Group Master Application for Variable Annuity Policy – Kemper Investors Life Insurance Company
Summary
This document is a Group Master Application form issued by Kemper Investors Life Insurance Company for a group variable annuity policy. The application collects information about the group, product, and principal office. It explains that benefits and payments under the policy may vary based on market value adjustments or investment performance, and are not guaranteed. The form requires signatures from an authorized representative and a licensed agent to be valid.
EX-4.(I) 10 0010.txt FORM OF GROUP MASTER APPLICATION EXHIBIT 5.1 Kemper Investors Life Insurance Company 1 Kemper Drive, Long Grove, Illinois 60049-0001 [LOGO] 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 Master Policy, when based on Guarantee Period Values, may increase or decrease in accordance with the Market Value Adjustment formula stated in the Master Policy Schedule. Benefits, payments and values provided by this Master 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-8696A
