SAMPLE POLICY SECTION

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1 SAMPLE POLICY SECTION 1

2 TERM LIFE INSURANCE POLICY ANNUAL RENEWABLE & CONVERTIBLE Insurance Payable at Death of Insured During Term Period Premiums Payable During Lifetime of Insured or Until End of Renewal Participating Face Amount Policy Number Right to Cancel Policy Within 20 Days. You may return this policy within 20 days after you receive it for a full refund. We will cancel the policy as of the policy date. 2

3 POLICY BENEFITS Death Benefits When we receive proof that the insured s death occurred while this policy was in effect, we will pay the insurance provided by this policy and its riders. A refund or charge will be made to adjust any premium payments to the end of the month in which the insured s death occurred. We will pay the resulting amount to the beneficiary. We will also pay interest on that amount from the date of death to the date of payment. The yearly rate of interest will be the same as we use for death benefits left with us at interest. Suicide Exception If the insured dies by suicide, while sane or insane, within two years of the policy date, no death benefits will be paid. Instead, we will return the premiums paid. Dividends At the end of the second and each following year, we ill determine your dividend, if any, and pay it to you in cash. We do not expect that any dividends will become payable. PREMIUMS, LAPSE AND REINSTATEMENT Payment Premiums are payable: in the amounts, at the intervals and on the due dates shown; to us or to our producer who will give you a receipt signed by our Secretary. Grace Period There is a grace period of 31 days for you to pay each premium after the first. Insurance will continue during the grace period. Lapse If any premium is not paid by the end of its grace period, this policy will lapse. The date of the lapse is the due date of the premium not paid. Upon lapse, this policy will terminate except as provided in the reinstatement clause. Renewal On each anniversary before the end of the renewal period, you may renew this policy for another term period of one year. To do this, simply pay the required renewal premium before the end of its grace period. Conversion At any time before the end of the conversion period, you may convert this policy to a new policy on the insured s life. To do this, you must apply in writing on a form we provide. You must also give us this policy to be cancelled. The date of cancellation will be the new policy s date. The new policy will become effective on its date only if the insured is then living. The amount of insurance on the new policy will be the same as the amount of insurance on this policy. If you wish, you may select a lower amount as long as it is not less than our regular minimum limit at the time of conversion. The new policy will be on the whole life or any higher premium plan we regularly issue at the time of conversion. It will be issued in the same underwriting class and contain the same restrictions, if any, as this policy. It will be issued at our published premium rates which apply at the insured s age in the new policy s date. Premium waiver may be included in the new policy if: premium waiver is included in this policy; the insured is not totally disabled on the new policy s date; the new policy s premium period is at least 20 years; and the insured s age on the new policy s date is 55 years or less. Other riders, whether or not included in this policy, will not be included in the new policy without our consent at the time. If we are waiving premiums for this policy at the insured s age 65, and if you then convert this policy to a whole life policy in the manner described above, we will waive premiums under the new policy while total disability continues without interruption. 3

4 Reinstatement You may reinstate this policy within five years of lapse if: you provide evidence of insurability which satisfies us; you pay all past due premiums with interest on each from its due date at 6% compounded each year; and the final renewal term period has not expired. INCOME BENEFITS Income Benefits Death benefits may be used to buy a monthly income for the lifetime of the beneficiary. After it starts the income will last for at least 10 years. The income is guaranteed to be 3% greater than the income based on our published rates for single premium immediate annuities at the time the income is bought. The income bought by each $1,000 will always be at least as large as that shown below. Monthly Income Monthly Income Age Male Female Age Male Female $ $ $ $ Monthly income amounts for ages not shown are halfway between the two amounts for the nearest two ages which are shown. Guaranteed amounts for ages under 30 are the same as those for age 30; guaranteed amounts for ages over 75 are the same as those for age 75. Amounts shown are based on the 1971 Individual Annuity Mortality Table with interest at 4% per year. Incomes must be at least $25 a month. We may require evidence of survival for incomes which last more than 10 years. GENERAL PROVISIONS The Contract The application is attached to the policy. Together, they make up the entire contract. All statements in the application are representations and not warranties. Only statements in the application can be used to void this policy or to defend a claim on the grounds of misrepresentation. Modifications Only our President or Secretary has the right to change or waive the terms of this policy. Incontestability This policy will be incontestable after it has been in force during the insured s lifetime for two years from the policy date. Misstatements If age or sex is misstated, benefits will be those the premiums paid would have bought for the correct age and sex. Settlements All payments under this policy are to be made at our home office. 4

