Sample Whole Life Insurance Policy with Riders

Whole life insurance is a form of permanent insurance that provides lifetime insurance coverage at a level premium rate that does not increase as the insured ages. The following sample whole life insurance policy provides a $100,000 death benefit, and, as noted on the policy face page, is a participating policy that gives the policyowner the right to share in the insurer’s divisible surplus by receiving policy dividends. As you can see by the length of this policy compared to the length of the sample one-year term life insurance policy, a whole life insurance policy is a much more complicated document than is a term life policy. The additional provisions included in a whole life insurance policy are required to specify how the policy’s cash value will build-up and the policyowner’s rights in that cash value. Page 3, for example, includes a “Table of Guaranteed Values,” which lists the minimum guaranteed cash values at the end of specified policy years. Other provisions also describe the policy’s cash value features, including the provisions on pages 7 and 8 under the heading “Cash Value and Loans.” Additionally, many of the provisions on page 6 concerning “Premiums” are included to describe the options a policyowner has to stop paying policy premiums and to either receive the accumulated cash value or use that cash value to provide continued insurance coverage. Included along with the sample whole life insurance policy are five sample policy riders that may be attached to such a policy. The sample riders included here are as follows: An accidental death benefit (ADB) rider that provides a benefit if the insured’s death is caused by accidental bodily injury while the rider is in effect. (See page 13.) The amount of the accidental death benefit provided is stated as $100,000 (continued on next page)

on the policy data page. (See page 2.) The rider specifies a number of exclusions for which the ADB will not be payable and states that the rider has no cash value or loan value. A disability waiver of premium (WP) rider under which the insurer agrees to waive the payment of renewal premiums if the insured becomes totally disabled. (See pages 15 and 16.) The rider defines the term “total disability” and specifies a number of disabilities that are excluded from coverage. A policy purchase option (PPO) rider that gives the policyowner the right to purchase a new policy on the life of the insured on specified future option dates. (See pages 17 and 18.) The face amount of the new policy must be at least $10,000 and may not be more than the option amount of $50,000 as specified on page 2. The new policy may be any life insurance or endowment insurance plan the insurer is offering for the selected face amount on the specified option date. The premiums payable for the new policy will be based on the insured’s age and the insurer’s premium rates on the option date. An option to purchase paid-up additions (OPP) rider that gives the policyowner the right to purchase new paid-up life insurance coverage on the insured. (See pages 19-21.) Note that the coverage purchased under this rider is paid-up life insurance that increases the amount of the death benefit payable under the policy. In addition, the paid-up additions purchased have a cash value and a loan value. By contrast, the coverage purchased under the aforementioned PPO rider is provided by a separate policy, and the rider does not have a cash value or a loan value. An acceleration of death benefits rider under which the insurer agrees to pay a specified lump-sum amount, known as the accelerated death benefit, if the insured is terminally ill. (See pages 23-26.) In order to receive the accelerated death benefit, the insured must meet a number of requirements, including providing the insurer with evidence that the insured has a life expectancy of 12 months or less as determined by a qualified physician. The rider specifies how the accelerated death benefit is calculated and guarantees that the benefit will never be less than a stated amount based on the amount of the policy cash value. The payment of an accelerated death benefit reduces the amount of the benefit, if any, that will be payable following the insured’s death.

The pages which follow are also a part of this policy. The premiums for this policy are shown in the Premium Schedule on the Policy Data page. Policy is Eligible for Dividends. John Johnson President Mary Smith Secretary Whole Life Policy. They are payable in accordance with the Premiums section. Upon such request. Premiums. Please examine your policy. USA ABC Life Insurance Company will pay the benefits of this policy in accordance with its provisions. Life Insurance Proceeds Payable at Insured’s Death. Premiums Payable During Insured’s Lifetime.Whole Life Insurance Policy with Riders L-27 INSURED – JOHN DOE POLICY NUMBER – 36 000 000 POLICY DATE – AUGUST 8. Anytown. and a full premium refund will be made. you can return it to ABC Life Insurance Company or to the agent through whom it was purchased. Within 10 days after delivery. This policy is executed as of the date of issue shown on the Policy Data page. ABC LIFE GAT111 . as shown on the Policy Data page. 10 Day Right To Examine Policy. with a written request for a full refund of premium. the policy will be void from the start. 1999 ABC Life Insurance Company 123 Main Street.

00 ADB $7.00 PPO $8.000.00 $134. THE EXPENSE CHARGE APPLIED TO ALL PAYMENTS MADE UNDER THE OPTION TO PURCHASE PAID-UP ADDITIONS (OPP) RIDER WILL NOT EXCEED 3%.1999 WHOLE LIFE WITH OPTION TO PURCHASE PAID-UP ADDITIONS (OPP) AND ACCIDENTAL DEATH BENEFIT (ADB) AND DISABILITY WAIVER OF PREMIUM (WP) AND POLICY PURCHASE OPTION (PPO) . DAY YR.00 AND ACCELERATION OF DEATH BENEFITS FACE AMOUNT ACCIDENTAL DEATH BENEFIT (ADB.00 $7. EXTENDED INSURANCE AND PAID-UP INSURANCE FOR THE FIRST 20 POLICY YEARS. OR. 1999 OWNER — INSURED PLAN AGE 37 MALE CLASS OF RISK . 881999 882008 882027 882032 888888881999 2008 2027 2032 TOTAL PREMIUM $144.** WP $5.00 $7.000.OPTION AMOUNT IS $50. IS IN ADDITION TO ANY OTHER INSURANCE BENEFIT) $100. GAT111 Page 2 . AS FOLLOWS (SEE ENDORSEMENT HEREON) (Premium includes the following amounts for any supplementary benefits) BEGINNING AS OF MO. DIVIDENDS ARE NOT GUARANTEED. B) 5% PER YEAR FOR THE COMPUTATION OF ALL OTHER VALUES.00 PAYABLE FOR REMAINDER OF INSURED’S LIFE. MORE PREMIUMS TO BE PAID.00 $130.STANDARD (NON-SMOKER DISCOUNT) DATE OF ISSUE AUGUST 15.50 $4.000. ARE AS FOLLOWS: A) 6.50 PREMIUM PAYING PERIOD MAY BE SHORTENED BY USING DIVIDEND VALUES TO MAKE POLICY FULLY PAID-UP . WE HAVE THE RIGHT TO CHANGE THE AMOUNT OF DIVIDENDS TO BE CREDITED TO THE POLICY WHICH MAY RESULT IN LOWER DIVIDEND VALUES. IF APPLICABLE. WHEN PAYABLE.25% PER YEAR FOR THE CALCULATION OF CASH VALUES. REFERRED TO IN THE BASIS OF COMPUTATION SECTION.00 $100.00 $123.L-28 LOMA’s Handbook of Insurance Policy Forms INSURED — JOHN DOE POLICY NUMBER — 36000000 POLICY DATE — AUGUST 8. THAN WERE ILLUSTRATED.ESTATE OF THE INSURED PREMIUM SCHEDULE PREMIUMS PAYABLE AT MONTHLY INTERVALS.00 AMOUNT BENEFICIARY (subject to change) FIRST . THE INTEREST RATES.

200 48.300.300 72.Whole Life Insurance Policy with Riders L-29 TABLE OF GUARANTEED VALUES* Alternatives to Cash Value End of Policy Year Cash Value Paid-Up Insurance or Extended Insurance Years 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 AGE 60 AGE 65 ***** ***** $400. paid-up additions.700.000 26.900 22.400.300 38.00 11.00 8.900 65.00 26.500.00 32.300 57.000.300 ** ** 1 3 5 6 8 9 10 11 11 12 13 14 15 15 16 16 16 16 14 13 Days *** *** 18 114 62 328 55 109 121 50 321 325 323 239 91 287 73 187 291 358 319 198 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 AGE 60 AGE 65 End of Policy Year *This table assumes premiums have been paid to the end of the policy year shown.00 22.200 30.00 4.700.00 20.700.600.900.400 77.500 53.700.00 41.800 75.800 69. These values do not include any dividend accumulations.800.700 61.00 6.900 12.300.00 *** *** $2.900 17.00 24.00 9.00 5. or policy loans.00 3.00 2.00 16.400.400 7.800.00 1.00 18.700.500.400 34.00 14. POLICY DATA ABC LIFE INSURANCE COMPANY GAT111 Page 3 .800.900 69.900.00 12.100 43.000.

