1.(5)(b)
Form of Policy Riders
ACACIA NATIONAL
LIFE INSURANCE
COMPANY LOGO
NOTICE: AS OF THE EFFECTIVE DATE OF THIS RIDER, IT IS UNCERTAIN WHAT EFFECT THE
RECEIPT OF BENEFITS UNDER THIS RIDER WILL HAVE ON YOUR TAX STATUS. PLEASE
CONSULT YOUR PERSONAL TAX ADVISOR PRIOR TO REQUESTING SUCH BENEFITS.
ACCELERATED BENEFIT RIDER
for TERMINAL ILLNESS
on SURVIVING INSURED
CONSIDERATION
This rider is attached to and made a part of your policy and is issued in
consideration of the application. A copy of the application is attached to the
policy.
PREMIUMS
There are no additional premiums or cost of insurance deductions for this rider.
BENEFITS
We will pay an accelerated benefit to you if the Surviving Insured is terminally
ill, subject to the provisions of this rider. This amount will be paid as a lump
sum. Payments other than as a lump sum may be made at your request, subject to
our approval.
DEFINITIONS
ELIGIBLE COVERAGES: Eligible Coverages under this rider will be the base policy
and any life insurance riders attached to the policy which provide coverage on
the Surviving Insured.
Eligible Coverages will be determined as of the date we receive satisfactory
proof of terminal illness at the Administrative Office. Coverage will only be
considered "eligible" when it is outside its two year contestable period and has
more than two years until its maturity or final expiration date.
ELIGIBLE AMOUNT: Eligible Amount is that portion of the current specified amount
of the base policy considered "eligible" under Eligible Coverages. For any
Eligible Coverages which are provided by life insurance riders, the Eligible
Amount will be the lowest scheduled death benefit within two years after
satisfactory proof of terminal illness is received at the Administrative Office.
MAXIMUM ACCELERATED BENEFIT: The maximum benefit is 50% of the Eligible Amount,
less an amount up to two guideline level premiums for the base policy and any
riders. This maximum benefit is subject to the limitations described in the
Total Accelerated Benefit provision.
RIDER EFFECTIVE DATE: The effective date of coverage under this rider will be
the policy date of the base policy to which this rider is attached.
TIRSL 8099
"SURVIVING INSURED" means the Insured who remains alive after one of the
Insureds has died.
TERMINAL ILLNESS: A non-correctable medical condition that, with a reasonable
degree of medical certainty, will result in the death of the Surviving Insured
in less than 12 months from the date of the physician's statement and that was
first diagnosed while the policy was in force.
"YOU" AND "YOUR" refer to the owner of the policy to which this rider is
attached. The Owner may also be the Surviving Insured.
"WE", "US" OR "OUR" refer to Acacia National Life Insurance Company. Our
Administrative Office is at P.O. Box 82579, Lincoln, Nebraska 68501-2579.
SATISFACTORY PROOF OF TERMINAL ILLNESS
Before payment of any accelerated benefit, we will require you to provide us
with proof, satisfactory to us, that the Surviving Insured has a terminal
illness. Satisfactory proof will include a properly completed claim form and a
written statement from a duly licensed physician who is licensed in the United
States and who is not yourself or the Surviving Insured, nor related to either
the Surviving Insured or yourself. We reserve the right to obtain a second
medical opinion at our expense.
EFFECT ON YOUR POLICY
The accelerated benefit first will be used to repay any outstanding policy loans
and unpaid loan interest. The accelerated benefit will be treated as a lien
against your policy values.
Death proceeds which are payable on the death of the Surviving Insured will be
reduced by the amount of the lien and any policy loans, plus accrued interest.
After payment of the accelerated benefit, and if sufficient premium to keep the
policy in force is not paid by the end of the grace period, premiums will be
paid by an addition to the lien for up to two years from the date we receive
satisfactory proof of terminal illness. After this two year period, you are
required to pay premiums when due to keep the policy in force. If the policy
lapses, the lien, any policy loans, and accrued interest will be deducted from
any accumulation values.
Your access to the net cash surrender value of your policy and to the net cash
surrender value of any riders through policy loans, partial withdrawals, if
permitted, or full surrender is limited to any excess of the net cash surrender
value over the lien including any accrued interest.
INTEREST
We will charge interest on the amount of the lien. The interest accrues daily at
the same interest rate as the policy's loan interest rate.
TIRSL 8099
Accrued interest will be added to the lien on the policy anniversary. Interest
does not continue to accrue on the lien when the lien and any policy loans, plus
accrued interest, equals the death benefit (prior to the deduction of the lien,
policy loans and accrued interest) of the policy and any riders.
CONDITIONS
The payment of any accelerated benefit is subject to the following conditions:
1. Any Eligible Coverages must be in force on the date we receive satisfactory
proof of terminal illness.
2. Any accumulation value less any applicable surrender charge must be less
than the maximum accelerated benefit.
3. We will not make payment of any accelerated benefit if that payment would
be less than $4,000.
