LifeScape Single Premium Whole Life Basic Illustration NARRATIVE SUMMARY

Transcription

1 Prepared for: Tom Jones Issue Age: 60 NARRATIVE SUMMARY Policy Description LifeScape Single Whole Life is a level-benefit, single premium, participating whole life insurance policy with maturity at age 121. Payment of the premium, assuming no loans are made, guarantees that the policy will remain in force until age 121. Any dividends declared on this policy due to its participating status will be paid according to the dividend option selected. Underwriting Class: Male, Select Non- Tobacco Initial Base : $100,000 Contract : $57, Initial Dividend Option Selected: Paid-Up Additions This policy is a modified endowment contract (MEC) at issue. Money distributed from a modified endowment contract by cash distributions, withdrawals, loans or assignments will be considered taxable income until all gain, if any, has been distributed. The taxable income amounts will also be subject to a 10% penalty tax unless the owner is at least 59 1/2, becomes disabled or annuitizes the entire cash value. benefits of modified endowment contracts paid to the beneficiary continue to be treated as life insurance proceeds and therefore are not subject to income tax. The premium required for the insurance coverage will depend on the outcome of the underwriting process and may vary from what is shown on this illustration. If so, you will receive a revised illustration with your policy. The initial base death benefit is $100,000. The contract premium is $57, Policy dividends are used to purchase additional paid-up insurance. The amount of additional insurance purchased is that which the dividend, applied as net single premium, can buy at the insured's attained age. This dividend option is selected from age 60 to 121. NUMERIC SUMMARY AND POLICY VALUES DEFINITIONS Guaranteed Columns Illustrate the policy values that are guaranteed and established at issue. These policy values assume no dividends are paid. Available cash values and death benefits will never be less than the values shown here assuming timely payment of the contract premium. THIS IS AN ILLUSTRATION ONLY. AN ILLUSTRATION IS NOT INTENDED TO PREDICT ACTUAL PERFORMANCE. INTEREST RATES, DIVIDENDS, OR VALUES THAT ARE SET FORTH IN THE ILLUSTRATION ARE NOT GUARANTEED, EXCEPT FOR THOSE ITEMS CLEARLY LABELED AS GUARANTEED. Version Page 1 of 9

2 Prepared for: Tom Jones Issue Age: 60 NARRATIVE SUMMARY (continued) Non-Guaranteed Columns Illustrated Scale Columns Midpoint Scale Columns Illustrate the policy values that are not guaranteed because the assumptions on which they are based are subject to change. These underlying assumptions will change as Assurity's future experience with respect to mortality, interest, expenses, taxes and other factors unfolds. The outlays, values and benefits shown in these columns are neither guarantees nor estimates of future Assurity performance. Actual outlays, values and benefits may be more or less favorable than those illustrated. The expense basis used in this illustration is the current NAIC-approved Generally Recognized Expense Table. Illustrate the policy values that are based on the current dividend scale. The values shown in these columns assume that dividends are payable according to the current scale for the life of the policy. This is very unlikely to occur. Actual results may be more or less favorable. Illustrate the policy values that are based on dividends payable at one-half of the current scale for the life of the policy. Contract Illustrated at the beginning of the year and represents the total premium payments required to maintain the base policy and rider benefits shown in this illustration. Guaranteed Cash Guaranteed Illustrated at the end of the year and represents the cash value guaranteed to be available upon policy surrender assuming timely payment of the guaranteed contract premium(s) by the owner/payor. Policy loans, withdrawals and partial surrenders will reduce the otherwise available death benefits and cash values. Illustrated at the end of the year and represents the death benefit guaranteed to be paid upon the death of the insured assuming timely payment of the guaranteed contract premium(s) by the owner/payor. Policy loans, withdrawals and partial surrenders will reduce the otherwise available death benefits and cash values. Outlay Shows the contract premium less any dividends paid in cash or used to reduce premium, any surrenders of paid-up additions, and/or any new policy loans or loan repayments in the year. These values are meant to represent the owner/payor's out-of-pocket cost for the given year. These premium outlay amounts are not guaranteed to maintain the policy and rider benefits illustrated since these outlays assume that portions or all of the contract premium will be paid from nonguaranteed elements. Annual Dividend Illustrated at the end of year and includes dividends earned on the base policy and any paid-up additions. These values are not guaranteed. The dividends illustrated are based on 100% of Assurity's current scale and are neither guaranteed nor estimates for the future. Surrender Illustrated at the end of year and includes the guaranteed cash value, terminal dividends and any paid-up additions cash value. Policy loans, withdrawals and partial surrenders will reduce the otherwise available death benefits and cash values. These values are not guaranteed. Illustrated at the end of year and includes the death benefits provided by the base policy, any riders, terminal dividends and any paid-up insurance purchased by the annual dividend on the policy or riders. Policy loans, withdrawals and partial surrenders will reduce any death benefit and cash values. These values are not guaranteed. Version Page 2 of 9

