Pacific Life Insurance Company [45 Enterprise Aliso Viejo, CA 92656] [ (800) ]

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1 Pacific Life Insurance Company [45 Enterprise Aliso Viejo, CA 92656] [ (800) ] READ YOUR POLICY CAREFULLY. This is a legal contract between you, the Owner, and us, Pacific Life Insurance Company, a stock insurance company. We agree to pay the benefits of this policy ( Policy ) according to its provisions. The consideration for this Policy is the Application for it, a copy of which is attached, and payment of the premiums. The method for determining the Death Benefit is described in the Death Benefit section of this Policy. The amount of the Death Benefit may decrease as a result of withdrawals or paid Policy or rider benefits. The long-term care benefits available with this policy may impact the cash value as well as lessen the death benefit of this policy. Benefits and Policy values as specified under this Policy will be reduced upon receipt of an accelerated death benefit. We recommend you contact a qualified tax advisor about the tax status of an accelerated death benefit payment. Premiums must be paid when due to keep the Policy In Force. It is possible that, due to loans, the Policy may lapse before any Death Benefit or accelerated benefits are payable. Interest Credited to the Policy is guaranteed to be not less than the amount shown on the Policy Specifications. Any excess amounts are not guaranteed. The cost for this product is based in part upon the gender of the person being insured. Buying this product means you agree to allow Pacific Life Insurance Company to determine the cost of this product based in part upon the gender of the person being insured. Chairman and Chief Executive Officer Signed for Pacific Life Insurance Company, FIXED PREMIUM UNIVERSAL LIFE INSURANCE Secretary Death Benefit Payable On The Death Of The Insured While This Policy Is In Force Maturity Date Automatically Extended Unless Maturity Proceeds Are Elected Level Guaranteed Premiums Payable As Scheduled Net Surrender Proceeds Payable Upon Surrender Non-Participating Terminal Illness Benefit (Accelerated Death Benefit) Insured: [JANE DOE] Owner: [JOHN DOE] Policy Number: [LTC ] Policy Date: [April 1, 2014] [STATE] Department of Insurance: [(XXX) XXX-XXXX] Free Look Right The Owner has 30 days from the day the Policy and any riders are received or 30 days from the Policy Date, whichever is later, to examine and return them to us if the Owner decides not to keep them. The Owner does not have to tell us the reason for returning the Policy and riders. The Policy and riders can be returned to us at our Administrative Office or to the Producer through whom they were bought. We will refund, directly to the payer, the full amount of any premium paid within 30 days of such a return and the Policy and any riders will be void from the start. P14PCF [PPCA MP]

2 [LTC ] (This page intentionally left blank) P14PCF Page 2

3 POLICY SPECIFICATIONS Summary of Coverages Effective on the Policy Date P14PCF Fixed Premium Universal Life Insurance (Life Coverage) R14ABR Accelerated Benefit Rider ( ABR ) for Long-Term Care [R14EBR Extended Benefit Rider ( EBR ) for Long-Term Care] Life Policy: Fixed Premium Universal Life Insurance Insured: [JANE DOE] Owner: [JOHN DOE] Policy Date: [April 1, 2014] Sex and Age: [Female 35] Risk Class: [Non-Smoker] [with Couples Discount] Death Benefit Qualification Test: Cash Value Accumulation Test Net Amount at Risk Factor: [ ] [This Policy Is a Modified Endowment Contract] [7-Pay Premium: $[742.42]] Guaranteed Annual Interest Rate: [3.50%] Reduced Paid Up Interest Rate [4.00%] Maximum Premium Load Rate: [4.00%] Minimum Face Amount: [$25,000.00] Maturity Date: [April 1, 2100] Monthly Deduction End Date: [April 1, 2074] Surrender Charge Initial Amount: [$8.75] Level Period: [5] Years Reduction Factor: [$1.75] Surrender Charge Period: [10] Years Terminal Illness Maximum Requested Portion Amount Lesser of [75%] of the Eligible Coverage or [$250,000] P14PCF Page 3

4 Summary of Values Effective on the Policy Date Life Coverage Amount Face Amount: [$25,000.00] Required Modal Premium Amount Coverage Type [Monthly] [Annual] [Semi-Annual] [Quarterly] Life Coverage: [$77.50] [$930.00] [$465.00] [$232.50] Accelerated Benefit Rider (ABR): [$68.25] [$819.00] [$409.50] [$204.75] [Extended Benefit Rider (EBR):] [$46.00] [$552.00] [$276.00] [$138.00] Total Required Modal Premium: [$191.75] [$2,301.00] [$1,150.50] [$575.25] Premium Mode and Frequency Premium Mode: [Annual] Number of Premium Paying Policy Years: [7] Elected Long-Term Care Benefit Limits Benefit Duration Benefit Amount Maximum ABR Benefit Limit: [2 Years] [$25,000.00] [Maximum EBR Benefit Limit:] [4 Years] [$50,000.00] [Inflation Benefit Option:] [$5,625.00] Total Long-Term Care Benefit: [6 Years] [$80,625.00] Monthly Maximum ABR [and EBR] Benefit Amount: [$1,041.67] Inflation Benefit Option for ABR [and EBR]: [Rejected] [3% Simple] Long-Term Care Benefits Alternative Care Benefit: Assisted Living Facility Benefit: Care Coordination Benefit: Caregiver Training Benefit: Home and Community Care Benefit: International Benefit: Non-Continual Alternative Care Benefit: Nursing Home Benefit: Elimination Period [0 ] Days [90] Days [0] Days [0] Days [0] Days [90] Days [0] Days [90] Days Non-Continual Alternative Care Benefit Lifetime Maximum Lesser of $[5,000] or Monthly Maximum ABR Benefit Amount at time of Policy issue while covered under ABR [and EBR]. Caregiver Training Benefit Lifetime Maximum $[1,000] for the Caregiver Training Benefit while covered under ABR [and EBR]. For questions about your Policy or to discuss Policy and rider benefits, you may contact us at our Administrative Office at (800) or at P14PCF7 Page 4

