1
EXHIBIT 1A(5)
PEOPLES BENEFIT LIFE INSURANCE COMPANY
A Stock Company
Home Office located at: 4333 Edgewood Road N.E., Cedar Rapids, Iowa 52499
(Hereafter called the Company, we, our or us)
(800) 866-6007
INSURED: JOHN DOE INITIAL FACE AMOUNT: $100,000
POLICY NUMBER: 710 01 SAMPLE POLICY DATE: DECEMBER 01, 2000
OWNER(S): JOHN DOE
WE AGREE -To pay Proceeds of this policy to the beneficiary upon receiving due proof of the
Insured's death prior to the Maturity Date. THE AMOUNT OF THE DEATH BENEFIT PROCEEDS
WILL INCREASE OR DECREASE DEPENDING ON THE INVESTMENT EXPERIENCE OF THE SUB-ACCOUNTS
IN THE SEPARATE ACCOUNT AND ON THE DEATH BENEFIT OPTION SELECTED AS DESCRIBED IN THE
DEATH BENEFIT PROVISION.
-To pay the Proceeds of this policy to the Owner if the Insured is living on the
Maturity Date. POLICY VALUES WILL INCREASE OR DECREASE IN ACCORDANCE WITH THE POLICY
VALUE PROVISIONS AND THE INVESTMENT EXPERIENCE OF THE SUB-ACCOUNTS IN THE SEPARATE
ACCOUNT. POLICY VALUES ARE NOT GUARANTEED AS TO DOLLAR AMOUNT.
-To provide you with the other rights and benefits of this policy.
These agreements are subject to the provisions of this policy.
10 DAY RIGHT YOU MAY CANCEL THIS POLICY BY DELIVERING OR MAILING A WRITTEN REQUEST TO US OR TO THE
TO CANCEL AGENT FROM WHOM IT WAS PURCHASED. YOU MUST RETURN THE POLICY TO US OR THE AGENT BEFORE
MIDNIGHT OF THE TENTH DAY AFTER THE DAY YOU RECEIVE IT. YOUR WRITTEN REQUEST GIVEN BY
MAIL AND RETURN OF THE POLICY BY MAIL ARE EFFECTIVE ON BEING POSTMARKED, PROPERLY
ADDRESSED AND POSTAGE PREPAID. WE MUST RETURN ALL PAYMENTS MADE FOR THIS POLICY, LESS
ANY WITHDRAWALS AND INDEBTEDNESS, AFTER WE RECEIVE NOTICE OF CANCELLATION AND THE
RETURNED POLICY.
Signed for us at our home office.
[SIG] [SIG]
SECRETARY PRESIDENT
This policy is a legal contract between the policyowner and the Company.
READ YOUR POLICY CAREFULLY
BENEFITS PAID UNDER THE TERMINAL ILLNESS ACCELERATED DEATH BENEFIT MAY BE
CONSIDERED TAXABLE INCOME TO YOU. WE URGE YOU TO CONSULT YOUR PERSONAL TAX
ADVISOR REGARDING MATTERS OF POSSIBLE TAXATION.
FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE POLICY
TERMINAL ILLNESS ACCELERATED DEATH BENEFIT
PREMIUMS PAYABLE TO MATURITY DATE OR UNTIL PRIOR DEATH OF INSURED
PROCEEDS, IF ANY, PAYABLE AT DEATH OR MATURITY DATE
NON-PARTICIPATING
SOME BENEFITS REFLECT INVESTMENT RESULTS
AVUL0709 00 1200
2
DEFINITIONS
When we use the following words, this is what we mean:
ACCOUNTS Allocation options including the Fixed Account and the Sub-accounts of the
Separate Account.
AGE The Insured's age at the Insured's last birthday.
BENEFICIARY The person to receive the proceeds in the event of the Insured's death.
DEATH BENEFIT Includes any Policy or Rider which provides a death benefit on the Insured,
excluding the supplementary rider for accidental death benefit.
FIXED ACCOUNT Allocation option other than the Separate Account.
FUND A designated investment fund from which each Sub-account of the Separate
Account will buy shares.
IMMEDIATE A spouse, child, brother, sister, grandparent or grandchild of the Insured or
FAMILY Owner.
INDEBTEDNESS All policy loans, if any, plus any accrued interest you owe.
IN FORCE The period of time the Insured's life remains insured under the terms of this
policy.
INSURED The person whose life is insured under this policy as shown on page 3.
INVESTMENT The latest of: (a) the date of the application; (b) the date all required medical
START DATE examinations or diagnostic tests are completed; (c) the date of issue requested
in the application unless underwriting is not yet completed; (d) the date of
underwriting approval; (e) the date we receive the first premium at our Home Office;
and (f) the date all other requirements are met.
MATURITY DATE The first Policy Anniversary following the Insured's 100th birthday.
MONTHLY DATE The same day of each month as the Policy Date.
PHYSICIAN An individual licensed to practice medicine and treat injury or illness in the state
in which treatment is received and who is acting within the scope of that license. A
Physician must be someone other than:
(a) the Insured;
(b) the Owner;
(c) a person who lives with the Insured or Owner; or
(d) a person who is part of the Insured's or Owner's Immediate Family.
PHYSICIAN'S A written statement acceptable to the Company and signed by a Physician
STATEMENT which:
(a) gives the Physician's diagnosis of the Insured's terminal medical condition;
and
(b) states with reasonable medical certainty the terminal medical condition will result in the
death of the Insured within 12 months from the date of the Physician's Statement.
This statement must take into consideration the ordinary and reasonable medical
care, advice, and treatment available in the same or similar communities.
POLICY The same day and month as your policy date for each succeeding year your
ANNIVERSARY policy remains in force.
POLICY DATE The Policy Date is shown on the Policy's Specifications Page, and we use it to
measure Policy months, years, and anniversaries. We begin to deduct the Monthly
Deductions on the Policy Date. Coverage is effective as of the Policy Date once all
requirements have been met.
AVULB709 00 1200 PAGE 2
3
PREMIUM A temporary holding account into which all premiums are allocated prior to
SUSPENSE the Investment Start Date. The Premium Suspense Account does not credit any
ACCOUNT interest or investment return.
PROCEEDS The amount we are obligated to pay under the terms of this policy when
your policy is surrendered or when the Insured dies. Upon Maturity the
proceeds are equal to the Cash Surrender Value providing the Insured is
living.
REINSTATE To restore coverage after the policy has lapsed.
SEC The United States Securities and Exchange Commission.
SEPARATE A separate investment account shown on the Policy Specifications Page,
ACCOUNT which is composed of several Sub-accounts established to receive and invest
Net Premiums under the Policy.
SPECIFIED The amount upon which death benefits are determined. The Initial Specified
AMOUNT Amount is shown on page 3.
SUB-ACCOUNT A sub-division of the Separate Account. Each Sub-account invests
exclusively in the shares of a specified Fund Portfolio.
TERMINAL A condition resulting from injury or illness which, as determined by a
CONDITION Physician, has reduced the Insured's life expectancy to not more than 12 months
from the date of the Physician's Statement.
TERMINATE The Insured's life is no longer insured under any of the terms of this policy.
VALUATION DATE Any day we are required by law to value the assets of the Separate Account.
VALUATION The period commencing at the end of one Valuation Date and continuing to
PERIOD the end of the next succeeding Valuation Date.
WRITTEN REQUEST A request in writing signed by you on a form agreeable to us.
YOU, YOUR The owner of this policy is as shown in the application, unless subsequently
changed as provided for in this policy. The owner is the Insured unless
otherwise stated.
AVULC709 00 1200 PAGE 2A
4
POLICY SPECIFICATIONS PAGE
POLICY NUMBER: 710 01 SAMPLE INSURED: JOHN DOE
INITIAL SPECIFIED AMOUNT: $100,000 AGE/SEX: 35 / MALE
MINIMUM SPECIFIED AMOUNT: $50,000 POLICY DATE: DECEMBER 01, 2000
DEATH BENEFIT OPTION: LEVEL MATURITY DATE: DECEMBER 01, 2065
NO LAPSE ENDING DATE: DECEMBER 01, 2020
OWNER(S): JOHN DOE
ADMINISTRATIVE CHARGE:
GUARANTEED: $10.00 per month (all years)
CURRENT: $10.00 per month (all years)
EXPENSE CHARGE:
GUARANTEED: 5.00% of any premium collected (all years)
CURRENT: 5.00% of any premium payment collected (years 1-10)
2.50% of any premium payment collected (years 11+)
PARTIAL WITHDRAWAL FEE: LESSER OF $25.00 OR 2% OF AMOUNT WITHDRAWN
TRANSFER FEE: $25.00 FOR THE 13TH AND ANY SUBSEQUENT TRANSFERS IN A POLICY YEAR.