Life Income / 9–11 Entire Contract. Basis of Computation. Loan Value. Election of Optional Method of Payment. When Unpaid Loan Exceeds Loan Value / 7–8 Annual Dividend. Suicide Exclusion. Application. Nonpayment of Premium. Change of Beneficiary. Policy Changes. Automatic Premium Loan (APL). Death of Beneficiary / 5 Payment of Premiums. When you write to us. GAT111 Page 4 . Loan Interest. Dividend Options. Assignment. Voting Rights / 12 Attached to the Policy. Protection Against Creditors. Attached to the Policy. and the words “you” or “your” refer to the owner of this policy. Automatic Dividend Option. Elected Income. Options 3A. Payments to Company. Change of Option. Loan Repayment. Premium Adjustment at Death / 6–7 Cash Value. Table of Guaranteed Values / 2–3 Life Insurance Proceeds I 5 Owner. Dividend at Death / 9 Payment. Change of Ownership I 5 Naming of Beneficiary. the words “we. Age and Sex. Grace Period. Dividend Values. Options Upon Lapse. Successor Owner. please include the policy number. CONTENTS POLICY DATA PAGES Policy Identification and Specifications. Payees. Minimum Payment. Proceeds at Interest. LIFE INSURANCE PROCEEDS POLICY OWNERSHIP BENEFICIARY PREMIUMS CASH VALUE AND LOANS DIVIDENDS PAYMENT OF POLICY PROCEEDS GENERAL PROVISIONS APPLICATION RIDERS OR ENDORSEMENTS (IF ANY) Note: This policy is a legal contract between the policyowner and the Company. 3B and 3C. Incontestability.” “our” or “us” refer to ABC Life Insurance Company. Options 2A and 2B. Loan Interest Rate. Fully Paid-up Policy. and your current address. Reinstatement. Options lAand lB. the Insured’s full name. Dates.L-30 LOMA’s Handbook of Insurance Policy Forms WE & YOU In this policy. Conformity with Law. READ YOUR POLICY CAREFULLY FOR FULL DETAILS.

or within 15 days after the Insured but before we receive proof of the Insured’s death. this right will pass to your estate. When we determine these proceeds. all rights of ownership in this policy will pass to the new owner. The stated shares of the proceeds will be paid to any first beneficiaries who survive the Insured. subject to any payment we made or action we took before recording these changes. we will pay the proceeds as though that beneficiary died first. Changing the owner or naming a new successor owner cancels any prior choice of successor owner. and so on. the words “you” and “your” refer to the owner of this policy. you have all rights of ownership in this policy while the Insured is living. If 2 or more are named in a class. survives the Insured. Unless stated otherwise in the policy or in your signed notice which is in effect at the Insured’s death. The successor owner will become the new owner when you die. Change of Ownership You can change the owner of this policy. second. your estate becomes the new owner. or in a notice you sign which gives us the facts that we need. you do not need the consent of any successor owner or beneficiary.Whole Life Insurance Policy with Riders L-31 LIFE INSURANCE PROCEEDS Life Insurance Proceeds We will pay the life insurance proceeds to the beneficiary promptly when we have proof that the Insured died. these changes will take effect as of the date you signed the notice. Death of Beneficiary If no beneficiary for the life insurance proceeds. If more than one beneficiary is named. To exercise these rights. When we record a change of owner or successor owner. Successor Owner A successor owner can be named in the application. you can change a beneficiary in a notice you sign GAT111 Page 5 which gives us the facts that we need. if you die before the Insured. Change of Beneficiary While the Insured is living. or in a notice you sign which gives us the facts that we need. they can be classed as first. Beneficiaries who survive in the same class have an equal share in the proceeds. We will deduct any unpaid loan. POLICY OWNERSHIP Owner In this policy. If no first beneficiaries survive. from yourself to a new owner. If no successor owner survives you and you die before the Insured. When we record a change. in a notice you sign which gives us the facts that we need. the right to these proceeds or this share will pass to you. and so on. if premiums have been paid as called for in the Premiums section. there may be an adjustment for the last premium. all as stated in the policy. When this change takes effect. . These proceeds will include the face amount and any other benefits from riders or dividends which are payable because of the Insured’s death. If you are the Insured. unless the shares are stated otherwise. but does not change the beneficiary. if any beneficiary dies at the same time as the Insured. subject to any payment we made or action we took before recording the change. their shares in the proceeds can be stated. BENEFICIARY Naming of Beneficiary One or more beneficiaries for any life insurance proceeds can be named in the application. payment will be made to any beneficiary surviving in the second class. We may require that these changes be endorsed in the policy. or for a stated share. As the owner. it will take effect as of the date you signed the notice.

Options Upon Lapse If the policy has cash value or dividend values at the time of lapse. All insurance will end when you send us your signed request for the cash value proceeds. It has cash value and loan value. and is eligible for dividends. All insurance will end at the time of lapse. 2. or begins at the end of the grace period if later. No more premiums are due for this insurance. the policy will continue under the paid-up insurance option instead. but any insurance or benefits from riders or dividends will end at the time of lapse. you can surrender this policy for its cash value and dividend values. Nonpayment of Premium If a premium is not paid by the end of the grace period. All insurance coverage continues during this grace period. it will continue as extended insurance. this amount will be less than the face amount of this policy. Premiums are payable at our Home Office or at one of our service offices. paid-up insurance can be elected or you can surrender the policy for cash. 3. We do this by applying the sum of the cash value and dividend values. 1. this policy will lapse. The paid-up insurance option can be elected in the application or in your signed notice. less any unpaid loan. less any unpaid loan. less any unpaid loan. In these cases. The premium for this policy can be paid at intervals of 3 months or 6 months. plus the amount of any paid-up additions and dividend accumulations. All insurance will end when you send us your signed request for the cash value proceeds. We calculate the term period as of the due date of the overdue premium. Surrender for Cash Instead of extended insurance or paid-up insurance. This insurance can be surrendered at any time for its cash value. on or before its due date as shown in the Premium Schedule on the Policy Data page. This insurance can be surrendered at any time. The term period is measured from that due date. but it has no loan value and is not eligible for dividends. as stated in the Cash Value provision. Paid-up Insurance Paid-up life insurance begins as of the date we record your notice electing it. The method we use to determine the premium rate for each of these intervals is the method that was in effect as of the policy date shown on the Policy Data page. It is payable to the beneficiary when we have proof that the Insured died while this paid-up insurance option was in effect. The amount of extended insurance will equal the face amount of this policy. No insurance or benefits from riders will be provided after this paid-up insurance option goes into effect. or once each year. We calculate the amount of paid-up insurance as of the due date of the overdue premium. Grace Period We allow 31 days from the due date for payment of a premium. Instead of extended insurance.L-32 LOMA’s Handbook of Insurance Policy Forms PREMIUMS Payment of Premiums Each premium is payable. In most cases. We must receive this notice no later than 3 months after the due date of the overdue premium. at the net single premium rate for the Insured’s age on that date. The interval can be changed by paying the correct premium for the new interval. Extended Insurance Extended insurance is level term insurance for which no more premiums are due. It is payable to the beneficiary when we GAT111 have proof that the Insured died after the end of the grace period and before the end of the term period. less any unpaid loan. if available. or the Table of Guaranteed Values on the Policy Data page shows that extended insurance is not available. Page 6 . It may happen that the amount of extended insurance would be less than or equal to the amount of paid-up insurance available. We do this by applying the sum of the cash value and dividend values. insurance can be continued only as stated in Options 1 or 2 of the Options Upon Lapse provision. at the net single premium rate for term insurance for the Insured’s age on that date. while the Insured is living. Premiums can be paid by any other method we make available. All insurance will end when you send us your signed request for the cash value proceeds. No insurance or benefits from riders or dividends will be provided after the end of the grace period. If the policy has cash value or dividend values. if the policy has no cash value and no dividend values.

