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12/07/2011

02:40:11 PM

CT PACKAGE
CRISTINA SIMAO 755
LS01451912 SUSAN SKENE CAITLIN LAVIANA CORINNE LAVIANA SPENSER LAVIANA
DOCUMENTS PRINTED:
q q q q q q q q MAIL SLIP COVER LETTER - #48 (LIFE ILLUSTRATION ONLY) (03-05) LT10/10 (2011) ILLUSTRATION - SUSAN SKENE LT10/10 (2011) ILLUSTRATION - CAITLIN LAVIANA LT10/10 (2011) ILLUSTRATION - CORINNE LAVIANA LT10/10 (2011) ILLUSTRATION - SPENSER LAVIANA L657-7 LT (2011) TOMBSTONE HOW MUCH IS ENOUGH

DOCUMENTS TO PICK & SPECIAL HANDLING:
q NEW AMICA LIFE BROCHURE L831-1

CT 06037 If you received this information via e-mail or fax. the return mailing address for applications. and other correspondence is: Attention: New Business Unit (for life insurance only) or Life Customer Service (for annuities only) . forms.Jeffrey Laviana 203 Hudson St Berlin.

you'll find information to help you take the next step towards financial security for your family. and quality coverage you need to protect your family's dreams. 2011 Jeffrey Laviana 203 Hudson St Berlin. please don't hesitate to call me toll-free at 1-800-234-5433.December 7. After you have reviewed this information. For your convenience. CT 06037 Dear Jeff. competitive rates. I will call you to follow-up and continue the process. and your final premium offer / rate will be determined after the underwriting process is complete. Please note that the premium quoted is based on preliminary information gathered. extension 89331. here is your personalized Amica Life Insurance Kit. Inc. on the cover page of each illustration is a detailed summary of the coverage being quoted. Sincerely. Cristina Simao Sales Development Representative Amica Life Insurance Company Amica General Agency. It was a pleasure speaking with you about Amica Life's products and services. As promised. we are commited to providing you with the professional service. Your Life Insurance Illustration: Refer to this customized illustration / quote for details about your proposed insurance coverage. If I do not hear from you within a few days. we can begin the application process by together completing the necessary forms over the telephone. If you have any questions or need assistance. please do not hesitate to contact me. Most people find the few minutes invested is time well spent. At Amica Life. . Inside. How Much Life Insurance Do You Need To Protect Your Family?: Completing this simple worksheet can help provide you with an estimate of the amount of life insurance you may need to ensure that your family is adequately protected. If there is anything else you need.

2011 Amica Life Insurance Company PO Box 6008 Providence. All sales representatives for Amica Life Insurance Company are employees of the company.96 TOTAL MONTHLY CONTRACT PREMIUM $33.67 $3.50 $202.63 * Premiums increase annually after the 10th year. RI 02940-6008 Cristina Simao CT Version . Any compensation paid to our employees for services provided to you (including your purchase of any life insurance or annuity contracts from Amica Life) is paid entirely by Amica Life. # The premium quoted above is based on preliminary information gathered. You will never be charged a separate fee for any such services or purchases.000 10 Years Monthly $29. Preferred Rate BENEFIT RIDERS AVAILABLE MONTHLY RIDER PREMIUM ( ) Waiver of Premium Benefit ( x ) Children's Insurance Benefit: 10 unit(s) $16.25 $102.21# ALTERNATE METHODS OF PAYMENT ANNUAL SEMI-ANNUAL QUARTERLY $398. December 07. 89331 Wednesday.25 Age 55. Female. Rhode Island 02865-1165 (800) 234-5433 ext. and your final premium offer / rate will be determined after the underwriting process is complete. PRESENTED BY: REPRESENTING: PREPARED BY: Cristina Simao 10 Amica Center Boulevard Lincoln.96 Not included $3.LIFE INSURANCE QUOTATION PREPARED FOR: Susan Skene Plan Summary: PLAN OF AMOUNT OF INSURED INSURANCE INSURANCE PREMIUM GUARANTEE PERIOD * METHOD OF PAYMENT MONTHLY CONTRACT PREMIUM Susan Skene 10 Year Level Term (with Cost-of-Living Benefit) $100.