SEPARATE ACCOUNT PROVISIONS:
SEPARATE ACCOUNT: PEOPLES BENEFIT VARIABLE LIFE ACCOUNT A
MORTALITY AND EXPENSE RISK CHARGE: 0.00002047 DAILY (0.75% ANNUALLY)
Premiums are payable to Maturity Date or until prior death of the Insured. It is
possible that coverage will expire prior to the Maturity Date where either no
premiums are paid following payment of the initial premium or subsequent
premiums are insufficient to continue coverage to such date. Coverage will be
affected by changes in the current interest rate for the Fixed Account, Loans,
Withdrawals, Administrative and Expense Charges, and Cost of Insurance in
addition to the investment experience of the Sub-accounts of the Separate
Account.
If the insured is living on the Maturity Date, we will pay the Proceeds equal to
the Cash Surrender Value, if any, to you.
THE TAX STATUS OF THIS POLICY MAY CHANGE. WE URGE YOU TO CONSULT YOUR PERSONAL
TAX ADVISOR EACH YEAR REGARDING MATTERS OF POSSIBLE TAXATION.
PREMIUM CLASS: TOBACCO
TYPE PAYABLE TO PLANNED
OF SPECIFIED INSURED'S PREMIUM
COVERAGE AMOUNT AGE PAYMENTS
(ANNUAL)
BASIC POLICY $100,000 100 $1,080.00
TOTAL PLANNED PREMIUM PAYMENTS............................................................$1,080.00
BASIC POLICY INITIAL PREMIUM..............................................................$1,080.00
AVUL0709 1200SP PAGE 3
5
SURRENDER CHARGES
End of Surrender End of Surrender
Policy Year Charge Policy Year Charge
----------- ------ ----------- ------
1 $2,800 11 $1,400
2 2,660 12 1,260
3 2,520 13 1,120
4 2,380 14 980
5 2,240 15 840
6 2,100 16 700
7 1,960 17 560
8 1,820 18 420
9 1,680 19 280
10 1,540 20 0
AVUL0709 00 1200SPA PAGE 3A
6
TABLE OF MINIMUM MONTHLY PREMIUMS
Minimum End of Year Minimum End of Year
------- Sum of all ------- Sum of all
Monthly Minimum Monthly Minimum
------- Monthly ------- Monthly
Policy Year Premium Premiums Policy Year Premium Premiums
----------- ------- ---------------- ----------- ------- ----------------
1 $61.66 $ 739.92 11 $61.66 $ 8,139.12
2 61.66 1,479.84 12 61.66 8,879.04
3 61.66 2,219.76 13 61.66 9,618.96
4 61.66 2,959.68 14 61.66 10,358.88
5 61.66 3,699.60 15 61.66 11,098.80
6 61.66 4,439.52 16 61.66 11,838.72
7 61.66 5,179.44 17 61.66 12,578.64
8 61.66 5,919.36 18 61.66 13,318.56
9 61.66 6,659.28 19 61.66 14,058.48
10 61.66 7,399.20 20 61.66 14,798.40
AVUL0709 00 1200SPB PAGE 3B
7
PART 1. GENERAL PROVISIONS
THE CONTRACT Your policy is issued in consideration of the application and the payment of
premiums as provided for in this policy.
Your policy and the copy of the application attached to it contain the entire
contract between you and us. Any statements made in the application either by
you or by the Insured will, in the absence of fraud, be considered
representations and not warranties. Also, any written statement made either
by you or by the Insured will not be used to void your policy nor defend
against a claim under your policy unless the statement is contained in the
application.
No change or waiver of any of the provisions of this policy will be valid
unless made in writing by us and signed by our president, a vice president,
our secretary or an officer of the company. No agent or other person has the
authority to change or waive any provision of your policy.
Any extra benefit rider attached to this policy will become a part of this
policy and will be subject to all the terms and conditions of this policy
unless we state otherwise in the rider.
SUICIDE If the Insured, whether sane or insane, dies by suicide within two years from
the Policy Date, our liability will be limited to an amount equal to the
premiums paid for this policy.
If the Insured, whether sane or insane, dies by suicide within two years from
the effective date of any increase in the Specified Amount, our liability for
the amount of increase will be limited to the Cost of Insurance for the
increase.
If you were a Missouri citizen at the time of issue or reinstatement, the
following provision will apply: The suicide of the Insured is no defense to
payment of regular life insurance benefits, nor is the suicide of the Insured
while insane a defense to payment of accidental death benefits, if any,
available under this policy, unless we can show that the Insured intended
suicide when he applied for these benefits.
If this Policy is reinstated, this Section will be reinstated. A new two-year
period shall apply beginning on the date of reinstatement. If the Insured,
whether sane or insane, dies by suicide within two years from the
reinstatement date, our liability will be limited to an amount equal to the
premiums paid from the date of reinstatement.
INCONTESTABILITY We cannot contest this policy, except for fraud or non-payment of Monthly
Deduction, after it has been in force during the lifetime of the Insured for
two years after:
(a) the Policy Date;
(b) the effective date of any increase in the Specified Amount, and then only
for the increased amount; or
(c) the effective date of reinstatement of this policy.
In the absence of fraud, only statements material to such reinstatement shall
be contested during the lifetime of the Insured for two years after the
effective date of reinstatement.
ASSIGNMENT You may assign your policy. The assignment must be in writing and filed at
our home office. We assume no responsibility for the validity or effect of
any assignment of this policy or of any interest in it. Any proceeds which
become payable to an assignee will be payable in a single sum and will be
subject to proof of the assignee's interest and the extent of the assignment.
P788 PAGE 4
8
MISSTATEMENT If the age and/or sex of the Insured has been misstated, the death
OF AGE OR SEX benefits will be adjusted to that which would have been purchased by the
most recent cost of insurance charge at the correct age and/or sex.
BENEFICIARY When we receive due proof of the Insured's death, we will pay the
proceeds of this policy to the beneficiary or beneficiaries who are
named in the application for this policy unless you subsequently change
the beneficiary. In that event, we will pay the proceeds to the
beneficiary named in your last change of beneficiary request as provided
for in this policy.
If a primary or contingent beneficiary dies before the Insured, that
beneficiary's interest in this policy ends with that beneficiary's
death. Only those beneficiaries who survive the Insured will be
eligible to share in the proceeds. If no beneficiary survives the
Insured, we will pay the proceeds of this policy to you, if living,
otherwise to your estate.
CHANGE OF OWNER If you have reserved the right to change the owner or beneficiary, you
OR BENEFICIARY can file a written request with us on a form satisfactory to the Company
to make such a change. If you have not reserved the right to change the
beneficiary, the written consent of the irrevocable beneficiary will be
required.
Your written request will not be effective until it is recorded in our
home office records. After it has been so recorded, it will take effect
as of the date you signed the request. However, if the Insured dies
before the request has been so recorded, the request will not be
effective as to those proceeds we have paid before your request was
recorded in our home office records.
NONPARTICIPATING This policy will not share in our surplus distributions.
ILLUSTRATIVE A new projection is available on an annual basis. Additional projections
REPORTS are available but may incur a fee, not to exceed $25.00.
PREMIUMS The Initial Premium is the premium due on the Policy Date, and is
payable in advance. All premiums are payable to us in advance and must
be mailed to our home office or to an agent authorized by us to collect
premiums. A premium receipt signed by a company officer will be
provided upon request.
PLANNED PREMIUM The amount and frequency of the planned premium payments are shown
PAYMENTS on page 3 of your policy. However, premium payments are flexible and
the Owner may change the amount and frequency of payments. Interruption
of planned premium payments or reduction in the amount of planned
premium payments may cause your policy to enter the Grace Period prior
to Maturity Date.
