FUTURE INSURABILITY OPTION RIDER

Terms Used This rider is issued by us as part of the policy to which it is attached and is subject to the
provisions of the policy, except as may be modified or amended by this rider. Any
modification or amendment made by this rider is only in effect while this rider is in force.
The terms used in this rider have the same meaning as indicated in the policy, unless
otherwise specified or required in the context of the following rider provisions.

Rider Date The Rider Date will be the same as the Policy Date, if this rider is included in the policy
when it is first issued by us. Otherwise, the Rider Date will be such later date as
established by the amendment to the contract to include this rider. The Rider Date is used
to determine duration, premium due dates, anniversaries and your age with respect to this
rider.

New Policy and New Policy refers to a policy issued in accordance with the provisions of this rider and
New Policies New Policies refer to all policies issued in accordance with the provisions of this rider, if
more than one.

Option Date Option Date means:

a) if you are not Disabled, any policy anniversary following the date this rider takes
th
effect up to and including the policy anniversary nearest your 55 birthday; and
b) if you are Disabled, the first policy anniversary occurring during the Period of
Disability. For further clarification, a Recurrent Disability will not result in more
than one Option Date being made available during a Period of Disability.

Application for On any Option Date the Owner may apply for a New Policy on the life of the Person
New Policy Insured to purchase additional coverage, without providing medical evidence of the
insurability of the Person Insured.

For any New Policy, the Owner may apply for:

a) a benefit period which is the same or shorter than that shown on the Policy
Details page for the policy to which this rider is attached; and
b) a waiting period which is the same or longer than that shown on the Policy Details
page for the policy to which this rider is attached.

Approval of New Approval of the application for a New Policy will be subject to the following conditions
Policy which must be met between 60 days before and 30 days after the applicable Option Date:
a) we must receive the application for the New Policy, in a form satisfactory to us;
b) the first premium for the New Policy must be received by us; and
c) if requested, you must provide financial evidence of your insurability, satisfactory
to us.

If the application is approved by us, the New Policy will take effect as of the Option Date.

If the application is not approved by us, the amount of any premium paid for the New
Policy will be refunded.

(Continued on the back.)

This rider should be kept with the policy.

17061 – 5/13
 FUTURE INSURABILITY OPTION RIDER (continued)

Maximum If you are not Disabled on an Option Date, the Maximum Disability Benefit that will be
Disability Benefit available under a New Policy will be the least of:
a) the maximum amount of monthly disability benefit, if any, which we would
normally then issue for your age, monthly earned income as described below, and
class of risk, according to our published issue and participation limits then in
effect, after taking into consideration any other benefits to which you would be
entitled if you become disabled;
b) 33 1/3% of the Total Benefit Available shown for this rider on the Policy Details
page, or if the Owner has under this rider purchased a New Policy on the
immediately preceding Option Date, 20% of the Total Benefit Available shown for
this rider on the Policy Details page; and
c) the Total Benefit Available shown for this rider on the Policy Details page less the
sum of the monthly disability benefit amounts under all New Policies issued in
accordance with this rider before the current Option Date.

If you are Disabled on an Option Date, the Maximum Disability Benefit that will be
available under a New Policy will be the least of:
a) the maximum amount of monthly disability benefit, if any, which we would
normally then issue for your age, monthly earned income as described below, and
class of risk, according to our published issue and participation limits then in
effect, after taking into consideration any other benefits to which you would be
entitled if you become disabled;
b) 20% of the Total Benefit Available shown for this rider on the Policy Details page;
c) the Total Benefit Available shown for this rider on the Policy Details page less the
sum of the monthly disability benefit amounts under all New Policies issued in
accordance with this rider before the current Option Date; and
d) $600.

If you are Disabled and you have more than one rider, issued by us and in force, which
provides the option to purchase additional coverage without providing medical evidence of
your insurability, the total amount of monthly disability benefit available on that Option
Date under all such riders cannot exceed $600.

If at the time of application for a New Policy:

a) you are not Disabled, your monthly earned income will be averaged over the
12 month period immediately before the date of application for the New Policy.
b) you are Disabled, your monthly earned income will be averaged over the
12 month period immediately before the date your Disability began.

The monthly disability benefit amount for a New Policy cannot be less than $200 and the
sum of monthly disability benefit amounts for all New Policies cannot exceed the amount
of Total Benefit Available for this rider shown on the Policy Details page.

(Continued on the next page.)

This rider should be kept with the policy.

17061 – 5/13
 FUTURE INSURABILITY OPTION RIDER (continued)

Conditions The following conditions will apply to any New Policy:

a) the disability insurance plan will be the same as shown on the Policy Details page
for the policy to which this rider is attached;
b) the Catch-Up Rider, Cost of Living (maximum 3% per year) Rider, Cost of Living
(maximum 8% per year) Rider, Expense Equalizer Rider, First Day Accident
Rider, Health Care Profession Rider, Own Occupation Rider, Partial Disability
Rider, Extended Partial Disability Rider, Regular Occupation Period Extender
Rider, Regular Occupation Period Extender (60 Months) Rider and Residual
Disability Rider will be added to any New Policy, if included in the policy to which
this rider is attached on the applicable Option Date. If the policy also included a
rider that provides for a return of premium benefit, any New Policy will include
such rider or a similar rider, as long as such rider or a similar rider is then offered
by us. No other additional benefit riders may be included in the New Policy
without our consent;
c) the premium will be based on our rates in effect on the date the New Policy takes
effect, using your age on that date and the occupation class and policy class for
the policy to which this rider is attached. However, if your occupation class on the
date the New Policy takes effect would produce a lower premium rate, the
premium rate for that occupation class will be used by us to determine the
premium for the New Policy;
d) any evidence of your insurability which forms part of this contract will form a part
of any New Policy; and
e) if you are Disabled on the applicable Option Date, the date you became Disabled
with respect to the New Policy will be deemed to be that Option Date. If you are
not Disabled on the applicable Option Date and thereafter suffer a Recurrent
Disability, the date you became Disabled with respect to the New Policy will be
deemed to be the date on which you suffer the Recurrent Disability.

Exclusions Any Exclusion Rider attached to the policy will form a part of any New Policy.

Rider Premium This rider is included in the policy in consideration for the payment of the Yearly Premium
for this rider shown on the Policy Details page. The premium for this rider is payable at the
same time and in the same manner, and in addition to the premium for the basic policy.
The premium is payable on the same terms and conditions as the premium for the basic
policy and for the Premium Period for this rider shown on the Policy Details page.

Rider Termination Subject to the provisions of the basic policy and any riders and benefits included in the
contract, this rider will terminate on the earliest of the following dates:
a) the date on which the total Monthly Disability Benefit for all New Policies is equal
to the Total Benefit Available for this rider shown on the Policy Details page;
b) the monthly anniversary following the date on which we receive the Owner’s
request for termination of this rider;
st
c) the 31 day following the final Option Date;
d) the date of your death; and
e) the date on which the policy terminates for any other reason.

THE CANADA LIFE ASSURANCE COMPANY

This rider should be kept with the policy.

17061 – 5/13