
has
refused
to
pay
D.T.
Allen
any
of the
proceeds ofthe Policy.
COUNT I:
BRE CH OF CONTR CT
12.
Plaintiff realleges
and
incorporates the allegations contained in the
.Il eceding
paragraphs as if set forth word for
word herein.
13. D.T. Allen sues for
breach
of contract for all death benefit proceeds owed to it
by
Allianz under
the
Pol
Icy.
14. Pursuant to the
insurance
contract, upon Mr. Allen's death, Allianz was required to
pay
all
insurance proceeds to the
designated beneficiary .
15, The
Policy identifies D.T.
Allen
as the beneficiary of
all
insurance benefits.
16. Despite demand, Allianz
has refused
to pay the insurance
benefits
due
to D.T.
Allen
under the Policy
based on the
unsubstantiated claim of a non-party to the insurance contract.
17.
Allianz
has breached
its contract
with
D.T. Allen
by
refusing to
pay
the
insurance
benefits
due to D.T.
Allen pursuant to the Policy.
2
-
~
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18.
As
a
direct
and
proximate result
of
such breach,
D T.
Allen is
entitled to judgment
against Allianz
in the
arnoimt of
Two Hundred
Fifty
Thousand
Dollars
( 250,000.00),
plus
twelve
percent
(12%) damages and
its
reasonable
attorney s fees pursuant to Ark.
Code
Ann. § 23-79-
208.
19. Alternatively, Plaintiff is entitled to
recover
its costs and attorney s fees pursuant
to
Ark.
Code
Ann.
§16-22-308
for breach of contract.
RESERVATION OF RIGHTS
20. D.T. Allen specifically reserves the right to
bring
any additional
causes
o
action
against
the
Defendants,
or additional defendants,
and
to
amend
this
Complaint
as
necessary.
21. D.T.
Allen
r ~ u s t s
ajury trial on all matters
to
which it is entitled.
WHEREFORE,
Plaintiff, D.T. Allen Co.,
Inc.,
respectfully requests that the
Court
grant
the
above requested
relief,
for its costs and attorneys fees, and for all other just
and
proper relief
to which it may be entitled.
Respectfully submitted,
D.T. ALLEN CO., INC.
By
and
through:
NEWLAND ASSOCIATES, PLLC
2228 Cottondale Lane, Suite 200
Little
Rock, AR
72202
(501)
221-9393 telephone
(501) 221-7058
facsimile
3
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Allianz Life
Insurance Company
of North America
PO
Box59060
Mlnneapolls, MN 55459-0060
800.950.1962
September
22 2014
D ALLEN ANDCO
INC
PO BOX459
NEWPORT
AR
72112
RE:
Policy number
aa
Dear D.T.
Allen
and CO lnc:
Per
your request, please find the enclosed
duplicate
policy.
llianz®
You
can access
current
policy
Information by going to our secure website at www.alllanzjlfe.com. If this Is
your
first
visit
to our website, cllck on register here
and
follow the Instructions to aeate
your
own account. Do you
have feedback about a product or our service? You
can submit
feedback by logging In
to
account
and
dicking
on
Contact
Us .
Thank
you for
the opportunity to
help you
reach your financial goals.
If
you
have any questions,
feel
tree to ciall us
at B00.950_.1962.
Polley
Administration
Allianz Life Insurance Company of
North
America
EXHI IT·
LPA-1390
Rev 04/08/2011
I
a ·
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Allianz Life
Insurance
Company
or North
Amerfca
Allianz
P P o ~ s e o e o
MlnnoojlOll1,
MN
ll545D OOOO
TelophGno:
BDOIUl IHi&
72
June S,
2002
D.T. ALLBN AND CO. INC
POBOX 59
NBWPORT,AR 72112
RE: Allianz Policy Number: 3871
Insured: Michael W. Allen
Sr.
Dear Policy Owner:
We have received and recorded the request to change the ownership
designation
on
the
above-mentioned
contract(s),
h ~ a s o
keep
this acknowledgment with
your policy.
Please review
the
changes to
make sure they
are as
desired.
We appreciate
the opportunity to
provide service
to
you. fyou have further questions, please do not hesitate to oall
your
representative or me at 800-950-1962, extension 46247.
Sincerely,
Brooke:
Wood
Polley Administration
Allianz Administrative Management
C:WYNTON C NORWOOD office
:5670
.OUPlJCATE
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ACKNOWLEDGEMENT FOR CHANGB
To be attached and
made
part of:
Policy : lm3s
Insured: Micheal W. Allen
Sr.
The
policy
is hereby changed
to read: all
rights, title and interest in the policy are hereby
transferred
and vested
in:
Primacy
Ownership:
D.T. ALLEN AND CO. INC
POBOX459
NEWPORT, AR 72112
Primary Beneficiary:
D.T. ALLEN
AND CO.
INC
POBOX 59
NEWPORT,
AA 72112
Contingent Beneficiary:
ESTATE
OF INSURED
In evidence thereof, t he
Company has
caused the
Acknowledgement
to be executed at its
ome Office
and
put
into effect this
31st
day
of
May, 2002.
Allianz Life Insurance Company ofNorth America
Minneapolis, Minnesota
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.
P1
lexible
Premium
djustable Life Policy
Death Benefit
payable
to
the
Beneficiary upon
death
of
the
Insured before
age
95.
Net
Cash Value, if any, paid
to the Owner
at
the
lnsured's age 95. Nonparticipating - No annual dividends.
Signed
for the Company
at
its Home
Office on
the
date of Issue.
Suzanne J
Pepin
Senior Vice President,
Secretary,
and
Chief
Legal Officer
YOUR 20 DAY RIGHT
TO
EXAMINE YOUR POLICY
Charles Kavltsky
President
You may
return
your pollcywlthln
20
days after receiVlng lt lf dissatisfied for
any
reason.
You may
return
It to the agent or
our
Home
Office. We will
void
the policy and
mall
a refund
of
any
premium you
paid
within
10 days of receipt.
This
ls
a egal
contract
between you
and
the Company.
READ
YOUR
POLICY
CAREFULLY
LifeUS • Insurance
Company
5701
Golden Hiiis Drive
Minneapolis,
MN 55416-1297
A
Stock
Company
- - ' ~ · - ·
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POLICY SCHBDULB
NOTB: TIIB
MATURITY
DA'fB
ISTHJ,nOLICY
ANNIVBRSARY
FOLLOWINO
THB
INSURBD'S
95
111
BIRTHDAY. COVERAGE
MAY
EXPIRE
PRIOR.