When you ask us. However. a lapse. The cash value on the due date of an unpaid premium will not decrease during the 3 months after that date. or on any other date we specify. Loan Interest Loan interest accrues each day. plus any dividend values.Whole Life Insurance Policy with Riders L-33 PREMIUMS (continued) Reinstatement Within 5 years after lapse. a loan increase or loan repayment. We set the interest rate each year. the loan value is the amount which. and any loan deducted when we determined the extended or paid-up insurance. All or part of these payments can be charged as a new unpaid loan if there is enough loan value.5% per year or the rate required by law. We may defer paying these proceeds for up to 6 months after the date of surrender. if necessary. GAT111 On a policy anniversary. the rate at any given time will apply to the entire amount of an unpaid loan. Cash values at other times depend on the date to which premiums have been paid. In that case. Interest will be paid from the date of surrender on any payment deferred more than 10 days. At any time after the policy has cash value or dividend values. We do not need evidence of insurability if we receive the required payment within 31 days after the end of the grace period. for as long as 6 months after we receive your loan request. but not more than 6%. Interest not paid when due becomes part of the loan and will also bear interest. Page 7 . Interest is due on each anniversary. or on the date of death. and they do not reflect any unpaid loan. or during the grace period. Interest will be paid on any amount deferred if that amount is not mailed within 10 days after we receive the necessary information to complete the loan transaction. we will reduce the proceeds by an amount equal to the premium for one policy month. Premium Adjustment at Death We will increase the life insurance proceeds by any part of a premium paid for the period after the policy month in which the Insured dies. Also. using this policy as sole security. we will tell you how much cash value there is. the loan value is the cash value. These values do not include dividend values. if premiums have been paid as called for in the Premiums section. Loan Interest Rate The loan interest rate for this policy may go up or down as described in this provision. Interest on the loan will be compounded once each year and will be based on the loan interest rate or rates that were in effect since the time of lapse. If the Insured dies during a grace period. We may require that you sign a loan agreement. Loan Value You can borrow any amount up to the loan value. All overdue premiums must be paid. We must have evidence of insurability that is acceptable to us. adjust it. but the Insured must be living when we receive it. We may defer a loan. you may apply to reinstate the policy if you have not surrendered it. All insurance will end when you send us your signed request for these surrender proceeds. less any unpaid loan. with interest at 6% per year from each of their due dates. except to pay a premium due us for this policy. if earlier. you can surrender it for the sum of these values. with interest. surrender. We will review this rate once every 3 months and.5% per year or the rate required by law. on a premium due date. the cash value of any extended or paid-up insurance on a policy anniversary will not decrease during the next 31 days after that anniversary. unless we declare a policy loan interest rate of less than 6%. We will set the interest rate to be at least 3. Extended insurance has no loan value. less any unpaid loan and accrued interest. CASH VALUE AND LOANS Cash Value Cash values for this policy at the end of selected policy years are as shown in the Table of Guaranteed Values on the Policy Data page. and on how much time has passed since the last policy anniversary. At any other time. must also be repaid. Any unpaid loan. will equal the loan value on the next anniversary or on the next premium due date. the interest rate for all overdue premiums at the time of reinstatement will be the same as the policy loan interest rate. This rate will be at least 3.

subject to 2 conditions. Loan Repayment All or part of an unpaid loan and accrued interest can be repaid before the Insured’s death or before you surrender the policy.L-34 LOMA’s Handbook of Insurance Policy Forms CASH VALUE AND LOANS (continued) The loan interest rate will not be more than the Monthly Average Corporates yield shown in Moody’s Corporate Bond Yield Averages published by Moody’s Investors Services. In this case. we will reduce the loan interest rate to reflect this. at this time. If that loan is not repaid. In this case. All insurance will end 31 days after the date on which we mail that notice. is made and when we send you notice of loan interest due. we will not deduct it again when policy proceeds are payable. If a loan is outstanding 40 days or more before the effective date of an increase in the interest rate. However if the rate. any loan which we deducted in determining that insurance may be repaid only if the policy is reinstated. as determined by the published monthly average. The loan interest rate will never be less than the interest rate shown on the Policy Data page plus 1%. as determined by the published monthly average. First. APL provides an automatic loan which pays an overdue premium at the end of the grace period. we will use a new basis approved by the insurance supervisory official of the state or district in which the policy is delivered. premiums can again be paid by APL.5% or more above the current loan interest rate. It may happen that the published monthly average ceases to be published. we will notify you of that increase at least 30 days prior to its effective date. You can also elect APL in your signed notice which we must receive before the end of the grace period. at this time. APL can be elected in the application. for the second calendar month prior to the date when we set an interest rate for this policy. If the policy is being continued as extended or paidup insurance. If the rate. if premiums have been paid by APL for 2 years in a row. Second.5% or more below the current loan interest rate.. We will notify you of any increase in the interest rate when a loan is made during the 40 days before the effective date of the increase. We will tell you the interest rate in effect when a loan. You can cancel this election for future premiums by telling us in your signed notice. When Unpaid Loan Exceeds Loan Value In a given policy year it may happen that an unpaid loan and accrued interest will exceed the sum of the cash value and any dividend values. Inc. We will not terminate this policy in a given policy year as the sole result of a change in the loan interest rate during that policy year. if the excess of the unpaid loan and accrued interest over the sum of the cash value and any dividend values is not paid within that 31 days. we will mail a notice to you at your last known address. before the end of the grace period. Automatic Premium Loan (APL) If elected. GAT111 Page 8 . the next premium will not be paid by APL. and a copy to any assignee on our records. we have the right to increase the loan interest rate to reflect this. the loan value must be enough to pay that premium. or any successor to that service (the published monthly average). We will deduct any unpaid loan when policy proceeds are payable. including an Automatic Premium Loan (APL). is 0. After a premium is paid other than by APL. is 0.

