Kemper Investors Life Insurance Company Group Master Application Form
Summary
This document is a group master application form issued by Kemper Investors Life Insurance Company for organizations seeking to apply for a group insurance product. The form requires details about the group, the product, and the principal office, and must be signed by an authorized representative and a licensed agent. The policy's benefits and payments may vary based on market value adjustments or investment performance, and are not guaranteed. The application is a preliminary step for groups to obtain insurance coverage under the specified product.
EX-4.I 10 dex4i.txt FORM OF GROUP MASTER APPLICATION Exhibit 4(i) Kemper Investors Life Insurance Company [LOGO] 1 Kemper Drive, Long Grove, Illinois 60049-0001 ZURICH KEMPER Group Master Application - -------------------------------------------------------------------------------- APPLICATION - -------------------------------------------------------------------------------- Application for: _______________________________________________________________ Name of Product: _______________________________________________________________ Name of Group: _________________________________________________________________ Principal Office Street Address: _______________________________________________ City: ____________________ State: ____________________ Zip: __________________ Benefits and payments provided by this policy, when based on Guarantee Period Values, may increase or decrease in accordance with the Market Value Adjustment formula stated in the contract schedule. Benefits, payments and values provided by this policy, when based upon the investment experience of the subaccounts, are variable and are not guaranteed as to dollar amount. Refer to the variable account and annuity period provisions for a determination of any variable benefits. - -------------------------------------------------------------------------------- SIGNATURES - -------------------------------------------------------------------------------- Signature of Authorized Representative: ________________________________________ Print Name: ____________________________________________________________________ Title: _________________________________________________________________________ Signed at (City, State and Zip): _______________________________________________ Date: __________________________________________________________________________ Witnessed by: __________________________________________________________________ Licensed Agent: ________________________________________________________________ L-8715