TO Tiffi MATURITY DATB IFNO
.PREMIUMS
ARE
PAID
A[ITEll 'fHE
INITIAL PREMIUM
OR [(I
SUBSEQUBNT
PREMIUMS
ARE INSUFFICIENT TO CONTINUE
COVBitOB
l'O SUCH DATE. COVERAGE MAY
ALSO BE
AFFECTED
BY
A0-IANOB IN CURRENT VALUES. IF THB
POLICY DOES
CONTINUE
IN PORCE
TO
THE
MATURITY DA TB, IT IS POSSIBLE THA'l' "rnBltE MAY
BE
U1 l'LE OR
NO CASH SURRENDER
VALUE
AT
THAT TIME.
MONTHLYEXl'ENSE CB'.An.GES:
S?.SO l'ER
POLICY
PER
MONTH, ALL POLICY
YEARS
POLICY LOAN INTEREST RA1'E:
7.40% JN
ADV
ANCll
CONSISTENT PREMIUM
BASIS:
$1,212.00.
im GURANTEED INTEREST RATE
USBD
IN
CALCULATING
THB ACCUMULATION
VALUB
IS
0.32737% PER MONTH, COMPOUNDBD
MONTHLY.
THIS IS
EQUIV
ALBNT
TO
4.0%
PER
YEAR,
COMPOUNDED YBARLY.
DlJPL CATE:
INSURED: MICHAE ilV
ALLEN
SR
POLICY NUMBER:
lm3 7 AGE
ANDS.EX: 43
MALE
INITIAL
SPECIFIED
AMOUNT1 $250,000 PREMIUM RATE CLASS: NON.SMOKER
DEATH BENEFIT
OPTIONr
POLICY
DATE: APRIL 17,
J991
JNITV..L
PREMIUM: SIOl.00
MONTHLY
ANNIVERSARY DAY:l7
PLANNED
PREMIUM:
$101.00
MATURI'N
DATE1APRIL17,
2043
PLANNED EXCESS; PAYABLE: MONTHLY
OWNER
AND BENEFICJAD.Y: AS NAMBD IN APPLICATION
OR
AS LATBR CH NOBD•
Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 8 of 25
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•
(POLICY SCHEDULE
C O ~ T I N U E D
POLICY
NU1r1b ::R:
:St :71
OTHER COVERAGES:
NO O T H E ~ COVERAGES ? R E S e ~ T
SP :'.CIFIED
~ · l O O N T
SURR:NoeR CHARGES
EFFECTIVE
DATE
.
TERMINATION
DATE
THE FOLLOWING
S U R ~ e ~ D E R
C H A ~ ~ e s A ~ E a ~ s e o ON
THE
END OF THE POLICY YEAR:
POLICY YEAil
4\JOUNT
POLICY YEAR
AMOUNT
s6,500,JO
2
S6,S00.00
3
61500.00
4 ~ 6 5 0 0 . 0 0
S615DO.OO
6
S6 5QQ OO
7
~ 6 5 i l 0 . 0 0
8 S6,500.00
9
$0,soo.oo
10
S6,soo.oo
11
ss zoo.oo
2
53,900. 00
13
S21600.00
14
s1,:soo.oo
15'+
so.oo
THE S U R R c N D c ~ CHARGE WILL SE I N C R E ~ S E O O U ~ I N G THE FIRST 15
YEARS
SY
A ~ Y EXCESS
I ~ T E R E S T
CREDITED
o u q l ~ G
THE 12 M O ~ T H S PRECEDING THE
SURRcNiHR
3A
DUPllCf\TE
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PE1003
MENDMENT ENDORSEMENT
This endorsement Is attached to the policy as of the
Polley
Date and amends
the
policy as
follows:
PAYMENT
OF THE DEATH BENEFIT (added):
Interest
on
Life Insurance Proceeds
w
We will pay Interest on the proceeds
of
any
benefit paid. under
this
policy more
than thirty
days after
the
Insured' death. We will
pay
interest for the period
after the date
of the lnsured's
death the
the
date
the
beneflt Is
paid. The interest
rate
wlll be equal to that
being used for
Settlement OpUon C, or
higher
If required by
aw.
In
all
other respects the provisions, condlUons,
exceptions
and llmllatlons contained
ln
the policy remain
unchanged and apply
to
this endorsement
LifeUS
InsuranceCompany
Suzanne
J,
Pepin
Senior
Vice President,
Secretary
and Chief Legal Officer
· :
·-
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PE1034
MENDMENT ENDORSEMENT
This endorsement
Is
attached
to
the policy
as of the Policy Date and amends the policy as.follows:
DEFINITIONS (added):
The
Preferred Annuitlzatlon Amount
la equal to
the Accumulation Value
on the Preferred
Annultizatlon Date
plus
four limes the
sum
of the excess Interest credited to the
Accumutatlon
Value since
the Polley
Date.
The
Preferred Annultlzatlon
Date
Is
the later
of
the pollcy anniversary after your age 65
or 15 years
from the
Policy Date.
The Preferred Annultlzatlon Elecllon Period
Is
the period of time
between the
Preferred
Annulllzallon Date
and the Preferred Annultlzation Expiration Date.
The Preferred Annultlzatlon Expiration Date ls
the later of
the policy anniversary after
your
age
70 or
15 years from the
Policy Date.
Excess Interest Is the monthly
accrued
Interest
credited
In excess of the monthly accrued
Interest credited at the guaranteed minimum Interest
rate
PAYMENT OF
THE
DEATH
BENEFIT (added):
Option
A: During
the
Preferred Annuitlzallon Electlon
Period,
the
Death Benefit will be the
greater of the Speclfled
Amount shown
on
the
Policy Schedule or the
Death BenefK
Factor
times
the Preferred
AnnuiUzation
Amount as
of
the date of
the
lnsured s
death.
Option
B: During the Preferred Annuitlzallon Election Period, the Death Benefit will e the
greater of the Specified
Amount shown
on the Policy Schedule plus
the
Accumulatlon
Value as of Iha
date
of
the
lnsured s
death or the
Death Benefit
Factor
times
the
Preferred
Annultlzation
Amount
es
of the
dale
o the lnsurecl s death.
l>UPllCATE
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PE1034
CASH VALUE (added):
r e f e r ~ e d
Annultlzatlon Electlon •
During the Preferred
Annuitizatlon Eleotlon Period, the
Preferred
Annultlzatton
Amount will be
paid
t you
If
you
request
II to be paid over
your
life,
your
life
with
a period
certain r
under a oint end
survivor
option.
To
qualify for
the
Preferred Annultlzatlon
Amount the followlng condition
must
be
met. At
the end of each five pollcy
years
beginning with the fifth and
at the Preferred Annu ltlzatlon
Date, the cumulative total to date of
any
renewal premiums paid must equal r exceed
the
number
Of
renewal
years since Issue times the Planned Periodic Premium.
We will tell
you
on
your Annual
Report
whether the quallncallon
for the
Preferred
Annulllzallon Amount
has
been met. You wlll have 60 days from the date of the Annual
Report
to
pay
a
premium large enough to meet the
qualification.