4. The release of any collateral assignees, the release of all parties to any
"split dollar" agreements and the approval of any irrevocable beneficiaries
is required.
5. The policy must be collaterally assigned to us for an amount equal to the
lien and accrued interest. No changes to the policy are permitted without
our consent.
6. This rider allows for the accelerated payment of death benefit proceeds,
which would otherwise be payable to your beneficiary. This is not meant to
cause you to be required to access and exhaust these benefits
involuntarily. Therefore, you are not eligible for this benefit:
a. If you are required by law to use this benefit to meet the claims of
creditors, whether in bankruptcy or otherwise; or
b. If you are required by a government agency to use this benefit in
order to apply for, obtain, or otherwise keep a government benefit or
entitlement.
ADDITIONAL BENEFIT
If the maximum accelerated benefit is not paid initially, an additional
accelerated benefit may be paid up to the difference as long as this amount is
at least $4,000. This additional benefit is only available if it has been less
than 12 months from the date we received satisfactory proof of terminal illness.
We may require additional satisfactory proof of terminal illness at this time.
TOTAL ACCELERATED BENEFIT
The total amount we will pay as an accelerated benefit due to the terminal
illness of the Surviving Insured will not exceed $250,000 even if there is more
than one policy with us or one of our affiliates which provides coverage on the
Surviving Insured.
TIRSL 8099
ADMINISTRATIVE CHARGE
We may charge a one-time administrative charge which will be deducted from the
accelerated benefit. This charge will not exceed $50.
GENERAL PROVISIONS
Incontestability: The validity of this rider cannot be contested after it has
been in force while either Insured is alive for a period of two years from the
effective date of the rider.
REINSTATEMENT: This rider may be reinstated with the policy. It will be
reinstated if you meet the requirements for policy reinstatement. If you have
received benefits under this rider, the lien with accrued interest may be paid
or it will be reinstated as if the policy had never terminated.
TERMINATION OF RIDER: This rider will automatically terminate on the earliest of
these conditions:
1. On surrender of this rider to us; or
2. On termination of the policy to which this rider is attached.
NONPARTICIPATING: This rider is nonparticipating.
INCORPORATION OF POLICY PROVISIONS INTO RIDER:
The provisions of the policy are hereby referred to and made a part of this
rider unless otherwise specified in this rider.
ACACIA NATIONAL LIFE INSURANCE COMPANY
/s/Robert-John H. Sands /s/Robert W. Clyde
Secretary President
TIRSL 8099
ACACIA NATIONAL
LIFE INSURANCE
COMPANY LOGO
DISABILITY BENEFIT RIDER on
DISABILITY of a COVERED INSURED
CONSIDERATION
This rider is issued in consideration of the application and payment of its cost
of insurance. A copy of the application is attached to the policy. The cost of
insurance for this rider is deducted from the accumulation value at the same
time and in the same manner as the cost of insurance for the policy.
DEFINITIONS
COVERED INSURED: Covered Insured means the person so named in the original
application and as shown on the schedule pages.
DISABILITY BENEFIT: For purposes of this rider, the disability benefit is an
amount shown on the schedule pages, selected by you on the application.
RIDER EFFECTIVE DATE: The effective date of all coverage under this rider shall
be as follows:
1. The policy date shall be the effective date for all coverage provided in
the original application.
2. For any rider issued after the policy date, the effective date shall be the
date shown on a supplement to the schedule pages.
3. For any insurance that has been reinstated, the effective date shall be the
monthly activity date on or next following the date we approve the
reinstatement.
RIDER EXPIRATION DATE: This date is also shown on the schedule pages. It is the
date on which this rider is no longer effective.
TOTAL DISABILITY: Total disability must begin after the effective date of this
rider as shown in the schedule pages and before the policy anniversary nearest
the Covered Insured's 60th birthday. It must result from bodily injury which
occurs or sickness which first manifests itself while this rider is in force.
Total Disability means:
1. Total loss of the sight of both eyes. This loss must be irrecoverable; or
2. Total loss of the use of both hands, both feet, or one hand and one foot.
This loss must be irrecoverable; or
3. The incapacity of the Covered Insured to engage in any substantial duties
of his or her occupation for at least six consecutive months. (Substantial
duties includes managerial or supervisory functions.)
DBRSL 8099
During the first 24 months of total disability, occupation means the usual
work, employment, business or profession in which the Covered Insured was
engaged immediately before the date of disability. This includes
attendance at school or college as a full-time student. After 24 months of
total disability a Covered Insured who is engaged in any occupation for
remuneration or profit will not be considered totally disabled.
BENEFITS
While the Covered Insured is totally disabled, the disability benefit will be
applied as premium. The premium will be credited as of the last monthly activity
date, prior to the approval date of the claim and will be credited annually
thereafter, during continuance of total disability. In addition, while the
Covered Insured is totally disabled, the cost of insurance for this rider will
not be deducted from the accumulation value. All other monthly deductions will
apply.
You may choose to continue to pay your planned periodic premiums or make any
unscheduled premium payments while you are receiving a disability benefit.