This share is payable as a dividend on the policy anniversary. We must receive your signed notice within 31 days of that date. Paid-up Addition Applied to provide paid-up life insurance at the net single premium rate for the Insured’s age at that time. and will not be less than required by law. Premium Payment Applied toward payment of a premium. Dividend Accumulation Left with us to accumulate at interest. Before the Insured’s death. PAYMENT OF POLICY PROCEEDS Payment We will pay the life insurance proceeds in one sum or. 4.5% per year. we will apply the dividend as a paid-up addition instead. Before the Insured’s death. On each policy anniversary. all or part of these proceeds may be placed under one or more of the options described in this section. except as extended insurance. we will apply it as a paid-up addition. if the sum of the cash value and dividend values equals the total single premium for the policy and any riders. 2. An option can be elected in the application. and the dividend check is not cashed within one year after that dividend became payable. Page 9 . Cash Paid in cash. This rate will be at least 3. Fully Paid-up Policy You may shorten the premium paying period for this policy by having it made fully paid-up with no more premiums due. if any. unless you have asked to have that part paid in cash. We do not expect a dividend to be payable before the second anniversary. No more premiums are due for this insurance. Naming these payees cancels any prior choice of successor payee. GAT111 Election of Optional Method of Payment While the Insured is living. we credit interest at the rate we set each year. 3. you can withdraw accumulations that have not been borrowed against. you can surrender paid-up additions for their cash value that has not been borrowed against. This may be done on any premium due date. Each year we determine the policy’s share. it is eligible to share in our divisible surplus. The person who elects an option can also name one or more successor payees to receive any unpaid amount we have at the death of a payee. After the Insured dies. It has cash value and is eligible for dividends.5% per year. If we pay a dividend in cash.Whole Life Insurance Policy with Riders L-35 DIVIDENDS Annual Dividend While this policy is in force. if elected. Dividend at Death The part of any annual dividend earned from the last policy anniversary to the end of the policy month in which the Insured dies will be part of the life insurance proceeds. Any accumulations which we still have at the Insured’s death will be part of the life insurance proceeds. The amount of this insurance in force at the Insured’s death will be part of the life insurance proceeds. based on the Insured’s age on that date. You can also elect or change the option for future dividends if you tell us in your signed notice. You can also name or change one or more beneficiaries for the life insurance proceeds who will be the payee or payees under that option. 1. Any life insurance proceeds paid in one sum will bear interest compounded each year from the Insured’s death to the date of payment. Any part of the dividend not needed to pay the premium will be used to pay any loan interest due. If we agree. if all premiums due before then have been paid. you can elect or change an option. We set the interest rate each year. Any part of the dividend not used to pay a premium or loan interest will be paid in cash. any person who is to receive proceeds in one sum (other than an assignee) can elect an option and name payees. with interest to the date of withdrawal. Dividend Options Each dividend can be applied under one of the 4 options listed below. Automatic Dividend Option If no other option is in effect when a dividend becomes payable. Dividend Values Dividend values are any dividend accumulations plus the cash value of any paid-up additions. provided any balance of that premium is also paid when due. This rate will be at least 3. the proceeds may be placed under some other method of payment instead.

OPTION 2A TABLE Minimum Monthly Payment per $1.5% per year. We may require proof of the age or the survival of a payee. 1A. and is always less than their sum. 2A.5% interest are shown in the Option 2A Table. The present value of any remaining payments is based on the interest rate used to compute them. and 3C in this policy. Payees Only individuals who are to receive payments in their own behalf may be named as payees or successor payees. Interest Accumulation We credit interest each year on the amount we still have. we will state in writing what each payment would be. every 3 months or every 6 months. or make any other change.83 20 5. If so. 1B. we may pay any unpaid amount or present value in one sum. or once each year. We set the interest rate each year. Change of Option If we agree. We pay interest to the date of withdrawal on sums withdrawn.35 10 9. This amount can be withdrawn at any time in sums of $100 or more.09 25 4. Proceeds at Interest The policy proceeds may be left with us at interest. 3B.5% on the amount we still have. 1B. Page 10 . We determine the amount of the monthly payment by applying the policy proceeds to purchase a corresponding single premium life annuity policy which is being issued when the first payment is due.65 5 $18. We set the interest rate for these options each year. This rate will be at least 3. as chosen. or the present value of any elected payments. a payee who elects Option 1A. Minimum Payment When any payment under an option would be less than $20. if made every 3 months or every 6 months. Options 1 A and 1 B. placed under some other option described in this section.5% per year. unless we agree to some other payee. and with interest compounded each year at 4%.27 8 11.38 11 9. 2A or 2B may later elect to have any unpaid amount we still have. and 3C. Interest Payment We pay interest once each month. we still have an unpaid amount. or once each year. based on the amount we still have. The total payments made each year must be at least 5% of the proceeds placed under this option. The minimum amounts are based on the “1983 Table a” mortality table with projection. the payee may be given the right to do one or more of these things if the person who elects the option tells us in writing and we agree.000 of Proceeds Years Years Years Years 1 $84. as chosen.Income for Elected Period We make the payments for the number of years elected. 3B. but will not be less than the corresponding minimum amount based on the tables for Options 3A.45 When asked. or there are some payments which remain to be made. or once each year. we will pay the unpaid amount with interest to the date of payment. take the payments in one sum.75 15 $7. for an elected period of years or for an elected amount.Income of Elected Amount We make payments of the elected amount until all proceeds and interest have been paid. GAT111 Options 2A and 2B. This rate will be at least 3. Each year we credit interest of at least 3. However.75 3 29. to that payee’s estate in one sum.05 6 15. every 3 months or every 6 months. or pay the present value of the remaining payments. It may happen that when the last surviving payee dies. 2B.5%. Elected Income We make equal payments once each month. Options 3A.L-36 LOMA’s Handbook of Insurance Policy Forms PAYMENT OF POLICY PROCEEDS (continued) A payee who did not elect the option does not have the right to advance or assign payments.10 2 43.46 30 4.12 9 $10. Payments are based on the appropriately adjusted annuity premium rate in effect at that time. we will increase each payment to reflect this. Life Income We make equal payments each month during the lifetime of the named payee or payees. Monthly payments based on 3.96 4 22.90 12 8.19 7 13. If the rate is more than 3.

05 6.28 5.73 Payee’s Adjusted Age Male 73 $6.89 6.33 5.70 6.98 8.37 6.97 7.10 5. OPTION 3B TABLE Minimum Monthly Payment per $1.54 5.71 4.33 7.78 6.93 61 62 63 64 65 66 67 68 69 70 71 72 5.64 4.13 4.47 74 75 76 77 78 79 80 81 82 83 84 6.68 4.62 5.03 7.49 5.84 5.Whole Life Insurance Policy with Riders L-37 PAYMENT OF POLICY PROCEEDS (continued) When asked.84 5.75 5.76 4.76 5.70 5. and are guaranteed for 5.48 5.00 8.62 6.36 5.05 5.69 85 10.72 5.39 6.85 8.80 6.61 4.27 6.41 9.49 5.97 5.16 7.11 6.28 5.34 5.88 6.60 5.48 5.11 7.84 5.18 5. Payments do not change.93 6. as chosen.27 6.98 7.61 $4.89 5.000 of Proceeds Payee’s Adjusted Age Male 60 $4.07 5.83 4.30 5.39 5.71 4.23 5.08 7.91 6.82 5.92 5.29 7.32 $4.58 6.42 5.09 5.92 7.81 5.49 5.11 5.50 5. 15.94 5.17 6.52 5.48 5.96 5.87 4.97 FEMALE Guaranteed Period 5 Yrs 10 Yrs 15 Yrs 20 Yrs $4.44 5.87 6.08 9.62 8.62 7.33 6.67 5.70 6.62 5.00 5.29 6.62 5.65 5.74 5.84 6.96 9.91 4.74 10.92 5.38 5.42 4.87 5.91 6.24 5.08 $4.000 of Proceeds Payee’s MALE Adjusted Guaranteed Period Age 5 Yrs 10 Yrs 15 Yrs 20 Yrs 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 $5.75 5.82 8.02 6. Life Income–Guaranteed Period We make a payment each month during the lifetime of the payee.97 4.40 5.30 5.30 5.35 3A.90 7.54 4.47 8.67 6.84 7.73 4.02 5.80 5. OPTION 3C TABLE 10 YEAR GUARANTEED PERIOD Minimum Monthly Payment per $1.93 4.57 6.18 5.14 $5.52 6.23 5. Life Income–Joint and Survivor We make a payment each month while both or one of the two payees are living.29 8.04 5. as follows: 1987–91 1992–98 1999–2006 2007–2013 2014–20 2021–28 2029+ +3 +2 +1 0 –1 –2 –3 3B.35 8.08 5. or 20 years.91 5.80 4.01 6.02 6. even if that payee dies sooner.42 7.13 5.81 4.92 4.42 5.75 6.25 5.67 $4.89 4. we will state in writing what the minimum amount of each monthly payment would be under these options.49 6.60 5.57 4.90 5.81 5.78 5.16 8.69 5.27 6.48 6. To find the adjusted age.61 6.81 5.81 6.01 5.44 6.08 5.87 4.46 5.91 5.16 6. even if that payee dies sooner.97 7.13 6.41 5.58 5.33 9.85 $4.50 5.31 6.07 8.20 5.91 8.84 & over GAT111 Page 11 .Life Income–Guaranteed Total Amount We make a payment each month during the lifetime of the payee.23 6.92 6.80 6.96 5.81 4. Payments do not change.40 7.42 7.42 6.14 5.81 7.14 5.60 6.82 5.77 6.25 5.94 5.89 Female $5.11 6.95 5.15 6.15 5.25 5.19 7.17 8.67 5.81 4.83 6.69 7.51 8.66 4.36 5.02 6.000 of Proceeds Male Payee’s Adjusted Age 60 65 70 75 80 Female Payee’s Adjusted Age 60 65 70 75 80 $4. even if both payees die sooner.37 5.54 5.72 5.75 5. 10.88 6.99 4.51 6.16 5.63 4.34 8.15 5.18 8.61 5.69 6.18 7.31 Female $4.84 6.12 7.34 6.67 8.82 $4.77 7.57 7.97 8.77 9. we increase or decrease the payee’s age at that time.04 6.66 7.36 5.19 5.07 5.99 5.50 $4. OPTION 3A TABLE Minimum Monthly Payment per $1.94 6.61 8.93 5.47 5.00 7.68 $4.75 4.95 6. Payments do not change.10 10.19 7.84 4.63 5.59 5. and are guaranteed for 10 years.67 4.73 4.37 7.34 5.77 6.94 85&over 9. and are guaranteed until the total amount paid equals the amount placed under this option.30 5.52 5.19 3C.57 4.46 6.95 7.03 5.09 8.17 5.98 $4. It is based on the sex and the adjusted age of the payee or payees in the year the first payment is due.34 4.16 6.87 5.46 7.79 4.21 6.57 7.63 5.81 8.36 5.78 5.

