Free Answer to Complaint - District Court of California - California

Case 3:07-cv-04723-MHP

Document 28-2

Filed 02/29/2008

Page 1 of 10

Exhibit A

3,?005:9:41Alv11 SAN fRA·a CISC0 923 Rr6-i0CT. Case 3:07-cv-04723-MHP Document 28-2
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Filed 02/29/2008 T·oe OFFICES>

Page 2 of 10/ b ·A6 i"¿ It l. 2 m

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Pararnedical $upplement Application to
Life Compahy f#ldelity anrlQtErsnty fnrurance
tits; lt{xvng Mi.'rfl+lnitill

O Atnericum lnd Annuitylnsursnce Lifs ComFany

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|

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cft

1, Havc yrJuHvcrlleqn g,eared or for

paln, preSsrlftr, cholesterol s) Anyhean rliscase high chert blood helrrafinck, hlgh murnrur, p*lpilrtinn.c, aoyorhar vessdsf dr of or diporder thehoa6 blood rlisorder lhcveiru artetlesT or TlA, oranyother of b) r irr-ullrory disenre, strokcr
bronchldr..r s) Any hrearhing lungdl*order, UUPD/ilsthma, or rtr of of blooddisordcr, dldordel the systcln. d) Diabettudisorder th+ immune el ,É arlCeL curTl·oe I·E L·oe

oY flnr

OY

,n ,m O Y ^ê ZR ^ê çq

OY OY oY g6t
O Y Ð " N Y "e

hack, folnxl splnr., or
disfiaseer disordet of the skin. cyEf, trr bgft?

(ARC) f]ositlvs (AlDs]. or nlDSrelatcd Complex tesl Syndrome Deficienry k) Arquired [nrmune irrdicg0nH Fru-et\ce lhgAfD rf result$ the _
2. AtHyou cursnll/ prc"cerlbErl medicationl nny ir) 3. H*ve you hc*n proscribecl medicarlorr the 10 4, tn lhe past yeerF. havcyoul hotfJiralizEd hadsurgcryl or ai tsecn
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o·w r blen l reatrrrn,µ SurBeryJ·oe advised to and OY ·ç ,,]I Had any eI·å trOcardiOEû Á ilb·oe"ry Erams,(OEû· L OEû lesu·OE nnt dflnero?

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Case 3:07-cv-04723-MHP

Document 28-2

Filed 02/29/2008I s ¯ Page 3` 1 ` 1 OE 6 S T OE ·F F · q >: l " Nl l of 10 =û l

- Continued
10.Personal Phy+icifrfi'* andAddrecs: Nnrne

Ddrc nnd

Cenrulred; Lq$t -_Hn#

( ,

aliF___,² ZO ZO L5_·c __·c --M ZR Renl w·¡ ·a,¯·oe l Å ·¡Orlned,¡ ,°on presc·a ,Sì"sb b·oe "ñ OE^ ·c·cj·[ ·[ _sM ·c·o·\ ^ê·c·csM ·c ·c·c "ñ·c

S·OE dR a diagnoS ler durttHan·OE upproprlarc: where ·b m<~ end number inclurlc 1 111 Givs Sbrfe ilnfi#ers. qUesilon ol details /Yeg" fu+ilitiesl and physlcianr medleal of anda.ldresseslll atrendlng

^ê

·x qnd enswcred this'ParEmedical to Supplement AFplication,The sLlerTlentt mJ·v·a :11lll I hlve reudrlrc qu+!*ions on trrtearrdcrrrrqcrly reqorded' cttmpft.te.