5 Owner The owner of this policy is as shown in this policy or in a later written change. If there is more than one owner, they will own this contract as joint tenants with right of survivorship unless stated otherwise. Beneficiary The beneficiary of this policy is as shown in this policy or in a later written change. Unless you state otherwise, death benefits will be paid in equal shares to the beneficiaries who live to receive them, or if none, amounts due will be paid to you or your estate. Assignment If you assign this policy, your rights and those of any beneficiary are subject to the rights of the assignee. Notice Changes, assignments, and requests will not affect us until we receive them in writing at our home office. Age and Dates As used in this policy and any riders, age means age as of nearest birthday on the policy anniversary. Policy years, months and anniversaries are determined from the policy date shown. 5

6 APPLICATION TERM LIFE INSURANCE PLEASE PRINT USING DARK INK SECTION A CLIENT INFORMATION PROPOSED INSURED 1. Full Name (PRINT AS TO APPEAR IN POLICY) 2. Sex Male Female 3. State of Birth 4. Date of Birth 5. Ins. Age 6. Address (CITY, COUNTY, STATE, ZIP CODE) 7. Telephone (OPTIONAL) 8. Employer Name and Address 9. Occupation 10. Specific Duties 11.Social Security No. or Taxpayer I.D. No. (SHOW ALL HYPHENS) OWNER (IF OTHER THAN PROPOSED INSURED) or PAYOR (IF PROPOSED INSURED IS JUVENILE) 12. Full Name (PRINT AS TO APPEAR IN POLICY) 13. Social Security No. or Taxpayer I.D. No. (SHOW ALL HYPHENS) 14. Address (CITY, COUNTY, STATE, ZIP CODE) 15. Telephone (OPTIONAL) 16. Contingent Owner BENEFICIARY 17. Primary Beneficiary (PRINT FULL NAME AND RELATIONSHIP) 18. Contingent Beneficiary (PRINT FULL NAME AND RELATIONSHIP) 19. Is Marital Deduction Desired? Yes No SECTION B PLAN INFORMATION (CHECK ONE) FIXED FLEXIBLE PREMIUM LIFE INSURANCE 1. Plan Desired: 2. Face Amount: 3. Total Mode Premium or Expected Annual Premium: QUES. #4 #5 FOR FIXED PREMIUM LIFE INSURANCE ONLY 4. A. Automatic Premium Loan to be in effect Yes No B. Variable Interest Loan Rider Yes No 5. Check one: Dividend/Credit Option Cash Accum. at Interest Reduce Premium Term/Reduce Premium One-Year Term/Paid-Up Insurance Added to Policy Value Additional Paid-Up Insurance Option: All Whole Life All One-Year Term Combination. Whole Life and One-Year Term With Target of $. QUES. #6 For Flexible Premium Life Insurance Only 6. Option A (Level) Death benefit equals face amount Option B (Increasing) Death benefit equals face amount plus accumulation value 6

7 7. Optional Benefits A. Term Rider on Proposed Insured for $ For Years B. ART on Other Covered Persons - Flexible Premium Plan C. Supplementary Term for Target in Ques. #5 D. Preliminary Insurance - Fixed Premium Plan 1 Yr 2 Yr # of Months Eff. Date E. Business Insurance Exchange F. Guaranteed Insurability G. AAR / AVR / AVP (Units) - Fixed Premium Plan H. ADB $ (Ins. Amt.) I. Disability Benefits (Units) - Flexible Premium Plan J. Premium Waiver / Waiver of Charges K. Owner Premium Waiver / Owner Waiver of Charges (Complete Part 2, B) L. Payor Premium Waiver / Payor Waiver of Charges (Complete Part 2, B) M. Survivor Life (Units) N. Children s Term (Units) (Complete Part 2, B) O. Family Term (Units) (Complete Part 2, B) - Fixed Premium Plan P. Increasing Death Benefit - Flex I Q. R. S. T. U. 8. If any Optional Benefit cannot be approved, should the policy be issued without it? Yes No SECTION C BILLING INFORMATION 1. Billing Method: Direct Billing Uni-Check Budget Pack Payroll Ded. List Bill Govt. Allotment Single Premium 2. Frequency of Premium Reminder Notice or Premium Payment Annual Semi-Annual Quarterly Monthly 7