If total disability begins after the grace period, no benefits under this rider
will be paid. If any portion of a disability benefit would affect the tax
qualifications of this policy as described in Section 7702 of the Internal
Revenue Code, as amended, the benefit payable will be reduced by that portion
considered to be excess premium.
GENERAL PROVISION
NOTICE OF DISABILITY: To receive this benefit, written notice of claim must be
received at the Home Office. It must be received: (a) while the Covered Insured
is living; (b) while the Covered Insured is totally disabled; and (c) not later
than 9 months after the Covered Insured has become totally disabled.
If such notice is not furnished in the required time limit, the claim will not
be accepted. But a late claim will be accepted if it can be shown that it was
not reasonably possible to meet the requirements and that notice was given as
soon as was reasonably possible. In no event, however, will the Covered Insured
receive any benefit under this rider for a period prior to one year before the
date on which notice was received.
PROOF OF TOTAL DISABILITY: Approval of the initial notice of claim will be
granted after we receive satisfactory written proof that the Covered Insured is
totally disabled. Proof must be presented at the Home Office: (a) while the
Covered Insured is living; (b) before total disability has ended or been
interrupted; and (c) within 12 months after we receive the notice of total
disability. Forms approved by us must be used.
Similar proof that the total disability is continuing may be required at
reasonable intervals. If the Covered Insured fails to furnish such proof, the
disability benefit will cease.
INCONTESTABILITY: While the Covered Insured is alive, the validity of this rider
cannot be contested after it has been in force for a period of 2 years from the
rider effective date.
DBRSL 8099
REINSTATEMENT: Coverage under this rider may be reinstated with the policy if no
more than 3 years have passed since the date of termination. Reinstatement must
occur before the rider expiration date. Such reinstatement may occur any time
before the policy anniversary nearest the Covered Insured's 60th birthday.
The requirements for reinstatement are:
1.Receipt of evidence of insurability satisfactory to us.
2. Payment of the minimum cost of insurance sufficient to keep the rider in
force for 3 months.
EXCLUSIONS: The Covered Insured will not be eligible for the disability benefit
if the total disability on which the claim is based results from:
1. Self-inflicted bodily injury while sane or insane, other than accidental
injury; or
2. War or any act of war, whether declared or not, regardless of whether the
Covered Insured is in the armed forces.
TERMINATION OF RIDER: This rider will automatically terminate on the earliest of
these conditions:
1. On the rider expiration date;
2. On the monthly activity date on or next following the date we receive your
written request;
3. On surrender of this rider to us; or
4. On termination of the policy to which this rider is attached.
CHANGE OF POLICY: Once the disability benefit commences, you cannot change the
specified amount of insurance, the death benefit option, the mode of the planned
periodic premium payments, or change the policy to another form of insurance.
COST OF INSURANCE DEDUCTIONS AFTER THE RIDER HAS TERMINATED: We will not be
liable for the cost of insurance deductions on this rider after it terminates
except to return them.
INCORPORATION OF POLICY PROVISIONS INTO RIDER: The provisions of the policy are
hereby referred to and made a part of this rider.
NONPARTICIPATING: This rider is nonparticipating.
ACACIA NATIONAL LIFE INSURANCE COMPANY
/s/Robert-John H. Sands /s/Robert W. Clyde
Secretary President
DBRSL 8099
ACACIA NATIONAL
LIFE INSURANCE
COMPANY LOGO
ESTATE PROTECTION RIDER
LAST SURVIVOR FOUR YEAR TERM INSURANCE
CONSIDERATION
This rider is issued in consideration of the application and the payment of its
cost of insurance. A copy of the application is attached to the policy. The cost
of insurance for this rider is deducted from the accumulation value at the same
time and in the same manner as the cost of insurance for the policy.
BENEFITS
We agree to pay the rider specified amount of insurance to the beneficiary upon
receipt of satisfactory proof of the death of both Insureds. Death must occur
while the policy and this rider are in force. Payment is subject to the
provisions of the policy and this rider.
DEFINITIONS
SURVIVING INSURED: Surviving Insured means the Insured who remains alive after
one of the Insureds has died.
BENEFICIARY: Unless otherwise changed, the beneficiary for the benefit payable
under this rider will be the named beneficiary as shown in the application for
the base policy.
While each Insured is living, you may change the beneficiary by written request
in a form satisfactory to us. The change will take effect on the date we record
it in the Home Office.
RIDER EFFECTIVE DATE: The effective date of coverage under this rider shall be
as follows:
1. The policy date shall be the effective date for all coverage provided in
the original application.
2. For any insurance that has been reinstated, the effective date shall be the
monthly activity date on or next following the date we approve the
reinstatement.
RIDER EXPIRATION DATE: This date is also shown in the schedule pages. It is the
date on which this rider is no longer effective.
RIDER SPECIFIED AMOUNT OF INSURANCE: The rider specified amount of insurance is
shown in the schedule pages.
