AO - LQ (07/09) State of California - Department of Insurance

Life Insurance Policy Form Filing Questionnaire

(version 01-26-09)
PLEASE COMPLETE AND ENCLOSE A SEPARATE QUESTIONNAIRE FOR EACH POLICY FORM BEING SUBMITTED FOR FILING.
(WHERE POSSIBLE PLEASE REFERENCE RELEVANT SECTION OR PAGE OF THE POLICY NEXT TO YOUR RESPONSE)
A COMPLETED QUESTIONNAIRE IS GENERALLY NOT REQUIRED FOR RIDERS & ENDORSEMENTS BUT MAY BE REQUESTED.

Company name:
NAIC number:
Form number:
Description of form being filed:
Filing contact person:
Phone number:
e-mail address:
Today's date:

GENERAL FILING REQUIREMENT

1. Life insurance policy forms which are subject to the Standard Nonforfeiture Law for Life Insurance (SNFL)
(CIC 10159.1 et seq) must be filed with the commissioner (CIC 10163.35) unless specifically excluded (CIC 10165).

a. Does the policy form being filed fall into any of the categories (a) - (h) listed in CIC 10165 YES NO
as being excluded?

b. If "Yes", please indicate which category (a) -(h) applies, and provide a brief explanation in the space below:

ILLUSTRATIONS YES NO N/A

2. Will the policy form be illustrated?
a. If "Yes", is a copy of the actuarial certification concerning the illustration being submitted
as required by CIC 10509.960?

CONSUMER COMPLAINTS
3. When this policy is issued, will the applicant receive a disclosure form in compliance with CIC 510, YES NO
describing how to contact the insurer, the agent or broker, or the Department of Insurance?
- If "Yes", please include a copy of the disclosure form in your submission

REQUIRED DISCLOSURE FOR SENIOR CITIZENS

4. For policies to be issued to persons age 60 and older: YES NO N/A
a. Is the notice required by CIC 10127.10(c) printed on the cover page or policy jacket?
(Please note that the required notice must contain the exact language specified, and must be in 12-point bold print with
one inch of space on all sides.) YES NO N/A
b. If the policy has surrender charges, is disclosure provided as required by CIC 10127.13?
(Please note that any applicable disclosure language regarding surrender charges must be separated from the notice required in a. above)

SURRENDER VALUE TERMINOLOGY YES NO N/A

5. Does the form contain surrender charges?
a. If the term "surrender value" or "cash surrender value" is used in the policy form, does it mean
anything other than the amount of cash the owner would receive upon surrender of the policy?
If "Yes", please explain in the space provided below:
STATEMENT OF VARIABILITY (SOV)
6. If the form contains bracketed variable items:
(If not, please indicate "N/A" and proceed to question 7. ) YES NO N/A
a. Has a SOV which describes each variable element together with its range been submitted?
b. Will such variable items only be changed for policies issued after the date of the change?

UNIVERSAL LIFE (UL) POLICY FORMS

7. If the form is a UL product: (If not, please indicate "N/A" and proceed to question 8.) YES NO N/A
a. Is the minimum guaranteed interest rate shown in the policy form?
b. Are the guaranteed maximum cost of insurance rates included in the policy form?
c. Do any of the guaranteed maximum cost of insurance rates exceed the corresponding
valuation mortality rates?
d. Are guaranteed maximum expense charges and policy loads shown in the policy form?
e. Are surrender charges shown in the policy form?
f. Does the policy disclose that planned premiums may not be sufficient to keep the policy in force?

NONFORFEITURE COMPLIANCE
8. If the form is a traditional life product (e.g. whole life, term life, etc.):
(If not, please indicate "N/A" and proceed to question 9. )
a. Has an Actuarial Memorandum been submitted showing compliance with the Standard YES NO N/A
Nonforfeiture Law (SNFL), CIC 10159.1 et. seq.?
b. Does the Actuarial Memorandum also include demonstration of compliance with the SNFL
requirements regarding consistent progression of cash surrender values with increasing YES NO N/A
policy duration, often referred to as the "smoothness test"?

