NATIONAL WESTERN LIFE INSURANCE COMPANY

Transcription

1 NATIONAL WESTERN LIFE INSURANCE COMPANY Disclosure and Benefit Summary for the Accelerated Death Benefits Rider for Chronic Illness Form ICC NOTICE TO POLICYOWNER THE ACCOUNT BALANCE, SURRENDER CHARGE, CASH VALUE, LOAN, RETURN OF PREMIUM VALUE, COST OF INSURANCE CHARGES, AND FACE AMOUNT OF THE POLICY WILL BE REDUCED IF YOU RECEIVE AN ACCELERATED DEATH BENEFIT PAYMENT. RECEIPT OF AN ACCELERATED DEATH BENEFIT PAYMENT MAY ADVERSELY AFFECT YOUR ELIGIBILITY FOR MEDICAID OR OTHER GOVERNMENT BENEFITS OR ENTITLEMENTS. RECEIPT OF AN ACCELERATED DEATH BENEFIT UNDER THIS RIDER MAY BE TAXABLE. NEITHER THE COMPANY NOR ITS AGENTS CAN PROVIDE TAX ADVICE. THE OWNER SHOULD SEEK ASSISTANCE FROM THE OWNER S PERSONAL TAX ADVISOR. This rider provides you with the option to accelerate a portion of the Death Benefit provided under the life insurance policy to which this rider is attached if the Insured becomes Chronically Ill as described in this rider. This rider is issued based on the responses to the questions on the application for the policy. Statements made in the application are representations and not warranties. No statement will be used by us to defend a claim or act to void coverage evidenced by this rider, unless the statement is in a signed application. This rider is a part of the policy to which it is attached in consideration of the application and the premium paid. The terms and conditions of the policy apply to this rider, except as changed by the terms and conditions of this rider. The premium for this rider is shown on Page 3 of the policy. DEFINITIONS Accelerated Death Benefit Amount ( Benefit Amount ) is the portion of the policy s Death Benefit requested by the Owner to accelerate subject to the terms and conditions of this rider. Activities of Daily Living mean bathing, continence, dressing, eating, toileting, and transferring. 1. Bathing is washing oneself by sponge bath or in either a tub or shower, including the task of getting into or out of the tub or shower. 2. Continence is maintaining control of bowel and bladder function; or when unable to maintain control of bowel or bladder function, performing associated personal hygiene (including caring for catheter or colostomy bag). 3. Dressing is putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs. 4. Eating is feeding oneself by getting food into the body from a receptacle, such as a plate, cup or table, or by a feeding tube or intravenously. 5. Toileting is getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene. 6. Transferring is sufficient mobility to move into or out of a bed, chair, or wheelchair or to move from place to place, either by walking, a wheelchair, or other means. Chronically III or Chronic Illness means the Insured has been certified by a Physician, through a written certification within the last 12 months, with one of the following conditions and that such condition has lasted for at least ninety (90) consecutive days. The Insured: 1. is permanently unable to perform, without Substantial Assistance from another individual, at least two Activities of Daily Living; or 01-S Rev Page 1 of 5