Wewlll notify
you at your last
known
address 60 days
prior
to
the
Preferred Annultlzatlon
Expiration Date that the Preferred Annultlzatlon Election Period wlll end.
SETTLEMENT
PROVISIONS
(Option
A
and
Bare
deleted and
replaced
with the
following):
OPTION
A: Installments for
a Guaranteed Period We wltl
pay
equal
ln&tallments
for
a
guaranteed period of one to thirty years. If
installments
are paid over a
minlm1 111
of ten
years,
the
Death Benefit
will
be Increased
by 10%. Each Installment wlll consist
of part
benefH and part Interest.
We
wlll pay the Installments as requested
ellher
monthly,
quarterly, semi-annually
or
annually, See
Table
A.
OPTION B:
Installments for Life with a
Guaranteed
Period
We wlll pay equal monthly
Installments
as long
as
the
payee ls
living,
lt
we
wlll
not make payments
for
less
than
the
guaranteed
perlod
the payee chooses.
The Death
Benefit will be Increased
10% under
this
Option. We
wlll
pay the lnsteUments monthly. See Table
8.
In
all other respects the provisions, conditions, exceptions and
lfmlle lons contained In
the
policy
remain
unchanged
and
apply lo this
endorsement.
LifeUS Insurance ompany
Vice President and Secretary
Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 12 of 25
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APPLICATlON FOR
LIFE
INSURAN.
1· PART1
OJesi•anr
11hrour
,
2
1n1t io
0
l OllOllO
IOllJ/ld
lolldll l d'v•DUll pOllCy
0
Pwuud 1 1 1 1 1 1 1 1 ~ llflOll
fUYei
1
11y lltOGl'lt 5 • Monthl1 l11:111r1
CJ
Ole
l n 1 1 1 1 ~ 1 u 1 1
S •
1llax Paw ~ ' 1 ' 4 1 1 1 1 1 1
J
\;Gil
ol L•v·•g CL•nnJ Collslml 1 1 ~ 1
l•llax
12 DEATH BENEFIT OPTION 1c11oo"11t1e1
0 AtC1A11w111oq value
lnch>dto
Sp1d1ed 11ntun1
0 b ~ i : u . 1 1 1 ~ 1 1 1 1 1 1 1
Y;rl '
f'lr•ble 11111 Spoerl1ad Arioll I
13 PLANNED PERIODIC PREMIUMS
CJ Aarw11 CJ
m1-.\•Rlll'
0 1 1 - J r t ~ )
is:'.
Mo•lll')I
PAC
CJ
loll
Bid
GIWI
llo
J
GO'll Allo• [J 8 •171 ,..mun
MODAL
PAEMIUJd
AMOUNTS _ _ , _ / ' 0 . . . _ / , u . O Q ~ ; . _ . - - - - - -
b ADDITIONAL P ~ E M I U M lil'loLr1 t txms al pl>Aoed
PlllOdlC Pl•OlllrT·1 I -
INITIAL PREMIUM
h
plus
b I
s
_ _ tO i ~ o - - _
4MDUll•
SUSYITIEO W1111 ~ P r $
IEHO P L A H ~ E D PERIODIC PAYMENT ~ O l l C f l
0
YES
II V.S D ftoposd '""'«
0 App
1
1n111
I
Ovrnaf
0 01111
ifeU
Insurance Company
Bo' 5011bfl
\ l m n e n p o l J ~ \hnnr,ot
a :;15.1511.1•1Jhll
llJISl..., 11 ll1M.,.
Ill
relalt
10
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NAME
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SOCIALSECURITYNUMBER
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RESIDENCE ADO
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s1 ZAP
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IN1rld'8pMA'
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11a CHILDREN
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th\ldr1•
•• 111'a11 """'II '
"OI boltg
••CGHltc•
C J ~
0 No
b ~ · • U-r11nr ch1\drc•
shown
1bo Who no rol '•n
11
h 1pphcr1t
D
Yet
[J No
IU 'YES , .... 11J111t 1'111111sar
1n
t.MAJIKS
...
l9e 11
~ ' ' '
Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 13 of 25
8/9/2019 DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint
14/25
14 BENEFICIARY· STATE
FULL
NAME AND
RELATIONSHIP
Pnmary lnsUfpd·s Benej1c1ary
_ jiut filth
fll/ :t_n 5 1 0 1 1 ~
Con11'418nt
Beneficiary
r
Other
lnsured/Spouses s
Beneficiary
Conlmgent Benehc1ary
BENEFICIARY FOR
CHILDREN
IS THE PRIMARY INSURED
15 OWN
ER 11 other
than the Person to be Insured)
CJ lnd1v1dual
Full
Name
0 Corporation
Soc
Soc
, Tax or Employer ID
No
D Partnership Address
0 Trustee
B11 mg Address (if d1fteron11
16 OWNER OF POLICY ON
A
JUVENILE
a
II
the appllcanl 1dent11Jed Quest1ons
·8
on
page
1
s a uvemlo,
complele
lhe
owner
mlormahon
below
Ralat1onsh1p
to Proposed Insured
(Child)
other
than paren
I or
r a n ~ a r e n t
01thera
arent
or guardian musI
sign this
appl1callon in
addition to the Applicant
b
Parents
name
lnsinnce
m
orce
rather
Mother
c
Stele the total amount
of hlo insurance
on each
brother and
sister
of
the child
Name
Amount__
Name Amount__
If
more space required. answer
1n
REMARKS
17 COMPLETE IF
APPLYING
AS ANON·SMOKER
YES NO
a Has
any
person
to be insured
smoked
cigarettes in the
past year? O p....-
Name(s)
b
Is tobacco other than c1g1rettes used by any person to
be
covered?
0 V
Name(s)
Type/lrequency
18 DRIVINB
RECORD
.
oo
a What is your drivers license no
tale
rJ../S.._
Within the
pas I
three
years, has any
pe1 on
to be covered
been
convicted
or pleaded gu11ly to YES MO
b Three
or mora moving v1olat1ons an\\/or accidents?
o
0
c Onvmg under the
Influence
ol
alcohol
and/or
drugs?
Cl
Name
· · ··
Oela1ls
(give dates,
type of
v1olat1on)
•
19
FOREIGN
TRAVEL. AVIATION
ANO
MILITARY
YES
NO
a Except lor
vacation tnps doea
1ny person
to bci
covered Inland to travel outside
the US or
Canada
within
lhe
next
two
years?
0
µ
b
Does any
petson
to be covered intend to lly other than
as 1
passenger or
has he
or
she
flown
olher
thin
as a
P.Y"assenger dunno
the
post
two
years? 0
If "Yes' complete
Avratton Ouesllonna1re
c
Isany parson to
be
covered
a
member or does he
or
she
intend to become
a
member
of
the
anned rorces
nclud1ng
reserves?