5 RETURN OF PREMIUM BENEFIT POLICY PERCENTAGE MONTHS [1-12] [100]% [13-24] [100]% [25-36] [100]% [37-48] [100]% [49-60] [100]% [61-72] [100]% [73-84] [100]% [85-96]+ [100]% P14PCF7 Page 5

6 TABLE OF REDUCED PAID UP INSURANCE END OF POLICY YEAR REDUCED PAID UP FACE AMOUNT [1 $1, , , , , , ,000] P14PCF7 Page 6

7 TABLE OF GUARANTEED CASH VALUE RATES FOR LIFE COVERAGE INSURED: [JANE DOE] GUARANTEED CASH VALUE RATES PER $1000 OF FACE AMOUNT APPLICABLE TO THIS COVERAGE POLICY YEAR END OF POLICY YEAR GUARANTEED CASH VALUE RATE POLICY YEAR END OF POLICY YEAR GUARANTEED CASH VALUE RATE POLICY YEAR END OF POLICY YEAR GUARANTEED CASH VALUE RATE [1 [ ] P14PCF7 Page 7

8 TABLE OF COST OF INSURANCE RATES FOR LIFE COVERAGE INSURED: [JANE DOE] MAXIMUM MONTHLY COST OF INSURANCE RATES PER $ OF NET AMOUNT AT RISK APPLICABLE TO THIS COVERAGE. POLICY YEAR MONTHLY RATE POLICY YEAR MONTHLY RATE POLICY YEAR MONTHLY RATE [ ] P14PCF7 Page 8

9 TABLE OF GUARANTEED COVERAGE CHARGE RATES RATES PER $1000 OF LIFE COVERAGE FACE AMOUNT POLICY YEAR MONTHLY RATE [ ] P14PCF7 Page 9

10 DEFINITIONS In this section, we define certain terms used throughout this Policy. Other terms may be defined in other parts of the Policy. Defined terms are usually capitalized to provide emphasis. Accumulated Value is the sum of Net Premiums and credited interest less withdrawals, Monthly Deductions, and any reductions due to the Terminal Illness Benefit Payment or benefit payments under a rider. See the Accumulated Value and Policy Loan sections for details. Administrative Office is the office that administers your Policy. The mailing address of the Administrative Office at the time you applied for this Policy is shown in the heading of the Application. If the address changes, we will send you written notice of the new address. Age means the age as of the Insured s birthday prior to the Policy Date, increased by the complete Policy years elapsed. The Age as of the Policy Date is shown in the Policy Specifications. Application consists of the application for this Policy, including any Statement of Good Health and Insurability, amendments, endorsements, and any application for reinstatement. Class is used in determining Policy Charges and interest credited, and depends on a number of factors, including (but not limited to) the Death Benefit, Face Amount, Policy Date, Policy duration, premiums paid, the Insured s Age and Risk Class and the presence of optional riders and benefits. Code is the U.S. Internal Revenue Code of 1986, as amended. Evidence of Insurability is information, including medical information, that is used to determine insurability and the Insured s Risk Class, subject to our approval. Face Amount is the Face Amount of Life Coverage while this Policy is In Force or continued under the Reduced Paid Up Nonforfeiture Benefit. The initial Face Amount is shown in the Policy Specifications. After Policy issue, unless otherwise specified, references to Face Amount in the Policy or any riders attached to it means the initial Face Amount adjusted by any reductions as a result of withdrawals, Terminal Illness Benefit payment, rider benefits paid and as a result of any Premium Lapse where the Policy is continued under the Reduced Paid Up Nonforfeiture Benefit. In Force means a Policy is in effect, is not continued under the Reduced Paid Up Nonforfeiture Benefit, and provides a Death Benefit or Residual Death Benefit on the Insured. Insured is the person insured under this Policy, as shown in the Policy Specifications. Life Coverage is insurance coverage on the Insured provided by this Policy as shown in the Policy Specifications, rather than coverage provided by rider. Life Coverage Cumulative Premium This is the sum of all Life Coverage Required Modal Premiums paid and received under the Policy. Life Coverage Required Modal Premium is the Required Modal Premium Amount shown in the Policy Specifications for the Life Coverage Type and the Premium Mode currently in effect. Loan Lapse If the Policy enters the Grace Period because the Policy Debt equals or exceeds the Cash Surrender Value, and sufficient Loan Repayment is not made by the end of the Grace Period and the Insured is still living, Loan Lapse will occur and the Policy will terminate with no value. Maturity Date as shown on the Policy Specifications. Maturity Proceeds is the Net Surrender Proceeds on the Maturity Date. P14PCF Page 10 ND