8 SECTION D GENERAL INFORMATION 1. Give Details of life insurance in force in other companies. If none (or if conversion application) check this box COMPANY YEAR TAKEN PLAN LIFE AMOUNT ACC. DEATH AMOUNT 2. Is the proposed insured married? Yes No If Yes, show amount of life insurance on spouse $ 3. For the proposed insured, provide the following: A. Annual earned income from occupation (after deduction of business expenses) $ B. Spouse s annual earned income $ C. Other income (state source in Remarks ) $ 4. Does any proposed insured contemplate leaving the U.S.A. for travel or residence? Yes No (IF YES, EXPLAIN IN REMARKS ) 5. Within the last two years, has any proposed insured: A. Flown or planned to fly as a pilot, student pilot or crew member? Yes No B. Engaged in parachute jumping, scuba diving, auto or motor boat racing or any form of motorcycling?.. Yes No C. Had a driver s license restricted or revoked, or been charged with 3 or more moving violations? Yes No (IF YES, TO A OR B, COMPLETE APPROPRIATE SECTION OF THE GENERAL QUESTIONNAIRE. IF YES TO C, GIVE STATE AND NUMBER OF DRIVER S LICENSE IN REMARKS ) 6. A. Has any proposed insured ever had insurance declined, rated, modified, cancelled or not renewed?... Yes No B. Has any proposed insured been convicted of a felony within the past 5 years? Yes No C. Has any other insurance been applied for within the last 3 months on any proposed insured? Yes No D. Will the policy applied for replace or change any existing insurance or annuity on any proposed insured? Yes No (IF YES, EXPLAIN IN REMARKS ) 7. Special dating requested: Date to save age Specific date (non-prepay only): Mo. Day Year 8. Is cash or check tendered with this application? Yes No If Yes, show amount $ If No, do not complete question #9 9. Do you understand, accept and agree to the terms of the Temporary Insurance Agreement (TIA)? Yes No If Yes, and a face amount is requested which is larger than that which Pacific Mutual will insure under the TIA, complete the following statement: If approved, please issue an alternate policy identical to the one applied for, but for a face amount of $ SECTION E MEDICAL CERTIFICATION (COMPLETE WHEN SUBMITTING MEDICAL EXAMINATION OF ANOTHER INSURANCE COMPANY.) 1. The attached examination is on the life of: Proposed Insured Spouse 2. Name of insurance company for which examination was made and date of examination: COMPANY DATE OF EXAMINATION 3. To the best of your knowledge and belief, are the statements in the examination true as of today? Yes No 4. Has the person who was examined consulted a doctor or other practitioner or received medical or surgical advice since the date of the examination? (IF YES, EXPLAIN IN REMARKS ) Yes No REMARKS IDENTIFY QUESTION NUMBER AND PERSON HOME OFFICE ENDORSEMENTS 8

9 SECTION B ADDITIONAL INSUREDS (OWNER, PAYOR, FAMILY CHILDREN) and PROPOSED INSURED UNDER AGE Full Name of Person To Be Covered Relationship To Proposed Insured Date Of Birth (MO/DAY/YR.) State Of Birth Height (FT./IN.) Weight (POUNDS) Amount Of Insurance Now In Force Amt. Of Ins Currently Applied For Note: If payor or owner premium waiver is being applied for, please indicate the individual s occupation and the employer s name and address: 2. Has any person named in Question1 during the past 10 years had or been told that he had, or been treated for: (CIRCLE APPLICABLE ITEMS AND GIVE DETAILS) Yes No A. Diabetes, cancer or epilepsy? B. Heart murmur, high blood pressure or any heart condition? C. Any disorder(s) of the Immune System, including AIDS (Acquired Immune Deficiency Syndrome) and ARC (AIDS Related Complex)? Has any person named in Question #1: A. Been in a hospital, sanitarium or other institution for diagnosis, treatment or a surgical operation within the past 5 years? B. Had any medical consultation or treatment within the past 3 years, other than as stated in any answer above? Give details below for each Yes answer in Questions 2 and 3: Question No. First Name Reason For Consultation Date Duration Result Name and Address of Physician DECLARATIONS I represent that the foregoing answers and statements (contained in Parts 1 and 2) are correctly recorded, complete, and true to the best of my knowledge and belief. I understand that: 1. Except as otherwise provided in any Temporary Insurance Agreement, no insurance will take effect before the policy for such insurance is delivered and the first premium paid during the lifetime(s) and before any change in the health of the Proposed Insured(s). Upon such delivery and payment, insurance will take effect if the answers and statements in this application are then true. 2. Acceptance of a life insurance policy will be ratification of any administrative change with respect to such policy made by the Company in the space entitled Home Office Endorsements. All other changes, including plan and amount of insurance, benefits, classification or age at issue, must be accepted in writing. 3. No producer or medical examiner is authorized to make or modify contracts or to waive any of the Company s rights or requirements. Dated at on CITY STATE MO. DAY YR. Signature of Proposed Insured (OR PARENT, IF PROPOSED INSURED UNDER AGE 16) I certify that I have truly and accurately recorded hereon the information supplied. Signature of Soliciting Producer Signature of Other Adult Proposed Insured Signature of Applicant (IF OTHER THAN PROPOSED INSURED) IF OWNER IS A CORPORATION, THE SIGNATURE AND TITLE OF AN AUTHORIZED OFFICER OTHER THAN THE PROPOSED INSURED IS REQUIRED AND THE FULL NAME OF THE CORPORATION MUST BE SHOWN. Signature of Owner (IF OTHER THAN PROPOSED INSURED OR APPLICANT) 9

