Certi cate of Insurance

Policy Information

Policy Number 389006 Date today January 1, 1960

General Information

Policy Initial Owner / Applicant Gender of Applicant Civil Status of Applicant

Ragnar Michaels Saph
Male Married

Residence Address of Applicant Birthday of Applicant Birthplace of Applicant

58 Maple Point, 94 Marcy Drive May 25, 1959 Morbi vel lec
Silver Spri, Maryland, 20918
United Age of the Applicant at issuance of Email Address
policy magusnet@example.com
53

Estimated Annual Income Name of Employer Nature of Business

534508 Integer ac leo. Aenean f

Home Phone Mobile Phone Business Phone

(50) 321-0673 (50) 321-0673 (37) 850-0498

Business Address
58 Maple Point
Silver, Mary, 20918
United Stat

Information of the person's life insured

Name of Life Insured Gender of Insured Civil Status of Insured

Ragnar Williams Saph
Female Married

Residence Address of Insured Birthday of Insured Birthplace of Insured

58 Maple Point, 94 Ma Friday, January 1, 1960 Integer ac
Silver, Marylan, 2091
United Stat Age of the Insured at Email Address
issuance of policy
magusnet@example.com
38

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Estimated Annual Income Name of Employer Nature of Business
389006 Integer ac le Aene

Home Phone Business Phone Mobile Phone

(50) 321-0673 (37) 850-0498 (50) 321-0673

Business Address
94 La Follette, 56 Vidon Trail
Akron, Oh, 44393
United

Policy Details

Effectivity Date Maturity Date

Thursday, March 8, 2001 Thursday, March 8, 2001

Bene ciary
Named Bene ciary Basic Bene t Premium Revocable or irrevocable
38900

Named Secondary Bene ciary Accidental Death Revocable or irrevocable

389

Summary of bene ts payable

Total Disability 389

Relationship

Relationship

Total Annual Premium Payable 8245

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 Acknowledgement

I acknowledge that I have applied with Signature Insurance, Inc. for an Insurance Policy an have reviewed the provisions
shoiwng how a life insurance policy performs using the company's assumptions based on the Insurance Commissioner's
guidelines on interest rates.

I likewise understand that the performance of fund may vary, the values of my units are not guaranteed and will depend on
the actual performance of a given period. The value of my policy could be less than the premiums paid. 

I understand that the risks of invesment under this policy shall be borne by me, as the policy owner.

Name of Applicant
Freemon Michaels Toffel

Date signed
Thursday, March 8, 2001

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 Provisions

The proposals, the application form, any endorsements and amendments

The Contract
agreed upon in writing after this policy is issued shall constitute the entire
Contract. The bene ts payable shall be based on the performance fo the
investment funds chosen by you.

The effectivity of this policy initiates upon the initial payment of its Premium
Effectivity
and the delivery of the Policy to the Owner while the Insured is in good health.

All amounts payable either to or by us will be in the currency speci ed in the

Currency and Place of Payment
Policy details. Acceptance of placement of payments shall be at any of our
o ces or such other location as determined by us from time to time

After two years from the time of effectivity or from last reinstatement of the
Incontestability
contract, the said contract shall be incontestable except for non-payment of
Premium and Insurance Charges or any other ground recognized by law.

No liability shall be borned by the Company if in case the life insured dies by
Suicide
suicide. However, if the death by suicide happens in the state of insanity, the
life insured shall be compensated regardless of the date of the commission,
within the period of effectivity of this Policy.

In case the death bene t is not payable, the liability of the Company shall be
limited to:

1. The Basic Premium

2. The value of the account based on the Unit price of the relevant fund, not
including bonuses.
3. Premiums paid under any part of the Contract for which the bene t of
death is not payable.

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 The assigned or named bene ciaries shall be as named  or assigned in the
Bene ciaries
application. 

The bene t proceeds are payable to the Bene ciaries named, or in his absence,
the Contingents. In cas no bene ciary is indicated, the bene t proceeds shall be
payable to the life insured, if living, or to his estate.

Should any provision of this Contract be held invalid by any competent court, the
Separability Clause
same shall apply only to the provision involved and the remaining provisions
hereto shall remain valid and enforceable.

No modi cation or alteration of this Contract shall be considered as having

Agreement Modi cation
been made unless executed in writing and duly signed by the parties hereto.

Signature of President Signature of Corporate Secretary

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