11 Monthly Deduction End Date is shown in the Policy Specifications and is the date when Monthly Deductions end. Monthly Payment Date is the same day in each month as the Policy Date and is the date on which certain Policy Charges are deducted from the Accumulated Value. The first Monthly Payment Date is the Policy Date. Net Accumulated Value is the Accumulated Value less any Policy Debt. Net Amount at Risk is the difference between the Death Benefit and the Accumulated Value. Net Premium is the Life Coverage Required Modal Premium we receive reduced by any Premium Load. Owner, you, or your refers to the Owner of this Policy. Policy Date is shown in the Policy Specifications and means the date the Policy and associated riders become effective. Policy and rider months, quarters, years and anniversaries are measured from this date. Policy Debt is the sum of the Loan Account and accrued Loan Interest charged, as described in the Policy Loans section. Policy Specifications is a section of the Policy that shows information specific to your Policy. Premium Lapse - If the Policy enters the Grace Period because the Total Required Modal Premium is not paid when due, and if payment is not made by the end of the Grace Period and the Insured is still living, Premium Lapse will occur, the Policy will no longer be In Force but coverage will continue under the Reduced Paid Up Nonforfeiture Benefit. Rider Cumulative Premium This is the sum of all Rider Required Modal Premiums paid and received under any applicable Rider. Risk Class is used in determining Policy Charges and is determined by us during the underwriting process. Risk Class depends on the Insured s gender, health, tobacco use, and other factors. The Risk Class of the Insured is shown in the Policy Specifications. Risk Class may also be referred to as Risk Classification. Total Cumulative Premium This is the sum of the Life Coverage Cumulative Premium and any Rider Cumulative Premium. We, our, ours, and us refers to Pacific Life Insurance Company. Written Request is your signed request in writing, or on a form we provide, and received by us at our Administrative Office, containing information we need to act on the request. DEATH BENEFIT When the Policy is In Force This Policy is In Force as of the Policy Date, subject to your acceptance of the delivered Policy and payment of the initial premium. The Policy remains In Force until the earliest of the following: Surrender, as described in the Surrender and Withdrawal of Values section; Lapse, as described in the Grace Period and Lapse section; The death of the Insured; or Upon the Maturity Date, subject to the Policy Maturity Date Extension provision. P14PCF Page 11 ND

12 Coverage under this Policy will be reduced by any decreases in Face Amount, as described in later sections of this Policy or riders attached to this Policy. Death Benefit This Policy provides a Death Benefit on the death of the Insured while this Policy is In Force or is continued under the Reduced Paid Up Nonforfeiture Benefit. This section describes how the Death Benefit is calculated. The Death Benefit is the larger of: The Face Amount; or The Minimum Death Benefit. The Death Benefit as calculated above is subject to any increase required by the minimum death benefit provisions set out in General Provisions to satisfy certain federal tax qualification requirements. Death Benefit Qualification Test In order for your Policy to qualify as a life insurance contract under the Code, it must at all relevant times satisfy the Cash Value Accumulation Test. The Policy provides a Minimum Death Benefit amount, as needed, for the Policy to qualify under the Cash Value Accumulation Test. Minimum Death Benefit The Minimum Death Benefit will be determined based on the Death Benefit Qualification Test for the Policy and at any time will be no less than the minimum amount we determine to be required for this Policy to qualify as a life insurance contract under the Code. Death Proceeds The Death Proceeds ( Proceeds ) amount is the actual amount payable to the beneficiary if the Insured dies while this Policy is In Force or is continued under the Reduced Paid Up Nonforfeiture Benefit. The Proceeds amount is equal to the greater of the Death Benefit or the Residual Death Benefit, as of the date of death: Less any Policy Debt; and Less any due and unpaid Total Required Modal Premium if death occurs during a Grace Period; and Plus any Life Coverage Required Modal Premium paid for a period beyond the end of the Policy month of death. Proceeds paid are subject to the conditions and adjustments defined in other Policy provisions, such as General Provisions, Withdrawals, Policy Loans, and Policy Lapse and Nonforfeiture. We will pay interest on the Proceeds from the date of death at a rate not less than the rate payable for funds left on deposit (see the Income Benefits section). If payment of Proceeds is delayed more than 31 calendar days after we receive the following requirements needed to pay the claim, we will pay additional interest at a rate of 10% annually beginning with the 31 st calendar day referenced above. Proceeds are paid as a lump sum unless you choose to have the Proceeds paid under an income benefit plan available on the date of election, subject to our requirements. Proceeds are paid upon receipt of proof of death, or not later than two months after receipt of proof. We will pay the Proceeds to the beneficiary after we receive, at our Administrative Office: Due proof of the Insured s death, consisting of a certified copy of the death certificate for the Insured or other lawful evidence providing equivalent information; Proof of the claimant s legal interest in the Proceeds; and Sufficient evidence that any legal impediments to payment of Proceeds that depend on parties other than us have been resolved. Legal impediments to payment include, but are not limited to (a) the establishment of guardianships and conservatorships; (b) the appointment and qualification of trustees, executors and administrators; (c) submission of information required to satisfy state and federal reporting requirements; and (d) conflicting claims. We will provide the beneficiary a proof of loss form within 20 days of our receipt of a notice of claim. The completed proof of loss form must be returned to us within 180 days of receipt of the blank form. P14PCF Page 12 ND

