APPENDIX A

Case 2:10-cv-09198-JVS-RNB Document 408-3 Filed 03/18/13 Page 1 of 4 Page ID
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QUESTIONS? CALL 1-800-XXX-XXXX OR VISIT WWW.______.COM

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QUESTIONNAIRE

INSTRUCTIONS

You are receiving this questionnaire because you have been identified as someone who may have
purchased an indexed universal life insurance policy issued by Life Insurance Company of the
Southwest (“LSW”). Please complete the enclosed questionnaire and return it to the address indicated
below by _______, 2013. [75 days from date of mailing]
QUESTIONS

If you believe that you purchased an indexed universal life insurance policy issued by LSW, please
respond to the following questions. You may use additional sheets if necessary.
1.
What is your name and current mailing address?
NAME:

ADDRESS:

CITY/STATE/ZIP:

2.
Did you purchase a SecurePlus Provider or SecurePlus Paragon life insurance policy issued by
LSW? (circle one)
YES
NO
I DON’T KNOW
(If your answer to Question #1 is “No,” you need not respond to the remainder of this
questionnaire. Please sign at the bottom and return it to the address indicated below)
3.
What is the policy number of your SecurePlus Provider or SecurePlus Paragon policy?
(beginning with “LS”)

4.
Was your SecurePlus Provider or SecurePlus Paragon policy issued on or after September 24,
2006?
YES
NO
I DON’T KNOW
5.
Was your SecurePlus Provider or SecurePlus Paragon policy issued on or after September 24,
2007?
YES
NO
I DON’T KNOW

Case 2:10-cv-09198-JVS-RNB Document 408-3 Filed 03/18/13 Page 2 of 4 Page ID
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QUESTIONS? CALL 1-800-XXX-XXXX OR VISIT WWW.______.COM

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6.
Do you still own your SecurePlus Provider or SecurePlus Paragon policy?
YES
NO
I DON’T KNOW
7.
What documents were you shown or provided with regarding your SecurePlus Provider or
SecurePlus Paragon policy before you applied for your policy? (list all that apply)

Please include photocopies of all documents listed above in response to Question No. 7, and
any other documents that you believe bear upon what you were told before you applied for
your policy. If copies of these documents are no longer available to you, please indicate who
else may have copies of them:

8.
Did you receive a Policy Illustration before you applied for your SecurePlus Provider or
SecurePlus Paragon policy?
YES
NO
I DON’T KNOW
(If your answer to Question #5 is “No,” you need not respond to the remainder of this
questionnaire. Please sign at the bottom and return it to the address indicated below)
9.
Did any illustration you received before you applied for your policy include the phrase “One
Policy Fee”?
YES
NO
I DON’T KNOW
10.
Did any illustration you received before you applied for your policy include pages entitled
“Policy Charges and Expenses” or pages containing the year-by-year amounts of charges and
fees associated with your policy (other than the Monthly Administrative Charge)?
YES
NO
I DON’T KNOW

Case 2:10-cv-09198-JVS-RNB Document 408-3 Filed 03/18/13 Page 3 of 4 Page ID
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QUESTIONS? CALL 1-800-XXX-XXXX OR VISIT WWW.______.COM

ACTIVEUS 105540852V.1

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SIGNATURE

Please sign and date where indicated, and return to Walker v. LSW Questionnaires, P.O. Box ___,
_________. To ensure that your questionnaire is considered, you must complete and return it by
________[75 days from date of mailing].
I swear or affirm that I have answered the questions above to the best of my recollection.

Name
Date

Case 2:10-cv-09198-JVS-RNB Document 408-3 Filed 03/18/13 Page 4 of 4 Page ID
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