COST OF INSURANCE
The annual cost of insurance upon renewal for this rider will be a rate per
thousand multiplied by the rider specified amount of insurance in thousands. The
rates will
ESP 8099
be based on the issue age, sex, tobacco usage and risk class of each Insured and
the rider duration. The rates will be adjusted for any table rating and/or flat
extra rating. The Maximum Guaranteed Cost of Insurance Rates per $1,000 are
shown in the policy schedule. We have the option of charging less than the
maximum. Each year, the current annual cost of insurance rates for this rider
will be declared for the next policy year. Any change in the current cost of
insurance rates will apply to Insureds covered under this rider having the same
issue age, sex, tobacco usage and risk class and whose riders have been in
effect for the same length of time. We cannot increase rates because of a change
in status of either Insured's health.
GENERAL PROVISIONS
TERMINATION OF RIDER: This rider will automatically terminate on the earliest of
these conditions:
1. On the rider expiration date;
2. On the monthly activity date on or next following the date we receive your
written request;
3. On surrender of this rider to us;
4. On termination of the policy to which this rider is attached; or
5. On the death of the Surviving Insured.
SATISFACTORY PROOF OF DEATH: All of the following must be submitted upon the
death of the Surviving Insured:
1) A certified copy of the death certificate for both Insureds;
2) A Notice of Death Claim;
3) Any other information that we may reasonably require to establish the
validity of the claim.
REINSTATEMENT: If both Insureds are living, this rider may be reinstated with
the policy if no more than 3 years have passed since the date of termination.
Reinstatement must occur before the expiration date of this rider. The
requirements for reinstatement are:
1. Receipt of satisfactory evidence of insurability that both Insureds are
insurable in the same rating classes as when the rider was issued.
2. Payment of the minimum cost of insurance sufficient to keep the rider in
force for 3 months.
SUICIDE EXCLUSION: We will limit our liability if the death of either Insured is
as a result of suicide, while sane or insane, within two years from the rider
effective date. The proceeds payable will be an amount equal to the cost of
insurance deductions charged for this rider.
INCONTESTABILITY: While either Insured is alive, the validity of this rider
cannot be contested after it has been in force for a period of 2 years from the
rider effective date.
ESP 8099
COST OF INSURANCE DEDUCTIONS AFTER RIDER TERMINATION DATE: We will not be liable
for the cost of insurance payments on this rider after it terminates except to
return them.
INCORPORATION OF POLICY PROVISIONS INTO RIDER: The provisions of the policy are
hereby referred to and made a part of this rider unless otherwise specified in
this rider.
This rider has no cash or loan value.
NON-PARTICIPATING: This rider is non-participating.
ACACIA NATIONAL LIFE INSURANCE COMPANY
/s/Robert-John H. Sands /s/Robert W. Clyde
Secretary President
ESP 8099
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ESP 8099
ACACIA NATIONAL
LIFE INSURANCE
COMPANY LOGO
FIRST-TO-DIE TERM RIDER
CONSIDERATION
This rider is issued in consideration of the application and the payment of its
cost of insurance. A copy of the application is attached to the policy. The cost
of insurance for this rider is deducted from the accumulation value at the same
time and in the same manner as the cost of insurance for the policy.
BENEFITS
We agree to pay the rider specified amount of insurance to the beneficiary upon
receipt of satisfactory proof of the death of either Insured. Death must occur
while the policy and this rider are in force.
Payment is subject to the provisions of the policy and this rider.
DEFINITIONS
BENEFICIARY: Unless otherwise changed, the beneficiary for the benefit payable
under this rider will be the named beneficiary as shown in the application for
this rider.
While both Insureds are alive, you may change the beneficiary by written request
in a form satisfactory to us. The change will take effect on the date we record
it in the Home Office.
RIDER EFFECTIVE DATE: The effective date of coverage under this rider shall be
as follows:
1. The policy date shall be the effective date for all coverage provided in
the original application.
2. For any insurance that has been reinstated, the effective date shall be the
monthly activity date on or next following the date we approve the
reinstatement.
RIDER EXPIRATION DATE: This date is also shown in the schedule pages. It is the
date on which this rider is no longer effective.
RIDER SPECIFIED AMOUNT OF INSURANCE: The rider specified amount of insurance is
shown in the schedule pages.
COST OF INSURANCE
The annual cost of insurance upon renewal for this rider will be a rate per
thousand multiplied by the rider specified amount of insurance in thousands. The
rates will be based on the issue age, sex, tobacco usage and risk class of each
Insured and the rider duration. The rates will be adjusted for any table rating
and/or flat extra rating. The Maximum Guaranteed Cost of Insurance Rates per
$1,000 are shown in the policy schedule. We have the option of charging less
than the maximum. Each year,
FTD 8099
the current annual cost of insurance rates for this rider will be declared for
the next policy year. Any change in the current cost of insurance rates will
apply to Insureds covered under this rider having the same issue age, sex,
tobacco usage and risk class and whose riders have been in effect for the same
length of time. We cannot increase rates because of a change in status of either
Insured's health.