13 Residual Death Benefit This Policy provides a Residual Death Benefit if greater than the Death Benefit, in an amount equal to the lesser of 5% of the initial Face Amount, as shown on the Policy Specifications, or $5,000. Any withdrawals and any Terminal Illness Benefit Payment will reduce the Residual Death Benefit in the same proportion that they reduce the Face Amount. Under the Reduced Paid Up Nonforfeiture Benefit, the Residual Death Benefit will be provided if greater than the Death Benefit, in an amount equal to the lesser of 5% of the Face Amount under the Reduced Paid Up Nonforfeiture Benefit, or $5,000. Face Amount Changes A requested increase or decrease in Face Amount is not allowed. Face Amount Decreases Although requested face amount decreases are not allowed, a decrease in Face Amount will occur as a result of: Withdrawals of Policy Accumulated Value; The Policy being continued under the Reduced Paid Up Nonforfeiture Benefit; or Rider benefits or Terminal Illness Benefit exercised while the Policy is In Force. The effective date of the decreased Face Amount will be the date we have processed the withdrawal, rider benefit, Reduced Paid Up Nonforfeiture Benefit or Terminal Illness Benefit. Upon processing any decrease, we will send you written notification reflecting the decrease. Policy and rider benefits and values that are affected by any Face Amount decrease will be described in the applicable Policy and/or rider provision. Change in Benefits Under the Cash Value Accumulation Test, any change in Policy or rider benefits or certain other factors may require an adjustment to the Policy s tax qualification limits. PREMIUMS Premiums The initial Total Required Modal Premium is payable either at our Administrative Office or to our authorized representative before your Policy is placed In Force. At your request, we will give you a premium receipt signed by one of our officers. Thereafter, the Total Required Modal Premium is payable at our Administrative Office on the premium due date. We reserve the right to return any premium received more than 30 days prior to the premium due date. The Total Required Modal Premium is the sum of the Life Coverage and Rider Required Modal Premium. We will consider any premium paid after the initial premium, whether delivered to an independent producer or otherwise, to be received when it is actually delivered to our Administrative Office and it will be applied as of the premium due date. Except for the initial premium, we bear no responsibility for any premium unless we have received the premium. If a premium is not paid when due, this Policy will enter a Grace Period and be subject to Premium Lapse. No premiums are allowed while the Policy is continued under the Reduced Paid Up Nonforfeiture Benefit. During the Premium Paying Policy Years, any payment we receive that is less than the Total Required Modal Premium will be returned to you unless you tell us that it is a Loan Repayment. Any amount in excess of the Total Required Modal Premium will be returned to you unless you tell us that such amount is a Loan Repayment. After the Premium Paying Policy Years, any payment received is treated as a Loan Repayment and any amount in excess of any loan amount will be refunded. Mode and Premium Paying Policy Years - At Policy issue, you chose a Premium Mode and the number of Premium Paying Policy Years which are shown on the Policy Specifications. The Premium Mode and the number of Premium Paying Policy Years determine the Total Required Modal Premium billed to you. The number of Premium Paying Policy Years may not be changed and the Premium Mode may only be changed on Policy anniversary by Written Request. At the end of the Premium Paying Policy Years shown in the Policy Specifications, no further premiums are allowed. P14PCF Page 13 ND

14 Premium Load The Premium Load is equal to the Life Coverage Required Modal Premium paid multiplied by the Premium Load Rate. The Maximum Premium Load Rate is shown in the Policy Specifications. Premium Processing First, the Premium Load will be deducted from the Life Coverage Required Modal Premium paid. Then, the resulting Net Premium will be credited to the Accumulated Value on the premium due date. Only the Life Coverage Required Modal Premium is used to determine values under this Policy. 7-Pay Premium If your Policy was not classified as a Modified Endowment Contract ( MEC ) at issue, a 7-Pay Premium is displayed in the Policy Specifications. The 7-Pay Premium is determined according to the rules applicable to this Policy set forth in the Code. The 7-Pay Premium may change whenever there is a change in the Face Amount of insurance or in other Policy benefits or factors. The 7-Pay Premium will also be adjusted to conform to any changes in the Code. The 7-Pay Premium is used solely to determine the MEC classification of the Policy and should not be used or interpreted for any other purpose. The test used to determine MEC classification is outlined in the Modified Endowment Tax Status subsection of the General Provisions section in this Policy. Even if a premium payment would exceed the 7-Pay limit (as described in the Modified Endowment Tax Status provisions) and cause your Policy to become a MEC, we will apply the premium payment to your Policy as per the provisions of this section (Premium). At such time we will send notification to you that this Policy is classified as a MEC. The notice will be sent to your last known address. TERMINAL ILLNESS BENEFIT Terminal Illness Benefit If the Insured has been diagnosed with a terminal illness, you have the option to receive a portion of the Face Amount while the Insured is still living and the Policy is not continued under the Reduced Paid Up Nonforfeiture Benefit. This is called a Terminal Illness Benefit. A "terminal illness" means an illness causing the Insured to have a life expectancy of 12 months or less. Eligible Coverage is the portion of the Face Amount that will qualify for determining the Terminal Illness Benefit at the time the benefit is exercised. Eligible Coverage is the Policy Face Amount less any reductions as a result of withdrawals or paid rider benefits on the Policy. Requested Portion is the amount of the Face Amount you request in a Written Request on a form provided by us. The Requested Portion cannot exceed the Terminal Illness Maximum Requested Portion Amount shown on the Policy Specifications. Requested Percentage is the Requested Portion divided by the Eligible Coverage. Terminal Illness Benefit Payment is the actual dollar amount of benefit you will receive as a Terminal Illness Benefit. The Terminal Illness Benefit Payment will be determined as of the date we approve your Written Request for a Terminal Illness Benefit. Your Terminal Illness Benefit Payment will equal your Requested Portion less the following adjustments: a) A reduction rate will be applied to the Requested Portion, and reflects the early payment of the Requested Portion of your Policy. The reduction rate will be based on the12 month life expectancy of the Insured at an annual interest rate declared by us. The reduction rate shall be no greater than the greater of the following rates in effect on the date of your written request for a Terminal Illness Benefit: i) the yield on 90-day treasury bills; or ii) the maximum statutory adjustable Policy loan interest rate. P14PCF Page 14 ND