When asked. An assignee may not change the owner or the beneficiary. or have it changed to another plan or to a smaller amount of insurance. and then only in writing. President. We have filed a statement with the insurance official in the state or district in which this policy is delivered. to the extent the law permits. Secretary. If a date on the Policy Data page is based on an age that is not correct. At the end of each policy year not shown in the Table on the Policy Data page. Protection Against Creditors Except as stated in the Assignment provision. If you do this. you may have riders added to this policy. for any premium paid to us. less any unpaid loan. and anniversaries are measured from the policy date. Payments to Company Any payment made to us by check or money order must be payable to ABC Life Insurance Company. write to the Secretary at our Home Office. Voting Rights Each year there is an election of persons to our Board of Directors. Only our Chairman. Age and Sex In this policy when we refer to a person’s age on any date. No agent is authorized to change this contract. we have relied on the statements made in the application. You have the right to vote in person or by mail if your policy is in force. Any policy proceeds payable to the assignee will be paid in one sum. New York 00000. As owner. months. No change will be made in the contract without your consent. the cash value of any extended or paid-up insurance or paid-up additions is the reserve on each of these. Application In issuing this policy. (SEE ENDORSEMENT HEREON) Dates Policy years. the cash value is the reserve based on the Commissioner’s Reserve Valuation Method. Policy Changes If we agree. you can assign this policy or any interest in it. your interest. or one of our Vice Presidents can change the contract. any amount payable under this policy will be what the premiums paid would have purchased at the correct age and sex. attachments. It will be subject to any payment we make or other action we take before we record it. At any time. Basis of Computation All cash values and net single premium rates referred to in this policy are based on the 1980 CSO Tables of Mortality. in detail. All extended insurance rates and cash values are based on the corresponding 1980 CET Insurance Tables. If the age or sex of an insured person is not correct as stated. we mean his or her age on the birthday which is nearest that date. Each value is at least as much as the law requires. is not covered by this policy. and anyone else’s is subject to that of GAT111 the assignee. Please refer to the Incontestability of Rider provision that may be in any rider or riders attached to this policy. 100 Ordinary Avenue. All such statements are deemed to be representations and not warranties. any attached riders or endorsements and the attached copy of the application. and may not elect or change an optional method of payment of proceeds. It describes. and has been in force for at least one year after the date of issue. In that event. To find out more about this. We will not be responsible for the validity of an assignment. Suicide Exclusion Suicide of the Insured within one year of the date of issue. we will give a counter-signed receipt. signed by our President or Secretary. you still have the rights of ownership that have not been assigned. Assignment While the Insured is living. We assume these statements are true and complete to the best of the knowledge and belief of those who made them. The interest rate is shown on the Policy Data page. New York. Page 12 . exempt from the claims.L-38 LOMA’s Handbook of Insurance Policy Forms GENERAL PROVISIONS Entire Contract The entire contract consists of this policy. this policy will end and the only amount payable will be the premiums paid to us. we may change the date to reflect the correct age. Conformity with Law This policy is subject to all laws which apply. Incontestability We will not contest this policy after it has been in force during the lifetime of the Insured for 2 years from the date of issue. the method we used to compute these cash values. No statement made in connection with the application will be used by us to void the policy or to deny a claim unless that statement is a material misrepresentation and is part of the application. Continuous functions are used. We must have a copy of any assignment. or levies of any creditors. payments we make under this policy are.

this rider will not be in effect if the policy lapses or is in force as extended or paid-up insurance. 3. and will not be in effect if that date is deferred. Contract This rider. If this rider is still in effect on the anniversary on which the Insured is age 70.Whole Life Insurance Policy with Riders L-39 RIDER ACCIDENTAL DEATH BENEFIT (ADB) Benefit We will pay this benefit to the beneficiary when we have proof that the Insured’s death was caused directly. declared or not. ABC LIFE INSURANCE COMPANY Mary Smith Secretary GAR011 John Johnson President Page 13 . if the Insured at any time during the aircraft’s flight acted in any role other than as a passenger. When this rider is part of an endowment policy. 4. or dies after the anniversary on which he or she is age 70. Dates and Amounts When this rider is issued at the same time as the policy. 1. When Rider Ends You can cancel this rider as of the due date of a premium. Also. or by any act incident to a war or to an armed conflict involving the armed forces of one or more countries. you must send the policy and your signed notice to us within 31 days of that date. and apart from any other cause. Incontestability of Rider We will not contest this rider after it has been in force during the lifetime of the Insured for 2 years from its date of issue. When Benefit Not Payable We will not pay this benefit if death is caused or is contributed to by any of these items. the rider will end on the day just before the endowment date. and that death occurred within one year after that injury and while this rider was in effect. The add-on rider shows the date of issue and the amount of ADB. based on the application for the rider. by accidental bodily injury. Values This rider does not have cash or loan values. 2. Suicide. We will not pay this benefit if the Insured dies prior to his or her first birthday. Disease or infirmity of mind or body. we also put in an add-on rider. The rider premium amount is shown in a new Premium Schedule for the policy. when paid for. This rider ends if the policy ends or is surrendered. The rider and the policy have the same date of issue. Any kind of war. Travel in or descent from an aircraft. is made a part of the policy. it will end on that date. To do this. we show the amount of ADB and the rider premium amount on the front page of the policy. When this rider is added to a policy which is already in force.