3 Prepared for: Tom Jones Issue Age: 60 NARRATIVE SUMMARY (continued) Accelerated s Rider (AB) Single Insurance Rider (SPI) RIDER DESCRIPTIONS In some states, this policy may include coverage under the Accelerated s Rider at no additional cost. The Accelerated s Rider provides the option to accelerate a portion of policy proceeds if the insured is terminally ill or, if age 65 and over, requiring continuous confinement in a long-term care facility or under a written plan of home care expected to last until death. Allows flexible additional payments to be applied to the policy. Each payment, less a premium load is applied as paid-up additions. Evidence of insurability may be required. Each payment must be at least $ DISCLOSURE Incontestability and Suicide Provisions Suicide, incorrect age and incontestability provisions apply. Please review the policy or ask your representative for more information. Version Page 3 of 9

4 Prepared for: Tom Jones Initial : $100,000 Issue Age: 60 Initial Annual : $57, NUMERIC SUMMARY Guaranteed Non-Guaranteed Mid-Point Surrender Illustrated Scale Surrender Yr Age Contract s Cash Outlay Outlay , , , , , , , , , , , , , , , , , , , , , , , ,083 I have received a copy of this illustration and understand that any non-guaranteed elements illustrated are subject to change and could be either higher or lower. The agent has told me they are not guaranteed. Policy Owner: Date: I certify that this illustration has been presented to the applicant and that I have explained that any non-guaranteed elements illustrated are subject to change. I have made no statements that are inconsistent with the illustration. Authorized Representative: Date: ALAN N. CANTON 8041 SIERRA STREET FAIR OAKS, California Phone Number: (916) License Number: 0F31110 Version Page 4 of 9

5 Prepared for: Tom Jones Initial : $100,000 Issue Age: 60 Initial Annual : $57, POLICY VALUES Yr Guaranteed Non-Guaranteed Annual Dividend Surrender Age Contract Cash Outlay ,575 52, ,000 57, , , , , ,006 61, , , , ,081 63, , , , ,164 65, , , , ,251 68, , , , ,340 71, , , , ,427 74, , , , ,511 77, , , , ,592 80, , , , ,676 84, , , , ,771 87, , , , ,880 91, , , , ,003 95, , , , ,135 99, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,464 Version Page 5 of 9

6 Prepared for: Tom Jones Initial : $100,000 Issue Age: 60 Initial Annual : $57, POLICY VALUES (continued) Guaranteed Non-Guaranteed Annual Dividend Surrender Yr Age Contract Cash Outlay , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,083 Version Page 6 of 9

7 Prepared for: Tom Jones Initial : $100,000 Issue Age: 60 Initial Annual : $57, MODIFIED ENDOWMENT CONTRACT DISCLOSURE STATEMENT The Technical and Miscellaneous Revenue Act of 1988 created a new class of life insurance contracts known as Modified Endowment Contracts. The principal purpose of this law was to restrict the use of life insurance as an investment. The law limits the amount of premium that is allowed to be paid into a life insurance contract. The allowable amount of premium is dependent on the death benefit. If the calculated premium limits (defined in IRS code section 7702A) for the life insurance contract are exceeded, the life insurance contract becomes a Modified Endowment Contract. The plan of insurance exceeds the calculated allowable premium limits and would therefore be considered a Modified Endowment Contract. A policy that is a Modified Endowment Contract has the following implications: 1) Money distributed from a Modified Endowment Contract by cash distributions, withdrawals, loans, or assignments, will be considered taxable income until all gain, if any, has been distributed. 2) The taxable income amounts will also be subject to a 10% penalty tax unless the Owner is at least 59 1/2, becomes disabled, or annuitizes the entire cash value. (If the Owner is a corporation, such proceeds are subject to the 10% penalty tax at any time). benefits of Modified Endowment Contracts paid to the beneficiary continue to be treated as life insurance proceeds and therefore are not subject to income tax. I acknowledge that I have read this disclosure statement and understand that the plan of insurance illustrated is a Modified Endowment Contract and therefore subject to special tax treatment as outlined above. / / Date (MM/DD/YYYY) Signature of Owner/Proposed Owner Printed Name Printed Insured/Proposed Insured s Name (First, Middle, Last) Policy Number (if applicable) Version Page 7 of 9

8 Prepared for: Tom Jones Initial : $100,000 Issue Age: 60 Initial Annual : $57, INDICES AND PREMIUM Life Insurance Indices at 5.00% 10 Year 20 Year Surrender Cost Net Payment Cost Equivalent Level Annual Dividend s Included Base policy $57, Version Page 8 of 9

9 Prepared for: Tom Jones Initial : $100,000 Issue Age: 60 Initial Annual : $57, HOME OFFICE INFORMATION New Business-ID Units LS SPWL ACCDB121 SPIR 0112 State: CA Version Page 9 of 9