UNSCHEDULED Additional premiums may be paid at any time before the Maturity Date,
PREMIUMS provided that the policy is in force and there is no indebtedness.
We reserve the right to limit the amount of premiums that may be paid on
the policy if we determine that: (a) the amount is below our current
minimum payment requirement; or (b) payment of a greater amount may
cause the proceeds of this policy to lose their tax status as life
insurance under the Internal Revenue Code; or (c) payment of a greater
amount would increase the Death Benefit by application of the Death
Benefit Ratio (unless we are provided evidence of insurability
satisfactory to us.)
The minimum amount of any premium that will be accepted is $25.00.
PB788 PAGE 5
9
CONTINUATION If planned premium payments are not paid and no unscheduled premiums are
OF COVERAGE received, this policy will continue in force unless the conditions of the
Grace Period provision apply. If the Insured is living on the Maturity Date,
any proceeds will become payable unless a different nonforfeiture option has
been elected.
GRACE PERIOD If the Cash Surrender Value on any Monthly Date is not sufficient to pay the
Monthly Deduction then due, a grace period of 61 days will begin when notice
has been sent to your last known address of record. If sufficient premium is
not paid by the end of the grace period, the policy will terminate without
value. If the Insured dies during the grace period, we will pay the Death
Benefit, less any indebtedness and any unpaid Monthly Deduction.
During the period beginning on the Policy Date and ending on the No Lapse
Ending Date shown on page 3, the policy will not enter the grace period if on
any Monthly Date the sum of the premiums that have been paid, less any
indebtedness and partial withdrawals, equals or exceeds the sum of all Minimum
Monthly Premiums beginning with the Policy Date. The Minimum Monthly Premium
is the amount you must pay to guarantee coverage until the No Lapse Ending
Date listed on the Policy Specifications Page.
For the period beginning on the Policy Date and ending on the No Lapse Ending
Date, the Minimum Monthly Premiums and the sum of all Minimum Monthly Premiums
for each policy year are shown on page 3B. The Minimum Monthly Premium is
increased for each policy month following the date of an increase in the
Specified Amount, or when an extra benefit rider is added or increased. The
Minimum Monthly Premium is decreased for each policy month following the date
an extra benefit rider is decreased or discontinued. The Minimum Monthly
Premium will not decrease following the date of decrease in the Specified
Amount. The new Minimum Monthly Premiums will be shown on a new page 3B. Any
new No Lapse Ending Date will be shown on a new page 3.
In any case, the policy will lapse if the total indebtedness equals or exceeds
the Cash Surrender Value.
REINSTATEMENT If a premium is not received before the end of the 61 day grace period, your
policy will terminate without value and no further premium payments may be
made.
However, even if your policy terminates, during the lifetime of the Insured,
this policy can be reinstated if it was terminated because a grace period
ended without sufficient payment. Any reinstatement must be done within 5
years from the end of the grace period. We will require:
(1) Your written request to reinstate this policy,
(2) the Insured's written consent to reinstatement,
(3) Evidence of insurability satisfactory to us,
(4) Payment or reinstatement of any indebtedness, and
(5) Payment of enough premium to keep this policy in force for at least 3
months.
The date of reinstatement will be the Monthly Date on or following the date
the application for reinstatement is approved by us, so long as the Insured is
still living. If all the conditions for reinstatement are satisfied, coverage
under this Policy will be effective as though it had continued in force from
the lapse date to the date of reinstatement.
Your policy cannot be reinstated if your policy was surrendered for cash.
PC788 PAGE 6
10
PARTIAL After the first policy year, one cash withdrawal per policy year may be made
WITHDRAWALS during the lifetime of the Insured. We must receive a written request at our
home office.
The withdrawal amount will be equal to the amount of the withdrawal requested
plus a fee equal to the lesser of $25.00 or 2% of the amount requested for
each withdrawal. No surrender charges apply to partial withdrawals. The
minimum withdrawal amount is $500.00. You must specify the Account from which
the withdrawal will be taken. The withdrawal fee will be removed from one of
the Accounts.
The Policy Value will be reduced by the withdrawal amount. If the Death
Benefit Option of this policy is Level, the Specified Amount will also be
reduced by the withdrawal amount (without the fee). However, no withdrawal
will be allowed if the resulting Specified Amount would be less than the
Minimum Specified Amount as shown on page 3.
If the amount of the withdrawal request is greater than or equal to the Cash
Surrender Value, or if less than $500 of Cash Surrender Value remains, the
withdrawal will be considered a surrender and the Cash Surrender Value
provision will apply.
We reserve the right to defer any withdrawals from the Fixed Account for the
period allowed by law, but not more than six months. We will not defer a
withdrawal if it is to be applied for the payment of premiums to us.
Reductions in the Specified Amount due to any Partial Withdrawals will be in
the following order:
1) To the most recent increase in the Specified Amount.
2) To the next most recent increase in the Specified Amount.
3) To the Initial Specified Amount or the current Specified Amount if less.
ANNUAL REPORT We will send you, at least once a year, an Annual Report which shows the
current Death Benefit, Policy Value, the amount of indebtedness, premiums
paid, and Monthly Deductions since the last report. Additional activity
within each Sub-account showing investment experience will also be provided.
POLICY PAYMENT All proceeds to be paid upon termination will be paid in one sum unless
otherwise elected under the Settlement Options of this policy.
All payments and transfers from the Sub-accounts will be processed as provided
in this policy unless one of the following situations exist:
1. The New York Stock Exchange is closed; or
2. The SEC requires that trading be restricted or declares an emergency; or
3. The SEC allows us to defer payments to protect our policyowners.
We reserve the right to defer the payment of any Fixed Account values for the
period permitted by law, but not more than six months.
EXCHANGE At any one time the Owner may exercise the Exchange Privilege, which results
PRIVILEGE in the transfer of the entire amount in the Sub-accounts to the Fixed Account,
and the allocation of all future net premiums to the Fixed Account. This will
serve as an exchange of the Policy for the equivalent of a flexible premium
fixed benefit life insurance policy. No charge will be imposed on such
transfer.
PD788 PAGE 7
11
Part 2. SEPARATE ACCOUNT PROVISIONS
SEPARATE ACCOUNT The variable benefits under this Policy are provided through the Separate
Account as shown on the Policy Specifications page. The assets of the
Separate Account are our property. Assets equal to the reserve and other
contractual liabilities under all policies issued in connection with the
Separate Account will not be charged with liabilities arising out of any
other business we may conduct. If the assets of the Separate Account exceed
the liabilities arising under the policies supported by the Separate
Account, then the excess may be used to cover liabilities of our general
account. The assets of the Separate Account shall be valued as often as any
policy benefits vary, but at least monthly.
SUB-ACCOUNTS The Separate Account has various Sub-accounts with different investment
objectives. We reserve the right to add or remove any Sub-account of the
Separate Account. Income, if any, and any gains or losses, realized or
unrealized, from assets in each Sub-account are credited to, or charged
against, the amount allocated to that Sub-account without regard to income,
gains, or losses in other Sub-accounts. Any amount charged against the
investment base for federal or state income taxes will be deducted from that
Sub-account. The assets of each Sub-account are invested in shares of a
corresponding Fund portfolio. The value of a portfolio share is based on
the value of the net assets of the portfolio determined at the end of each
Valuation Period in accordance with applicable law.
TRANSFERS The owner may transfer all or a portion of this Policy's value in each
Account to other Accounts. We will charge a $25 fee for each transfer in
excess of twelve per policy year. This charge will be deducted from one of
the Accounts from which funds were transferred. A request for a transfer
must be made in a form satisfactory to us. The transfer will ordinarily
take effect on the first Valuation Date on or following the date the request
is received by us in our home office. We will treat all transfer requests
received on the same day as a single request. A minimum of $100 (or, if the
Account is less than $100, the entire amount in the Account) must be
transferred out of each Account from which money is being transferred.
ADDITION, DELETION We reserve the right to transfer assets of the Separate Account, which
OR SUBSTITUTION we determine to be associated with the class of contracts to which this
OF INVESTMENTS policy belongs, to another Separate Account. If this type of transfer is
made, the term "Separate Account", as used in this policy, shall mean the
Separate Account to which the assets were transferred. We also reserve the
right to add, delete, or substitute investments held by any Sub-account.