L-40 LOMA’s Handbook of Insurance Policy Forms THIS PAGE INTENTIONALLY LEFT BLANK GAR011 Page 14 .

while the Insured is living and totally disabled. of the sight of both eyes or the use of both hands. we will waive only those premiums which fall due during that total disability. Those that are caused by any kind of war. After we have waived premiums for 2 years in a row. because of disease or bodily injury. because of disease or bodily injury. Any other premium paid and then waived will be refunded in full. GAR012 Page 15 . all insurance goes on as if they had been paid. As long as we waive premiums. he or she is not able to go to school. we may have the Insured examined by doctors we approve. disability is not total and premiums will not be waived. If the Insured can do some but not all of these acts and duties. Those that start prior to the fifth birthday of the Insured. and if it goes on for at least 6 months in a row. and prior to the anniversary on which the Insured is age 65. While we waive premiums. with no more premiums due. until we approve a claim under this rider. 2. or one hand and one foot. we may require proof from time to time. or by any act incident to a war or to an armed conflict involving the armed forces of one or more countries while the Insured is a member of those armed forces. or as soon as it can reasonably be done. we will make the policy fully paid-up as of that date. As part of the proof. “Total Disability” means that.Whole Life Insurance Policy with Riders L-41 RIDER DISABILITY WAIVER OF PREMIUM (WP) Waiver of Premiums We will start to waive the premiums for this policy when proof is furnished that the Insured’s total disability. If a total disability starts during a grace period. 1. 3. If a total disability starts on or prior to the anniversary on which the Insured is age 60. “Total Disability” also means the Insured’s total loss. as defined in this rider. Refund of Premiums If a total disability starts after a premium has been paid. both feet. training. Total Disabilities For Which Premiums Not Waived We will not waive premiums in connection with any of these total disabilities. Proof of Total Disability Written notice and proof of this condition must be given to us. or of any other job for which he or she is suited based on schooling. we will refund the part of that premium paid for the period after the policy month when that disability started. Those that are caused by an injury that is selfinflicted on purpose. If it goes on until the anniversary on which the Insured is age 65. or start at a time when this rider is not in effect. If the Insured is a minor and is required by law to go to school. the Insured can not do any of the essential acts and duties of his or her job. starting while this rider is in effect. the overdue premium must be paid before we will approve any claim. we will not need to have this proof more than once each year. Premiums are waived at the interval of payment in effect when the total disability started. Payment of Premiums Premiums must be paid when due. If a total disability starts after the anniversary on which the Insured is age 60. has gone on for at least 6 months in a row. declared or not. we will waive all of the premiums which fall due during that total disability. or experience. Definition of Total Disability “Total Disability” means that. We will not deduct a waived premium from the policy proceeds.

when paid for. based on the application for the rider. we show the rider premium amount on the front page of the policy. When Rider Ends You can cancel this rider as of the due date of a premium. Contract This rider.L-42 LOMA’s Handbook of Insurance Policy Forms DISABILITY WAIVER OF PREMIUM (WP) (continued) Values This rider does not have cash or loan values. Incontestability of Rider We have no right to contest this rider after it has been in force during the lifetime of the Insured for 2 years from its date of issue. Also. When this rider is added to a policy which is already in force. you must send the policy and your signed notice to us within 31 days of that date. Dates and Amounts When this rider is issued at the same time as the policy. is made a part of the policy. To do this. ABC LIFE INSURANCE COMPANY Mary Smith Secretary John Johnson President GAR012 Page 16 . If this rider is still in effect on the anniversary on which the Insured is age 65. it will end on that date. This rider ends if the policy ends or is surrendered. The add-on rider shows the date of issue. The rider and the policy have the same date of issue. this rider will not be in effect if the policy lapses or is in force as extended or paid-up insurance. we also put in an add-on rider. unless the Insured is totally disabled at some time within 2 years of the date of issue. The rider premium amount is shown in a new Premium Schedule for the policy.

43. with premiums based on the Insured’s age and the Company’s premium rates on that date. If the Insured dies prior to the option date. less the savings allowance. On an option date. 25. This rider must be in effect on the date the marriage. Each purchase of a new policy as of a Special Option Date cancels the next available Scheduled Option Date. an amount of insurance can be purchased which equals the Option Amount times the number of these children. This allowance is used to reduce premiums that are due during the first policy year of the new policy. these must be received by the Company while the Insured is living. 34. The birth of a living child to the Insured.Whole Life Insurance Policy with Riders L-43 RIDER POLICY PURCHASE OPTION (PPO) Benefit The Owner can purchase a new policy on the Insured on each Scheduled Option Date or Special Option Date. In this case. 2. 28. if the Owner does not have an insurable interest in the life of the Insured that is acceptable to the Company. No new policy can be purchased on any Scheduled Option Date which has been cancelled by a prior Special Option Date purchase. except when a larger amount can be purchased on a Special Option Date. or endowment plan offered on the option date. The application and the first premium for the new policy. The amount of this insurance is equal to the largest face amount of the new policy that can be purchased under this rider on that date. GAR013 Page 17 . for the face amount being purchased. Purchase of Policy The Owner’s application for the new policy must also be signed by the Insured. The number of Scheduled Option Dates cancelled by this amount of purchase is equal to the number of these children. the Company provides term insurance on the Insured. 40. the Insured may purchase the new policy instead. The legal adoption of a child by the Insured. At the time of purchase. 3. the Company will tell the Owner how much the total allowance is for the new policy. New Policy The new policy may be on any life. without proof of insurability. birth. and on which this rider is in effect. During the 3 months prior to a Special Option Date. It will have the same provisions and be subject to the same limitations on the Company’s liability as are generally in the series of policies being issued on that date. The new policy will take effect as of the option date. 31. The new policy may not be on a plan which provides only term insurance or provides an increasing amount of insurance. 1. The marriage of the Insured. any new policy which has been applied for will not take effect. may be required. Special Option Dates A Special Option Date is the date 3 months after any of the events listed below. However. 37. The face amount of the new policy may not be less than $10. except where 2 or more children are born or adopted on the same date. or adoption takes place. The amount of this allowance is on file with the insurance official in the state or district in which the policy is delivered.000 or more than the Option Amount of the rider. Savings Allowance The Company provides a savings allowance when a new policy is purchased. and the Company will refund any premium paid for it. and 46. termlife. may be submifted to the Company during the 60 days before or the 31 days after the option date. The Insured’s class of risk will be the same as it was for the rider. Proof acceptable to the Company. Scheduled Option Dates The Scheduled Option Dates are the anniversaries on which the Insured is age 22. that the event took place.

the policy and the Owner’s signed notice must be sent to the Company within 31 days of that date. which relate to a suicide exclusion or to a contest of that policy. The rider and the policy have the same date of issue. ABC LIFE INSURANCE COMPANY Mary Smith Secretary GAR013 John Johnson President Page 18 . the Company also puts in an add-on rider. when paid for. The rider premium amount is shown in a new Premium Schedule for the policy. The time periods of the new policy. Values This rider does not have cash or loan values. the new policy will be on a preferred risk basis only if it meets the Company’s minimum amount and age limits for that class. The amount of that rider may not be more than the face amount of the new policy. The new policy must be on a plan with premiums payable for the rest of the Insured’s life. When Rider Ends The Owner can cancel this rider as of the due date of a premium. and with the same premium interval as this policy. on an option date. the Company shows the Option Amount and the rider premium amount on the front page of the policy. When this rider is added to a policy which is already in force. it will end on that date. Dates and Amounts When this rider is issued at the same time as the policy. Incontestability of Rider The Company will not contest this rider after it has been in force during the lifetime of the Insured for 2 years from its date of issue. and which required the Company’s agreement. unless the Company agrees. the Company will waive the premiums for the new policy which fall due during that disability. in some cases the new policy may be issued with a rider or an additional amount of insurance which the Owner requested. if this rider was issued with a policy in a preferred risk class. However. Also. If this rider is still in effect on the anniversary on which the Insured is age 46. No other riders can be made a part of the new policy. this policy has a waiver of premium rider in effect. is made a part of the policy. Contract This rider. To do this. this rider will not be in effect if the policy lapses or is in force as extended or reduced paid-up insurance. This rider ends if the policy ends or is surrendered.L-44 LOMA’s Handbook of Insurance Policy Forms POLICY PURCHASE OPTION (PPO) (continued) However. based on the application for the rider. An accidental death benefit rider can be made a part of the new policy if one is in effect under this policy on an option date. Waiver of Premiums for New Policy If. However. The add-on rider shows the date of issue and the Option Amount. will start on the date of issue of this rider. that rider can only be in a new policy for which premiums are payable for the rest of the Insured’s life. and if the Insured is totally disabled and all conditions for waiver of premiums in that rider have been met. the time periods for that rider or amount will start instead on the date of issue of the new policy. If this happens. Availability of Riders A waiver of premium rider can be made a part of the new policy if one is in effect under this policy on an option date. if the Insured has recovered from a total disability that had gone on for at least 6 months in a row.