GENERAL PROVISIONS
TERMINATION OF RIDER: This rider will automatically terminate on the earliest of
these conditions:
1. On the rider expiration date;
2. On the monthly activity date on or next following the date we receive your
written request;
3. On surrender of this rider to us;
4. On termination of the policy to which this rider is attached; or
5. On the death of either Insured.
SATISFACTORY PROOF OF DEATH: All of the following must be submitted upon the
death of either Insured:
1) A certified copy of the death certificate;
2) A Notice of Death Claim;
3) Any other information that we may reasonably require to establish the
validity of the claim.
REINSTATEMENT: If both Insureds are living, this rider may be reinstated with
the policy if no more than 3 years have passed since the date of termination.
Reinstatement must occur before the expiration date of this rider. The
requirements for reinstatement are:
1. Receipt of satisfactory evidence of insurability that both Insureds are
insurable in the same rating classes as when the rider was issued.
2. Payment of the minimum cost of insurance sufficient to keep the rider in
force for 3 months.
SUICIDE EXCLUSION: We will limit our liability if the death of either Insured is
as a result of suicide, while sane or insane, within two years from the rider
effective date. The proceeds payable will be an amount equal to the cost of
insurance deductions charged for this rider.
INCONTESTABILITY: While either Insured is alive, the validity of this rider
cannot be contested after it has been in force for a period of 2 years from the
rider effective date.
FTD 8099
COST OF INSURANCE DEDUCTIONS AFTER RIDER TERMINATION DATE: We will not be liable
for the cost of insurance payments on this rider after it terminates except to
return them.
INCORPORATION OF POLICY PROVISIONS INTO RIDER: The provisions of the policy are
hereby referred to and made a part of this rider unless otherwise specified in
this rider.
This rider has no cash or loan value.
NON-PARTICIPATING: This rider is non-participating.
ACACIA NATIONAL LIFE INSURANCE COMPANY
/s/Robert-John H. Sands /s/Robert W. Clyde
Secretary President
FTD 8099
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ACACIA NATIONAL
LIFE INSURANCE
COMPANY LOGO
SECOND-TO-DIE TERM RIDER
CONSIDERATION
This rider is issued in consideration of the application and the payment of its
cost of insurance. A copy of the application is attached to the policy. The cost
of insurance for this rider is deducted from the accumulation value at the same
time and in the same manner as the cost of insurance for the policy.
BENEFITS
We agree to pay the rider specified amount of insurance to the beneficiary upon
receipt of satisfactory proof of the death of both Insureds. Death must occur
while the policy and this rider are in force. Payment is subject to the
provisions of the policy and this rider.
CONVERSION OF THIS RIDER
While the policy and this rider are in force, you may convert this rider as an
increase in the specified amount of the policy. It may not be converted to
another policy. You may do this at any time after the rider conversion option
date. Evidence of insurability will not be required, except for additional
benefits.
DEFINITIONS
SURVIVING INSURED: Surviving Insured means the Insured who remains alive after
one of the Insureds has died.
beneficiary: Unless otherwise changed, the beneficiary for the benefit payable
under this rider will be the named beneficiary as shown in the application for
the base policy.
While each Insured is living, you may change the beneficiary by written request
in a form satisfactory to us. The change will take effect on the date we record
it in the Home Office.
RIDER CONVERSION OPTION DATE: The date shown on the schedule pages.
RIDER EFFECTIVE DATE: The effective date of coverage under this rider shall be
as follows:
1. The policy date shall be the effective date for all coverage provided in
the original application.
2. For any insurance that has been reinstated, the effective date shall be the
monthly activity date on or next following the date we approve the
reinstatement.
STD 8099
RIDER EXPIRATION DATE: This date is also shown in the schedule pages. It is the
date on which this rider is no longer effective.
RIDER SPECIFIED AMOUNT OF INSURANCE: The rider specified amount of insurance is
shown in the schedule pages.
COST OF INSURANCE
The annual cost of insurance upon renewal for this rider will be a rate per
thousand multiplied by the rider specified amount of insurance in thousands. The
rates will be based on the issue age, sex, tobacco usage and risk class of each
Insured and the rider duration. The rates will be adjusted for any table rating
and/or flat extra rating. The Maximum Guaranteed Cost of Insurance Rates per
$1,000 are shown in the policy schedule. We have the option of charging less
than the maximum. Each year, the current annual cost of insurance rates for this
rider will be declared for the next policy year. Any change in the current cost
of insurance rates will apply to Insureds covered under this rider having the
same issue age, sex, tobacco usage and risk class and whose riders have been in
effect for the same length of time. We cannot increase rates because of a change
in status of either Insured's health.
GENERAL PROVISIONS
TERMINATION OF RIDER: This rider will automatically terminate on the earliest of
these conditions:
1. On the rider expiration date;
2. On the monthly activity date on or next following the date we receive your
written request;
3. On surrender of this rider to us;
4. On termination of the policy to which this rider is attached; or
5. On the death of the Second Insured.
SATISFACTORY PROOF OF DEATH: All of the following must be submitted upon the
death of the Second Insured:
1) A certified copy of the death certificate for both Insureds;
2) A Notice of Death Claim;
3) Any other information that we may reasonably require to establish the
validity of the claim.