52 398.750.00 5.00 4. 2011 Representing: Amica Life Insurance Company CT Version Page 1 of 2 .52 398.SUPPLEMENTAL TABULAR DETAILS Gender: Age: Rate Class: Female 55 Preferred Class Amount of Insurance: Total Monthly Contract Premium: Premium Guarantee Period: $100.000 100.836.52 398.00 18.52 398.00 10.733.00 13.00 16.00 12.000 100.000 100.00 6.376.52 398.000 100.000 100.869.000 100.00 15.000 100.635.52 398.000 100.070.00 11.000 100.LIFE INSURANCE QUOTATION 10 YEAR LEVEL TERM PREPARED FOR: SUSAN SKENE GUARANTEED PREMIUMS -.000 100.00 8.189.000 $33.000 Guaranteed * Maximum Premium $398.960.147.000 100.000 100.000 100.00 20.089.485.456.000 100.00 9.00 5.52 3.000 100.000 100.351.000 100.793.00 4.000 100.077.000 100.000 100.52 398.52 398.000 100.000 100.000 100.00 7.00 6.696.21 10 Years Benefit Riders Available: ( ) Waiver of Premium Benefit ( x ) Children's Insurance Benefit: 10 unit(s) Not included $3.00 Prepared by: Cristina Simao December 07.283.000 100.000 100.00 3.000 100.52 398.000 100.00 4.129.440.000 100.000 100.96 End of Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Age 56 57 58 59 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 85 Guaranteed Death Benefit $100.

00 25.000 100.000 100.00 36.00 * For years 11 and later.831.000 100.248.060.000 100.587.00 39.00 54.832.915.236.00 42.00 34.LIFE INSURANCE QUOTATION 10 YEAR LEVEL TERM PREPARED FOR: SUSAN SKENE GUARANTEED PREMIUMS -.000 100.SUPPLEMENTAL TABULAR DETAILS End of Year 31 32 33 34 35 36 37 38 39 40 Age 86 87 88 89 90 91 92 93 94 95 Guaranteed Death Benefit $100.00 28.141.000 Guaranteed * Maximum Premium $22. this plan provides for premiums which may be less than the guaranteed maximum premiums shown above.000 100.000 100.797. 2011 Representing: Amica Life Insurance Company CT Version Page 2 of 2 .425. Prepared by: Cristina Simao December 07.000 100.00 47.000 100.00 31.

2011 Amica Life Insurance Company PO Box 6008 Providence. You will never be charged a separate fee for any such services or purchases.LIFE INSURANCE QUOTATION PREPARED FOR: Caitlin Laviana Plan Summary: PLAN OF AMOUNT OF INSURED INSURANCE INSURANCE PREMIUM GUARANTEE PERIOD * METHOD OF PAYMENT MONTHLY CONTRACT PREMIUM Caitlin Laviana 10 Year Level Term (with Cost-of-Living Benefit) $100. All sales representatives for Amica Life Insurance Company are employees of the company.92# ALTERNATE METHODS OF PAYMENT ANNUAL SEMI-ANNUAL QUARTERLY $107. and your final premium offer / rate will be determined after the underwriting process is complete. Rhode Island 02865-1165 (800) 234-5433 ext. PRESENTED BY: REPRESENTING: PREPARED BY: Cristina Simao 10 Amica Center Boulevard Lincoln.92 Age 24. December 07. Any compensation paid to our employees for services provided to you (including your purchase of any life insurance or annuity contracts from Amica Life) is paid entirely by Amica Life.96 Not included Not included TOTAL MONTHLY CONTRACT PREMIUM $8. 89331 Wednesday.00 $56. # The premium quoted above is based on preliminary information gathered.75 * Premiums increase annually after the 10th year.42 $3. RI 02940-6008 Cristina Simao CT Version .000 10 Years Monthly $8. Preferred Select Rate BENEFIT RIDERS AVAILABLE MONTHLY RIDER PREMIUM ( ( ) Waiver of Premium Benefit ) Children's Insurance Benefit: 10 unit(s) $1. Female.50 $29.