We reserve the right, when permitted by law, to:
1. De-register the Separate Account under the Investment Company Act of 1940;
2. Manage the Separate Account under the direction of a committee at any time;
3. Restrict or eliminate any voting privileges of owners or other persons
who have voting privileges as to the Separate Account;
4. Combine the Separate Account or any Sub-account(s) with one or more other
Separate Accounts or Sub-accounts;
5. Operate the Separate Account as a management investment company;
6. Establish additional Sub-accounts to invest in either a new Fund or in shares
of another diversified, open-end registered investment company;
7. Fund additional classes or variable life insurance contracts through the
Separate Account.
SA200 PAGE 8
12
CHANGE OF We reserve the right to change the investment objective of a Sub-account.
INVESTMENT If required by law or regulation, an investment objective of the Separate
OBJECTIVE Account, or of a Fund portfolio designated for a Sub-account, will not be
materially changed unless a statement of the change is filed with and approved
by the appropriate insurance official of the state of our domicile or deemed
approved in accordance with such law or regulation. If required, approval of
or change of any investment objective will be filed with the Insurance
Department of the state where this policy is delivered.
UNIT VALUE Some of the policy values fluctuate with the investment results of the
Sub-accounts. In order to determine how investment results affect the policy
values, a unit value is determined for each Sub-account. The unit value of
each Sub-account was originally established at $10 per unit. The unit value
may increase or decrease from one Valuation Period to the next. Unit values
also will vary between Sub-accounts. The unit value of any Sub-account at the
end of a Valuation Period is the result of:
1. The total value of the assets held in the Sub-account. This value is
determined by multiplying the number of shares of the designated Fund
portfolio owned by the Sub-account times the net asset value per share;
minus
2. The accrued charges for mortality and expense experience. The daily
amount of this charge is no greater than the net assets of the Sub-account
multiplied by the Mortality and Expense Risk Charge shown on the Policy
Specifications page; minus
3. The accrued amount of reserve for any taxes or other economic burden
resulting from the application of tax laws that are determined by us to
be properly attributable to the Sub-account; and the result divided by
4. The number of outstanding units in the Sub-account.
The use of the unit value in determining contract values is described in the
Policy Values provisions.
SAB200 PAGE 9
13
Part 3. POLICY VALUES
SPECIFIED The Specified Amount for your policy is shown on page 3. After the first
AMOUNT Policy Anniversary, you may change the Specified Amount at any time by sending
a written request to our home office, subject to the restrictions set forth
below for increases in the Specified Amount. However, you may change the
Specified Amount only once during a 12-month period. Any change in the
Specified Amount will take effect on the first Monthly Date following approval
of your written request.
If you request a change in the Specified Amount or Death Benefit Option, we
will issue a new Policy Specifications Page (page 3) upon approval.
INCREASE IN You may, prior to the Insured's age 86 and upon completion of a new
THE SPECIFIED application, increase the Specified Amount as described above. Any increase
AMOUNT will be subject to our underwriting requirements as well as Suicide Exclusions
and Incontestability restrictions (see page 4).
DECREASE IN You may, upon written request, decrease the Specified Amount as described
THE SPECIFIED above. The decrease will be applied against the most recent increase in the
AMOUNT Specified Amount. It will then be applied to other increases in the reverse
order in which they occurred. No decrease in Specified Amount below the
minimum shown on page 3 will be allowed.
DEATH BENEFIT This policy will provide the following death benefits:
INCREASING: The Death Benefit is the greater of the Specified Amount plus the Policy Value
or the Policy Value multiplied by the Death Benefit Ratio.
LEVEL: The Death Benefit is the greater of the Specified Amount or the Policy Value
multiplied by the Death Benefit Ratio.
DEATH BENEFIT RATIOS
-------------------------------------------------------------
Attained Death Benefit Attained Death Benefit
Age Ratio Age Ratio
0-40 2.50 61 1.28
41 2.43 62 1.26
42 2.36 63 1.24
43 2.29 64 1.22
44 2.22 65 1.20
45 2.15 66 1.19
46 2.09 67 1.18
47 2.03 68 1.17
48 1.97 69 1.16
49 1.91 70 1.15
50 1.85 71 1.13
51 1.78 72 1.11
52 1.71 73 1.09
53 1.64 74 1.07
54 1.57 75-90 1.05
55 1.50 91 1.04
56 1.46 92 1.03
57 1.42 93 1.02
58 1.38 94 1.01
59 1.34 95-99 1.00
60 1.30
-------------------------------------------------------------
V694 PAGE 10
14
After the first Policy Anniversary, you may change the Death Benefit Option
upon written request but not more often than once during a 12 month period.
The change will go into effect on the Monthly Date on or following the date we
approve the request.
If you change from LEVEL to INCREASING, the Specified Amount will be decreased
by the Policy Value. The resulting Specified Amount must not be less than the
minimum Specified Amount shown on the Policy Specifications Page. If you
change from INCREASING to LEVEL, the Specified Amount will be increased by the
amount of the Policy Value.
The Death Benefit Option for this policy is disclosed on page 3.
We will pay the Death Benefit, less any indebtedness and any Monthly
Deductions due, if the Insured dies while this policy is in force, subject to
the terms of this policy. We will pay as soon as we receive written due proof
at our home office that the Insured has died. The Death Benefit payable will
be calculated as of the actual date of death.
INTEREST FROM If the proceeds under this policy are not paid within thirty days after we
DATE OF DEATH receive due proof of the death of the Insured (or where required by law within
thirty days after the death of the Insured), we will pay interest on the
proceeds from the date of death to the date of payment. The interest rate
will be determined by us, but never less than 3%.
POLICY VALUE At the end of any Valuation Period, the Policy Value is equal to the sum of
the Sub-account values plus the Fixed Account value.
NET PREMIUMS The Net Premium is any premium collected minus the Expense Charge. The
Expense Charge is disclosed on page 3. We may use an Expense Charge lower
than the Guaranteed Expense Charge but will never charge in excess of the
Guaranteed Expense Charge. Any change in the Expense Charge will be applied
uniformly to all members of the same premium class.
ALLOCATION OF All net premiums received prior to the Investment Start Date will be allocated
NET PREMIUMS to the Premium Suspense Account. On the first Valuation Date on or following
the Investment Start Date, the values in the Premium Suspense Account will be
transferred to the Sub-accounts of the Separate Account and the Fixed Account
in accordance with the Owner's allocation as shown in the application. All
net premiums received on or after the Investment Start Date will be allocated
to the Sub-accounts of the Separate Account and the Fixed Account on the first
Valuation Date on or following the date the premium is received at our home
office.
Any allocation to an Account is limited to no less than 5% of total premium.
No fractional percentages may be permitted. No more than 10 accounts may be
receiving current premium allocations. The current premium allocation may be
changed by the Owner. Only 4 premium allocation changes are permitted within
one policy year. The request for change of allocations must be in a form
satisfactory to us. The allocation change will be effective on the date the
request for change is recorded by us.
MONTHLY On the Policy Date and each Monthly Date thereafter, a Monthly Deduction
DEDUCTION will be withdrawn from the Policy Value. Each Monthly Deduction consists of:
1. The monthly Cost of Insurance; plus
2. The Administrative Charge (see page 3); plus
3. Any premium for additional benefits provided by riders (see page 3); plus
4. Any charges for substandard premium class rating.
Deductions will be withdrawn from each Sub-account and the Fixed Account on a
pro-rata basis.
VB694 PAGE 11
15
COST OF The Monthly Cost of Insurance is determined by multiplying the difference
INSURANCE between the Death Benefit divided by 1.0024663 and the Policy Value at the
beginning of each month, by the Monthly Per Dollar Cost of Insurance Rate.
The Monthly Cost of Insurance Rate is based on the Insured's:
-Sex,
-Attained age, and
-Premium class shown on page 3.
The Monthly Guaranteed Maximum Cost of Insurance Rates are shown in the
Insured's Guaranteed Maximum Cost of Insurance Table on pages 18 and 18A. We
may use Cost of Insurance Rates lower than the guaranteed rates but will never
charge rates in excess of the Guaranteed Maximum Cost of Insurance Rates. Any
change in the Cost of Insurance Rates will be applied uniformly to all members
of the same premium class.
