Certi cate of Insurance Template

Policy Information

Policy Number 801982 Date February 18, 1984

General Information

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

Hilde Michaels Gisburne
Male Married

Residence Address of Applicant Birthday of Applicant Birthplace of Applicant

561 Anderson P, 0181 Anthes Lan August 17, 1991 In hac habita
Houston, Texas, 77228
United Age of the Applicant at issuance of Email Address
policy johnbob@example.com
80

Name of Employer Nature of Business Estimated Annual Income

Proin at turpis In hac h 819658

Home Phone Business Phone Mobile Phone

(26) 399-7604 (86) 168-2176 (86) 168-2176

Business Address
561 Anderson Pa
Housto, Texa, 77228
United Stat

Information of the person's life insured

Name of Life Insured Gender of Insured Civil Status of Insured

Salaidh Williams Frosdick
Female Married

Residence Address of Insured Birthday of Insured Birthplace of Insured

03764 Independ, 106 R Saturday, February 18, 1984 Integer ac
Sacram, Califor, 9428
United Stat Age of the Insured at Email Address
issuance of policy
laird@example.com
81

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 Certi cate of Insurance Template

Name of Employer Nature of Business Estimated Annual Income

In hac habita Inte 801982

Home Phone Business Phone Mobile Phone

(86) 168-2176 (58) 199-3789 (26) 399-7604

Business Address
03764 Independ, 106 Ronald Rega
Sacramento, Ca, 94286
United

Policy Details

Effectivity Date Maturity Date

Thursday, August 1, 1991 Saturday, February 18, 1984

Bene ciary
Named Primary Bene ciary Relationship Revocable or irrevocable

Named Secondary Bene ciary Relationship Revocable or irrevocable

Summary of bene ts payable

Basic Bene t Premium 81965

Accidental Death 801

Total Disability 819

Total Annual Premium Payable 6542

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 Certi cate of Insurance Template

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
Blaine Michaels Pauleau

Date signed
Thursday, March 9, 2017

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 Certi cate of Insurance Template

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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 Certi cate of Insurance Template

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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