15 b) If there is a Policy Loan on your Policy as of the date we approve your Written Request, we will reduce the Requested Portion in order to repay a portion of the Policy Loan equal to the Requested Percentage times the outstanding Policy Debt. c) A processing charge deducted from the Terminal Illness Benefit, not to exceed $150. We will refund the amounts discussed in a) and c) above should the death of the Insured occur within 30 days of the Terminal Illness Benefit Payment. The Terminal Illness Benefit Payment will be made upon our receipt of the below requirements to determine eligibility, but no later than two months after such receipt. The Terminal Illness Benefit Payment will be paid as a lump sum. The minimum Terminal Illness Benefit Payment amount is $500. We place no restrictions on how you use any Terminal Illness Benefit that may be paid under this provision. This Terminal Illness Benefit is not meant to cause involuntary access to proceeds payable to the beneficiary on the death of the Insured. Therefore, this benefit is not available if either you or the Insured: a) is required by law to use this benefit to meet the claims of creditors, whether in bankruptcy or otherwise; or b) is required by a government agency to use this benefit in order to apply for, obtain or keep a government benefit or entitlement. To Whom We Will Pay Benefits All benefits will be payable to the Owner or the Owner s estate while the Insured is still living, unless otherwise designated by the Owner, subject to any required acknowledgment of concurrence for payout. We will be discharged to the extent of any such payment made in good faith. Effect of Terminal Illness Benefit Payment on Policy and Riders After a Terminal Illness Benefit Payment is made, the Policy and riders will remain In Force subject to the following adjustments. The Face Amount, Coverage Charge, any remaining future unpaid Life Coverage Required Modal Premiums and any Accumulated Value will be reduced by the Requested Percentage. Any Life Coverage Required Modal Premiums that are due and unpaid at the time a Terminal Illness Benefit Payment is made will not be reduced. The Return of Premium Benefit will be reduced by the Requested Portion corresponding to the Terminal Illness Benefit Payment amount paid. Any outstanding Policy Debt balance will be reduced by the amount repaid as specified in the Terminal Illness Benefit Payment Section. Cost of Insurance Charges will be adjusted to reflect the reduction in the Death Benefit and any Surrender Charges will be adjusted to reflect the reduction in the Face Amount. A statement demonstrating how the Terminal Illness Benefit impacts your Policy values will be sent with the Terminal Illness Benefit Payment. Eligibility The following conditions must be met before any Terminal Illness Benefit Payment is made: The Policy must be In Force on the date the Terminal Illness Benefit Payment is approved; We must receive written proof that the life expectancy of the Insured is 12 months or less from the date of the Written Request. Proof will include the certification by a licensed physician. Such person may not be you, the Insured, or a member of either person s family. Such proof should include clinical, radiological or laboratory evidence of the condition. We reserve the right to obtain a second medical opinion from a physician of our choice at our expense. In the case of conflicting opinions, eligibility for benefits shall be determined by a third medical opinion, at our expense, that is provided by a physician that is acceptable to you and to us. The Owner or legal guardian must make the Written Request. The Terminal Illness Benefit Payment will be due immediately upon receipt of the due written proof of eligibility. If the Insured dies and we receive written notice of the death at our Administrative Office before P14PCF Page 15 ND

16 Terminal Illness Benefit is paid, no such payment will be made and Death Benefit Proceeds will be paid according to the terms of the Policy. However, any payment made by us prior to receiving written notice of the Insured s death at our Administrative Office is effective and will reduce the Death Benefit Proceeds payable under the Policy. Terminal Illness Benefit Payment Notice Prior to or concurrent with the election to effect the Terminal Illness Benefit Payment, we will send the Owner, a statement demonstrating the effect of the Terminal Illness Benefit Payment on the Accumulated Value, Death Benefit, Face Amount, Premium, Cost of Insurance Charges, and Policy Loans (including loans to pay premiums). There is no separate premium required for this benefit. However, this benefit does not eliminate the need to pay premiums to keep the Policy In Force. The Owner must continue to pay any premiums necessary to avoid Policy lapse as described in the Premium section of this Policy. Expiration Date Your right to exercise the Terminal Illness Benefit will end when: The Policy is no longer In Force including when the Policy is continued under the Reduced Paid Up Nonforfeiture Benefit; When the Cash Surrender Value is zero; or When a Terminal Illness Benefit is paid. Termination of this benefit shall not prejudice the payment of benefits for any claim that occurred while the benefit was In Force. Disclosure The following should be taken into consideration before you exercise your option to receive the Terminal Illness Benefit: Policy Death Benefits, Coverage Charge, Accumulated Value, and Cash Surrender Value will be reduced if a Terminal Illness Benefit is paid; This Terminal Illness Benefit is NOT health, nursing home or long-term care insurance, and it is not intended or designed to eliminate the need for such coverage; Receipt of the Terminal Illness Benefit Payment may affect Medicaid, Medicare, and/or Supplemental Security Income (SSI) eligibility. Exercising the option to accelerate and receive benefits before you apply for these programs, or while you are receiving government benefits, may affect your initial or continued eligibility. ACCUMULATED VALUE Accumulated Value The Accumulated Value equals the sum of: Fixed Accumulated Value; and Loan Account Value, as described in the Policy Loans section. There is no Accumulated Value if the Policy is continued under the Reduced Paid Up Nonforfeiture Benefit. Fixed Accumulated Value On the Policy Date, the Fixed Accumulated Value equals the Net Premium received less the first Monthly Deduction. On each other day while the Policy is In Force, the Fixed Accumulated Value equals: The Fixed Accumulated Value as of the prior day; Plus interest earned on such amount since the prior day; Plus, on a premium due date, the amount of any Net Premiums credited; Less a reduction for any withdrawal since the prior day; P14PCF Page 16 ND