Signrd {C'ily $LateJ ot and on
Wlqq+s(rvredicol
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age15dr hrrre; orhu.*i* p*ontffiiiE

of F16p666d Ingured

Case 3:07-cv-04723-MHP

Document 28-2

Filed 02/29/2008

Page 4 of 10

orB) Life lnsurance Application (pase1
Cornpany f-idelify& Cuurantylifs Insurance Nalne(Fir5t M I 51 L·¡ 3·oe ·¡n,,K.Keel " Home Add"ì

á í ' PI '

·4A .É , Ì ,OE
L0531119 |

() Americom Life & Annu

91124-." --* - 14$0. | 5 t . ; i Avenue ;5altlgrylecsr-tA- , l J a t c o f B l ( h t , t a . l ' i i E 1 i i i i . , | r r t , , i * r ; n , . ' ' g t ' . t t [ o l ' 5 d t Oakdde r y T ; . _ # ' i ' ' f f i * ; . i i

| 200 .'' +ilo" .-.: trlarrieo -l oe'r+::* :--il sr0,1?-$s45----l---lt1l, G ; r " f f i # r # ; i - - - - E ; p s i l i r i , . ; ; J i , ; r - - ' * ' - - " : : l t i : : : - - l v i ' r f w i c ' " " " m r ' i ' i ? i wq_ r '"ii"J*i'*'.-5*r,,1., pacific Eree!o.lF__*__l** . I ion*t.u"uon _ | "
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Hulltiotrchip lfl Prifiary lrrrufffi

Honre Adrless

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Case 3:07-cv-04723-MHP

Document 28-2

Filed 02/29/2008

Page 5 of 10

or$) Life lnsuranceApplication (page?
pftlducl Namc I

n I lnstl,¡ Ce Amouilt·oe nmount oi In$urnncg

l ln·a I

id Premlurn rr'rrrs"t rrrrrrirr

i.NonOEûo I
uurrrotr.-

bacC·oe Nontulrilcco

RO"p*-. saveetectrerm20/20 -rERM; llml _ o t.evet

i...,n*i".1lrt*=*;,;i*.,, -Icrrn rrcmlulll (Number o{Yuarr)
Fgriod |

t E! rw r**l-scn

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HFE UNtyEftSAt

urrly) UL finrequrry-i'ilexed produrts o/" l:ixe{l liletFt oPrion lntcrctoiliol1-,oh {r rncrrirslrtg I$ | tquit}Inftxed j-n-'onai'i*ta= '-l--:;;;i'-'---P"F,ettt,ni-trJng-iu--"i*Coto '.-r"'- ' ' *\urrEU' pnyff'.nt c"'[E-ron non aufiiiiriii,rn, anrjirriti.rl *r-yme"r n""[ffi-, .o,npten" tro, ffi.,r Bank | $ ar* Fi-Weekly Draft ffc;urtrcrlv O Annuil 'i oth'.' r,*rr. nnn".r 'rff{m r+t*^'#

{) f}ecreasing ] ._l--nf *

to -gitf

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to

o eemi.Annuar -11#,!p+$,:i-"?s.;t'Erruct-loni Numbcr
Egufor . , Acco(rnt EilEiit:arrJ corrrPiln) rurrefir FracJrcEf I o visa q "-Mastr!!4l
.rr**

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,Jl 1 llU ·u... i Ll,Åwitil.·¡ll pr:)dllc,¢Or in·¡ 111,Ü (N ol·oe ll·oe·A re[V·¡l·oe 6sne{i{ Rider t) Accelerated O Accidental peath Benefit Ricler O CI·a Cal llineis tider c O Disability inCOn·R Rider Amounti $ Amountr $ Clasr: tequrrcd' gucstionnaire 5u pplementa!

Monthly PaPut $ l} 3 rnonth elimination, 2 year benefit D 6 rnontlrelimination,5 year bcnefit

dl Retumof PremiurnRidcr

Rider OPtirrn Incrrme O Ultimatc

InitialLumP
of: Monthly InCome $ lor yCars FinalLtrmPSurn:$

//s5traticrn rcquircd.