58 $3. # The premium quoted above is based on preliminary information gathered. You will never be charged a separate fee for any such services or purchases. 2011 Amica Life Insurance Company PO Box 6008 Providence. Female. 89331 Wednesday.000 10 Years Monthly $16.LIFE INSURANCE QUOTATION PREPARED FOR: Corinne Laviana Plan Summary: PLAN OF AMOUNT OF INSURED INSURANCE INSURANCE PREMIUM GUARANTEE PERIOD * METHOD OF PAYMENT MONTHLY CONTRACT PREMIUM Corinne Laviana 10 Year Level Term (with Cost-of-Living Benefit) $100.75 * Premiums increase annually after the 10th year. and your final premium offer / rate will be determined after the underwriting process is complete. RI 02940-6008 Cristina Simao CT Version . PRESENTED BY: REPRESENTING: PREPARED BY: Cristina Simao 10 Amica Center Boulevard Lincoln.96 Not included Not included TOTAL MONTHLY CONTRACT PREMIUM $16. Standard Rate BENEFIT RIDERS AVAILABLE MONTHLY RIDER PREMIUM ( ( ) Waiver of Premium Benefit ) Children's Insurance Benefit: 10 unit(s) $2. All sales representatives for Amica Life Insurance Company are employees of the company. December 07. Any compensation paid to our employees for services provided to you (including your purchase of any life insurance or annuity contracts from Amica Life) is paid entirely by Amica Life.25 Age 18.00 $100.25# ALTERNATE METHODS OF PAYMENT ANNUAL SEMI-ANNUAL QUARTERLY $195.50 $51. Rhode Island 02865-1165 (800) 234-5433 ext.

# The premium quoted above is based on preliminary information gathered. You will never be charged a separate fee for any such services or purchases. and your final premium offer / rate will be determined after the underwriting process is complete. Male. 89331 Wednesday.92 Age 20.000 10 Years Monthly $11.92# ALTERNATE METHODS OF PAYMENT ANNUAL SEMI-ANNUAL QUARTERLY $143. December 07.00 $74.92 $3.50 $38. PRESENTED BY: REPRESENTING: PREPARED BY: Cristina Simao 10 Amica Center Boulevard Lincoln. Rhode Island 02865-1165 (800) 234-5433 ext. Any compensation paid to our employees for services provided to you (including your purchase of any life insurance or annuity contracts from Amica Life) is paid entirely by Amica Life. RI 02940-6008 Cristina Simao CT Version .75 * Premiums increase annually after the 10th year.LIFE INSURANCE QUOTATION PREPARED FOR: Spenser Laviana Plan Summary: PLAN OF AMOUNT OF INSURED INSURANCE INSURANCE PREMIUM GUARANTEE PERIOD * METHOD OF PAYMENT MONTHLY CONTRACT PREMIUM Spenser Laviana 10 Year Level Term (with Cost-of-Living Benefit) $100.96 Not included Not included TOTAL MONTHLY CONTRACT PREMIUM $11. All sales representatives for Amica Life Insurance Company are employees of the company. 2011 Amica Life Insurance Company PO Box 6008 Providence. Preferred Rate BENEFIT RIDERS AVAILABLE MONTHLY RIDER PREMIUM ( ( ) Waiver of Premium Benefit ) Children's Insurance Benefit: 10 unit(s) $1.

