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EXHIBIT 1A(5)(g)
PEOPLES BENEFIT LIFE INSURANCE COMPANY
Home Office located at: 4333 Edgewood Road N.E., Cedar Rapids, Iowa 52499
A Stock Company
(Hereafter called the Company, we, our or us)
(800)866-6007
CHILDRENS BENEFIT RIDER
This extra benefit rider, attached to and made a part of the policy, provides as
described below, term insurance on each insured dependent child of the Insured.
While this rider and policy remain in force, we agree:
1. To pay the amount of insurance provided by this rider to the beneficiary
when we receive due proof of the death of an insured dependent child of
the Insured on or before the expiry date of this rider.
2. To continue this rider in force until the Expiry Date without any further
premiums being paid when we receive due proof of the death of the Insured.
INSURED
The Insured is the person shown as the Insured on page 3 of the policy.
DEPENDENT CHILD
A dependent child is a child, stepchild, or legally adopted child of the
Insured. A child is not a dependent child prior to becoming 14 days old.
To become an insured dependent child at the time of application, a dependent
child must:
1. Be named in the application for this rider, unless specifically excluded;
2. Be under 18 years old on the date of the application; and
3. Receive principal support from the Insured.
To become an insured dependent child after the date of the application, a child
must:
1. Become a dependent child after the date of the application;
2. Be under 18 years old on the date the child becomes a dependent child;
3. Receive principal support from the Insured;
4. Provide evidence of insurability if the child is a stepchild of the
Insured; and
5. Provide evidence of insurability, if at the time of application for this
rider that child was specifically excluded.
EXPIRY DATE
The expiry date of this rider is the policy anniversary after every insured
dependent child has reached his or her 25th birthday.
AMOUNT OF INSURANCE
We will pay a death benefit to the beneficiary upon our receipt of due proof of
the death of any insured dependent child of the Insured. The amount of death
benefit with respect to each insured dependent child is
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$1,000 per unit multiplied by the number of units shown on page 3. After one
rider year, the Insured, upon completion of a new application, may increase the
death benefit of an insured dependent child. Any increase will be subject to our
underwriting requirements as well as the Incontestability provision of this
rider.
OWNERSHIP
Unless the Insured requests otherwise, the following ownership arrangement will
apply:
1. You, the Insured, are the owner of this rider.
2. Upon your death, the insurance on each insured dependent child will be
owned by your spouse at the time of your death if that child had been born
to, or legally adopted by that spouse.
3. If you have died and if any requirement of 2 above is not met with respect
to an insured dependent child, the insurance on that insured dependent
child will be owned by that child.
BENEFICIARY
Unless the Insured requests otherwise, the beneficiary arrangement of this rider
will be as follows:
1. The Insured, if living.
2. If the Insured is not living, the beneficiary of the insurance on each
insured dependent child will be the Insured's spouse at the time of the
Insured's death if that insured dependent child had been born to, or
legally adopted by that spouse.
3. If the Insured is not living and if any requirement of 2 above is not met
with respect to an insured dependent child, the beneficiary of the
insurance on that insured dependent child will be that child's estate.
REINSTATEMENT
If this rider lapses, the Insured may reinstate it at any time during his
lifetime by submitting the following items:
1. A written application for reinstatement.
2. Evidence of insurability satisfactory to us for the Insured and each
dependent child.
3. Overdue premiums with interest as provided by the policy.
You must also reinstate the policy at the time you reinstate this rider.
PAID-UP INSURANCE UPON DEATH OF INSURED
Upon the death of the Insured while this policy is in force other than under a
Nonforfeiture Option, any insurance provided by this rider shall become paid-up
term insurance for the unexpired period.
THE CONTRACT
In this rider "policy" means the policy in which you have requested that this
rider be included. "Page 3" means page 3 of the policy.
This rider is issued in consideration of the application and the payment of
premiums as provided. The amount of premium and the premium-paying period for
this rider are shown on page 3.
If a waiver of premium rider is included in the policy, that rider will also
apply to this rider.
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This rider is a part of the policy. All provisions of the policy which are not
inconsistent with the provisions of this rider apply to this rider.
RIDER DATE
Rider months, years and anniversaries are measured from the rider date. The
rider date is the policy date unless a different rider date is shown in the
policy. When used in the rider, "date of issue" means the rider date.
INCONTESTABILITY
We cannot contest this rider after it has been in force during the lifetime of
the Insured for two years after the later of:
1. The Rider Date;
2. The effective date of any increase in the death benefit of an insured
dependent child, and then for the increased amount only;
3. The effective date that any insured dependent child is added by
endorsement, and then for that child only; or
4. The effective date of reinstatement of this rider.
Only statements material to such reinstatement shall be contestable for one year
from the date of reinstatement.
TERMINATION
The term insurance on an insured dependent child shall terminate on the earliest
of the following dates:
1. The expiry date of this rider.
2. The date this rider or policy lapses for failure to pay a premium.
3. The date the policy becomes paid-up, expires, matures as an endowment or
otherwise terminates.
4. The date a Nonforfeiture Option under the policy, if any, becomes
effective.
5. The conversion of the policy to another policy under which premiums would
not continue to the expiry date of this rider.
6. The policy anniversary following the date of marriage for that child.
7. The policy anniversary following that child's 25th birthday.
CONVERSION
When the insurance on the life of an insured dependent child terminates for any
reason provided above, except for lapse of rider, while the basic policy
continues in force other than as paid-up or extended term insurance, that child
has the option to convert to an individual policy. Such insurance may be
converted at the then attained age to any level premium whole life or endowment
plan of insurance then being issued by us, for the then current rates and
limits, without further evidence of insurability in accordance with the
following:
1. Proper written application for the new policy accompanied by the first
premium must be made to us at our home office within 31 days after such
expiry.
2. The policy date of the new policy shall be the date such application is
made and the premium is paid.
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3. The amount of insurance on any insured dependent child under the new
policy may be increased up to the lesser of :
a) 5 times the death benefit at the termination date, or
b) 50,000.
4. The new policy shall not provide for benefits in event of total disability
or for benefits in event of total disability or for any accidental death
benefit unless at the time of conversion the life to be insured submits
evidence of insurability which is satisfactory to us.
Signed for us at our home office.
/s/ [SIG] /s/ BART HERBERT JR.
SECRETARY PRESIDENT
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