Rider O Waiver of Monthly Dedr'rction (Ut"onlY) D Waiver of PrentiunrRidet (Ternr onlyl O Clrild Rider (J Other: AmOunti rcqilifcd quc'etionnatie 5u pgiementdl

Case 3:07-cv-04723-MHP

Document 28-2

Filed 02/29/2008

Page 6 of 10

3or Life Insurance Application (pasc 8)
· d (Nolaçp "s"e
with all producls gr in all rtalts) av.rilable

Rider O OtherlnsurxVDePcnrlent
fJ DirabilitYIncome Rider

Amount: $
Icrm Feritxl:
yrs,

Fol tenn products,leffn perio{t must matclr ba.cePolicl tem Peti}d,

Morrthly lbyout: $ O 3 mqnth elirnination,z year benefit t) 6 month elintinatlon,-5year benefit

1· · W ² ãJ 1 · g , ­ ¦ . · a· ¡ E O N , · ·· V" i m c u v · g·ºoe
or Litc lrtSUr,rnCe DisebilitY lncornt'Ailutll
AIJII Ailrolnt _ , .Ycar lrsu{

~Zi :
l~b ^Å 1­Q O N O Y O N

or life.insuranceannuityf any or replace, change existin8 if issued, will thisPolicy/certi{icate, or are irui;, J,.r.'nfiich policylcertific.ae(s) above to he replaced changed. listcrl ir
Anrount being rePlacerl $ dct'rils): applic.rtionpendingl (lf yes' provicie 2. ls nnv ollrcr insurancu for postFontd/ rated,mtrdified,trr refitsed Havc you had an/ insuranceapplicationtjeclined' tlf rcinstrtemenL? ycs, provide cletalls);

O Y

OY ON

OY ON

N OY·oe

OY ON

·\ ·\ ·\ ·\ ·d ,P ,P ,P ,P "ú ·\ ^ ^ ·¡ ·¡ ·¡

Case 3:07-cv-04723-MHP

Document 28-2

Filed 02/29/2008

Page 7 of 10

·, k O N Y OY ON c)YON OY p,,G C;;..;'F;'"'r;I'l':::ll*:,"!#',{-iilT1i1,;Jlt.fllil%i:li 5.i",h- il;h"'. I·OE W·" I·Ò ·y Z§ ntr·¡ m ,² ·ð yl·oe N OY ON l·i ,,[ZÈ ·OE u d'^ ·" Y·oe "û ·OE [·u ·£ ·c ^ê ·c ·è·ã ·u |àe ^ê ^ê ^ê^ê ·\ ·c ^ê ·c ^ê ^ê ON ral: or cFeW mCmherOY an aiÈ of loI·OE · ·B h...·B a ,µ ,ÍOEû :Past 5IÌ·va --· p11·< yc:áe Á w·u 5md,± 0,:n·a "IunãJ o,OE¤ adv,É lD E ON ·u recJ"d u ever::18ht·B treament |,¢10r the V i·v:·u :|:have,¢ 7.Zs alcoholl'p ·u ·S useof

below {adtlilional ht{ornntion may be retluircd)' Detai/ *lf ycs .rns-rryt't'$ tnarldition,rvlnplclcqut,r|ionrl,ritesforVfsr}fl5t#8f5trrQrrctfiorrst,5,and6. P·E -1 · ·oe CiLnt earn3 00,000 Ç W·aoe arn3 585=|||·oe ·oe m·aned ln,ome s12 =121

Other Inrqred

Case 3:07-cv-04723-MHP

Document 28-2

Filed 02/29/2008

Page 8 of 10

E or Life lnsuranceApplication (pagen) l·E Iame JOEû , sb ,`,,ditll Welch M_D. ·D
irc',N0NfaifPriileD,inil|L\J(hNs,rdlhdyl',1P(T$rnrlpfipirjan-1

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Case 3:07-cv-04723-MHP

Document 28-2

Filed 02/29/2008

Page 9 of 10

6or Life I nsurance Application (page s)

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q|!gq$lose-d*E-trg-"t*d r, naveV"" everbcc.n hean attoctt,chestpain' hj8X^?tj-ifl=sure' a) Any hcartdisease, ' of clisordcr the heanqr-.big#-"5t-t# or - paipitatiqns, anyrrther
·u d·g _--} Fl,É ·a ·N iOE~ ,inYbttaZR d)D·· betes·OE Zå di50rdttr" nil--¢ ' 9·ô Zï ­] --· OE^ R ll­¿ OE^ "° --· OE^ ·± OE · v V · v· ç R

murmur' high cholesterol'
-,.**^,;^.?