9. If the submitted form is a UL policy:

(If not, please indicate "N/A" and proceed to question 10. )
a. California has not adopted the nonforfeiture provisions of the NAIC Model Universal
Life Regulation but requires that, for all issue ages, cash values provided at all durations under
the UL policy (using GMPs as annual premiums and policy guarantees for interest, expenses
and mortality charges) are at least as great as those required under the SNFL for a policy
equivalent to the UL plan of insurance. Has an Actuarial Memorandum which includes YES NO N/A
such a demonstration for issue age 35 been submitted with this policy form?
b. Are any applicable taxes deducted in the calculation of nonforfeiture values?
c. Are these taxes deducted in determining the minimum nonforfeiture values in the
demonstration in 9.a?

NO LAPSE GUARANTEES
10. If the policy form includes a no lapse guarantee:
(If not, please indicate "N/A" and proceed to 11.) YES NO N/A
a. Does the supporting Actuarial Memorandum describe all available no lapse guarantee periods
applicable to each issue age?
b. Is the no lapse guarantee premium and the period for which it is payable disclosed on the
specifications page?
c. Does the policy define the policy benefits available during the no lapse guarantee periods?
d. If the no lapse guarantee provision may be terminated due to changes to the policy, is this
disclosed in the policy?
MARKET VALUE ADJUSTMENTS
11. If the policy form includes a Market Value Adjustment (MVA) provision:
(If not, please indicate "N/A" and proceed to 12.) YES NO N/A
a. Is the MVA formula applicable for both upward and downward adjustments?
b. Is the basis for the MVA formula explained in the accompanying Actuarial Memorandum?
c. Does the MVA formula provide for reasonable equity for both the policyowner and company?
d. Can the market value adjusted benefit be less than the minimum
nonforfeiture amount required when there is no MVA?

INDEXED BENEFITS
12. If the policy form provides for indexed benefits, either within the form itself or by rider:
(If not, please indicate "N/A" and proceed to 13.) YES NO N/A
a. Is it disclosed in the policy form that indexed interest will not be credited on amounts
withdrawn prior to the end of the indexed interest period?
b. Is the indexed interest period greater than one year?
c. Are minimums and maximums of all parameters, e.g. participation rate, cap, length of
index term, etc, shown on a spec page, along with current values?

HEALTH-TYPE BENEFITS
13. Does the form contain any embedded health-type benefits? (An example of such a YES NO
benefit might be waiver of surrender charges in case of nursing home confinement
or accelerated death benefits within the policy form itself.)

ADDITIONAL QUESTIONS:
14. Does this policy form contain any unusual or possibly innovative features which differ from YES NO
current industry practices or standards?
a. If yes, please describe briefly in the space provided below

15. Do the same cost of insurance rates apply as long as the policy is in force regardless of YES NO N/A
whether or not premium is being paid under the policy? (For UL policies only)

16. Does this policy form include a "return of premium" (ROP) benefit either in the policy form YES NO N/A
itself or in a rider attached to the policy form?
a. Is a ROP benefit paid regardless of whether or not the policy owner surrenders the policy?
b. Does the calculation of required minimum nonforfeiture values assume payment of significantly
higher premiums after the ROP benefit is paid?

17. Does the policy provide protection from the claims of creditors by placing underlying assets
in a separate account which are not chargeable with liabilities arising out of any other business YES NO
the insurer may conduct?

PLEASE COMPLETE AND ENCLOSE A SEPARATE QUESTIONNAIRE FOR EACH POLICY FORM BEING SUBMITTED FOR FILING.
(WHERE POSSIBLE PLEASE REFERENCE RELEVANT SECTION OR PAGE OF THE POLICY NEXT TO YOUR RESPONSE)
A COMPLETED QUESTIONNAIRE IS GENERALLY NOT REQUIRED FOR RIDERS & ENDORSEMENTS BUT MAY BE REQUESTED.