The Independent Order Of Foresters ( Foresters ) Critical Illness Rider (Accelerated Death Benefit) Disclosure at the Time of Application

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1 The Independent Order of Foresters ( Foresters ) - A Fraternal Benefit Society. 789 Don Mills Road, Toronto, Canada M3C 1T9 U.S. Mailing Address: P.O. Box 179 Buffalo, NY T foresters.com The Independent Order Of Foresters ( Foresters ) Critical Illness Rider (Accelerated Death Benefit) Disclosure at the Time of Application CRITICAL ILLNESS COVERAGE: The rider provides a limited benefit when you are diagnosed with a critical illness. Coverage of this type is designed to provide you with limited or supplemental coverage. READ YOUR CERTIFICATE AND RIDER CAREFULLY: This disclosure only provides a very brief description of the important features of the Critical Illness Rider. This is not the insurance contract and only the provisions of the rider and the certificate to which the rider is attached will control. The rider and certificate set forth in detail the rights and obligations of both you and the insurance company. THEREFORE, IT IS IMPORTANT THAT YOU READ THE CERTIFICATE AND RIDER CAREFULLY! Critical illness coverage is designed to provide you with coverage paying benefits only when certain losses occur as a result of the critical illness. Coverage is provided for the benefits outlined in the Benefits section. The benefits described in the Benefits section may be limited by the Risks not Covered section. The rider provides an accelerated payment of the life insurance death proceeds under conditions specified in the rider. It is not intended to provide health or long term care insurance. The cash value (if any), loan value (if any), premium payments, and the death proceeds will be reduced if an accelerated benefit is paid. Please read the Critical Illness Rider carefully it contains waiting periods and limitations. DISCLOSURE: Receipt of an accelerated benefit may affect you, your spouse or your family s eligibility for public assistance programs such as medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), supplementary social security income (SSI), and drug assistance programs. You are advised to consult with a qualified tax advisor and with social service agencies concerning how receipt of such a payment will affect you, your spouse and your family s eligibility for public assistance. TAX CONSEQUENCES: This accelerated benefit is not intended to qualify under Section 101(g) (26 USC 7702B) of the Internal Revenue Code of 1986 as amended by Public Law Benefits paid under the rider may be taxable. If so, you may incur a tax obligation. You should consult a qualified tax advisor to assess the impact of this benefit. Foresters TM is the trade name and a trademark of The Independent Order of Foresters US 05/06 Page 1 of 6

2 BENEFITS The Critical Illness Benefit Subject to the provisions of the entire contract, we will pay to you, in a lump sum, the benefit if we receive proof satisfactory to us that the insured has a diagnosis of a critical illness or the insured has completed a critical procedure. The Critical Illnesses and Procedures provision provides the definitions for the critical illnesses and critical procedures for which a benefit will be paid under the rider. If a condition or procedure is not defined in the Critical Illnesses and Procedures provision of the rider, it is not covered and no benefit will be paid. The notice of claim and proof requirements must be met in order to pay the benefit. These are described in the Notice of Claim and Proof provision of the rider. The benefit is payable only for the first ever diagnosis of each critical illness and that diagnosis must be made for the first time while the rider is in effect. The critical illness of life threatening cancer must first manifest itself, and each symptom or medical problem which initiated an investigation leading to the diagnosis of life threatening cancer must have arisen, on or after the later of the 30 th day that the rider first comes into effect and the 30 th day after the date of the last reinstatement of the rider, if any. The other critical illnesses and the medical necessity for a critical procedure must first manifest itself, and each symptom or medical problem which initiated an investigation leading to the diagnosis of a critical illness, other than life threatening cancer, or the medical necessity for a critical procedure must have arisen, on or after the later of the day that the rider first comes into effect and the date of the last reinstatement of the rider, if any. The critical procedure must be completed while the rider is in effect. Effect of Payment of a Critical Illness Benefit Payment of the benefit will not end the certificate. The face amount of the certificate, however, will decrease by the amount of the benefit paid under the rider. This will result in a lower amount of life insurance death proceeds payable under the certificate. The premium for the certificate will be adjusted based on this new face amount. Payment of more than one benefit is possible under the rider if the amount of the benefit paid is less than 100% of the benefit amount. The benefit amount will be reduced by the amount of the benefit paid under the rider and the premium for the rider will be adjusted based on this reduction. If as a result of this payment the benefit amount is reduced to zero, the rider will end. The cash value, if any, under the certificate, will be reduced. This reduction will be in the same proportion that the amount of the benefit paid bears to the face amount before this payment. At the time of the benefit payment, we will provide to you a statement specifying the amount of the benefit paid and the effect of the benefit payment on the face amount, cash value (if any) and loan(s) under a rider (if any) US 05/06 Page 2 of 6