2 2. has permanent Severe Cognitive Impairment and requires Substantial Supervision to be protected from threats to health and safety due to the Severe Cognitive Impairment. Immediate Family means spouse, parents, grandparents, siblings, children, stepchildren, and grandchildren of either the Owner or the Insured. Physician means a licensed doctor of medicine or osteopathy legally authorized to practice medicine by the state where he or she performs such function or action. The Physician cannot be a member of the Immediate Family. Severe Cognitive Impairment means the deterioration or loss of intellectual capacity requiring Substantial Supervision for protection of self and others, as established by the clinical diagnosis of a Physician who is licensed and authorized in the state where the diagnosis is provided to make such a diagnosis. Such diagnosis shall include the patient s history and neurological, psychological, and/or psychiatric evaluations and laboratory findings. The deterioration or loss of intellectual capacity is measured by clinical evidence and standardized tests, which reliably measure impairment in: 1. Short-term or long-term memory; or 2. Orientation to person, place or time; or 3. Deductive or abstract reasoning; or 4. Judgment as it relates to safety awareness. Substantial Assistance means: 1. the physical assistance of another person without which the Insured would not be able to perform an Activity of Daily Living; or 2. the presence of another person within arm s reach of the Insured that is necessary to prevent, by physical intervention, injury to the Insured while the Insured is performing an Activity of Daily Living. Substantial Supervision means continual supervision, which may include cueing by verbal prompting, gestures or other demonstrations, by another person that is necessary to protect the Insured from threats to his or her health or safety, such as may result from wandering. BENEFITS This rider will pay an Accelerated Death Benefit Payment ( Benefit Payment ) as described below for a Chronic Illness. The Benefit Payment will be paid to Owner or Owner s estate while the Insured is still living, unless the Benefit Payment has been otherwise assigned or designated by the Owner. The Benefit Payment will continue until the termination date as described in the Termination provision of this rider. You may request a Benefit Amount subject to the limitations of this rider. The Benefit Amount will reduce the policy benefits as described below. Accelerated Death Benefit Payment ( Benefit Payment ) We will pay the Benefit Payment described below provided the requirements in the Eligibility for Payment of Benefits provision of this rider are satisfied. The Benefit Payment is equal to (1) minus (2), where: (1) is the Accelerated Death Benefit Amount approved by us; (2) is any Partial Loan Repayment as described in the provision titled Effect of Accelerated Death Benefit Payment on Other Policy Provisions. The Benefit Payment will be no less than the Cash Value, net of any loans, multiplied by the current Benefit Amount, divided by the current Death Benefit. Accelerated Death Benefit Amount The Accelerated Death Benefit Amount elected by the Owner must be no less than $500 and no greater than the Maximum Benefit Amount. The total of all Benefit Amounts elected under this rider cannot exceed $500,000, and the remaining Face Amount cannot be less than $12,500. The final Benefit Amount will be reduced if the elected Benefit Amount would result in a Face Amount of less than $12, S Rev Page 2 of 5

3 Maximum Accelerated Death Benefit Amount for Chronic Illness The Maximum Accelerated Death Benefit Amount that you may elect is either: 1. an annual Benefit Amount that is the lesser of: a. 24% of the current Death Benefit as of the date Eligibility for Payment of Benefit requirements are satisfied; or b. $120,000; or 2. a monthly Benefit Amount that is the lesser of: a. 2% of the current Death Benefit as of the date Eligibility for Payment of Benefit requirements are satisfied; or b. $10,000. The Benefit Amount may be elected once every 12 months. If a new Benefit Amount is not elected, the previous election will stay in effect for the next 12 months. We may require evidence at least every 12 months that the Insured is living. You must terminate the Benefit Payment under this rider if you are electing benefits from the Accelerated Death Benefit Rider for Terminal Illness. If the Insured dies after you request an Accelerated Death Benefit under this rider but before any Benefit Payment is made, the request will be canceled, and the Death Benefit proceeds will be paid as provided in the policy. EFFECT OF ACCELERATED DEATH BENEFIT PAYMENT ON OTHER RIDERS AND ENDORSEMENTS Upon your election of the Accelerated Death Benefit for Chronic Illness, all riders and endorsements attached to the policy will continue to be effective subject to the terms and conditions of each rider or endorsement. However, you may not elect an Accelerated Death Benefit under this rider if you have already elected an Accelerated Death Benefit under the Accelerated Death Benefit Rider for Terminal Illness. ELIGIBILITY FOR PAYMENT OF BENEFIT Before the Accelerated Death Benefit under this rider will be approved, you must satisfy the following conditions: 1. The policy and this rider are in force; and 2. We receive documentation acceptable to us, as stated in the Notice of Claim and Proof of Loss provisions; and 3. The Insured is living at the time the Accelerated Death Benefit is requested; and 4. We receive a written statement acceptable to us by a Physician certifying the Chronic Illness of the Insured; and 5. We receive written consent from any irrevocable beneficiaries and assignees. EFFECT OF ACCELERATED DEATH BENEFIT PAYMENT ON OTHER POLICY PROVISIONS After each Benefit Payment the policy values will be reduced for the Face Amount, Account Balance, Surrender Charge, Loan, and Return of Premium Value. The values after the Benefit Payment will be equal to their values prior to the Benefit Payment times the result of: (1) minus the result of (2) divided by (3), where, (1) is 1.0 (2) is the Benefit Amount for the current Benefit Payment (3) is the current Death Benefit just prior to the Benefit Payment Any required premium will be reduced to reflect the reduction in Face Amount. Any Monthly Administrative charge will be based on the Face Amount at that time. The Partial Loan Repayment is equal to the difference in the Loan value before and after the Benefit Payment. Any Accidental Death Benefit Rider provided under the policy will not be affected by the Benefit Payment. 01-S Rev Page 3 of 5