10 SAMPLE LIFE POLICY The Company agrees to insure your life and pay the benefits listed, subject to the provisions of this policy. The basic benefit of this policy is: A DEATH BENEFIT. Upon receipt of due proof of your death while this policy is in force we will pay the Face Amount to the Beneficiary. 10 DAY RIGHT TO EXAMINE POLICY. This policy may be returned either to the Producer or to our Home Office for a full refund of any premium paid, for any reason, within 10 days after receipt and it will be deemed void from the beginning. SECRETARY PRESIDENT REGISTRAR WHOLE LIFE INSURANCE POLICY Proceeds payable at death. Premiums payable as stated in the policy schedule. A Participating Policy. (Dividends may be paid.)...as a policyowner, you should contact your (name of insurance company) representative or the Home Office for information and assistance in the following: Change of Address. Collecting benefits under this policy. It is not necessary to employ any person or corporation for this purpose. Suggestions to terminate or exchange this policy for any other policy or plan. Dropping existing policies to buy new policies is generally not advantageous and will usually result in loss to you through increased cost and less favorable benefits. Please refer to your policy number when corresponding with the Home Office. 10

11 POLICY SCHEDULE BENEFITS: ANNUAL PAYABLE TO PREMIUM AGE * LIFE POLICY 100 *PREMIUMS PAYABLE AS STATED, OR UNTIL PRIOR DEATH OF INSURED. QUARTERLY SEMI-ANNUAL ANNUAL THIS POLICY IS IN A STANDARD PREMIUM CLASS. POLICY NUMBER: 1800 INSURED: JOHN J. DOE FACE AMOUNT: $10,000 AGE: 35 DATE OF ISSUE: JUNE 1, 1978 POLICY DATE: JUNE 1, 1978 TABLE OF GUARANTEED VALUES ISSUE AGE 35 FACE AMOUNT $10,000 POLICY ANNIVERSARY IN END OF POLICY YEAR CASH OR LOAN VALUE PAID UP INSURANCE YEARS EXTENDED INSURANCE DAYS , , , , ,540 1,900 2,260 2,580 2, , , , , , ,210 3,510 3,790 4,080 4, , , , , , ,610 4,860 5,100 5,320 5, AT AGE , , , ,540 7,350 7, NON-FORFEITURE FACTORS POLICY YEARS FACTORS ALL

12 This contract is a legal contract between the contract owner and (name of insurance company) READ YOUR CONTRACT CAREFULLY. It sets forth, in detail, the rights and obligations of both you and your insurance company. IT IS THEREFORE IMPORTANT THAT YOU READ YOUR CONTRACT CAREFULLY. ALPHABETIC GUIDE TO YOUR CONTRACT PAGE PAGE Age Insured Beneficiary Misstatement of Age or Sex Change of Beneficiary Modification of this Policy Date of Issue Ownership Death Benefit Reinstatement Definitions Right to Examine Contract Dividends and Dividend Options Schedule of Coverage Exchange Settlement Options Face Amount Settlement Tables Grace Period Suicide Incontestability ADDITIONAL BENEFITS The additional benefits, if any, listed on the Schedule of Coverage are described in the additional benefit riders that follow page 0. DEFINITIONS We, ours, or us: You, your, or yours: Age: Policy Date: Due Date: the Company the Insured means age nearest birthday means the date shown on the Policy Schedule from which policy years, policy months, policy anniversaries and premium intervals will be determined. each premium after the first is due at the end of the period for which the preceding premium was paid. Home Office: Proceeds: Payee: Our Company s principal place of business at. the net amount payable under this policy as a death benefit. A person entitled to any payment under this policy. 12