SUB-ACCOUNT At the end of any Valuation Period, the Sub-account value is equal to the
VALUE number of units that the Policy has in the Sub-account, multiplied by the unit
value of that Sub-account.
The number of units that the Policy has in each Sub-account is equal to:
1. The initial units purchased on the Investment Start Date; plus
2. Units purchased at the time of additional Net Premiums are allocated to
the Sub-account; plus
3. Units purchased through transfers from another Sub-account or the Fixed
Account; minus
4. Those units that are redeemed to pay for monthly deductions as they are
due; minus
5. Any units that are redeemed to pay for partial withdrawals; minus
6. Any units that are redeemed as part of a transfer to another Account.
FIXED ACCOUNT At the end of any Valuation Period, the Fixed Account value is equal to:
VALUE
1. The sum of all Net Premiums allocated to the Fixed Account; plus
2. Any amounts transferred from a Sub-account to the Fixed Account; plus
3. Total interest credited to the Fixed Account; minus
4. Any amounts charged to pay for monthly deductions as they are due; minus
5. Any amounts withdrawn from the Fixed Account to pay for partial withdrawals; minus
6. Any amounts transferred from the Fixed Account to a Sub-account.
We reserve the right to defer payment of any amounts from the Fixed Account
for no longer than six months after we receive such written request.
INTEREST RATE The guaranteed interest rate for amounts in the Fixed Account is .24663% per
month, compounded monthly which is equivalent to 3% per year, compounded
annually.
We may use current interest rates greater than the guaranteed rates to
calculate the Fixed Account Value. These interest rates will be declared by
us. We may apply a rate of interest less than the current rate to separate
portions of the Fixed Account Value including the amount of the Fixed Account
Value equal to any outstanding loan(s). However, each rate cannot be less
than the guaranteed rate.
If any interest in excess of the Guaranteed Interest Rate is declared by us,
the following interest rates will apply to the Fixed Account Value. It will
not be applied to the portion of the Fixed Account Value equal to any
outstanding loans.
- For All Policy Years, the current interest rate will be applied.
If no interest in excess of the guaranteed interest rate is declared by us,
the Guaranteed Interest Rate will be applied to the total Fixed Account Value,
including any outstanding loans.
VC694 PAGE 12
16
EXTENDED You may elect to extend the Maturity Date shown on page 3, by submitting
MATURITY DATE a written request to our home office. The written request must be received in
our office 30 days prior to the original Maturity Date.
1. The Death Benefit will be equal to the greater of the Death Benefit payable
on the original Maturity Date or the Policy Value multiplied by 1.05;
2. Interest will be credited to the Fixed Account Value as stated in the Interest
Rate section of the Policy Value provisions;
3. The Sub-account Values, Policy Value and Cash Surrender Value will continue as
stated in the Policy. The Administrative Charge and Expense Charge will be
reduced to zero;
4. Monthly Deductions will be calculated on a basis of the Monthly Cost of
Insurance being $0.00;
5. Interest will continue to accumulate on Policy Loans as stated in the Loan
Interest provision of the Policy;
6. The Extended Maturity Date will apply to the Base Insured Rider if attached
to the Policy. All other riders attached to the Policy will terminate as of
original Maturity Date;
7. No future premium payments will be accepted, except for the amount required
for the Policy to continue in force;
8. No further Policy Loans may be initiated against the Policy; and
9. You may not increase or decrease the Death Benefit.
This provision may not be exercised if the event of this option disqualifies
the Policy as life insurance under any applicable section included in the
Internal Revenue Code of 1986 (as amended).
VD694 PAGE 13
17
Part 4. LOAN VALUES
LOANS Upon written request you can borrow up to the available Loan Value of your
policy. The amount of any policy loan may be limited to no less than $250,
except as noted below. The loan date is the date we process a loan
request. Payment will usually be made within seven days of the date we
receive proper loan request, subject to the Policy Payment section of the
General Provisions of this Policy. Loans have priority over the claims of
any assignee or other person. Your policy is the sole security of all loans.
The Loan Value of your policy is:
- 90% of the Cash Surrender Value, less six months of Monthly Deductions.
A policy which becomes over-loaned will not lapse until one month after
notice has been mailed to the last known address of the owner. Your policy
will become over-loaned when your total indebtedness equals or exceeds the
Policy Value, less any applicable Surrender Charge.
When a loan is made, an amount equal to the loan plus interest in advance
until the next Anniversary will be withdrawn from the Accounts and
transferred to the loan reserve. The loan reserve is a portion of the Fixed
Account used as collateral for any policy loan. The owner must specify the
Account or Accounts from which the withdrawal will be made.
At each anniversary, we will compare the amount of the outstanding loan
(including interest in advance until the next Anniversary, if not paid) to
the amount in the loan reserve. We will also make this comparison anytime
the owner repays all or part of the loan. At each such time, if the amount
of the outstanding loan exceeds the amount in the loan reserve, we will
withdraw the difference from the Accounts from which the loan originated,
and transfer it to the loan reserve, in the same fashion as when a loan is
made. If the amount in the loan reserve exceeds the amount of the
outstanding loan, we will withdraw the difference from the loan reserve and
transfer it to the Accounts in accordance with the owner's current
allocation instructions. However, we reserve the right to require the
transfer to the Fixed Account if such loans were originally transferred from
the Fixed Account.
LOAN INTEREST The Loan Interest Rate is 5.66% per annum, charged in advance. On each
PROVISION policy anniversary loan interest for the next year is due in advance.
Interest not paid when due will be added to the loan.
Certain loan amounts taken after the tenth policy anniversary will be
considered preferred loan amounts. Preferred loan amounts are equal to 25%
of the Policy Value. The Loan Interest Rate for preferred loan amounts is
3.85% per annum, charged in advance.
LOAN REPAYMENT You can repay all or part of a loan at any time while this policy is in
force. Each payment must be at least $25.00 unless the loan amount is less
than $25.00 in which case full payment is required.
The policy will not lapse for failure to repay any loan or interest until
the total indebtedness shall equal or exceed the Policy Value less any
applicable Surrender Charge.
L400 PAGE 14
18
Part 5. NONFORFEITURE OPTIONS
CASH You may surrender your policy for its Cash Surrender Value which may
SURRENDER be paid in cash or under an elected Settlement Option.
VALUE
Your Cash Surrender Value is determined as follows:
- The Policy Value,
MINUS - The Surrender Charge, if any,
MINUS - Any Indebtedness.
We may require that your policy be sent in with your written request before
making surrender payment. We may defer payment of any Cash Surrender Value
earned from the Fixed Account for not more than six months. When you
surrender your policy for its Cash Surrender Value, your policy will terminate.
SURRENDER The Surrender Charges are disclosed on page 3A for the Initial Specified
CHARGE Amount. We may use Surrender Charges lower than those shown, but will never
charge in excess of those shown on page 3A.
If an increase in the Specified Amount is requested and approved, additional
Surrender Charges will apply to the policy. These additional Surrender
Charges are shown on pages 21, 21A, 22, and 22A. They are listed by the
Insured's attained age and sex at the time of the increase and by duration.
REDUCED PAID- If you elect in writing, we will use the Cash Surrender Value to buy a
UP INSURANCE nonparticipating Paid-Up Endowment at Age 100 Insurance Policy at the net
single premium rate for the Insured's attained age for an amount equal to or
less than the current Specified Amount of this policy, payable under the same
conditions as this policy.
If there is any excess Cash Surrender Value remaining, following the purchase
of the paid-up insurance, such excess shall be returned to you in cash.
If a Paid-Up Policy is surrendered the amount of surrender proceeds is
determined by multiplying the Endowment at Age 100 Net Single Premium at the
Insured's then attained age by the amount of Reduced Paid-Up Insurance.
BASIS USED FOR All Nonforfeiture Options for this policy are based on the Commissioner's
CALCULATION Male or Female 1980 Standard Ordinary Mortality Table (S or NS), Age Last
Birthday, with an assumed interest rate of 3% compounded annually. Reserves
are not less than the required minimum reserves and shall never be less than
the Cash Surrender Value.
All of the values are equal to or greater than the minimums set by laws of the
states where the policy is delivered. If required, we have filed a detailed
statement about this with your State Insurance Department. It shows the
figures and methods used.