17 Less the amount of any Policy Loan, including any Policy Loan to pay Policy Loan interest, taken since the prior day; Less a reduction for benefits paid since the prior day as described in the riders attached to this Policy; Less a reduction for the Requested Portion for any Terminal Illness Benefit Payment since the prior day as described in the Terminal Illness Benefit section; Plus the amount of any Loan Repayment made since the prior day; and Less, on a Monthly Payment Date, the Monthly Deduction. We credit interest to the Fixed Accumulated Value on a daily basis at the end of each day, using a 365-day year, at a rate not less than the Guaranteed Annual Interest Rate shown in the Policy Specifications. At our discretion, we may credit additional interest. Any such additional interest may be adjusted to reflect expenses, taxes, profit, or sources of earnings other than investment earnings and will be applied uniformly to all members of the same Class. Once credited, the additional interest is nonforfeitable except indirectly due to the Surrender Charge. POLICY CHARGES Monthly Deduction The Monthly Deduction provides coverage for the Policy month following the Monthly Payment Date and is deducted from the Accumulated Value on each such date before the Monthly Deduction End Date. It is equal to the sum of the following items: The Cost of Insurance Charge; The Coverage Charge; and Rider charges, if any. The maximum for each such charge is described below or in the rider forms. We may charge less than such maximum charge. Any lesser charge will apply uniformly to all members of the same Class. The Cost of Insurance Charge and the Coverage Charge can be adjusted by us at our sole and exclusive discretion and such adjustment can be based on our experience factors such as investment earnings, mortality, persistency, taxes, and expenses, but will not exceed the maximums as shown in the Policy Specifications. We may profit from such charges, and may use those profits for any lawful purpose, such as the payment of distribution and administrative expenses. There is no Monthly Deduction if the Policy is continued under the Reduced Paid Up Nonforfeiture Benefit. Coverage Charge This charge is based on the Face Amount of the Policy and will not exceed the Guaranteed Coverage Charge Rates shown in the Policy Specifications. The monthly Coverage Charge is equal to (1) multiplied by (2), where: (1) is the Monthly Coverage Charge rate divided by 1000 as shown in the Policy Specifications; and (2) is the Face Amount reflecting any reductions as a result of withdrawals, any Terminal Illness Benefit payment or any rider benefits paid. Rider Charges Any rider charges are described in the rider. Cost of Insurance Charge The Cost of Insurance Charge is equal to (1) multiplied by (2), where: (1) is the Monthly Cost of Insurance Rate divided by 1000 as shown in the Policy Specifications; and (2) is the Death Benefit divided by the Net Amount at Risk Factor shown in the Policy Specifications, reduced by the Accumulated Value as of the beginning of the Policy month before the Monthly Deduction is assessed. Cost of Insurance Rates The Maximum Monthly Cost of Insurance Rates for the Life Coverage are shown in the Policy Specifications. P14PCF Page 17 ND

18 GRACE PERIOD AND LAPSE Grace Period A Grace Period of 61 days will begin on any Monthly Payment Date where: The Total Required Modal Premium is not paid when due; and/or When the Policy Debt equals or exceeds the Cash Surrender Value. If the Policy entered the Grace Period because the Total Required Modal Premium was not paid when due, you will need to pay all past due and unpaid premiums by the end of the Grace Period to keep the Policy from being continued under the Reduced Paid Up Nonforfeiture Benefit. If you pay the Total Required Modal Premium during the Grace Period, the Guaranteed Cash Value and Accumulated Value will be re-calculated, based on the amount of the Life Coverage Required Modal Premium paid, from the beginning of the Grace Period through the date of the premium payment. The policyowner will be entitled to these values beginning on the date of the premium payment. If the Policy entered the Grace Period because the Policy Debt equaled or exceeded the Cash Surrender Value, you will need to pay a sufficient Loan Repayment to keep the Policy In Force. The repayment must be an amount at least equal to the sum of the following: Any Monthly Deductions due since the start of the Grace Period, without interest; Three times the Monthly Deduction due when the insufficiency occurred; and The excess of the Policy Debt over the Cash Surrender Value. At the start of any Grace Period, we will send a notice to you, any assignee of record, and any additional person you designated to receive such notice. The notice will state the due date and the payment amount required for your Policy to remain In Force. Any payment sent to us by United States mail and postmarked within the Grace Period will be accepted. During the Grace Period your Policy will remain In Force and there will be no penalty for making a payment during this period. At any time prior to the end of the Grace Period, you may request a surrender of this Policy for its Net Surrender Proceeds, in which case the Policy will terminate. If the Insured dies during the Grace Period, the Death Proceeds will be equal to the Death Proceeds as of the beginning of the Grace Period reduced by any due and unpaid Total Required Modal Premium and any Policy Debt. Notification of Non-Payment If we have not received payment within 30 days after the start of any Grace Period, we will send a notice to you, any assignee of record, and any additional person you designated to receive such notice. The notice will be provided to each person at their last known addresses by first class United States mail, postage prepaid and will state the due date and the payment amount required. Non-Payment of Premium During Grace Period - If the Policy entered the Grace Period because the Total Required Modal Premium was not paid when due, and if the payment is not made by the end of the Grace Period and the Insured is still living, Premium Lapse will occur. Under Premium Lapse, the Policy is no longer In Force and coverage will continue as Reduced Paid Up Insurance according to the terms of the Nonforfeiture Benefit provision of this Policy. If there is an outstanding loan, the loan will be repaid by a distribution of Policy values equal to the Policy Debt as of the day prior to the Grace Period. The loan will be repaid effective on the date the Policy is continued under the Reduced Paid Up Nonforfeiture Benefit. Non-Repayment of Loan During Grace Period - If the Policy entered the Grace Period because the Policy Debt equaled or exceeded the Cash Surrender Value, and if a sufficient Loan Repayment is not P14PCF Page 18 ND