3 The Amount of the Critical Illness Benefit The amount of the benefit is a percentage of the benefit amount, where the percentage varies based on the type of critical illness and/or critical procedure. These percentages are shown in the Certificate Data Pages or in the notification sent with the rider. Critical Illnesses and Procedures The rider defines the following critical illness and critical procedures: A. Critical Illnesses Life Threatening Cancer (Invasive Cancer) Myocardial Infarction Stroke Advanced Alzheimer s Disease (before the insured s 75th birthday) B. Critical Procedures Coronary Heart Disease requiring Coronary Bypass Surgery Coronary Heart Disease requiring Angioplasty The following two pages outline the specifics to each of these situations and what effect is on the Critical Illness Rider benefit. A. Critical Illnesses a. Life Threatening Cancer (Invasive Cancer): Only a type of cancer clinically confirmed by a malignant tumor that demonstrates uncontrolled growth with the spread of malignant cells and the invasion of tissue. Leukemia and lymphoma are life threatening cancers. For purposes of the rider, life threatening cancer does not include any of the following, regardless of the location in or on the body: A malignant tumor wherein the tumor cells have not invaded neighboring tissue. Pre-malignant tumors. Lesions (such as but not limited to intraepithelial neoplasia). Benign tumors. Polyps. Early prostate cancer diagnosed as T1N0M0 or equivalent staging. Non- invasive cancer. Cancer in situ. A skin cancer other than invasive malignant melanoma into the dermis or deeper. A malignant tumor in the presence of the Human Immunodeficiency Virus (HIV) US 05/06 Page 3 of 6

4 b. Myocardial Infarction: An acute myocardial infarction resulting in the death of a portion of the heart due to inadequate blood supply to the relevant area resulting from a blockage of one or more coronary arteries requiring an inpatient hospital stay and resulting in a loss of the normal function of the heart lasting at least 60 days after hospital discharge. The diagnosis of an acute myocardial infarction must be made by a physician who is board certified in the United States in cardiology or internal medicine and based on both of the following: New electrocardiographic (EKG) changes, which confirms the diagnosis of an acute myocardial infarction. Elevation of cardiac (heart) enzymes to a level that confirms a diagnosis of an acute myocardial infarction. For purposes of the rider, myocardial infarction does not include any previously established myocardial infarction. c. Stroke: An acute cerebrovascular accident (death of brain tissue), due to hemorrhage, thrombosis or embolus producing neurological impairment and resulting in paralysis or other medically measurable objective neurological deficits persisting for at least 30 days and the prognosis by a physician, who is board certified in the United States as a neurologist, is that this paralysis or deficit is permanent. For purposes of the rider a stroke does not include any of the following: TIA s (transient ischemic attacks). Head injuries. Chronic cerebrovascular insufficiency (restricted blood flow to the cerebrum) Reversible ischemic neurological deficits. d. Advanced Alzheimer s Disease (before the insured s 75th birthday): A progressive degenerative disease of the brain supported by medical evidence that the insured exhibits loss of intellectual capacity resulting in impairment in judgment and memory. This impairment must be medically and objectively determined to have resulted in a significant reduction in mental and social functioning such that the insured requires permanent and continuous daily supervision and is unable to independently perform three or more of the following activities of daily living: transferring (moving in or out of bed or a chair), dressing, bathing, feeding, toileting, and continence. The physician providing the diagnosis of advanced Alzheimer s disease and the physician making the objective determination must be board certified in the United States as a neurologist. This diagnosis must be made before the insured s 75th birthday and while the rider is in effect. For purposes of the rider advanced Alzheimer s disease does not include any of the following: Other dementing organic brain disorders. Psychiatric illnesses US 05/06 Page 4 of 6