N400 PAGE 15
19
PART 6. TERMINAL ILLNESS ACCELERATED DEATH BENEFIT
You may elect to receive a portion of the Policy's Death Benefit in a Single Sum
Benefit, when the Insured, specified on page 3, has incurred a Terminal
Condition while the policy is in force.
When we receive your request and proof satisfactory to us that the Insured has
incurred a Terminal Condition we will pay the Single Sum Benefit to the Owner.
We will make payment when all of the terms and conditions of proof have been met
and subject to the conditions and limitations within this benefit.
The Single Sum Benefit may only be elected once.
Payment of the Single Sum Benefit will result in reductions of the Policy's
values and benefits, as described below.
The Single Sum Benefit is equal to:
The Policy Death Benefit in effect on the date the Single Sum Benefit is
paid.
MULTIPLIED BY
The Election Percentage. A percentage equal to no less than 25% but no
more than 75% of the Policy's Death Benefit, subject to a maximum
benefits of $500,000. If the maximum benefit of $500,000 is paid, the
election percentage will equal $500,000 divided by the Policy's Death
Benefit. This could result in an election percentage of less than 25%.
DIVIDED BY
(1+ i), where i equals the greater of (A) and (B) on the date the Single
Sum Benefit is paid. (A) equals the current yield on 90 day treasury
bills; and (B) equals the current maximum statutory adjustable Policy
Loan Interest Rate.
MINUS
Indebtedness, if any, at the time the Single Sum Benefit is paid,
multiplied by the Election Percentage.
BENEFIT AND The Policy's Specified Amount, Policy Value, Surrender Charge, and
VALUE REDUCTION indebtedness, if any, as those amounts exist on the date the Single Sum
Benefit is paid, will be reduced by the Election Percentage. The Policy Value
in the Fixed Account and each Sub-account will be reduced by the Election
Percentage.
At the time of payment we will provide you with revised policy specification
pages which reflect the reduction of all values applicable to the Policy and
all benefits it provides.
REQUEST FOR The Request for Acceleration may be given to us any time after the date the
ACCELERATION Insured incurs a Terminal Condition as defined on page 2A. This request must
identify the Insured and be sent to us at our Home Office.
REQUEST FORMS We will send request forms to the Owner when the request for acceleration is
received. If we do not send the request form within 15 days, the Owner will
be considered to have complied with the Proof of Terminal Condition
requirements by giving us a Physician Statement acceptable to us and a written
statement of the nature and extent of the Terminal Condition.
PROOF OF TERMINAL Written proof of the Insured's Terminal Condition must be received by us at
CONDITION our Home Office before we will make a Single Sum Benefit payment. This proof
will include a properly completed request form and a Physician Statement
acceptable to us. We may request additional medical information from the
Physician submitting the statement, or any other Physician providing care to
the Insured. We will not unreasonably withhold our acceptance of Proof of
Terminal Condition. All benefits described in the provision will be available
as soon as we receive satisfactory Proof of Terminal Condition.
PHYSICAL We reserve the right to have a Physician of our choosing examine the
EXAMINATION Insured, at our expense, prior to making a Single Sum Benefit payment. In the
event that the Physician we choose provides a different diagnosis of the
Insured's medical condition, we reserve the right to rely on the statement
from the Physician of our choosing for acceleration request purposes.
AD200 PAGE 16
20
PAYMENT OF All terminal illness accelerated death benefits will be paid to the Owner.
ACCELERATED Upon the death of the Owner, if other than the Insured, we will pay the
BENEFITS benefits to the estate of the Owner.
BENEFIT Payment of the Single Sum Benefit is subject to the following rules:
CONDITIONS
(a) You must complete a form provided by us, signed by the Owner;
(b) The Policy must be in force;
(c) The Policy or an eligible term rider must not be within two years of
expiration or endowment at the time the benefit is requested;
(d) If there is an irrevocable beneficiary or assignee, they must consent in
writing to payment of this benefit;
(e) Your Policy is not eligible for this benefit if:
(1) the Terminal Condition is the result of intentionally self-inflicted
injuries;
(2) the Owner is required by law to use this benefit to meet the
claims of creditors, whether in bankruptcy or otherwise; or
(3) you are required by a government agency to use this benefit to apply
for, obtain, or keep a government benefit or entitlement; and
(f) You must provide proof that the Insured has met conditions under the
Benefits provision, including an attending Physician's Statement and any
other proof we may require. We reserve the right to seek a second
medical opinion or have the Insured examined at our expense by a
Physician we choose.
ANNUAL The Annual Statement for this Policy will reflect payment of the Single Sum
STATEMENT Benefit, if paid during the prior year, as well as resulting reductions in
Policy Value, Death Benefit, and remaining benefits and values.
CONSENT FOR We must obtain consent from any irrevocable beneficiary and any assignee
BENEFIT PAYMENT record before the Single Sum Benefit is paid. An assignee's consent is
required only to the extent that benefits paid would reduce this Policy's
values and benefits below the amounts assigned.
ADB200 PAGE 17
21
MALE AND FEMALE TOBACCO (T)
GUARANTEED MAXIMUM COST OF INSURANCE RATES**
MALE FEMALE MALE FEMALE
MONTHLY MONTHLY MONTHLY MONTHLY
COST COST COST COST
ATTAINED OF INSURANCE OF INSURANCE ATTAINED OF INSURANCE OF INSURANCE
AGE PER $1000* PER $1000* AGE PER $1000* PER $1000*
--- ---------- ---------- --- ---------- ----------
0 $ .2192 $ .1567 50 $ .8333 $ .5642
1 .0858 .0700 51 .9108 .6050
2 .0825 .0667 52 .9983 .6517
3 .0808 .0650 53 1.0975 .7033
4 .0775 .0642 54 1.2058 .7558
5 .0733 .0625 55 1.3217 .8100
6 .0692 .0608 56 1.4442 .8633
7 .0650 .0592 57 1.5733 .9133
8 .0625 .0583 58 1.7092 .9625
9 .0617 .0575 59 1.8550 1.0150
10 .0625 .0567 60 2.0175 1.0775
11 .0675 .0583 61 2.2008 1.1558
12 .0767 .0608 62 2.4075 1.2567
13 .0892 .0642 63 2.6383 1.3792
14 .1033 .0683 64 2.8908 1.5158
15 .1467 .0800 65 3.1583 1.6600
16 .1633 .0842 66 3.4383 1.8067
17 .1750 .0883 67 3.7283 1.9483
18 .1842 .0925 68 4.0325 2.0917
19 .1900 .0950 69 4.3625 2.2475
20 .1933 .0975 70 4.7267 2.4317
21 .1933 .0992 71 5.1358 2.6650
22 .1900 .1017 72 5.5983 2.9508
23 .1867 .1042 73 6.1108 3.2908
24 .1817 .1067 74 6.6725 3.6783
25 .1758 .1092 75 7.2725 4.1017
26 .1725 .1133 76 7.8858 4.5517
27 .1708 .1167 77 8.5017 5.0217
28 .1708 .1208 78 9.1242 5.5183
29 .1733 .1258 79 9.7750 6.0592
30 .1775 .1317 80 10.4758 6.6650
31 .1833 .1367 81 11.2467 7.3525
32 .1908 .1425 82 12.1008 8.1342
33 .2008 .1500 83 13.0242 9.0367
34 .2125 .1583 84 13.9858 10.0150
35 .2267 .1675 85 14.9533 11.0542
36 .2433 .1817 86 15.9033 12.1458
37 .2642 .1983 87 16.8783 13.2792
38 .2875 .2175 88 17.8942 14.4600
39 .3142 .2383 89 18.9042 15.6875
40 .3450 .2633 90 19.9233 17.0483
41 .3783 .2900 91 20.9833 18.5133
42 .4150 .3167 92 22.2125 20.1383
43 .4550 .3433 93 23.7892 22.0467
44 .4992 .3700 94 25.9392 24.6025
45 .5458 .3983 95 29.3217 28.4183
46 .5942 .4275 96 35.0825 34.4900
47 .6467 .4575 97 45.0833 44.7700
48 .7033 .4900 98 62.0958 61.9967
49 .7650 .5258 99 83.3333 83.3333
* See Cost of Insurance, page 12.
** When any insurance is sold on a substandard risk, the guaranteed cost of
insurance rates shown above are increased 25% for each additional rating
class above standard.