D
If ·Yes",
give
details
in
REMARKS
20
AVOCATION AND SPORTS
YES O
Does any person to be
covered part1c1pate 1n
rocreatronal
acllv1t1es
mvolving
a Aeronautics (includinghang gliding, ultra
kght.
soaring,
cir,/
ky
d1vma.
ballooning)?
0
Frequency Equipment
Looa11on/area
Future
part1cipa11on
·b
Powered racing
or
compet111ve
vehicles (1nclud1ng
otorcycles, au1omob1les and motor boats)?
Cl
Type
of vehicle
Racmg
ctass1f1cation
Speeds
attained
Maximum
Average
I
Races
a•mually
"fype ol track
c
Recreational vehicles ovar
open terrain.
trails,
sand, snow or
ice (including
snowmobiles,
dirt
b1kea and dune buggtes)?
0
r
Type
of
vehicle
Where usod?
Frequency
Compet1bve
tac1ng?
II yes specify engine
sae
d
Skin
or
SCtJba d1v1ng, mountain clmbmg, rodeos,
compebtl\le
sk11ng?
D
f
Frequency
Locat1onfare11
DIVING
-
Typa
ol
equipment Frequency
Maximum
and
average depths
2.1 OTHER INSURANCE YES NO
a
Has
any
company
dllchnod
to
issue,
romstate. or
renew. rated mod111ed,
postponed
or canceled
any
hie
or health insurance on any person to be covered?
b Wiii insurance. mcludmo annuities, 1n
any
c;ompany
be
discontinued or changed If the
insurance
applied
for 1s
issued?
c
Is
any apphcauon for life
or
health insurance
on
any
a
person 10 be oovered pending in any
other company?
a
22 LIFE
INSURANCE
IN FORCE WITH
ALL
COMPANIES
Proposed
lnsurod
l..Jle
~ 3 9 )
Other
lnsUfed(s)
•
ADB
I
Dis Income
L
oo?>feu 1H
loopuifE.
Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 14 of 25
8/9/2019 DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint
15/25
_____
.•
...
~ ~ ~ P l E T E WITH RESPECT
TO ALL
PE NS TO BE COVERED, AS SHOWN
BELOW
NAM ; ANO ADDRESS OF YOUR FAMILY
PHYSICIAN
De, Paul H e r ~ e Y 1 1
Oeb.
/fJQC/q/h st AJgup t A
COMPLETE
OUESTIDllS
S·l CAREFULLY, GIVE DETAILS OF LL
YES
ANSWERS, lllCLUDIND llAME
Of PEllSllH
AFFECTED. All
DATES. lllAONOSES,
OU RATIONS,
OUTCOME
AND
THE
llAME3
ND
ADDNESSU
OF
LL
HOSPITALS ND
ATTEHDlllB
PHY&ICIAKS If ADDITIONAL SPACE
REQUIRED, MTACH SHEET
Of PAPEll. SIONEO. MTED AHO WITNESSED
3 IS ANY
PERSON
TO
BE COVERED
PRESENTLY
TAKING
MEDICATION?
4
WITHIN
THE
PAST FIVE YEARS HAS ANY PERSON
TO BE
COVERED
a Consulted, been exa1111ned or been
treated
by
any
phys1c1an or pracl11toner?
b
Had
an
x•ray. ileclrocatd1ogram
or any
laboratory test
r tudy?
c
Had
observation or
treatment
al acl1mc. hospital or sanitarium?
d Had or bean advised \o have a
surgical
operation? ·
e Had d1wness, shortness
of breath.
pain
or
pressuf" m
he
chest?
f Had
any
in1ury requiring treatment?
5
TO
THE
BES
TOF Y UR
ICNOWLEl>GE.
HAS ANY
PERSON
TO BE
COVERED
HAD
OR
BEEN TOLD HE OR SHE HAD\I
a
Epilepsy.
fainting spells. nervous or mental
condll1on,
neuritis. paralysis,
or any
d1smo or
abnorrnahty of the
brain or
nervous ayatem'
b Heart
allack,
murmur, palp1lat10n.
or
tugh blood pressure. anam1a, vancose
vems. or
any disease
or alJlormahlY of the heart.
blood
or blood
vessels
II
c l\Jben:utosis, asthm1, pleurlb)',
or
any disease
or abnormality ol
th11
lungs,
bronchial tubes, throat
or respiratory
system?
Ulcer.
ind1gest1on, coht1s,
gall stone,
hem111. or
any disease
orabncrmahty
of the
stomacn. intestines, rectum, gall
bladder or l1ver11
e Urinary 111Jgar, albumin or stone, syphilis,
menslrual
d1sorller, or disease or
abnormality ol the breas\s, kidneys.
prostate, unnary
or genital systems?
D1ab&tes . gout.
or
any dlS1Jas11 or
abnonnahty ol
Iha thyroid or other glands?
Arthritis, rheumalic fever. back trouble, or any disease or abnormality of the
1omts, muscle& or bonas?
h Any disease or
abnormality
of the eyus, ears
or
skm?
1
Cancer
or tumor?
1 Any physical deformity or
defect?
k
AAY
immune def1c1llllcy
disorders, Acquired
Immune
Oef1c1ency
Syndrome
(AIDS), or AIDS Related Complex (ARC), or test retults md1ca•1ng
eicposura
to the AIDS
virus?
6 WITHIN THE PAST TEN YEARS, HAS ANY PERSON TO BE COVERED REGULA
a
Amphotam1nes. barbiturates
orsedauves, except as p11scnbed by a
physician?
b Cocaine,
heroin,
morphin1, LSD, mar11uana.
PCP, oranyotherhalluc1nogenicor
narcotic d1Jg >
7 a
Have
any close relative&
of any person
to
be ooverad aver
had
cancer,
diabetes,
heart disease, or a nervous or mental abnormahty\I
Has eny person to be covered everroceiv11d
treatment or
101ned
an organization
for alcoholism or
dru11
addlc11on?
G Is any person to be covered now pregnant"
REMARKS
HOME OFFICE CHANGES IN THIS
APPLICATION.
0 utd¥µ1}
D U P L ~ C T E
.
I
I
Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 15 of 25
8/9/2019 DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint
16/25
·
' l ~ I I ' ' · ~ .
·Li feU• n s u r ~ c e Company
PART II
OF application
for
Insurance to
PROPOSED ,
INSURED:
\'f\,
t_1 a
e
(\\\f. ?
First Name ln1t1al Last
Name
Date
of
Birth
a
Name end address
of your personal
phys1c1an? _ ; ~ b . \ o c .
b Date and reason last c o ~ s u f l e d ? - q
d What med1ca11ons are
YoU
presenU
taking?