REINSTATEMENT: If both Insureds are living, this rider may be reinstated with
the policy if no more than 3 years have passed since the date of termination.
Reinstatement must occur before the expiration date of this rider. The
requirements for reinstatement are:
STD 8099
1. Receipt of satisfactory evidence of insurability that both Insureds are
insurable in the same rating classes as when the rider was issued.
2. Payment of the minimum cost of insurance sufficient to keep the rider in
force for 3 months.
SUICIDE EXCLUSION: We will limit our liability if the death of either Insured is
as a result of suicide, while sane or insane, within two years from the rider
effective date. The proceeds payable will be an amount equal to the cost of
insurance deductions charged for this rider.
INCONTESTABILITY: While either Insured is alive, the validity of this rider
cannot be contested after it has been in force for a period of 2 years from the
rider effective date.
COST OF INSURANCE DEDUCTIONS AFTER RIDER TERMINATION DATE: We will not be liable
for the cost of insurance payments on this rider after it terminates except to
return them.
INCORPORATION OF POLICY PROVISIONS INTO RIDER: The provisions of the policy are
hereby referred to and made a part of this rider unless otherwise specified in
this rider.
This rider has no cash or loan value.
NON-PARTICIPATING: This rider is non-participating.
ACACIA NATIONAL LIFE INSURANCE COMPANY
/s/Robert-John H. Sands /s/Robert W. Clyde
Secretary President
STD 8099
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ACACIA NATIONAL
LIFE INSURANCE
COMPANY LOGO
TERM RIDER FOR COVERED INSURED
CONSIDERATION
This rider is issued in consideration of the application and the payment of its
cost of insurance. A copy of the application is attached to the policy. The cost
of insurance for this rider is deducted from the accumulation value at the same
time and in the same manner as the cost of insurance for the policy.
DEFINITIONS
BENEFICIARY: The term "beneficiary" in this rider means only the beneficiary for
the benefit payable at the Covered Insured's death. The term "beneficiary" in
other provisions of the policy means only the beneficiary for the benefits
payable under the policy.
Unless otherwise changed, the beneficiary for the benefit payable under this
rider will be the named beneficiary as shown in the application for this rider.
While the Covered Insured is living, you may change the beneficiary by written
request in a form satisfactory to us. The change will take effect on the date we
record it in the Home Office.
COVERED INSURED: Covered Insured means each person so named in an application or
supplemental application, if approved by us, and shown on the schedule pages.
RIDER CONVERSION OPTION EXPIRATION DATE: The date shown on the schedule pages.
RIDER EFFECTIVE DATE: The effective date of coverage under this rider shall be
as follows:
1. The policy date shall be the effective date for all coverage provided in
the original application.
2. For any rider issued after the policy date or for any coverage on another
Covered Insured, the effective date shall be the date shown on a supplement
to the schedule pages.
3. For any insurance that has been reinstated, the effective date shall be the
monthly activity date that falls on or next follows the date we approve the
reinstatement.
RIDER EXPIRATION DATE: This date is also shown in the schedule pages. It is the
date on which this rider is no longer effective.
RIDER SPECIFIED AMOUNT OF INSURANCE: The rider specified amount of insurance for
a Covered Insured is shown for that Covered Insured on the schedule pages.
TRCI 8099
BENEFITS
We agree to pay the rider specified amount of insurance to the beneficiary upon
receipt of satisfactory proof of the death of any Covered Insured. Death must
occur while this rider is in force with respect to the Covered Insured. Payment
is subject to the provisions of the policy and this rider.
COST OF INSURANCE
The annual cost of insurance upon renewal for this rider will be a rate per
thousand at the attained age of that Covered Insured multiplied by the rider
specified amount of insurance in thousands. The rates will be based on the issue
age, sex, tobacco usage and risk class of the Covered Insured and the rider
duration. The rates will be adjusted for any table rating and/or flat extra
rating. The rating and risk class of the Covered Insured are shown in the policy
schedule. The Maximum Guaranteed Cost of Insurance Rates per $1,000 are
attached. We have the option of charging less than the maximum. Each year, the
current annual cost of insurance rates for this rider will be declared for the
next policy year. Any change in the current cost of insurance rates will apply
to Covered Insureds under this rider having the same issue age, sex, tobacco
usage and risk class and whose riders have been in effect for the same length of
time. We cannot increase rates because of a change in status of the Covered
Insured's health.
CONVERSION OF THIS RIDER
While the policy and this rider are in force, you may convert it for a permanent
policy on the life of the Covered Insured. You may do this at any time prior to
attained age 70 of the Covered Insured. Evidence of insurability will not be
required, except for additional benefits.
If the policy terminates prior to the rider conversion option expiration date
due to the death of the insured(s) under the basic policy, the Covered Insured
may still convert within 60 days of the date of termination.