5 B. Critical Procedures e. Coronary Heart Disease requiring Coronary Bypass Surgery: The completion of coronary artery bypass surgery using a saphenous vein or internal mammary artery graft for the treatment of coronary heart disease deemed as a medical necessity by a physician to correct a narrowing or blockage of one or more coronary arteries. The physician who deems this coronary bypass surgery as a medical necessity and the physician who performs this procedure must be board certified in the United States in cardiology. For purposes of the rider, coronary bypass surgery does not include any of the following: Other surgical or non-surgical techniques, such as laser relief or other intra-arterial procedures. Angioplasty, with or without a stent. f. Coronary Heart Disease requiring Angioplasty: The completion of a percutaneous transluminal angioplasty, with or without a stent, for the treatment of coronary heart disease deemed as a medical necessity by a physician to correct a narrowing or blockage of one or more coronary arteries. The physician who deems this angioplasty as a medical necessity and the physician who performs this procedure must be board certified in the United States in cardiology. For purposes of the rider angioplasty does not include: Other surgical or non-surgical techniques, such as, but not limited to, laser relief or other intra-arterial procedures. Risks Not Covered We will not pay the benefit if the critical illness or critical procedure results directly or indirectly from any of the following: An attempted suicide. Intentionally self-inflicted injury. The administration, injection, or taking of a drug, hypnotic or narcotic, unless administered on the advice of, and as prescribed by, a physician. Committing or attempting to commit an assault or a crime. Premiums While the rider is in effect, premiums are due according to the terms of the certificate. We reserve the right to change the premiums for the rider. We can increase the premium for the rider but not more than once in every 12 month period. Each increase will be subject to the approval of the insurance regulator for the state governing the rider, if required. We will send you 45 days notice of the premium increase. Renewability This rider is guaranteed to be in effect up to the expiry date for this rider, as long as you pay the total premium when due, as described in the certificate. The total premium, up to the expiry date for this rider, includes the required premium for this rider. This disclosure is only a brief summary of the rider. It is not the rider or the certificate. The rider sets forth all your rights and obligations, as well as ours US 05/06 Page 5 of 6

6 The Independent Order of Foresters ( Foresters ) - A Fraternal Benefit Society. 789 Don Mills Road, Toronto, Canada M3C 1T9 U.S. Mailing Address: P.O. Box 179 Buffalo, NY T foresters.com PLEASE READ YOUR CERTIFICATE AND RIDER CAREFULLY! Owner Name (Please print) Agent Name (Please print) _ Owner Signature Agent Signature _ Foresters TM is the trade name and a trademark of The Independent Order of Foresters US 05/06 Page 6 of 6 Owner Copy

7 The Independent Order of Foresters ( Foresters ) - A Fraternal Benefit Society. 789 Don Mills Road, Toronto, Canada M3C 1T9 U.S. Mailing Address: P.O. Box 179 Buffalo, NY T foresters.com PLEASE READ YOUR CERTIFICATE AND RIDER CAREFULLY! Owner Name (Please print) Agent Name (Please print) _ Owner Signature Agent Signature _ Foresters TM is the trade name and a trademark of The Independent Order of Foresters US 05/06 Page 6 of 6 Foresters Copy

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