2
WITHIN THE
PAST FIVE YEARS
HAVE
YOU
a Con1:1ultecl
been
examined or
been
treated by ny
phys1e1en
or?
b
Had an X-ray, EKG or
anyJab9£aloJ:®I
or study?
c
Had obsarvahon or treatment at
a clinic, hospital
or
san1tanum?
d Had or been advised lo have a surgical operation?
a
Had dizziness, shortness of breath,
pain
or pre&sure
in
Iha chest?
3
HAVE
YOU
EVER BEEN
TOLD
YOU
HAD
a Epilepsy,
fainting spells,
nervous or mental
cond1 1on,
paralysis.
or
any disease
or
abnormality
of the
brain or
nervous system?
b Heart attack.
m u r m u r ~ .
anemia,
or
any disease
or abnormality of
the
heart, blood
or blood vessels?
c Tuberculosis, asthma. pleurisy, or
any
d1Bease or
abnormality al the
lungs. or respiratory
eystam?
.
d Ulcer,
1nd1gest1on,
colrtis.hern1a orany
disease
or abnormality of the
stomach,
mtestrnea, rectum, gall
bladder or
fiver?
e Urinary sugar, albumin
or
stone,
syphll1a.
or disease or abnormahty
of the
breasts. kidneys, prostate. urinary or genital systems?
Diabetes. gout, or any disease or abnormality of
the
thyroid or
other
glands?
g
Arthnha,
rheumatic fever, back
trouble,
or any disease or ebnormeltty
of
the
Joints.
muscles
or
bones?
h
Any
disease
or abnormality of h e ~ r s or skin?
1 Cancer or tumor?
J
Any
physical deformity
or delect?
k
An
immune
de 1c1ency
disorder,
Acquired
Immune
oer1c1ency
Syndrome (AIDS), Aids
Releled Complex (ARC),
or
test results
1nd1oating
exposure
to the
AIDS virus?
4 a
W1th1
ii
the past ten
yea
rs.
have
you used amphetamines, barbiturates,
cocaine. heroin.
morphine.
LSD. manruana,
PCP,
or
any
other
hallucmogen1c or
narcot10
drug?
b
Have
you ever received treatment
or rorned an
organizabon for
alcoholism or
drug addiction?
c Has your weight changed more than 15
pounds
m
he past year?
5
· Family History
Diabetes,
· high
blood
pressure, heart or
kidney
disease.
nervous or mental rffneas or su1c1de?
If Living Age at If Deceased
Stale of Health Death Cause of Death
Father
Mother
Brothers
& Sisters 0
Bo 69000
· \ l l 1 1 1 1 c u p o l 1 ~ . \fmnesot1t 5'5459·0000
~ M a l e
{a
~ L
ff
Female
Day
ear
I
DECLARE
that,
to
the best
of my
knowledge
and
belief.
the
statements
end
answers m
Part II
of this Appltcatronare lull,
complete, and true These statements and answers are
to
be tons1dered
as
the basis for
any insuranc& wrttten
hereon
JAUTHORIZE
any licensed phys1c1an, medical
prectt11oner.
hospital, oltmc or other medical
or
medically related
fac1lrty
insurance company.
the Medical
lnlormal1on Bureau or other organ1zalion. 1nst1tullon or person. that has ny
reoorda
or
knowledge of me or
my
health, to give to the Company .any such information This
authonzabon
11 good for
SO
months
from
the
apphca1lon date · ·
To fac1htate rapid aubm1ss1on of such mformat1on. I authorize all
said
sources. except the Medical lnform.allon Bureau, lo
give such
records or
knowledge to ~ n y
egenoy employed by
the
insurance com pany lo collect
and
transmitsuch mformatton
A photographic copy of this authorization shall be es vahd as
the
ortg1nal · ·
··
· · · : . .
~ e d _ a t
( C 1 l y S t ~ ) ~ j } A ) s
< f \ t l . _ o . . ~ , . , ) . On . .
.
1 ~ - 2 : _
s : : s \ , ~ ; i k s ±
l \ ) q . . s ~ Q , € ,
.-/ ~ · ... ,.... ·:.:.
Signature of Witness
1
' ) ~ \ l e ; )
Signature of
PROPOSED INSURED
..
hJR M r
•? l tQ
•.
_ .• • ' ; • •
Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 16 of 25
8/9/2019 DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint
17/25
•.
lllelJS
( the Co(11plnt}
•=
· · · · .
3fJ?/
:
..
,.,._.
·· I-Rf
PRESENT thal the
statements and
answers given hrs Apphcatron are
lrve complete,
and correctly
recorded to the
bes Iof 1ny
(our) knowledge and
bel1el
I AGREE Iha 1) This Appl1cation shall consrst
of
Par I
and
Parl II 11 apphcable) and
shalt
be
the
basrs
lor
any poltcy issued
on this
Application (2.)
Except as
otherwise provided the cond1t1onal
receipt, issued
any
policy issued on this
Apphcat1on
shall
not
lake e1f1ct unless all ol the follo1Vmg
cond1t1011s
aro met
(a)
The
ltrst
run
pramnrn
is
paid,
(b)
Tho
policy
1s
delivered lo tho
ownor dunno
tna
hlohme of
the
person(s)
t
be
cover11d
by
such
policy, and (c) AU ol tho stalements and
answers
given in thtS Appl1cahon to the hostol my
(our)
knowledge and
belier
conhnue Io be lrueandcomplete as
or
the date of delivery
ol
lho policy. (3)
No
agont
or
medical exernmermaywa1ve or
alter a
provision
ol
any pohty
and
nowaiver
ormod1l1cat1on
ol any
pohey issued on
lh1a Apphcahon
shall be binding
upon lhe
Comp11nyunless tn
wn11ng
and signed by lhe Presiden\ ora Vice Pres 1denl
and lhe
Sucretaiyor
an Ass1stanl Secretary (4J Tlla
Company may md1catechanges m
ha
SPlJCC
for
Home
OH1ce Changes
m ho
Application
foradmuwstrallve purposes only
f\rrt o1her changes rn this Appl1cauon shall be sub1ec1 to wntten consent by the owner
I
AUTHORIZE any phys1c1an modrcal pract1t1oner
hospital
cllnrc, medically
rel
t e ~
lacilrty.
mstranoe compuny, the Medical lnforrnat1on Bureau
(MIBI
or
other oruamzahon uuhtutmn orpnrson that has any mlormatlon
in 111
records on
me
ormy children to give the
Company
us legal
represenlal1vos and
its
re1nsurers any such
information
10 use (or underwntrno rnsurance and for delerm1nmg eltgibll11y
lorbenaflls
The Company may release mf
0
8/9/2019 DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint
18/25
.