T328 PAGE 18
22
MALE AND FEMALE NON-TOBACCO (NT)
GUARANTEED MAXIMUM COST OF INSURANCE RATES**
MALE FEMALE MALE FEMALE
MONTHLY MONTHLY MONTHLY MONTHLY
COST COST COST COST
ATTAINED OF INSURANCE OF INSURANCE ATTAINED OF INSURANCE OF INSURANCE
AGE PER $1000* PER $1000* AGE PER $1000* PER $1000*
--- ---------- ---------- --- ---------- ----------
0 $ .2192 $ .1567 50 $ .4275 $ .3617
1 .0858 .0700 51 .4667 .3892
2 .0825 .0667 52 .5117 .4208
3 .0808 .0650 53 .5633 .4558
4 .0775 .0642 54 .6208 .4917
5 .0733 .0625 55 .6850 .5300
6 .0692 .0608 56 .7550 .5683
7 .0650 .0592 57 .8292 .6058
8 .0625 .0583 58 .9117 .6433
9 .0617 .0575 59 1.0042 .6858
10 .0625 .0567 60 1.1075 .7358
11 .0675 .0583 61 1.2225 .7975
12 .0767 .0608 62 1.3550 .8742
13 .0892 .0642 63 1.5050 .9683
14 .1033 .0683 64 1.6717 1.0742
15 .1133 .0717 65 1.8542 1.1883
16 .1233 .0750 66 2.0517 1.3067
17 .1308 .0775 67 2.2633 1.4275
18 .1358 .0800 68 2.4933 1.5525
19 .1392 .0825 69 2.7483 1.6917
20 .1400 .0842 70 3.0367 1.8550
21 .1383 .0858 71 3.3658 2.0542
22 .1358 .0867 72 3.7458 2.2983
23 .1325 .0883 73 4.1758 2.5908
24 .1292 .0900 74 4.6483 2.9275
25 .1250 .0917 75 5.1533 3.3033
26 .1225 .0942 76 5.6867 3.7100
27 .1208 .0958 77 6.2442 4.1458
28 .1200 .0983 78 6.8292 4.6175
29 .1200 .1017 79 7.4600 5.1400
30 .1208 .1042 80 8.1567 5.7342
31 .1233 .1075 81 8.9375 6.4175
32 .1267 .1108 82 9.8183 7.2050
33 .1317 .1150 83 10.7950 8.0933
34 .1375 .1200 84 11.8483 9.0725
35 .1442 .1258 85 12.9542 10.1317
36 .1517 .1342 86 14.0983 11.2633
37 .1617 .1442 87 15.2633 12.4658
38 .1725 .1550 88 16.4442 13.7400
39 .1842 .1667 89 17.6575 15.0958
40 .1983 .1808 90 18.9208 16.5442
41 .2133 .1958 91 20.2633 18.1183
42 .2292 .2108 92 21.7350 19.8775
43 .2467 .2258 93 23.4792 21.9458
44 .2658 .2408 94 25.8192 24.6025
45 .2875 .2575 95 29.3217 28.4183
46 .3108 .2750 96 35.0825 34.4900
47 .3358 .2942 97 45.0833 44.7700
48 .3633 .3142 98 62.0958 61.9967
49 .3933 .3367 99 83.3333 83.3333
* See Cost of Insurance, page 12.
** When any insurance is sold on a substandard risk, the guaranteed cost of
insurance rates shown above are increased 25% for each additional rating
class above standard.
TB328 PAGE 18A
23
Part 7. PAYMENT OF PROCEEDS
SETTLEMENT You may, during the Insured's lifetime, request that we pay the proceeds under
OPTIONS one of the following settlement options. We will also use any other method of
payment that is agreeable to you and us. The following options do not depend
on the investment experience of the Sub-Accounts.
OPTION 1 - Interest Payments -
(Payment of interest on the proceeds at such times and for a period that is
agreeable to you and us.) Withdrawal of proceeds may be made in amounts of at
least $100. At the end of the period, any remaining proceeds will be paid in
either a single sum or under other any other method we approve.
OPTION 2 - Payments for a Specified Period -
(Monthly payments for a specified number of years.) The amount of each
monthly payment for each $1,000 of proceeds applied under this option is shown
in Option 2 Table. The monthly payments for any period not shown will be
furnished upon request.
Option 2 Table
---------------------------------------------------------
PAYMENTS FOR A SPECIFIED PERIOD
---------------------------------------------------------
Number of Amount of
Years Payable Monthly Payments
----------------------------- ---------------------------
5 $17.91
10 9.61
15 6.87
20 5.51
25 4.71
30 4.18
----------------------------- ---------------------------
OPTION 3 - Life Income -
(Monthly payments for the life of the person who is to receive the income.)
We will require satisfactory proof of the person's age and sex. Payments can
be guaranteed for 10 or 20 years or as the "Guaranteed Return of Policy
Proceeds." The amount of each monthly payment for each $1,000 of proceeds
applied under this option is shown in Option 3 Table. The monthly payments
for any ages not shown will be furnished upon request.
Option 3 Table
----------------------------------------------------------------------
LIFE INCOME
----------------------------------------------------------------------
MONTHLY INCOME PAYMENTS
----------------------------------------------------------------------
Guaranteed For Guaranteed For
Life 10 Years
M AGE F M AGE F
------------- ----------- ----------- ----------- ---------- ---------
$3.84 50 $3.53 $3.82 50 $3.52
4.20 55 3.81 4.15 55 3.79
4.67 60 4.17 4.59 60 4.14
5.33 65 4.68 5.17 65 4.61
6.26 70 5.39 5.89 70 5.24
------------- ----------- ----------- ----------- ---------- ---------
Guaranteed Return of Guaranteed For
Policy Proceeds 20 Years
M AGE F M AGE F
------------- ----------- ----------- ----------- ---------- ---------
$3.71 50 $3.47 $3.74 50 $3.49
4.00 55 3.71 4.02 55 3.73
4.37 60 4.02 4.34 60 4.03
4.84 65 4.42 4.69 65 4.38
5.45 70 4.94 5.02 70 4.77
------------- ----------- ----------- ----------- ---------- ---------
S410 PAGE 19
24
OPTION 4 - Payments of a Specified Amount -
(Monthly payments of a specified amount until the proceeds and interest are
fully paid.)
OPTION 5 - Joint and Survivor Life Income -
(Monthly payments during the joint lifetime of two persons and continued
during the lifetime of the survivor.) We will pay the amount retained,
with interest, in equal monthly payments, as shown in the Option 5 Table
for example. The monthly payment for other age or sex combinations will be
furnished upon request.
OPTION 5 TABLE
---------------------------------------------------------------------------
JOINT AND SURVIVOR LIFE INCOME
---------------------------------------------------------------------------
MONTHLY PAYMENTS FOR EACH
$1,000 OF AMOUNT RETAINED
---------------------------------------------------------------------------
AGE OF OTHER PAYEE*
AGE (FEMALE)
OF -------------- -------------- ------------- --------------
ONE 15 Years 10 Years 5 Years
PAYEE* Less than Less than Less than Same as
(MALE) Male Male Male Male
Payee's Payee's Payee's Payee's
---------------- -------------- -------------- ------------- --------------
50 $2.98 $3.08 $3.19 $3.30
55 3.10 3.23 3.36 3.51
60 3.26 3.42 3.60 3.80
65 3.45 3.67 3.91 4.18
70 3.72 4.00 4.34 4.72
---------------------------------------------------------------------------
* Age nearest birthday.
---------------------------------------------------------------------------
OTHER The proceeds will be paid in any other manner agreed to by us.
SETTLEMENT
OPTIONS
CONDITIONS Proceeds of less than $1,000 may not be applied under any settlement
option. We may change the payment frequency if payments under an option
become less than $20.
A corporation may receive payments under a life income option only if the
payments are based on the life of the Insured, or a surviving spouse or a
dependant of the Insured.
If a settlement option is requested, we will prepare an agreement to be
signed which will state the terms and conditions under which the payments
will be made. This agreement will include a statement regarding the
withdrawal value, if any, and to whom any remaining proceeds will be paid
following the death of the person receiving the payments.