13 Whole Life Insurance Policy Summary This is a summary of your life insurance policy. A life insurance policy is a legal contract between you as the owner and the company as the insurer. Its purpose is to pay an amount of money upon your death, or the insured s death if you are not the insured, to the person you designate. In exchange for that benefit, you agree to pay premiums when due. In this policy summary, some of the basic provisions of your life insurance policy are explained. Not everything can be explained here, however. If you have any questions about your policy that are not answered in this summary, the policy itself may contain the answers. If not, ask the producer or the company. You have ten days after receipt of this policy to review it. If you decide you don t want to keep it, return it to the producer or the company within the ten day period and you will receive a refund of all premiums paid. 1. The amount of insurance. The face amount of insurance is shown on the Policy Schedule. 2. Premiums. The yearly premium on your policy is shown on the Policy Schedule. Any year by year variation in premiums is also shown. If you were charged an extra premium due to a health problem or any other reason, that too is shown. You may also pay the premium more often than once a year. There are extra charges for this right because the expenses are higher and because the company cannot earn as much interest as it would if it received the full premium at the beginning of the year. a. Grace Period. The law allows you to pay any premium without penalty during a grace period of 31 days after the due date. If you do not pay your premiums within the grace period, your policy will lapse unless any accumulated dividends are sufficient to pay the premium or you have elected the Automatic Premium Loan provision. b. Reinstatement. If the policy lapses, you have the right to reinstate the policy. That means put it back in force any time within five years after the due date of the premium you failed to pay. There are some conditions for this reinstatement and they are explained in the policy. 3. Policy Loans. After the policy has a cash value, you may borrow on your policy for any purpose. The loan will bear interest at 8%. Any amount of the loan outstanding plus interest will be deducted from the policy proceeds if you die or surrender the policy. 4. Dividends. This is a participating policy. This means that the company may pay dividends to the owner, depending upon mortality rates, interest rates and costs of doing business. Dividends can be paid in cash or they can be used in a number of ways such as the purchase of additional insurance. The choices you have are outlined in the Dividends and Dividend Options provisions of this policy. 5. Exclusions. There are certain situations in which the Company can refuse to pay the death benefit under this policy. Suicide within two years of the date of issue of the policy is one such situation. If you gave a material, false statement when you applied for this policy, and die within two years from its date of issue, the Company may refuse to pay the death benefit. 13

14 PREMIUMS AND REINSTATEMENT (a) (b) Payment. Each premium is payable on or before the due date. The first premium is due on the Policy Date. Upon request we will send a signed receipt. Frequency. Premiums may be paid once per year, twice per year or once per quarter. The Owner may change the mode of payments if we approve. (c) Grace Period. If a premium is not paid on or before the due date, it is in default. There is a grace period of 31 days from the due date. During this period, this policy will remain in force. After that, if your premium is unpaid this policy will expire except as provided in the Benefits on Lapse or Surrender Provisions. If you die during the grace period, a month s premium will be deducted from the policy proceeds. (d) Premium Refund at Death. At your death we will refund as part of the policy proceeds the portion of any premium paid for a period beyond the policy month of your death. Reinstatement. This policy may be reinstated at any time within five years after default in premium payment, if: (a) (b) (c) The policy has not been surrendered for cash; You provide evidence of insurability accepted by us; and All past due premiums are paid and any indebtedness is paid or reinstated with compound interest on both at 6% per year. LOAN AND REPAYMENT Policy Loan. We will make loans on this policy. It must be in force other than as extended term insurance. The policy must be assigned to us as security for the loan. The loan value is the sum which with interest, shall not exceed the net surrender value: (a) on the date to which premiums have been paid; or, (b) if no further premiums are payable, on the next policy anniversary. Whenever indebtedness equals or exceeds the cash value, this policy will be void 31 days after notice has been mailed to the last known address of the Owner and any assignee shown on our records. We may defer making any loan, except to pay premiums, for not more than six months from receipt of written request for the loan. Automatic Premium Loan. We will charge the amount of any premium not paid before the end of the grace period as a loan against the policy from the due date of that premium. To do this we require a written request received by us before the end of the grace period. If the loan value is not enough to pay the premium then due, no automatic premium loan shall be made and this policy will expire except as provided in the Benefits on Lapse or Surrender Provisions. As long as the policy is in force under this provision, payment of premiums may be resumed without evidence of insurability. The automatic premium loan may be stopped at any time by written request to us. Interest and Repayment. Interest on loans will accrue at the yearly rate of 8% due on each policy anniversary. Any interest not paid when due will be added to the loan and will bear interest at the same rate. Indebtedness may be repaid at any time while this policy is in force, other than as Extended Term or Reduced Paid-Up Insurance. 14