4 EFFECT OF BENEFIT STATEMENT After we receive your request to accelerate the Death Benefit for Chronic Illness, we will send you and any irrevocable beneficiaries an Effect of Benefit Statement. The Effect of Benefit Statement will show the effect of the requested Benefit Amount on the policy values in effect prior to and after the Benefit Payment. Such policy values include the following: (1) Death Benefit, (2) Face Amount; (3) Planned Periodic Premium; (4) Account Balance; (5) Surrender Charge; (6) Cash Value; (7) net Return of Premium Value; and (8) Any outstanding policy Loan and Partial Loan Repayment. An Effect of Benefit Statement will be given to you each time we make an Accelerated Death Benefit Payment to you. TERMINATION This rider terminates on the earliest of: 1. The date of the Insured s death; 2. The date the policy matures, surrenders or terminates; 3. The date you receive an Accelerated Death Benefit under an Accelerated Death Benefit Rider for Terminal Illness under the policy; 4. The date we receive written request from you to terminate this rider; 5. The date the new Face Amount is reduced to $12,500; or 6. The date the total elected Benefit Amount equals $500,000. OTHER TERMS OF THIS RIDER Incontestability. This rider is contestable on the same basis as the policy to which it is attached. Reinstatement. If this rider terminates due to termination of the policy, it may be reinstated under the same conditions as the policy. This rider may not be reinstated unless the policy is in force or is being reinstated at the same time. Upon the date of reinstatement, the Owner s rights and our rights will be those that were in effect before the rider terminated. Notice of Claim. Notice of claim for an Accelerated Death Benefit may be made by telephone or sent to our office. Contact information for the Company can be found on Page 1 of this rider. The notice should include: (1) the name of the Insured; (2) the Policy Number shown on Page 3 of the policy; and (3) the address to which the claim form should be sent. We will provide the claimant with the forms needed for filing Proof of Loss within 15 days of our receipt of the claimant s notice of claim. If we do not give the claimant the forms within 15 days, it will be considered that the claimant has complied with the claim requirements if the claimant submits written proof covering the occurrence, the character, and the extent of the occurrence for which claim is made. Proof of Loss. Proof of Loss of the Insured s Chronic Illness must be provided to us within 12 months of the date of the Physician s certification that the Insured is Chronically Ill. Such proof includes: (1) properly completed forms; (2) a written statement acceptable to us by a Physician certifying to the Chronic Illness; and (3) any other documentation required by us. After we receive Proof of Loss for the Chronic Illness, we may require a second opinion and examination by a Physician we designate. In the event the Insured s Physician and our appointed Physician disagree on whether the Insured is Chronically Ill, the Accelerated Death Benefit eligibility will be determined by a third medical opinion provided by a Physician mutually acceptable to both you and us. We will pay for the expense of these additional medical opinions. 01-S Rev Page 4 of 5

5 Example 1: Benefit: Chronic Illness Without Loan Elected Accelerated Death Benefit Amount: $2,000 Monthly Proportionate Reduction Percentage: 2% Before Payment After Payment Account Balance $15, $14, Surrender Charge $2, $1, Cash Value (before Return of Premium) $13, $12, Cash Value (including Return of Premium) $50, $49, Face Amount $90, $88, Death Benefit $100, $98, Loan Balance $0.00 $0.00 Return of Premium Value $50, $49, Death Benefit Proceeds $100, $98, Premium Annual $0.00 $0.00 Monthly Deduction $ $ Benefit Payment: $2, Example 2: Benefit: Chronic Illness With Loan Elected Accelerated Death Benefit Amount: $24,000 Annually Before Payment After Payment Account Balance $15, $11, Surrender Charge $2, $1, Cash Value (before Return of Premium) $8, $6, Cash Value (including Return of Premium) $45, $34, Face Amount $90, $68, Death Benefit $100, $76, Loan Balance $5, $3, Return of Premium Value $50, $38, Death Benefit Proceeds $95, $72, Premium Annual $0.00 $0.00 Monthly Deduction $ $ Benefit Payment: $22, The single premium charge for this rider is. Applicant Date Agent Date 01-S Rev Page 5 of 5