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l--J.L^ ....;-,. Ordr d the vdns or artelc5: a p n e a · OE·
O Y · oe

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l _ D Y di50rder of th·Û ·c ·V ·]·è ],11S ___ · oe Y · oe N l O Y

he inmunc systeml·v

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e) Cancer,tulnor, or q4sti

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ol1nt91:'T"'ulI ncEllq*ggor9ito4i'{ .l--*.*/l*heimer's,
Içp ·¡ ttIq Shm ·± "° r Pr112·± --¢ OE^ ·¡ ·¡ ,è L -,^--^ch·OE "ncrOal·OE uéD ·T _ ____[__ __ _·g i-e-r;-.,a jnesI lr in"... ^·m ·OE^· \ ­Lc · c \ · ·E \ OE^ · !V · c · c l_ZR c · c · c · c · \ t",TMð "'@ ·\ ·]·] ·\ _ , ·¡ musrles ltO :riCludC 57Elin5 0·u Zå ­] OE^ ·\

O Y · oe

N

· oe V O N

O Y

O N · OE · oe N

O Y

O N

( n ^ : · ] · ¡· M· oe _ , ¡ J n " . 5prain5)·OE tendOnsl ,n

OY ON ,n ,x O N

1) Arthrlti5 0r any disease or di5order of t1lc·E

^ê ^ê ^ê ·N ·E ·@ ·@ ·E ·@ · oe N ·@ ·@ · @ ·@ ·@ ·@ ·@ ·@ ·@ ·@ ^ê ·@ ·@ ·@ , n ·@ ^ê ^ê ·N ·E

·@ ·@ ·N ,n ,x

O N

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the skin·OE

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arrd locutiorr of rnrr/ical recunJsl) rLrtc of dr.r6nr-rsj'$ phlsici'ur, c{iaFno.,iis.

Other Insured

Case 3:07-cv-04723-MHP

Document 28-2

Filed 02/29/2008

Page 10 of 10

';liJi*'tl'1ffitffi ti#$r:r#H;rffi durinscacnpropofo # '"L-"J*iuni' ptis$-gt' Ei;;,i:i;E;il1rl15:d}jg#fg:'$ffi ,H:l*rffi,$fi aro. oi-o{ifi.aJrr 'r"ti.. erert unleEs {ffi iniuii[iiity '11111 ":tttff"F-l1'3il*10'1flffi,il H;ft*dilhi"s
#-iililHt;; *,'itt
I

*'rryry:r-o:iurt'is"ppti"ati0nare:contp1ctc;truejondcorrect[y

nT'#;'.rHH,uu#;T"r.lmffi ffi orI#:Jffi*: fmflf:+tflfl$**'ffi other "Tie#gf r.*itF'Y Acrministratnr: n"dito]':'l
11d ,

and Federal fur*u, Inc'; the r,y, m**mu"fixii#_?T"rdffi.'fi and S.*:J";;HT,tr"rs'H.'#i*-'"t';;$i-;r;+nirpaidatourHome r**i,,roJ,r*ri unrlersrarrrrffi;#t;i-q;ii*ir "Jiffiiriilrt'"iiiiii"n | have rckncvur.cdgethil