The new policy will have a specified amount of insurance no more than the rider
specified amount of insurance in effect on the date of conversion for that
Covered Insured.
The policy date of the new policy will be the date of conversion. The new policy
will be subject to our then current rules as to the amount and the kind of
policy issued. The rates for the new policy will be adjusted for any table
rating and/or flat extra rating that was being charged for this rider. Any
restrictions found in this rider will also be found in the new policy.
Application must be made and the first premium for the new policy paid to us
before this rider terminates for the Covered Insured on whom coverage is being
converted. In addition, the Covered Insured on whom coverage is being converted
must be alive on the policy date of the new policy.
GENERAL PROVISIONS
TERMINATION OF RIDER: This rider will automatically terminate for each Covered
Insured on the earliest of these conditions:
1. On the rider expiration date for each Covered Insured;
TRCI 8099
2. On the monthly activity date on or next following the date we receive your
written request;
3. On surrender of this rider to us; or
4. On termination of this policy.
REINSTATEMENT: This rider may be reinstated with the policy if no more than 3
years have passed since the date of termination. Reinstatement must occur before
the expiration date of this rider. The requirements for reinstatement are:
1. Receipt by us of evidence of insurability of the Covered Insured for whom
coverage is being reinstated. This evidence must be satisfactory to us.
2. Payment of the minimum cost of insurance sufficient to keep the rider in
force for 3 months.
SUICIDE: If the Covered Insured commits suicide, while sane or insane within 2
years from the rider effective date with respect to that Covered Insured, the
total liability shall be the cost of insurance for that Covered Insured.
INCONTESTABILITY: While the Covered Insured is alive, the validity of this rider
cannot be contested after it has been in force for a period of 2 years from the
rider effective date.
COST OF INSURANCE DEDUCTIONS AFTER RIDER EXPIRATION DATE: We will not be liable
for the cost of insurance deductions on this rider for any Covered Insured after
it terminates except to return them.
INCORPORATION OF POLICY PROVISIONS INTO RIDER: The provisions of the policy are
hereby referred to and made a part of this rider unless otherwise specified in
this rider.
This rider has no cash or loan value.
NONPARTICIPATING: This rider is nonparticipating.
ACACIA NATIONAL LIFE INSURANCE COMPANY
/s/Robert-John H. Sands /s/Robert W. Clyde
Secretary President
TRCI 8099
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MAXIMUM GUARANTEED ANNUAL COST OF INSURANCE RATES
PER $1000 APPLICABLE UPON RENEWAL
MALE MALE MALE FEMALE FEMALE FEMALE
AGE PREFERRED NON-TOBACCO TOBACCO PREFERRED NON-TOBACCO TOBACCO
- --------------------------------------------------------------------------------
20 1.68 1.68 2.32 1.01 1.01 1.17
21 1.66 1.66 2.32 1.03 1.03 1.19
22 1.63 1.63 2.28 1.04 1.04 1.22
23 1.59 1.59 2.24 1.06 1.06 1.25
24 1.55 1.55 2.18 1.08 1.08 1.28
25 1.50 1.50 2.11 1.10 1.10 1.31
26 1.47 1.47 2.07 1.13 1.13 1.36
27 1.45 1.45 2.05 1.15 1.15 1.40
28 1.44 1.44 2.05 1.18 1.18 1.45
29 1.44 1.44 2.08 1.22 1.22 1.51
30 1.45 1.45 2.13 1.25 1.25 1.58
31 1.48 1.48 2.20 1.29 1.29 1.64
32 1.52 1.52 2.29 1.33 1.33 1.71
33 1.58 1.58 2.41 1.38 1.38 1.80
34 1.65 1.65 2.55 1.44 1.44 1.90
35 1.73 1.73 2.72 1.51 1.51 2.01
36 1.82 1.82 2.92 1.61 1.61 2.18
37 1.94 1.94 3.17 1.73 1.73 2.38
38 2.07 2.07 3.45 1.86 1.86 2.61
39 2.21 2.21 3.77 2.00 2.00 2.86
40 2.38 2.38 4.14 2.17 2.17 3.16
41 2.56 2.56 4.54 2.35 2.35 3.48
42 2.75 2.75 4.98 2.53 2.53 3.80
43 2.96 2.96 5.46 2.71 2.71 4.12
44 3.19 3.19 5.99 2.89 2.89 4.44
45 3.45 3.45 6.55 3.09 3.09 4.78
46 3.73 3.73 7.13 3.30 3.30 5.13
47 4.03 4.03 7.76 3.53 3.53 5.49
48 4.36 4.36 8.44 3.77 3.77 5.88
49 4.72 4.72 9.18 4.04 4.04 6.31
50 5.13 5.13 10.00 4.34 4.34 6.77
51 5.60 5.60 10.93 4.67 4.67 7.26
52 6.14 6.14 11.98 5.05 5.05 7.82
53 6.76 6.76 13.17 5.47 5.47 8.44
54 7.45 7.45 14.47 5.90 5.90 9.07
55 8.22 8.22 15.86 6.36 6.36 9.72
56 9.06 9.06 17.33 6.82 6.82 10.36
57 9.95 9.95 18.88 7.27 7.27 10.96
58 10.94 10.94 20.51 7.72 7.72 11.55
59 12.05 12.05 22.26 8.23 8.23 12.18
(Continued on next page)
The annual cost of insurance upon renewal for this rider will be a rate per
thousand at the attained age of that Covered Insured multiplied by the rider
specified amount of insurance in thousands. The rates will be based on the issue
age, sex, tobacco usage and risk class of the Covered Insured and the rider
duration. The rates will be adjusted for any table rating and/or flat extra
rating. The rating and risk class of the Covered Insured are shown in the policy
schedule. The Maximum Guaranteed Cost of Insurance Rates per $1,000 are
attached. We have the option of charging less than the maximum. Each year, the
current annual cost of insurance rates for this rider will be declared for the
next policy year. Any change in the current cost of insurance rates will apply
to Covered Insureds under this rider having the same issue age, sex, tobacco
usage and risk class and whose riders have been in effect for the same length of
time. We cannot increase rates because of a change in status of the Covered
Insured's health.