What Insurance May Be Purchased The amount of the payments made each year to purchase the new insurance is in addition to the premium payable for the policy. payments can no longer be made on a scheduled basis. Cash values and net single premiums are based on the 1980 CSO Tables of Mortality (the male Page 19 . but no scheduled or unscheduled payments will be accepted to purchase new paid-up insurance. Waiver of Premium Benefit Not Applicable Scheduled payments for this rider will not be included in any amount being waived under any rider providing waiver of premiums in case of total disability. this rider will remain in force. However. the amount of any subsequent scheduled payments cannot exceed that reduced payment. Upon receipt of an unscheduled payment. and is eligible for dividends. Scheduled Payments Payments made on a scheduled basis must be received by us while the Insured is living and within 31 days of each of their due dates. In addition. In each subsequent year. but in no event can a single scheduled payment be less than $10. Any payments made more than 31 days after a policy anniversary are subject to a reduction based on the amount of time since the anniversary and an interest rate which we set at the beginning of each calendar year. each unscheduled payment or the total of all scheduled payments in a policy year must be at least $100. Prior to the purchase of any insurance. If this occurs. the new insurance will take effect as of the date we receive the payment. No insurance may be purchased under this rider after it ends. we will use a new basis approved by the insurance supervisory official in the state or district in which the policy is delivered. unless we agree. This reduction is in addition to the expense charge. Unless we agree otherwise. For the calendar year 1993. However. Additional payments can be made from time to time. any insurance under this rider will continue. subject to the Excess Purchases provision of this rider. In this case. The amount of this insurance in force at the Insured’s death will be part of the life insurance proceeds of the policy to which this rider is attached. Any paid-up life insurance purchased under this rider is a paid-up addition. However. unless we agree otherwise. but must be received while the Insured is living. and no more premiums are due for this insurance. If a scheduled payment is not received within 31 days of its due date. or while it is not in effect. for the month of October of the prior calendar year. Upon receipt of a scheduled payment. all payments made under this rider are subject to an expense charge shown on the policy data page of the policy. the rate is 9. Inc.5%. Values The paid-up insurance under this rider has cash value and loan value. or any successor to that service (the published monthly average). the total of all payments in any given policy year cannot be more than 100% of the annual premium amount for the basic plan of insurance (excluding premiums for any riders and excluding the policy fee). and unscheduled payments can still be made. we will not require this evidence of insurability if the total of all payments made during the policy year do not exceed the limitations stated in the What Insurance May be Purchased provision. The amount of paid-up additions purchased by each payment is based on the net single premium rate for the Insured’s age as of the most GAR014 recent policy anniversary. Unscheduled Payments Unscheduled payments may be made from time to time under this rider. It may happen that the published monthly average ceases to be published. based on a standard class of risk. the new insurance will take effect as of its due date. the rate will be equal to the Monthly Average Corporates yield shown in the Moody’s Investors Services.Whole Life Insurance Policy with Riders L-45 RIDER OPTION TO PURCHASE PAID-UP ADDITIONS (OPP) Benefit This rider provides you with the right to purchase new paid-up life insurance on the Insured. if the policy lapses or is surrendered. It may happen that you make a scheduled payment which is less than the scheduled amount. As long as premiums continue to be waived under any waiver rider. unless satisfactory evidence of insurability is furnished. the values of any paid-up insurance under this rider will be included in the determination of any proceeds under the Options Upon Lapse provision in the policy.

The application used to apply for this excess amount of insurance will be attached to and made a part of the policy. or any new insurance which does not exceed the limitations specified in this rider. Satisfactory evidence of insurability may be required for the excess amount of insurance. ends or is surrendered. We will not contest any excess amount of paid-up insurance purchased in accordance with the Excess Purchases provision of this rider. but no new insurance can be purchased unless this rider is reinstated. In this event. In this case. Dates This rider and the policy have the same date of issue. To do this. a signed notice must be sent to us within 31 days of that date. the cash value of paid-up insurance purchased by that payment will be limited to the amount of that payment. this rider will end and the only amount payable will be all payments made under this rider. This rider ends when no premium for paid-up insurance is paid by the second anniversary or for 3 anniversaries in a row. Contract This rider is made a part of the policy. after such insurance has been in force for 2 years from the date of purchase. is not covered by this rider. this rider will not be in effect if the policy is in force as extended insurance or if the policy lapses. if we agree. based on the application for the rider. The excess amount of insurance will be subject to the Incontestability and Suicide Exclusion provisions of this rider beginning as of the date that insurance is purchased. During the policy year in which a payment is made under this rider. In this case. GAR014 Page 20 . Also. Suicide Exclusion Suicide of the Insured within 2 years of the date of issue of this rider. for which we required evidence of insurability. the in force paidup insurance under this rider will continue. Continuous functions are used. less any unpaid loan. this rider will automatically be restored after the fifth year the DOT rider has been in effect. Evidence of insurability acceptable to us will be required with any such reinstatement. after the rider has been in force during the lifetime of the Insured for 2 years from its date of issue. Reinstatement If this rider is reinstated. if the policy continues. unless premiums for the policy are being waived on account of total disability. if this rider has ended for any of the reasons mentioned in this paragraph. Any paid-up insurance in force when this rider ends will continue. This rider will not be in effect if the policy is in force as paid-up insurance. When Rider Ends You can cancel this rider as of any date. Interest is compounded at 4%. except that the amount may be reduced to offset any outstanding policy loan. new paidup insurance can be purchased only as of a date which is on or after the date of the reinstatement. Incontestability We will not contest this rider. unless the rider is added to a policy which is already in force. the date of issue of this rider is shown in an add-on rider which we put in the policy. In that event. It may happen that the policy to which this rider is attached also includes a Dividend Option Term (DOT) rider. Excess Purchases You can make a payment under this rider which exceeds the limits stated in the rider.L-46 LOMA’s Handbook of Insurance Policy Forms OPTION TO PURCHASE PAID-UP ADDITIONS (OPP) (continued) table if the Insured is a male or the female table if the Insured is a female).