DEFINITIONS
We,
our,
us
or The Company
means
LlfeUSA Insurance
Company.
You and your means the
owner
of
this
policy named In the
application, unless later changed.
The owner may
be other
than the peraon(s) Insured. The owner s
solely
entitled to
exercise all policy rights.
Insured means the person or persons whose life
is
Insured
lft lderthls
Policy.
Accumulation
Value
is the policy s
total value.
It
Is
describoo
In the
AccumulaUon
Values
section.
Age
means the
lnsured s
age
on the
last
birthday.
The Beneficiary Is the person or entity to whom we will
pay
the
Death Benefit if
the Insured
dies.
Cash Value means
the Accumulation
Value
less any
surrender penalty,
Lapse
means
termination
of the
pollcy
due
lo Insufficient
premium
payment
as
described in the Grace Period
section.
A
Polley
Loan
Is
the Indebtedness
to
us
for
a
loan
secured
by this
policy.
The Maturity
Date
Is
the policy anniversary
followlng the
lnsured s 95th
birthday.
The Maximum Loan Value Is
the IEM gest amount
you may
borrow under the
loan
provision.
·
The Net Cash
Value
Is the Cash Value less any remaining
loan balance.
The Net Premium Is 100 of any premium
you
pay.
Reinstate
means to
restore
coverage
after
the policy
has
lapsed.
A Rider
Is
en
attachment to the policy
that
provides
an
additional
benefit.
The Polley Date Is shown In the Policy Schedule and
detennlnes
the monthly anniversary
day,
policy
anniversaries, end policy
years.
Insurance Is effective as
shONll
on
the Application.
GUIDE TO POLICY PROVISIONS
Accumulation Values ..................................................
6
Ownership Definition ..................................................
2
Application ................................................................10
Payment of
Cash
Values and
Loans
...........................7
Beneficiary s Rights ...................................................
4
Payment of Death Benefit... .......................................4
Cash Value .................................................................
7
Polley Changes ..........................................................
6
Change of Beneficiary ................................................4
Polley Loans ...............................................................
7
Consistent
Premium
Payment Provislon .....................
5
Polley Schedule ..........................................................3
Death Benefit ............................................................ 4
Premlums ...................................................................
5
Definitions ..................................................................2
Reinstatement
of Lapsed Policy .................................5
General
Provlslons ...................................................
10
Settlement Provisions ................................................. B
Guaranteed Values ....................................................
6
Surrender
Option
........................................................ 7
Grace Period
..............................................................5
Table of Guaranteed Mortallty Rates ........................
11
Misstatement of Age .................................................10
Table of Surrender Charges .................................... 3A
2
O U P L \ t ~ f E
...
-- · - · - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 18 of 25
8/9/2019 DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint
19/25
THE BENEFICIARY
Who
Receives the
Death
Benefit
·We
will
pay the Death
Benefit to the
Beneficiary
when the Insured dies. The
Beneficiary
Is the person
or
entity
named
In
the application
unless changed,
Protection
of
the
Death
Benefit·
To
the
extent permitted
by law, the Death Benefit will not
be
subject
to
the claims of
tie
Beneficiary s
creditors.
If the Beneficiary Dies ~ I f any Beneficiary
dies before
the
Insured,
that
Beneflclarv s
Interest
In the Death
Benefit
will
end.
If any Beneficiary dies et
the
same time as the Insured,
or within 30 days after the Insured that Beneficiary s
Interest In the
Death
Benefit
will
end.
If he
Interest of all
named
beneficiaries
has ended
when
the Insured dies,
we
will
pay
the
Death
Benefit
to
you.
If you are not living
at
the
time, we
will ray the
Death Benefit
to the executor or
a
8/9/2019 DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint
20/25
PREMIUMS
Subject to the
Preml
Limlta lon provision
and
the
followlng
condltlons, we wlll accept
any
payment you send
to us while this policy ls In force.
1.
You
may
pay the first premium to our
authorized
representative. You may send subsequent premiums
to our Home Office
oryou
may pay them to an agent or
cashier
we authorize.
We will
give you a receipt
If
you
ask
for
one.
2. You may
pay premiums
at any time,
but
only If each
premium Is at least 25.
Premiums
paid by payroll
deduction are accepted.
3. To quallfy for the Consistent
Premium Payment
Pro-
vision, you must submit the Consistent Premium
Payment Basis stated In the Polley Schedule.
You
must
abide
strictly
by the
conditions
In the
Consistent
Premium Payment Provision
section.
Premium
Limitation · ny
premium received di.ling
a
policy year which
Is more than
three tlmes
the
total of
the
Monthly
Deductlons
for
the last year
may
be
refunded.
We
may also refund
any
unscheduled premlums that exceed
25,000 In any twelve month
period.
We
will not refund any
amouri lf
doing so would cause
your
policy to lapse
before the
next
monthly anniversary day,
We
will apply any
refund
first
toward reduction of any
outstanding
loan If you
give
us wrllten Instructions
lo
apply
the
refund
In
this
manner.
We
wlll remove
the excess premium
at the
end
of any policy
year
If
he
premiums
paid
exceed
the
amount allowable
for
the Death Benefit to qualify for federal income tax exclusion.
Interest
wlll
be
paid on the amount removed to the end of
that policy year. We will refund this excess amount
(Including
Interest)
within 60
days
after the end
of
that policy
year.
Continuation of
Insurance
•
Subject to
the
Grace Period
provision, your policy
will
continue between premium
payments
at the same
face
amount plus additional benefits
pro\'ided by Rider, Refer to the
Monthly
Deduction section
for further explanation.
Grace
Period
· grace period Is
a period
of
61 days
after
which either of
the
following has
occurred:
1.
The
Accumulation
Value minus any
loan
is less than
the
Monthly
Deduction
due.
2.
On a
monthly
anniversary date
there
Is Insufficient Net
Cash Value
to cover tile
next Monthly
Deductron
and
the
sum of the premllm paid lo date
ts
less than one-
lwelrth
of
the Planned Periodic Premium on an
annual
basis limes the
n ber
of months since Issue.
At
least
30
days
prior
to termination,
we
will
give you written
nollce at your laet
known address that
the grace period has
begun. You
must
then pay
a
premium large
enough to keep
the policy In
force.
If
you
do not pay enough
premium,
your
policy
will
lapse.
We will subtract the premium necessary to provide cover-
age
to the date
of
death If the Insured dies during
the
grace
period.
Reinstatement
of
Lapsed
Polley
w Unless this policy was
surrendered,
it may
be reinstated after lapse. To reinstate
the
policy, you
must meet
the following conditions.
1. You must request reinstatement In writing within three
years from the date of lapse and before the lnsured's
age 95.
2.
The
Insured
must
still
be Insurable
by
our standards.