y:,s,ans -medical :l::it*.,r*p"nio, a consumer ii*flX"#***l 6:iili.'i'fif:,1.ffi*fi:,1'-'Jfrft rti *r"J"ra'ilo, otn*'rroninc ('l*Fncvprescriptiorr insuran[e and other Information,Rur;'"--iil.; Mecrical J*riqn&' tacrrrry..u{e rnedicarty+clated r, rti" rnru*r,

and for life insurance' ls i'r,ranigsr, my uenerrr rwords,phrrmarry "mproyoito'gi"".* or anyrnembcr'"i"nyiii;iiv who applying ,*gi'LrT"5 1s whiclrnrayhe pertine*nr thq svaiuatiu" f'rmilywho is also'rpplyingfor informrtion nty coniutler "po't on tle il^'ol any menrber'of to otrtainan invq'Stigativc wlrichmry be requestetl prePare ug*ucv the I alsoauthorize Insurer.to by () i"t'ir*r t'iU* intqiu'i"#cd anv:..",,t-lT'*L:*l*iting if intervicw requeited: I unrterrtansi-hJtiii* ftq''jii' Chkli litu insurance, nd--t irusinets ct'ntatred'a'.,'iing +s illncss definedin *']l sucha re*rrl a5lsng as, .# ,.lion"'Uiy'he Rirler r'rJ',,erit antl l.am laterdiagnosecl ponitrnof nrv'encJ* early'tre iLolTintl the.Accelerarccr ,..,_rr]es thar I untJerstand if my."rorg* ir-r*ril sr_cei**rE receive.a a."i'r, rereiPt otthe c.ertificate drdt orb'+rnenu up I the rit,er, mayrccerve t, s-tiv" "r'|Jiily:, *irr*.TroY::ffiili'f?{',:ni*iil;iilit-t!*i*;*i"*,1*,;d

payahie ann,rnr attreti*re'Ir-riviiir'n
to
Isrrppricd upon inforiration r,- aboutrny i,ilp,slrtilI:r*neu'u , in.rcr.'ia't" wir reried information iu.t l;"j#,,il1?1;.#fiI'i;.ilHffii*iltiT.-.r*,"',*nheahh inmrfiaHJf,-ni ,,,iv procluct, frrr my lnsuraD*ty rhar

which insurance to Inrav tor orher companics apprv trffin$il";l*;l;l,ll;'*ruJfo'i,',i;-:":lilH:;liifrT'.t maytresubmittctl' or will covcra8e to whicl'ta ctairn Authurization tE as healtt insurance of
copy this life or r"r'" p*ri"o of .tt) m'nrrrs;a phora6raphic wi, ThisAuthorizarion rrc v.rrid.irc* ,l* glg-liglP-o'--*n-tf,hd icccivea copyof thisAuthorization' to benefiti' and/or for valicl theoriginul;l, or flnyof our represenutiues as U*rmirre eligibility insurance by u" .,f'f i""'l'*'ization will t* "i-Ai" tlre on provirled thisform are Numbers I understandthat informiit'n otrt'rirted gocialsecurity rax tdentificatioa or 'il"*V of unclcrthe perraliiel PeriuryI certi{y certification:
true, correct arrd cnmPlete,

-rn_r-<.x,r",i-iii.fr'*iir',

$atr Francircs' GA ,É1,° ­Ê e h ' ó R1 R m à u r O I P l lim,·²" [ ä ø 3 0 r rm · oe àu :·a ,¢ fÉ: 1·, ­Ê F SZ"·,É ·oe·v~b æ·, ·G·¡ e15 or mure
.:.--.T:maryi;**;; I of SrH,nilture Owne(s) (il nut Ltr+ ''f[ir-";w lnsrrrslis lt:r lhnn e6elBi

gprn K' KPel

l·Ü à Jtte tt d·å ar,½ ·Ø On od"^ Z­ ^× tttT,± TII:[ n5idered a 1035 Exchan3o7 0 Ves (, VVill thiS rttPiCemeni bO~"Ú lf 50·OE ·u

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