19 made by the end of the Grace Period and the Insured is still living, Loan Lapse will occur and the Policy will terminate with no value. NONFORFEITURE BENEFIT Reduced Paid Up Insurance Upon Premium Lapse, at the end of the Grace Period, the Policy is no longer In Force and coverage will continue as Reduced Paid Up Insurance in which the Net Cash Surrender Value will be used to provide paid up whole life insurance. Face Amount At the time the Reduced Paid Up Insurance becomes effective, the Face Amount will be equal to X Y, where: X = Net Cash Surrender Value as of the day before the Grace Period started Y = Net Single Premium as of the day the Grace Period started Thereafter, the Reduced Paid Up Face Amount will be reduced for any rider benefits paid. If the Reduced Paid Up Face Amount causes the Policy to become a Modified Endowment Contract (see the Modified Endowment Contract Tax Status provisions), we will send notification to you that this Policy is classified as a Modified Endowment Contract under Section 7702A of the Code. The notice will be sent to your last known address. Net Single Premium A Net Single Premium is calculated at each Policy anniversary. These are based upon the mortality and interest rate for a Reduced Paid-Up benefit as described in the Basis of Values section of this Policy. As of any date, the Net Single Premium will be prorated between the Policy anniversaries to the beginning of the month in which the calculation occurs. Surrender of Reduced Paid Up - At any time, you may request a surrender of the Reduced Paid Up Insurance for its Net Surrender Proceeds. POLICY REINSTATEMENT Reinstatement If it has not been surrendered or continued under the Reduced Paid Up Nonforfeiture Benefit, this Policy may be reinstated within three years after the end of the Grace Period and prior to the Maturity Date. To reinstate this Policy you must provide us with the following: A written application; Full repayment of Policy Debt, if a loan was outstanding at the time of lapse; Evidence of Insurability satisfactory to us, at your expense, that the Insured is insurable in the same Risk Class as when the Policy was issued; and Payment of any past due Life Required Modal Premiums with interest on each from its due date, compounded each year at an annual rate not to exceed 5.5%. The effective date of the Policy reinstatement will be the Monthly Payment Date on or next following the date we approve your reinstatement application. Upon reinstatement: The Accumulated Value will equal the amount it was at the beginning of the Grace Period, plus the reinstatement Net Premium (without interest), less all Monthly Deductions due and unpaid from the beginning of the Grace Period until the reinstatement effective date; The Surrender Charges, Life Return of Premium Benefit and Policy Charges (including Cost of Insurance Charges) for Life Coverage under this Policy will resume on their original schedule as if P14PCF Page 19 ND

20 lapse had never occurred, reflecting the Insured s Age at reinstatement and Policy duration measured from the original Policy Date; The Guaranteed Cash Value is calculated using the Face Amount upon reinstatement and Guaranteed Cash Value Rates that resume their original schedule as if lapse had never occurred, reflecting the Insured s Age at reinstatement and Policy duration measured from the original Policy Date; and The periods during which we may exclude death by suicide and contest coverage due to a material misstatement in the reinstatement application will begin from the reinstatement date. SURRENDER AND WITHDRAWAL OF VALUES Surrender Upon Written Request while the Policy is In Force or continued under the Reduced Paid Up Nonforfeiture Benefit, you may surrender this Policy for the Net Surrender Proceeds. If surrendered within 30 days following a Policy anniversary, the value available shall not be less than the anniversary value, less any withdrawal, Policy Loan, Terminal Illness Benefit Payment, or rider benefit paid since the Policy anniversary. If surrendered at any time other than on a Policy anniversary, the value available shall be calculated with allowance for lapse of time from the last preceding Policy anniversary. The Policy will terminate on the date the Written Request is received at our Administrative Office. Cash Value Date This is the date of Policy surrender or the date that the cash value is being calculated for use in determining values under this Policy. If the Policy is in a Grace Period, the Cash Value Date is the day before the beginning of the Grace Period. Guaranteed Cash Value The Guaranteed Cash Value of this Policy at the end of each Policy year is the Face Amount of the Policy multiplied by the Guaranteed Cash Value rate shown in the Policy Specifications. The Guaranteed Cash Value on any Cash Value Date is the sum of the following: The Face Amount multiplied by the interpolated Guaranteed Cash Value rates as of the end of the Policy month of the Cash Value Date; The Unearned Net Premium. The Unearned Net Premium is equal to the Net Premium paid prorated for the number of months from the end of the Policy Month of the Cash Value Date until: The next premium due date; or If no premium due dates remain, then the next Policy anniversary. The Unearned Net Premium is reduced by the amount of any withdrawals, terminal illness payment or benefit payments made under the Riders, in proportion to the reduction in Face Amount. The Guaranteed Cash Values shown in the Policy Specifications are applicable as long as all due premiums have been paid and the Policy is not continued under the Reduced Paid Up Nonforfeiture Benefit. Cash Surrender Value If not continued under the Reduced Paid Up Nonforfeiture Benefit, the Cash Surrender Value on the Cash Value Date is equal to the greater of: The Accumulated Value less any Surrender Charge; or The Guaranteed Cash Value. Reduced Paid Up Cash Surrender Value At any date after the Policy has been continued under the Reduced Paid Up Nonforfeiture Benefit, the Cash Surrender Value of this Policy will be the Face Amount multiplied by the Net Single Premium as of that date. P14PCF Page 20 ND