000.000 or more.000. 15. To learn more about Amica Life’s excellent health pricing. this policy may be converted to any permanent policy available at the time of conversion regardless of your health. It is designed to provide a substantial amount of level coverage for the life of the policy at very affordable rates. based on your then current age and current rate class. Alternatively. This policy can be purchased for a 10-. you're guaranteed the same level of protection to age 95. Conversion is allowed up to the earlier of the policy anniversary date immediately following the insured's 65 th birthday. In addition. we will automatically increase the face amount on all Level Term policies (except those issued on a "special" class basis) on every second policy anniversary during the level-premium period when you are between the ages of 18 and 60. or the completion of 80 percent of the level-premium period.) No Policy Fees We do not charge an annual fee or any other administrative fees whatsoever. POLICY FEATURES Guaranteed Level Protection You may purchase a 10-. Acceptance of this increase is automatic. 20. 20-. 15-.999. Issue ages for this policy may vary based on the term selected and your resident state at time of issue. Excellent Health Pricing If you’re a non-nicotine user and are in excellent health. you may be able to qualify for our Premier Select rates.000. For example. simply ask your Amica Life representative for more detailed information. provided premiums are paid in accordance with the Payment of Premiums provision contained in the policy. 25. th th Convertible Level Term* with the Annual Renewable Term provision provides level term insurance coverage to age 95.and 30-year plans also offer premiums that are designed to remain level for the full term period but have a shorter premium guarantee period (10 years) and a lower cost. 25 or 30 Years Converting to Permanent Coverage To guarantee level-premium lifetime coverage. Your coverage amount does not go down as you get older. and no evidence of insurability is required for such increase.000. CCD 9526 L657-7 . your policy will continue in force automatically on an Annual Renewable Term basis until age 95. These are the lowest premium rates we offer for Level Term. 25. And with the Annual Renewable Term provision available at the end of the level-premium period. This enables us to establish our premiums at a lower initial cost. rounded to the nearest $1.or 30-year period. Guaranteed Level Protection Regardless of the term period selected. This policy is fully convertible to any Amica Life permanent plan available without medical examination. There is no established maximum limitation placed on the amount of life insurance coverage for which you can apply. The amount of each increase will be the lesser of (a) an amount arrived at by multiplying the face amount of the policy then in effect by the cost of living factor.000 to $499.or 30-year level-premium policy with rates that are guaranteed to remain level throughout the period selected. 20-. An even larger discount is available on policies of $500. our life insurance policies are not priced to include the payment of dividends and no dividends are payable. 15-. Our largest discount is reserved for policies of $1. this provision will be terminated. coverage can be provided up to age 95. Discounts for Larger-sized Policies A substantial discount is available on policies of $250.000 to $999. POLICY B ENEFITS Level Term has a minimum policy size of $100. the 20-.LEVEL TERM LIFE INSURANCE IMPORTANT PRODUCT AND POLICY OPTION INFORMATION PROVIDE Y OUR FAMILY WITH INCREASED FINANCIAL SECURITY Choose From Among Five Level Term Periods of 10. 25.999. Cost of Living Provision To offset the effects that inflation can have on your coverage. The first time an increase is rejected. (Not available in some states. or (b) $20. subject to limitations of the policy's elective conversion provision. At the end of the level-premium period for which this policy is issued. the elective conversion provision expires on the: 8 policy anniversary for a 10-year Level Term policy 12th policy anniversary for a 15-year Level Term policy 16 policy anniversary for a 20-year Level Term policy 20th policy anniversary for a 25-year Level Term policy 24th policy anniversary for a 30-year Level Term policy Conversion is offered without a medical examination at rates then in effect for the new policy.