15 DIVIDENDS AND DIVIDEND OPTIONS Sample Policy Section Dividend. This policy, while in force (except as extended term insurance), will share in any divisible surplus of our participating business as determined each year by us. Dividends, if any, are due on policy anniversaries. The dividend at the end of the first policy year will be payable only if the premium then due for the second policy year is paid. Options. At the option of the Owner, each dividend may be: (a) paid in cash; or (b) used toward payment of any premium then due on this policy if the balance of such premium is duly paid; or (c) held by us at interest at the rate we set, but not less than 2-1/2% compounded annually; or (d) used to buy participating paid-up additions to this policy; such additions would be paid upon receipt of due proof of your death; or (e) used to buy a one-year term insurance addition (term additions); or (f) used in any other manner to which we consent. Term Additions. Option (e) may be chosen only if this policy is in a Standard Premium Class. It must be requested in the application for this policy or by written request received and approved by us. Option (e) shall apply only to dividends which become due after our receipt and approval of such request and before this option is cancelled by written request. Each term addition shall be payable upon receipt by us of due proof that your death occurred within one year starting with the date such dividend became due. Each term addition shall expire without grace or notice at the end of said year so that only one term addition may be in force at any time. For policies in a Standard Premium Class, the charge for each term addition shall not exceed the net annual premium according to the Commissioners 1958 Extended Term Table and 3% interest with continuous functions. General Provisions. Options (a), (b), (c), or (d) may be chosen for any part of any dividend not used under option (e) at any time within 31 days starting with the due date of such dividend. Option (d) shall apply if no other option has been chosen for any part of any dividend within 31 days starting with the due date of such dividend. If they have not been used under the Benefits on Lapse or Surrender Provisions, dividends held by us and dividend additions (but not term additions) may be surrendered for their cash value less any indebtedness. If not otherwise used, dividend additions and dividends held by us will be paid at your death. OWNERSHIP, BENEFICIARY AND ASSIGNMENT Ownership. You are the Owner of this policy, unless someone else is named owner in the application or a written request approved by and filed with us. Unless otherwise provided: (a) the Owner may exercise policy rights during your life and (b) if the Owner dies during your life, all rights will vest in the Owner s estate. Beneficiary. The beneficiary choice in the application will stay in effect unless changed by the Owner. If there is no beneficiary living or chosen, the proceeds will be paid to the Owner or his estate. Change of Owner or Beneficiary. The Owner may transfer ownership or change the beneficiary by written request approved by us. When the request is filed at our Home Office, the transfer or change will be effective as of the date signed by the Owner, whether or not the Owner or Insured is living when the request is filed. We will not be liable for action taken by us before that filing. Assignment. This policy may be assigned by the Owner. We are not bound by any assignment until it is received at our Home Office. We are not responsible for the validity of an assignment. 15

16 GENERAL PROVISIONS Suicide. If you die by suicide, within two years from the Date of Issue your insurance shall be limited to the amount of premiums paid. This applies whether you are sane or insane at the time of suicide. Incontestability. This policy may not be challenged after it has been in force during your life for two years from the Date of Issue except for failure to pay premiums. This provision does not apply to added benefits for disability or accidental death. Contract. This insurance is granted in consideration of the application and payment of the scheduled premiums. This policy and the application attached at issue are the entire contract. All statements made in the application are deemed representations and not warranties. No statement shall void the policy or be used to defend a claim unless it is contained in the application. Modification of this Policy. No person except the President, a Vice President, the Secretary or Assistant Secretary can modify this contract on our behalf. No producer may bind the Company by making a promise not contained in this contract. Misstatement of Age or Sex. If your age or sex has been misstated, any amount payable shall be such as the premium paid would have purchased at the correct age or sex. Payments by Company. Payments by us are payable at our Home Office. Any indebtedness will be deducted from any payment under this policy. Protection from Creditors. Unless contrary to law, (a) neither this policy, nor any policy payments are subject to the claims of creditors of the Owner or any payee and (b) the policy is not subject to attachment or judicial process. BENEFITS ON LAPSE OR SURRENDER Guaranteed Values. After premiums have been paid until this policy has a cash value, the owner may select, within 90 days after the due date of the premium in default, any one of the options listed below. If no written selection is made within the 90 days, then the automatic option will apply. The automatic option for a standard premium class policy is Option (c). The automatic option for a special premium class policy or a policy issued under a tax qualified retirement program is Option (b). Option (c) is not available if this is a special premium class policy. The Net Surrender Value is the tabular cash value shown in the Table of Guaranteed Values, plus the present value of any dividend additions and the amount of any dividend accumulations, less any indebtedness. These values shall be calculated as of the due date of the premium in default, except that any indebtedness to be deducted shall include any indebtedness charged against the policy after such due date. (a) Surrender. This policy may be surrendered for the Net Surrender Value. We may defer payment up to six months. Interest at the yearly rate of 3% will be allowed on any payment of the Net Surrender Value which is deferred more than 30 days. (b) Participating Paid-Up Insurance. This policy may be continued without any further premium payment as a paidup participating contract payable upon receipt of due proof of your death. The Net Surrender Value of the policy shall be used as a net single premium at your then attained age to purchase the paid-up insurance. In no event shall the amount of paid-up insurance exceed a sum equal to the basic death benefit plus the amount of any dividend accumulations, less any indebtedness. 16