3. If any loans
existed
when
the
policy lapsed, you must
repay
or reinstate them together w
th· interest
'Milch
had
accrued
to
the dale
of
lapse,
4.
You
must pay a premium
large
enough
to
cover
the
two
Monthly
Deductions due when the policy lapsed
and
three Monthly Deductions
due when
the
poftcy
le
reinstated.
The Accumulation
Value of the reinstated policy
will
be any
loan repaid,
plus 100%
of any premium you pay
at
reinstatement, minus the
Monthly Deductions due
at the
time
of
lapse.
Consistent Premium Payment Provision ·The
Consistent
Premium Payment Provision Is an Increase to the
Accumulallon
Value of 30%
of
the
Consistent
Premium
Payment Basis on each
poBcy
anniversary
from
the
eleventh
through
the
twentieth.
These Increases wl I be
credited
to
your Accumulallon
Value if the following condition Is met:
1.
Al the e ld of each of the policy years beginning
with
lhe
eleventh
and
ending
with
the
twentieth,
the cumulallve
total to date of any renewal premiums paid
must
equal
or
exceed
the
number of
renewal
years
since Issue
times the Consistent Premium Payment Basis on the
Policy Schedule.
These
Increases
will
terminate when the
policy terminates.
5
DUPLICATE
Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 20 of 25
8/9/2019 DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint
21/25
POLICY
CHANGES
Changes In Specified Amount ·Subject to
the following
conditions, you may request
a
change In the lnsured's
Specified
Amount
after the
first policy anniversary.
1. Specified Amount Decreases
Any decrease will become
effective
on the monthly
anniversary
day that
falls
on
or next
foUows
receipt of
request. Any such decrease
will reduce Insurance In
the
following order:
(a)
Insurance
provided by
the most
recent inaease;
(b) the
next most
recent
inaeases
successively; and
(c)
Insurance provided
under the original application.
2.
Specffled Amount Increases
Any
request
for an
Increase must be
applied
for on
a
supplemental
appllcatfon. such increase sh.all be
subject lo evidence
of insurabllity
satisfactory to
us.
No
Increase
Is
allowed
unless the Net Cash
Value
Is
sufficient to cover the
next
Monthly
Deduction.
Change In Death
Benefit Option ·You
may request
a
hqe
In
the
death benefit
option In
effect after the first
policy anniversary. The request must
be In
a
written
form
acceptable
to us.
Subject
to the following,
he effective
date
of
the
change wlll
be
the monthly anniversary day that fells
on
or next
follows the
date we receive
your requesl
1 If
the change Is
from Option A toOption 8
the
Specified
Amount after
such
change
shall be equal
to
the
lnsured's Specified Amount before sueh change less
the
Accumulation
Value
on
the
date
of
change.
2.
If
the change
la
from Option
8
to
Option
A,
the lnsured's
Spedfied
Amount
after such
change
shall be
e q u ~
to
the lnsured's Death Benefit before such change.
GUARANTEED VALUES
Accumulation Values ·The Accumulation
Value
on any
specified
date ls equal to:
1. The Accumula6on Value
on
the last monthly
an
nlversary day
plus accrued Interest from that
date
to the specified
date.
plus 2.
All
net premiums paid since the last monthly
anniversary day
plus
accrued interest from the
date
of receipt
to the specified date Iese any
refunds since
the last
monthly anniversary day.
minus
3-
Any partial
surrenders since the last monthly
anniversary
day.
At
the end of each policy month, the
Monthly
Deduction
wRI
be subtracted from
the Accumulatlon
Value.
Interest
Rates
•
The
guaranteed
minimum Interest rate
for
all polk::y years Is 4%.
We
may
declare a higher lnlerest
rate than the guaranteed
minimum
rate at any time. We may
change
this higher rate
at
our
option.
We
will never declare
a
rate lower than the
guaranteed minimum Interest
rate.
We will pay Interest on any part of the Accumulatlon Value
securing
a
Polley
Loan.
The excess rate may
be
lower than
the rate
credited to
the
unborrowed portion
of
the
Accumulatlon Value.
Monthly Mortality Charge - We
will determine the Monthly
Mortality Cost Charge for each policy year at the beginning
of
that
year. We
will use
the lnsured's age as of that
policy
year.
A
Table of
Guaranteed Maximum
Monthly Mortality
Cost
Charges
Is shown on
page
11.
We
may use rates
lower
than
these monthly
deduction
rates. We will
never use
higher
rates.
A
reduction In
the guaranteed
Monthly Mortality Cost
Charges for this policy
will also
apply
to all
other policies
Issued
on the same plan
and
to the same class
of
Insured.
The
reduced rate
will not
be affected
by
any
change In the
lnsured's health
or
occupation.
Monthly Deduction • We will take
the
Monthly Deduction
for the prior month from the Accumulation Value at the end
of
that
policy month.
The Monthly Deduction is equal to
{a the Monthly
Mortallty
Cost Charge times
the
difference between
the Death
Benefit and
the
Accumulation Value at the beglMing
of the
month,
plus (b)
the
Monthly Deduction for any Riders,
plus (c) the monthly
expense
charge
as
shown
In
the
Polley
Schedule.
·
... ~ D U P L ~ C A T E
Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 21 of 25
8/9/2019 DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint
22/25
BASIS
OF
COMPUTATION
The
Cash Values of
the
policy will not be less than the
minimum
values required by the Stale
where
the pafcy
Is
dellvered. Tue gunnteed Monthly
Deduclicn rates and
the
guaranteed Interest rate are
the
basis
fa
the Cash Values.
Calcufetfon
a minimum
Cash Value and ncnforfelture
benefits
Is based
en
the Commissioners 1980 Standard
Ordinary
Smoker/Nonsmdcer
Ultlmale Mortality Tables
for
males and
females, age last
birthday
and
4%
Interest
Death Is assumed lo occur t the end
of the poUcy
year.
We have flied the method we used to compute minimum
Cash
Values and nonforfeiture benefits
with
the Supervisory
Official
a the
Shte of policy
delivery.
SETILEMENT
PROVISIONS
·When the Insured dies, we will pay the Death
Benefit
In
a
lump sum unless you or
the
Beneficiary
choose a
settlement option.
You may
choose a settlement
option
while
the
Insured Is llvlng. The Benellclary may choose
a
settlement option after the Insured
has
died.
You may
also choose one of these
opllons as
a method
receiving the surrender
or
maturity
proceeds
if any
ll e
available
under
this
policy. if
the
BeneHciary Is no
an
Individual, Home
Office approval ts required.
When we receive
a
satisfactory wrlllen r q u s ~ we
will
apply the benefit according
to
one of these options:
OPTION A: Installments for a Guaranteed Period • We
wfll
i:>ay
equal
Installments
for
a guaranteed
period
of
one
to thirty years. Each Installment will consist of
part benefit
and
part Interest. We ·win pay the Installments as
requested either monthly, quarterly, semi-annually or
ainually.