000 of paid-up life insurance in force at attained age indicated) ATTAINED AGE CASH M VALUE 1 $ 87 2 90 3 92 4 95 5 98 6 101 7 104 8 108 9 111 10 115 11 119 12 123 13 127 14 131 15 135 16 140 17 144 18 148 19 152 20 157 21 162 22 166 23 171 24 177 25 182 26 188 27 194 28 200 29 207 30 214 31 221 32 228 33 236 ATTAINED AGE CASH M VALUE 34 $ 244 35 252 36 261 37 269 38 278 39 288 40 297 41 307 42 317 43 327 44 337 45 348 46 359 47 370 48 381 49 393 50 405 51 417 52 429 53 442 54 455 55 468 56 481 57 494 58 507 59 521 60 534 61 548 62 562 63 576 64 590 65 604 66 617 67 631 ATTAINED AGE CASH M VALUE 68 $ 645 69 659 70 673 71 686 72 700 73 713 74 726 75 739 76 751 77 763 78 774 79 786 80 797 81 808 82 818 83 828 84 838 85 847 86 856 87 864 88 872 89 880 90 887 91 895 92 903 93 911 94 920 95 931 96 943 97 953 98 970 99 986 100 1.000 ATTAINED AGE CASH F VALUE 1 $ 72 2 74 3 76 4 79 5 81 6 84 7 86 8 89 9 92 10 95 11 98 12 101 13 105 14 108 15 112 16 116 17 119 18 123 19 127 20 132 21 136 22 140 23 145 24 150 25 155 26 160 27 165 28 171 29 177 30 183 31 189 32 195 33 202 ATTAINED AGE CASH F VALUE 34 $ 209 35 216 36 223 37 230 38 238 39 246 40 254 41 262 42 271 43 280 44 289 45 298 46 307 47 317 48 326 49 337 50 347 51 357 52 368 53 379 54 391 55 402 56 414 57 426 58 438 59 451 60 464 61 477 62 491 63 505 64 519 65 533 66 548 67 563 ATTAINED AGE CASH F VALUE 68 $ 577 69 592 70 608 71 623 72 639 73 654 74 670 75 685 76 701 77 715 78 730 79 745 80 759 81 773 82 786 83 800 84 812 85 825 86 836 87 847 88 858 89 868 90 878 91 888 92 898 93 908 94 918 95 929 96 941 97 953 98 972 99 986 100 1.Whole Life Insurance Policy with Riders L-47 OPTION TO PURCHASE PAID-UP ADDITIONS (OPP) (continued) Table of Cash Values (per $1.000 ABC LIFE INSURANCE COMPANY By Mary Smith Secretary John Johnson President GAR014 Page 21 .

L-48 LOMA’s Handbook of Insurance Policy Forms THIS PAGE INTENTIONALLY LEFT BLANK GAR014 Page 22 .

DEFINITIONS “Eligible amount” is the total of the following: 1.000. The interest rate will be the rate used by us and will not exceed the rate charged on policy loans. As with all tax matters you should consult your personal tax advisor to access the impact of this benefit. A portion or any outstanding policy loan balance will be deducted. or the Specified Amount plus the cash value. the Specified Amount. 2. you or your beneficiary may incur a tax obligation. The accelerated amount may not be more than the lesser of: (a) 75% of the eligible amount. The accelerated amount may never be less than $10. This rider is non-participating. the accelerated death benefit will never be less than the cash surrender value of the policy. However. The administrative fee in use by us on the date we receive your written request to pay an accelerated benefit. or (b) $250. The benefit paid under this rider will reduce the death benefit or amount due upon the death of the insured and other values in your policy. “Accelerated amount” is the portion of the eligible amount you request: 1. The “effective date” is the Policy Date unless a later date is shown for this rider in the Policy Data. The benefits paid may be taxable. 3. Future monthly deductions corresponding to the accelerated amount are based on the insured’s life expectancy. GAR015 Page 23 . “Accelerated death benefit” is the amount we pay under this rider. The “insured” is the primary insured named in the Policy Data. NOTICE: The benefits paid under this rider may effect eligibility for Medicaid or other public assistance programs. if death benefit Option 1 is in effect. If so. if death benefit Option 2 is in effect. multiplied by the ratio of the accelerated amount to the eligible amount. The administrative fee will not exceed $500. Please read carefully. 2. 2.000.00.Whole Life Insurance Policy with Riders L-49 ACCELERATION OF DEATH BENEFITS This rider is attached to and is a part of the entire policy. The portion will be the outstanding policy loan balance multiplied by the ratio of the accelerated amount to the eligible amount. 4. This amount is the accelerated amount adjusted for the following: 1. An interest discount factor will be applied to the accelerated amount based on the insured’s reduced life expectancy not to exceed 12 months. if any.

2. (Doctor of Osteopathy). mother-in-law. “You.L-50 LOMA’s Handbook of Insurance Policy Forms “Qualified Physician” is a person who is duly qualified. GAR015 Page 24 . the policy fund. The eligible amount is determined as of the date we pay the accelerated death benefit. and authorized to and uses the designation MD (Doctor of Medicine). father-in-law. The outstanding policy loan balance will be reduced by the portion deducted from the accelerated amount as described in the Definitions section of this rider. sister. BENEFIT Subject to the provisions of this rider and the policy. or 2. or child of yours or the insured’s or insured’s spouse. your” is the Owner of this policy. A qualified physician must be someone other than you or the insured. or a spouse. or step or adoptive or natural brother. the minimum monthly premium. EFFECT ON POLICY If an accelerated death benefit is pard under this rider. us” is ABC Life Insurance Company. 4. A new Policy Data page showing the accelerated benefit payment will be issued and become part of the policy. the Specified Amount. parent. the policy will stay in force according to the policy provisions. a physician of osteopathy who uses the designation D. we will pay the accelerated death benefit to you if the insured is terminally ill. The following will be reduced in the same proportion as the ratio of the accelerated amount to the eligible amount: 1. the table of future surrender charges. 3. a physician or surgeon practicing medicine and surgery. legally licensed in the United States and practicing within the scope of the license who is: 1. grandparent. “We”.O. “Terminally ill” means having a life expectancy of 12 months or less as determined by a Qualified Physician.

The main purpose of life insurance is to meet your estate planning needs. We receive consent that the benefit may be paid to you from any irrevocable beneficiary or assignee. GAR015 Page 25 . or keep a government benefit or entitlement. Therefore.000. 13. The policy must not be assigned except to us as security for a loan. The accelerated amount is requested after the incontestability period of the policy. except as otherwise provided in this rider. 11.Whole Life Insurance Policy with Riders L-51 GENERAL PROVISIONS AND CONDITIONS Your right to be paid under this rider is subject to the following: 1. obtain. 7. You must submit a written request for the accelerated amount. The accelerated amount is requested while the policy and this rider are in force. 8. This rider provides for the accelerated payment of life insurance proceeds. or (b) by a government agency to use this option in order to apply for. 3. Any refund of premiums payable as a result of the insured’s suicide will not include the premiums for any accelerated amount paid under this rider. If the death of the insured occurs before approval of the benefit or before the approved benefit is paid. Only the insured under the base policy is covered by this rider. The payment provided by this rider will be made only once under this policy. 5. Our liability will discharged to the extent of any payment made or action taken prior to receipt of proof of the death of the insured. No coverage is provided for any other person covered by riders attached to the base policy. and (b) the insured’s life expectancy is not more than 12 months due to the severity and nature of the terminal illness. whether in bankruptcy or otherwise. 2. 4. The total accelerated amounts under all policies issued by The ABC Life Insurance Company or its subsidiaries or affiliates on the life of the insured will not exceed $250. 14. The payment will be made in one lump sum to you. 6. Accelerated death benefits will be made available to you on a voluntary basis only. We have the right to have the insured examined at our expense by a physician we choose. and (c) the diagnosis of the terminal illness was made after the effective date of this rider. It is not meant to cause you to involuntarily invade proceeds ultimately payable to the named beneficiary. You provide evidence that satisfies us in a written statement signed by a qualified physician that: (a) the insured is terminally ill. 9. 16. 12. This rider does not apply if the insured’s illness is the result of an attempt to commit suicide. while any policy suicide exclusion provision is in effect. 10. This rider is subject to all the conditions and provisions of the policy. 15. no benefit will be payable under this rider. This rider is subject to the terms of the policy incontestability provision. you are not eligible for the benefit provided by this rider if you are required: (a) by law to use this option to meet the claims of creditors.

or we receive a written request to cancel this rider. 4. 2. the policy terminates. 3.L-52 LOMA’s Handbook of Insurance Policy Forms TERMINATION This rider will terminate if and when any of the following takes place: 1. or the policy lapses at the end of the Grace Period. or a benefit is paid under this rider. THE ABC LIFE INSURANCE COMPANY Mary Smith Secretary John Johnson President GAR015 Page 26 .