17 (c) Non-Participating Extended Term Insurance. This policy may be continued without further premium payment as non-participating Extended Term Insurance beginning with the due date of the premium in default. The amount of insurance shall equal the face amount of the policy, plus any paid-up additions and any dividend accumulations, less any indebtedness. The amount of insurance shall not include any one year term insurance addition. The Net Surrender Value of the policy shall be used as a net single premium to determine the duration of insurance. This option is not available if the Net Surrender Value exceeds the present value of Extended Term Insurance for life. Surrender of Paid-up or Extended Term Insurance. While it is in force as paid-up or extended term insurance, this policy may be surrendered to the Company at its Home Office for its cash value which shall equal the then present value of such paid-up or extended term insurance, including the then present value of any dividend additions and the then amount of any dividend accumulations to such paid-up insurance and less any indebtedness; except that within 31 days after any policy anniversary such cash value shall be calculated as of such anniversary. Basis of Values. All net single premiums and present values referred to in this policy are based on the Commissioners 1958 Standard Ordinary Mortality Table except that net single premiums for extended term insurance are based on the Commissioners 1958 Extended Term Insurance Table. The calculations are based on continuous functions, age nearest birthday and with an interest rate of 3% per year. On any policy anniversary the tabular cash value of this policy shall equal the excess, if any, of (a) the then present value of the future basic benefits as defined in the policy schedule, over (b) the then present value of a series of annual amounts beginning on such anniversary and continuing during the remaining premium paying period. Each such annual amount shall equal the Non-Forfeiture Factor shown in the table of Guaranteed Values for the appropriate policy year. All guaranteed values in this policy are at least as great as the minimums required by the law of the state in which this policy is delivered. Any supplemental agreement attached to this policy will not increase the cash values or paid-up insurance benefits unless otherwise provided in the agreement. The Table of Guaranteed Values gives the values for the full face amount of this policy, provided this policy is free of indebtedness and has neither dividend additions nor accumulations. Allowance shall be made for lapse of time and payment of premiums beyond the beginning of each policy year. Any values not shown will be quoted on request. The entire loan value at the end of any policy year, less interest for the intervening period, will be available during the same year if the entire premium for that year has been paid. OPTIONAL SETTLEMENT METHODS OF RECEIVING POLICY PROCEEDS While you are living, the Owner may elect settlement of the net policy proceeds under one or a combination of the following options and may revoke or change an election before any proceeds are so applied. If no such election is in force at your death, the beneficiary may elect settlement. Election of any option is subject to the conditions provided in this policy for changing a beneficiary and to the following: (1) If the net proceeds for any one Payee under any option is less than $5,000, we will pay such amount as a single sum. We will lengthen payment intervals to make payments to any Payee at least $50. (2) Election of any option by a corporation, partnership, association, assignee or fiduciary is permitted only with our consent. (3) Options B or E may be elected only if the Payee is the Insured or Annuitant. Proof of the Payee s age is required if Option B or E is elected. (4) Unless otherwise directed in the election of the option and approved by us, the Payee shall not have the right to commute, encumber or assign any installment or interest payment under any option, nor to withdraw any amount held by us under Option C or D. Under Option E no payment may be commuted, encumbered or assigned. We have the right to require 6 months written notice of any commutation or withdrawal. 17