See Table A.
OPTION B: Installments for Life with a Guaranteed
Period
· e
will pay equal monthly installments as long
as
the payee Is living, but we Will
not
make payments for
less
than the guaranteed period
the
payee chooses. The
guaranteed
period
may be either ten or twenty years. We
will pay
the Installments monthly. See Table B.
OPTION C:
Benefit Deposited with Interest
· e
wlll
hold the
benefit
on deposll.
It
will earn Interest
at
such
Interest rates as we declare, but
not less
than 4%
annually.
We will
pay
the earned interest
as requested
either
monthly,
quarterly, semi-annually or annually.
The
payee may
withdraw part
or
all
of
the benefit and earned
Interest
t
any time.
.
OPTION D:
Installments of a
Selected
Amount.
We will
pay
Installments
of
a
selected amount untll we have paid
the
entire benefit
and
accumulated
Interest.
OPTION
E:
Annuity -We
wlll use
the
benefit as
a single
premium
to
buy an annuity.
The
annuity may be payable
to one or
two
payees. It may
be
payable as
requested
for
life with
or wltliout a guaranteed
period. The
annully
payment wlll
not
be
less
than
our current amulty contracts
are then paying.
The payee may
arrange
af Y
other
method
of settlement
as
long as we agree to
It.
The payee must be an Individual
receiving payment In
his or
her
own
right.
There must
be
at
least 1,000
avallable
for
an
optlon
and each
installment to each
payee
must be
Et least $26.
If the
benefit ls not enough to meet these
requirements,
we will
pay the benefit In
a
lump sum.
We
will
pay the ftrst lnstaHment
under
any
option
as
of
the
date of death,
maturity, or
surrender. Any
unpaid
balance
we hold under
Option
A, 8 or D will earn Interest at the
rate we are 1>aying at the time
of
the
settle1mr1l
We wlll
not
pay
less
than
4% annual Interest.
If the payee does
not
live to
receive ll guaranteed
payments under Oi:>tlon
A, B,
D
or
E or
any amount
deposited under
Option
C,
plus any accumulated
interest,
we will pay
the
remaining benefit
to
the
payee's
estate.
The
payee
may
name
and
change a
successor
payee for
any amount
we would otherwise
pay the payee's
estate.
a ·
D U P l ~ C T E
Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 22 of 25
8/9/2019 DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint
23/25
TABLE A
INSTALLMENTS
FOR
EACH 1000 PAYABLE UNDER
OPTION
A
GuaranlH
Monthly
Gueranloa
Monthly Guarantee
Monlhly
Porlod
1n1lallm1nt1
Period
ln•tallm111t1
Period
lnmlallm1nla
1
$84.84
11
$1.31 21
11.111
2
8/9/2019 DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint
24/25
·•
GENERAL
PROVISIONS
Annual
Report·
We wHI
send
you
a
report
at least
once
a year which shows the premium payments,
expense
charges, Interest· credited,
mortality
charges, and
partial
surrenders
since lhe
last report. It
will also
show any
a.itstand(ng
loans,
the
current
Accumulation Value, and
current Net Cash
Value.
Projection
of
Benefits· If you
send us
a
written request,
we wll
furnish
you a
report which
shows
future
benefits
and values, The report will assume your Speclrled
Amount, type of Death
Benefit option,
Interest rate
and
future premium
payments. We
may
specify other
assumptions
a
necessary. You may request
one
report
free each
year.
Addltlonal reports will
not
cost
more
than
25 each.
lncontcstablllty
of
the Polley ·This
policy wlll be
lncontes able after It has been In force during
the
lnsured's nfetime
for two years from
the
Policy Date. This
provision does not apply to any Rider providing benents
speclflcally for
disability
or
death
by accident.
Amount
We Pay Is
limited
In
the Event of Suicide
We wlll
be
Hable only for
the
premiums paid, less any
particular surrenders, if
the
Insured dies by suicide whlle
sane or Insane w ithin one year from the Polley Dale.
Misstatement of
Age
or
Sex In the
Appllcation If
there Is a
misstatement
of the
lnsured's age
or sex
In
the
pol cy, we will adjust the excess of the Death Benefit ova."
the
Accumulatlon Value to
that which the most
recent
Monthly
Deduction
would purchase at
the
correct age or
sex.
The
Contract Consists of
the Polley and the
Appllcatlon
We
have Issued
this pollcy In consideration
of
the
application
and
Initial premium.
A
copy of the
application Is attached
and
Is
a
part of this
policy.
The
policy and the
application
together are the
entire contract. All statements
made by or for the Insured are considered representations
m
not warranties.
No
statements other
than
those
contained
In
the application wlll be used
lo
void
the pollcy
or defend
a
clalm.
Who Can Make
Changes
In
the Polley ·Only
our
Presldent or a Vice
President
together with our Secretary
have the
authority
to
make any changes ln this pollcy. Any
change must be
In
writing.
Assignment of the Polley
You may assign
or transfer all
or specific rights of
your
poUcy. No assignment wlll be
effective unlll you
notify
us In
writing. We
will
record
your
assignment. We wlll not be responsible
for
Its
valldlty
or
effect.
Death of the Owner
If
you die before the Insured, your
rights
will pass
to the executor
of your estate unless
ownership has been otherwise assigned.
Termination of Insurance ·This
policy
ill terminate m
lhe earliest of:
a the date
of surrender;
b. the poOcy anniversary following the lnsured's age
9 ;
or
c. the date of lapse.
No
Dividends
are
Payable
This Is nonparticipating
Insurance. It does not participate In our profits or surplus.
We do
not
distribute past surplus or recover past
losses by
changing the Monthly Deduction rates.
Notice •
Any
notice given
under
the provisions of this pollcy
will be sent to your last knCM'n address
and to
any assignee
of
record
10
Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 24 of 25
8/9/2019 DT ALLEN & CO INC v. ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA complaint
25/25
GUARANTEED
MAXIMUM MONTHLY
MORTALITY COST CHARGES
PER DOLLAR NET AMOUNT AT RISK
AGE
1
2
3
4
G
7
II
9
10
11
12
13
14
Hi
111
17
18
19
20
21
22
23
2'4
25
28
27
211
211
30
31
32
33
34
35
36
37
38
39
'40
41
42
43
44
45
46
NONSMOKER
MALE FEMALE
0.000219215 0.00011i6691
o.ooooao641 0.000010005
0.000092507 0.000006611
0.0000110040
0.000065004
0.000077606 0.000064171
0.000073339 0.000062604
0.0000611171
0.0000601137
O.OOOOBB004 0.0000811170
0.000082604 0.000068337
0.000061670 0.000057503
o.ooooe2s
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