TRCI 8099
(Continued from previous page)
MAXIMUM GUARANTEED ANNUAL COST OF INSURANCE RATES
PER $1000 APPLICABLE UPON RENEWAL
MALE MALE MALE FEMALE FEMALE FEMALE
AGE PREFERRED NON-TOBACCO TOBACCO PREFERRED NON-TOBACCO TOBACCO
- --------------------------------------------------------------------------------
60 13.29 13.29 24.21 8.83 8.83 12.93
61 14.67 14.67 26.41 9.57 9.57 13.87
62 16.26 16.26 28.89 10.49 10.49 15.08
63 18.06 18.06 31.66 11.62 11.62 16.55
64 20.06 20.06 34.69 12.89 12.89 18.19
65 22.25 22.25 37.90 14.26 14.26 19.92
66 24.62 24.62 41.26 15.68 15.68 21.68
67 27.16 27.16 44.74 17.13 17.13 23.38
68 29.92 29.92 48.39 18.63 18.63 25.10
69 32.98 32.98 52.35 20.30 20.30 26.97
70 36.44 36.44 56.72 22.26 22.26 29.18
71 40.39 40.39 61.63 24.65 24.65 31.98
72 44.95 44.95 67.18 27.58 27.58 35.41
73 50.11 50.11 73.33 31.09 31.09 39.49
74 55.78 55.78 80.07 35.13 35.13 44.14
75 61.84 61.84 87.27 39.64 39.64 49.22
76 68.24 68.24 94.63 44.52 44.52 54.62
77 74.93 74.93 102.02 49.75 49.75 60.26
78 81.95 81.95 109.49 55.41 55.41 66.22
79 89.52 89.52 117.30 61.68 61.68 72.71
80 97.88 97.88 125.71 68.81 68.81 79.98
81 107.25 107.25 134.96 77.01 77.01 88.23
82 117.82 117.82 145.21 86.46 86.46 97.61
83 129.54 129.54 156.29 97.12 97.12 108.44
84 142.18 142.18 167.83 108.87 108.87 120.18
85 155.45 155.45 179.44 121.58 121.58 132.65
86 169.18 169.18 190.84 135.16 135.16 145.75
87 183.16 183.16 202.54 149.59 149.59 159.35
88 197.33 197.33 214.73 164.88 164.88 173.52
89 211.89 211.89 226.85 181.15 181.15 188.25
90 227.05 227.05 239.08 198.53 198.53 204.58
91 243.16 243.16 251.80 217.42 217.42 222.16
92 260.82 260.82 266.55 238.53 238.53 241.66
93 281.75 281.75 285.47 263.35 263.35 264.56
94 309.83 309.83 311.27 295.23 295.23 295.23
95 351.86 351.86 351.86 341.02 341.02 341.02
96 420.99 420.99 420.99 413.88 413.88 413.88
97 541.00 541.00 541.00 537.24 537.24 537.24
98 745.15 745.15 745.15 743.96 743.96 743.96
99 900.00 900.00 900.00 900.00 900.00 900.00
The annual cost of insurance upon renewal for this rider will be a rate per
thousand at the attained age of that Covered Insured multiplied by the rider
specified amount of insurance in thousands. The rates will be based on the issue
age, sex, tobacco usage and risk class of the Covered Insured and the rider
duration. The rates will be adjusted for any table rating and/or flat extra
rating. The rating and risk class of the Covered Insured are shown in the policy
schedule. The Maximum Guaranteed Cost of Insurance Rates per $1,000 are
attached. We have the option of charging less than the maximum. Each year, the
current annual cost of insurance rates for this rider will be declared for the
next policy year. Any change in the current cost of insurance rates will apply
to Covered Insureds under this rider having the same issue age, sex, tobacco
usage and risk class and whose riders have been in effect for the same length of
time. We cannot increase rates because of a change in status of the Covered
Insured's health.
TRCI 8099