18 The income under these options may be paid monthly, quarterly, semi-annually or annually. Option A Fixed Period. Income to the Payee in equal installments for a specified number of years, the first installment being immediate. The amount will be as shown in the Option A Settlement Table, which is calculated at a 3% yearly rate of interest. Any share of surplus apportioned by us shall be paid on each anniversary of the first installment. Option B Life Income. Income to the Payee, the first installment being immediate, for the lifetime of the Payee, or for a guaranteed period and as long thereafter as the original Payee shall live. The guaranteed period may be 5 years, 10 years, 20 years or a refund period such that the sum of the installments payable, including any fractional final payment, shall equal the proceeds applied. The amount of each installment shall be as declared by us and in effect at the time the first installment comes due, but shall not be less than the amount shown in the Option B Settlement Table, determined by the sex and adjusted age of the Payee on the due date of the first installment. Option C Interest. Interest income to the Payee on the proceeds and applied at such rate as we declare each year, but never less than the equivalent of the yearly rate of 3%. Option D Fixed Amount. Income to the Payee in equal installments, the first to be immediate, until the proceeds applied are exhausted. The amount payable in each year shall not be less than 5% of such proceeds. The final installment shall be the unpaid balance of such proceeds. On each anniversary of the first installment, interest will be added to the unpaid balance at such rate as we declare each year but never less than the yearly rate of 3%. Option E Joint and Survivor Income. Income during the joint lifetime of the Payee and one Contingent Payee, on whose lives the option is based, and providing installments of the full amount if the Payee alone shall survive or installments of either the full amount or one-half the full amount, as elected, if the Contingent Payee alone shall survive. Payments shall be made jointly to the Payee and Contingent Payee while both are living. Thereafter the elected payment shall be made to the survivor while living. The amount of each installment shall be determined, in accordance with the Option E Settlement Table, by the sex and adjusted ages of the Payees on the due date of the first installment. The amount of income for any combination of adjusted ages not shown will be quoted upon request. This option shall not be available unless both Payees adjusted ages at nearest birthday are at least 25 years. Death of Payee. At the death of the Payee, any unpaid proceeds and accrued interest thereon under Option C or D, or the then commuted value of any installments certain then remaining unpaid under Option A or B, shall be payable in one sum to the executors or administrators of the Payee unless otherwise directed in the settlement election and approved by us. Other Settlement Options. Provisions may be made for settlement of the net proceeds of this policy in any other manner approved by us. Adjusted Ages. The adjusted age of the Payee is as follows: Policy Year in which First Adjusted Age of Payee is Payment Falls Due Age Nearest Birthday Plus 1 through through through and over 0 18

19 SETTLEMENT TABLES Monthly Installments Payable in Lieu of Each $1,000 Payable in One Sum Option A Fixed Period Years Amount Years Amount Years Amount Years Amount Years Amount $ $ $ Option B Life Income Adjusted Age Period Certain Adjusted Age Period Certain Male Female 10 Yrs. 20 Yrs. Refund Male Female Life 5 Yrs. 10 Yrs. 20 Yrs. Refund 10 or under or under $ $ $ or over $ $ $ $ $ $ or over NOTE: To obtain the amount of each annual, semi-annual or quarterly installment under Option A, multiply the corresponding monthly Installment by respectively; under Option B multiply the corresponding monthly Installment by respectively. 19

20 SETTLEMENT TABLES Monthly Installments Payable in Lieu of Each $1,000 Payable in One Sum Option E Joint and Full Survivor Income Adjusted Age The Income will be payable while both payees are living and all such Income will be continued to the survivor. of other Specified Payee ADJUSTED AGE OF PAYEE Male Fem Option E Joint and One-Half Contingent Survivor Income Adjusted Age The Income will be payable while both payees are living and all such Income will be continued to the survivor. of Contingent Payee ADJUSTED AGE OF PAYEE Male Fem NOTE: To obtain the amount of each annual, semi-annual or quarterly installments, multiply the corresponding monthly installment by,, or respectively. 20

21 XYZ Life Insurance Company Executive Office: Home Office: (Address) (Address) In this policy the owner is referred to as you or your. The XYZ Life Insurance Company is referred to as we, our, or us. In this policy he is used to mean he or she. Insured means the person named on the Policy Schedule. Debt means debt plus interest due or accrued. We agree to pay the beneficiary the death benefit and any other proceeds due to the Insured s death while this policy is in force and before the Maturity Date. Payments will be made upon receipt at our Executive Office of due proof of the Insured s death. We agree to pay you the Cash Surrender Value if the Insured is living on the Maturity Date. The policy is issued as of its Policy Date. It is subject to the terms set forth on the following pages. CONSIDERATION This policy is issued in consideration of the application and payment of the First Premium. While the Insured is alive monthly deductions will be made to the Maturity Date. TWENTY-ONE DAY RIGHT TO EXAMINE POLICY It is important to us that you are satisfied with this policy and that it meets your insurance goals. Read it carefully. If you are not satisfied with it you may return to our Executive Office or to your producer within 21 days after you receive it. We will then cancel it as of the Policy Date and refund any premiums which have been paid. Signed for the XYZ Life Insurance Company at the Executive Office, (address). Corporate Secretary Chairman of the Board Flexible Life Insurance with Premium Adjustment Provision Adjustable Maturity Date Death Benefit Payable at Death Prior to Maturity Date Cash Surrender Value Payable on Maturity Date Adjustable Death Benefit Flexible Premiums Payable During Lifetime of Insured until the Maturity Date Not Eligible for Dividends Section Name Section Number Policy Schedule (See immediately following pages) Insurance Coverage Premiums, Grace Period and Reinstatement Nonforfeiture Payment of Proceeds Exchange of Policy Basis of Cash Values, Nonforfeiture Rights and Reserves Ownership, Assignment and Beneficiary Loans General Provisions Termination Riders, if any. Application(s) 21

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