21 Net Cash Surrender Value If not continued under the Reduced Paid Up Nonforfeiture Benefit, the Net Cash Surrender Value as of any Cash Value Date is the Cash Surrender Value less any Policy Debt. If the Policy is continued under the Reduced Paid Up Nonforfeiture Benefit, the Net Cash Surrender Value as of any Cash Value Date is the Reduced Paid Up Cash Surrender Value. Net Surrender Proceeds The Net Surrender Proceeds as of any Cash Value Date is equal to A + B, where: (A) is the Net Cash Surrender Value; and (B) is the excess, if any, of the Life Return of Premium Benefit and any Return of Premium Benefit under the riders attached to the Policy, over the Cash Surrender Value. Life Return of Premium Benefit The Life Return of Premium Benefit on any Cash Value Date is equal to the Life Coverage Cumulative Premium received multiplied by the Vesting Percentage shown in the Policy Specifications for the Policy Month in which this benefit is calculated. The Life Return of Premium Benefit may be adjusted, as described below. Return of Premium Benefit The Return of Premium Benefit is equal to the Life Return of Premium Benefit and any Return of Premium Benefit under the riders attached to the Policy. The Return of Premium Benefit is not available if your Policy was issued upon the exercise of a conversion option from another Policy. Any Return of Premium Benefit is reduced by the following events: Any withdrawals; The Requested Portion corresponding to any Terminal Illness Benefit Payment made under the Policy; Any benefit payments made under the riders; and At the time the Policy is continued under the Reduced Paid Up benefit, by the amount of any Policy Debt that is terminated. On any Cash Value Date, the Return of Premium Benefit is adjusted for these events. Adjustments will first be made to the Life Return of Premium Benefit until it is zero, and then any Rider Return of Premium Benefit. The payment of any Return of Premium Benefit will be made within 30 days of surrender of the policy. Surrender Charge If you surrender this Policy, there may be a Surrender Charge deducted from the Accumulated Value. During the Level Period, the Surrender Charge is equal to the Initial Amount. After the Level Period, the Surrender Charge decreases by the Reduction Factor for the remaining Surrender Charge Period. The Initial Amount, Level Period, Reduction Factor and Surrender Charge Period are shown in the Policy Specifications. The Surrender Charge will decrease proportionately to any Face Amount Decrease as a result of a withdrawal or payment of a Terminal Illness or rider benefit. Withdrawals After the end of the Premium Paying Policy Years, you may withdraw a portion of the Net Cash Surrender Value of this Policy upon Written Request. There is no Surrender Charge imposed for a withdrawal, even if the Face Amount is reduced as a result of the withdrawal. Withdrawals may be restricted or prohibited by certain riders attached to the Policy and are not available if the Policy is continued under the Reduced Paid Up Nonforfeiture Benefit. Withdrawals will be subject to the following conditions: The amount of each withdrawal must be at least $200; The Net Cash Surrender Value remaining after a withdrawal must be at least $500; and The Face Amount remaining after the withdrawal must be at least the Minimum Face Amount as shown in the Policy Specifications. P14PCF Page 21 ND

22 A withdrawal will reduce the Face Amount. The Face Amount reduction will be equal to A multiplied by (B divided by C) where: (A) is the Face Amount before the Withdrawal; (B) is the Withdrawal Amount; and (C) is the greater of the Cash Surrender Value before the Withdrawal or the Life Return of Premium Benefit before the Withdrawal. If such a reduction in Face Amount would cause the Policy to become a Modified Endowment Contract, we will not process your withdrawal request unless and until we receive your Written Request to have your Policy classified as a Modified Endowment Contract. A withdrawal will reduce the Accumulated Value. The Accumulated Value reduction will be equal to A multiplied by (B divided by C) where: (A) is the Accumulated Value before the Withdrawal; (B) is the Withdrawal Amount; and (C) is the greater of the Cash Surrender Value before the Withdrawal or the Life Return of Premium Benefit before the Withdrawal. A withdrawal will reduce the Surrender Charge. The Surrender Charge reduction will be equal to A multiplied by (B divided by C) where: (A) is the Surrender Charge before the Withdrawal; (B) is the Withdrawal Amount; and (C) is the greater of the Cash Surrender Value before the Withdrawal or the Life Return of Premium Benefit before the Withdrawal. If the Insured dies after the request for a withdrawal is received by us and prior to the withdrawal being processed, the withdrawal, if allowed under this provision, will be processed and paid to the Owner, or to the Owner s estate, before the Death Proceeds are determined and paid to the beneficiary. INCOME BENEFITS Income Benefits All or part of any Policy proceeds may, instead of being paid in a lump sum, be left with us under any one, or a combination of the income benefit plans available, subject to our minimum amount requirements on the date of election. If the payee is not a natural person, the choice of a payment option will be subject to our approval. We guarantee that the income benefit will not be less than the income that would be provided by the single premium immediate annuity purchase rates we offer at the time. We guarantee that we will have at least the following income benefit plans available. Fixed Income Equal payments of the amount chosen with interest of not less than 2% per year until the funds left on deposit are exhausted. Life Income Monthly income will automatically be guaranteed to continue for at least ten years. If the payee dies before the end of the ten-year period, payments will continue to the end of the ten-year period to a person designated in writing by that payee. The purchase rates for the monthly income for a male or female income recipient bought by each $1,000 of benefits are shown below. Age Monthly Income Age Monthly Income Age Monthly Income Age Monthly Income Age Monthly Income P14PCF Page 22 ND

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