Liberty Life Assurance Company of Boston

100 Liberty Way, Dover, NH 03820

Term Life Insurance Contract to Age 90

Contract Form: TERM-2005057-T
Liberty Series Passport 20
Designed for: DAVID A HINKLEY Presented by: SCOTT RHINEHART
Rating Class: Male, Age 18, Table F Tobacco 1800 MARKET PLACE BLVD
Premium Mode: Pre-Auth. Check CUMMING, GA 30041
Face Amount: $50,000
This proposal is valid only in the state of GA.
Coverage Summary:
Initial
Initial Pre-Auth. Check
Amount Premium
Term Life Insurance Contract to Age 90 /
20-Year Initial Guaranteed Level Premium $50,000 $36.82
Accidental Death and Dismemberment Rider $50,000 $3.60
Total $40.42

Coverage Description:
Term Life Insurance The Term Life Insurance contract that you are considering offers a level death
Contract to Age 90 / benefit. Contract premiums are payable to age 90 and are guaranteed to be level for
20-Year Initial the first 20 contract years. Premiums increase annually thereafter according to the
Guaranteed Level schedule in the contract. The contract owner may convert this contract without
Premium
evidence of insurability to a permanent plan on or before the contract's fifteenth
contract year.
Accidental Death and An amount equal to the accidental death benefit will be paid in addition to the base
Dismemberment Rider contract death benefit upon the accidental death of the insured as defined in the
$50,000 rider. An amount equal to the accidental death benefit will be paid if loss of limb(s)
or sight occurs as defined in the rider. An additional amount equal to the accidental
death benefit amount will be paid if the insured was riding as a fare-paying
passenger in a public conveyance as defined in the rider when the accident which
caused the injury occurred. Coverage is to the contract anniversary following the
insured's 70th birthday while the base contract is in force.

Liberty Life compensates representatives by commission for the placement of our insurance products and
services provided on our behalf.
Version: 2.85.0215 Date Prepared: 11/30/2012 Page 1 of 3
 Liberty Life Assurance Company of Boston
100 Liberty Way, Dover, NH 03820

Term Life Insurance Contract to Age 90

Designed for: DAVID A HINKLEY Rating Class: Male, Age 18, Table F Tobacco
Pre-Auth.
Annual Semi-Annual Quarterly Check
Available Modes: $449.00 $233.48 $118.98 $40.42
Mode Selected: Pre-Auth. Check

Guaranteed
Annualized
Attained Contract Contract Death
Age Year Premium* Benefit
19 1 485 50,000
20 2 485 50,000
21 3 485 50,000
22 4 485 50,000
23 5 485 50,000
24 6 485 50,000
25 7 485 50,000
26 8 485 50,000
27 9 485 50,000
28 10 485 50,000
29 11 485 50,000
30 12 485 50,000
31 13 485 50,000
32 14 485 50,000
33 15 485 50,000
34 16 485 50,000
35 17 485 50,000
36 18 485 50,000
37 19 485 50,000
38 20 485 50,000
39 21 961 50,000
40 22 1,026 50,000
41 23 1,103 50,000
42 24 1,198 50,000
43 25 1,310 50,000
44 26 1,441 50,000
45 27 1,589 50,000
46 28 1,738 50,000
47 29 1,886 50,000
48 30 2,012 50,000
49 31 2,106 50,000
50 32 2,228 50,000
51 33 2,386 50,000
52 34 2,592 50,000
53 35 2,842 50,000

Version: 2.85.0215 Date Prepared: 11/30/2012 Page 2 of 3

 Liberty Life Assurance Company of Boston
100 Liberty Way, Dover, NH 03820

Term Life Insurance Contract to Age 90

Designed for: DAVID A HINKLEY Rating Class: Male, Age 18, Table F Tobacco

Guaranteed
Annualized
Attained Contract Contract Death
Age Year Premium* Benefit
54 36 3,142 50,000
55 37 3,499 50,000
56 38 3,882 50,000
57 39 4,276 50,000
58 40 4,640 50,000
59 41 4,989 50,000
60 42 5,396 50,000
61 43 5,900 50,000
62 44 6,514 50,000
63 45 7,219 50,000
64 46 7,975 50,000
65 47 8,731 50,000
66 48 9,471 50,000
67 49 10,186 50,000
68 50 10,908 50,000
69 51 11,647 50,000
70 52 12,461 50,000
71 53 13,349 50,000
72 54 14,493 50,000
73 55 15,822 50,000
74 56 17,163 50,000
75 57 18,614 50,000
76 58 20,227 50,000
77 59 22,016 50,000
78 60 24,084 50,000
79 61 26,457 50,000
80 62 29,070 50,000
81 63 31,925 50,000
82 64 34,959 50,000
83 65 38,081 50,000
84 66 41,409 50,000
85 67 45,171 50,000
86 68 49,437 50,000
87 69 54,065 50,000
88 70 58,982 50,000
89 71 64,109 50,000
90 72 69,381 50,000
* Annualized Contract Premium includes rider premiums.

Version: 2.85.0215 Date Prepared: 11/30/2012 Page 3 of 3