email or fax the application for your review. Policyholder must be under age 61 at the time of application. premiums may increase or decrease. we will refund to you all premiums paid from the original date of disability.000 increments. Monthly payments are deducted electronically directly from your checking account. Call 1-800-234-5433 today to apply. Coverage is available in $1. L657-7 . In this brochure we have tried to highlight the most significant state-specific differences.) H OW D O Y OU A PPLY? One of our licensed life insurance professionals can complete an application with you over the phone. with a maximum of $10. It provides the same amount of coverage for each child. but less than age 18 on the date of the application.Convenient Premium Payment Options Amica Life offers an array of premium payment plans with some of the most flexible payment schedules available for this type of insurance – one of which will fit comfortably within your budget. * Policy title and some product features may be different in certain states. However. the Annual Renewable Term provision includes both current and guaranteed maximum rates. H OW A RE PREMIUMS D ETERMINED? On those plans with a fully-guaranteed level-premium period. Coverage for children born after th the application date will commence on their 15 day of life. for up to five times the original face amount. in the 11th and subsequent policy years. you cannot be individually singled out for premium adjustment. you will never be charged more than the current premium rate during the entire level-premium period. quarterly or even monthly.000 per child. On all plans. but will never exceed the guaranteed maximum rates. we will waive your policy premium and continue your coverage if you are disabled for six consecutive months. Waiver of Premium This valuable benefit eliminates the additional financial burden of having to pay for life insurance at a time when you may be faced with huge medical expenses and lost income as a result of a disability. Each child’s coverage is convertible to any permanent insurance policy available at the time of conversion. After the sixth month. lapse ratios and investment earnings experience. after the level-premium period. Coverage remains in effect until the policy anniversary date following your 65 th birthday. Rates are based on the company's expectations of expenses. and all future premiums due will be waived until you recover or your policy matures. this option provides additional coverage with benefits to be paid if you die due to an accident (as defined in the rider). stepchild or adopted child of the principal policyholder listed on the application for such coverage. Amica Life has never increased its rates on existing policies in the history of the company. Current rates can be changed only if rates are changed on all Amica Life policies of your class in your state. You can purchase amounts up to the face amount of the policy. mortality. In addition. regardless of any changes in their health. With this benefit. Our premium rate structure allows us to set current rates in a very competitive manner. This benefit also applies to any child born to or legally adopted by the policyholder after the application date. the current rate is intended to remain level for the full period.and 30-year plans with a 10-year guarantee. We will then mail. Please note: The information presented herein describes our standard policy available in most states (policy form numbers ICC11 FGCLT02-01 and ICC11 CLT02-01). Accidental Death Benefit For an additional premium. You can choose to pay your premiums annually. Please refer to the personalized illustration to review your state's specific policy features. 25. Children must be at least 15 days old. For 20-. Any increase or decrease in premium will not result in an increase or decrease in benefits. Although we cannot promise that your current rates will not change in the future. (Not available in Connecticut. while guaranteeing their future insurability. to a maximum of $150. which enables you to design a plan that best meets your needs. O PTIONAL B ENEFITS AND R IDERS Several options are available with this policy. semiannually. Coverage for children will continue until the earlier of the policy anniversary date following the child’s 23rd birthday. Children’s Insurance Benefit This benefit insures your children today.000. or the policy th anniversary date following the policyholder’s 65 birthday.

82 . 9 Total capital required: Add lines 4. * Annual Survey of colleges: The College Board.0 B NUMBER OF YEARS BEFORE C OLLEGE 5 10 15 20 F ACTOR . car loans.6 17. 11 Retirement savings: IRAs. stocks. before taxes.6 15. spouse’s earning. 6 and 8.75% of total income) 2 Annual income your family would receive from other sources: Dividends. (Social Security may be available) 3 Income to be replaced: Subtract line 2 from line 1. to maintain its current standard of living. money market accounts. You should consult with an insurance agent or other financial advisor before buying any insurance products. 11 and 12. 4 Capital needed for income: Multiply line 3 by the appropriate factor in Table A.1 13. Subtract line 13 from line 9. 2005 .56 . and disability insurance. a non-profit organization designed to address the public’s growing need for information and education on life. Keoghs. CDs. however. A NUMBER OF YEARS INCOME NEEDED 10 15 20 25 30 35 40 FACTOR 8. ASSETS: 10 Savings and investments: Bank accounts. (2004-2005 average 4-year costs: Private $118. etc. mutual funds.602.7 20.938*) 7 College costs for each child. credit card debt. INCOME: 1 Total annual income your family would need if you died today: What your family needs. etc. EXPENSES: 5 Funeral and other final expenses: (Typically the greater of $15. 5. The rate of return on investments is assumed to be 8% This worksheet was developed by the Life and Health Insurance Foundation for Education.1 11. It’s only approximate.46 Important note: Inflation is assumed to be 4%. (Typically between 60% . health. 13 Total income producing assets: 14 Life insurance needed: Add lines 10.090 or 4% of your estate) 6 Mortgage and other outstanding debts: Include mortgage balance. pension and profit sharing plans. interest income. 401(k)s. 12 Present amount of life insurance: Include group insurance as well as insurance purchased on your own. bonds.68 . Public $48. in today’s dollars: 8 Capital needed for college: Multiply line 7 by the appropriate factor in Table B. The worksheet assumes you die today.3 18.H OW M UCH L IFE I NSURANCE D O Y OU N EED T O P ROTECT Y OUR F AMILY? This simple worksheet can give you an idea.