A beneficiary may select a settlement option only after the Insured's
death. However, you may provide that the beneficiary will not be permitted
to change the settlement option you have selected.
PROCEEDS EXEMPT To the extent permitted by law, each option payment and any withdrawal
FROM CLAIMS OF shall be free from legal process and the claim of any creditor of the
CREDITORS person entitled to them.
RATE OF INTEREST Options 1 through 5 are based on a guaranteed interest rate of 3.0% using
the "1983 Table a" Mortality Table with projection.
SB410 PAGE 20
25
SURRENDER CHARGES PER $1000 OF
INCREASES IN SPECIFIED AMOUNTS (MALE TOBACCO)
Duration
Attained
Age 1 2 3 4 5 6 7 8 9 10
--- - - - - - - - - - --
18 19.00 18.05 17.10 16.15 15.20 14.25 13.30 12.35 11.40 10.45
19 19.00 18.05 17.10 16.15 15.20 14.25 13.30 12.35 11.40 10.45
20 20.00 19.00 18.00 17.00 16.00 15.00 14.00 13.00 12.00 11.00
21 20.00 19.00 18.00 17.00 16.00 15.00 14.00 13.00 12.00 11.00
22 20.00 19.00 18.00 17.00 16.00 15.00 14.00 13.00 12.00 11.00
23 21.00 19.95 18.90 17.85 16.80 15.75 14.70 13.65 12.60 11.55
24 21.00 19.95 18.90 17.85 16.80 15.75 14.70 13.65 12.60 11.55
25 22.00 20.90 19.80 18.70 17.60 16.50 15.40 14.30 13.20 12.10
26 22.00 20.90 19.80 18.70 17.60 16.50 15.40 14.30 13.20 12.10
27 23.00 21.85 20.70 19.55 18.40 17.25 16.10 14.95 13.80 12.65
28 23.00 21.85 20.70 19.55 18.40 17.25 16.10 14.95 13.80 12.65
29 24.00 22.80 21.60 20.40 19.20 18.00 16.80 15.60 14.40 13.20
30 24.00 22.80 21.60 20.40 19.20 18.00 16.80 15.60 14.40 13.20
31 25.00 23.75 22.50 21.25 20.00 18.75 17.50 16.25 15.00 13.75
32 26.00 24.70 23.40 22.10 20.80 19.50 18.20 16.90 15.60 14.30
33 27.00 25.65 24.30 22.95 21.60 20.25 18.90 17.55 16.20 14.85
34 27.00 25.65 24.30 22.95 21.60 20.25 18.90 17.55 16.20 14.85
35 28.00 26.60 25.20 23.80 22.40 21.00 19.60 18.20 16.80 15.40
36 29.00 27.55 26.10 24.65 23.20 21.75 20.30 18.85 17.40 15.95
37 30.00 28.50 27.00 25.50 24.00 22.50 21.00 19.50 18.00 16.50
38 31.00 29.45 27.90 26.35 24.80 23.25 21.70 20.15 18.60 17.05
39 32.00 30.40 28.80 27.20 25.60 24.00 22.40 20.80 19.20 17.60
40 33.00 31.35 29.70 28.05 26.40 24.75 23.10 21.45 19.80 18.15
41 34.00 32.30 30.60 28.90 27.20 25.50 23.80 22.10 20.40 18.70
42 35.00 33.25 31.50 29.75 28.00 26.25 24.00 22.75 21.00 19.25
43 36.00 34.20 32.40 30.60 28.80 27.00 25.20 23.40 21.60 19.80
44 38.00 36.10 34.20 32.30 30.40 28.50 26.60 24.70 22.80 20.90
45 39.00 37.05 35.10 33.15 31.20 29.25 27.30 25.35 23.40 21.45
46 41.00 38.95 36.90 34.85 32.80 30.75 28.70 26.65 24.60 22.55
47 42.00 39.90 37.80 35.70 33.60 31.50 29.40 27.30 25.20 23.10
48 44.00 41.80 39.60 37.40 35.20 33.00 30.80 28.60 26.40 24.20
49 46.00 43.70 41.40 39.10 36.80 34.50 32.20 29.90 27.60 25.30
Years 11-20 are shown on page 21A.
SC269MT PAGE 21
26
SURRENDER CHARGES PER $1000 OF
INCREASES IN SPECIFIED AMOUNTS (MALE TOBACCO)
Duration
Attained 20 &
Age 11 12 13 14 15 16 17 18 19 Thereafter
--- -- -- -- -- -- -- -- -- -- ----------
18 9.50 8.55 7.60 6.65 5.70 4.75 3.80 2.85 1.90 -0-
19 9.50 8.55 7.60 6.65 5.70 4.75 3.80 2.85 1.90 -0-
20 10.00 9.00 8.00 7.00 6.00 5.00 4.00 3.00 2.00 -0-
21 10.00 9.00 8.00 7.00 6.00 5.00 4.00 3.00 2.00 -0-
22 10.00 9.00 8.00 7.00 6.00 5.00 4.00 3.00 2.00 -0-
23 10.50 9.45 8.40 7.35 6.30 5.25 4.20 3.15 2.10 -0-
24 10.50 9.45 8.40 7.35 6.30 5.25 4.20 3.15 2.10 -0-
25 11.00 9.90 8.80 7.70 6.60 5.50 4.40 3.30 2.20 -0-
26 11.00 9.90 8.80 7.70 6.60 5.50 4.40 3.30 2.20 -0-
27 11.50 10.35 9.20 8.05 6.90 5.75 4.60 3.45 2.30 -0-
28 11.50 10.35 9.20 8.05 6.90 5.75 4.60 3.45 2.30 -0-
29 12.00 10.80 9.60 8.40 7.20 6.00 4.80 3.60 2.40 -0-
30 12.00 10.80 9.60 8.40 7.20 6.00 4.80 3.60 2.40 -0-
31 12.50 11.25 10.00 8.75 7.50 6.25 5.00 3.75 2.50 -0-
32 13.00 11.70 10.40 9.10 7.80 6.50 5.20 3.90 2.60 -0-
33 13.50 12.15 10.80 9.45 8.10 6.75 5.40 4.05 2.70 -0-
34 13.50 12.15 10.80 9.45 8.10 6.75 5.40 4.05 2.70 -0-
35 14.00 12.60 11.20 9.80 8.40 7.00 5.60 4.20 2.80 -0-
36 14.50 13.05 11.60 10.15 8.70 7.25 5.80 4.35 2.90 -0-
37 15.00 13.50 12.00 10.50 9.00 7.50 6.00 4.50 3.00 -0-
38 15.50 13.95 12.40 10.85 9.30 7.75 6.20 4.65 3.10 -0-
39 16.00 14.40 12.80 11.20 9.60 8.00 6.40 4.80 3.20 -0-
40 16.50 14.85 13.20 11.55 9.90 8.25 6.60 4.95 3.30 -0-
41 17.00 15.30 13.60 11.90 10.20 8.50 6.80 5.10 3.40 -0-
42 17.50 15.75 14.00 12.25 10.50 8.75 7.00 5.25 3.50 -0-
43 18.00 16.20 14.40 12.60 10.80 9.00 7.20 5.40 3.60 -0-
44 19.00 17.10 15.20 13.30 11.40 9.50 7.60 5.70 3.80 -0-
45 19.50 17.55 15.60 13.65 11.70 9.75 7.80 5.85 3.90 -0-
46 20.50 18.45 16.40 14.35 12.30 10.25 8.20 6.15 4.10 -0-
47 21.00 18.90 16.80 14.70 12.60 10.50 8.40 6.30 4.20 -0-
48 22.00 19.80 17.60 15.40 13.20 11.00 8.80 6.60 4.40 -0-
49 23.00 20.70 18.40 16.10 13.80 11.50 9.20 6.90 4.60 -0-
Attained Ages 50-85 are shown on page 22.
SCB269MT PAGE 21A
27
SURRENDER CHARGES PER $1000 OF
INCREASES IN SPECIFIED AMOUNTS (MALE TOBACCO)
Duration
Attained
Age 1 2 3 4 5 6 7 8 9 10
--- - - - - - - - - - --
50 47.00 44.65 42.30 39.95 37.60 35.25 32.90 30.55 28.20 25.85
51 49.00 46.55 44.10 41.65 39.20 36.75 34.30 31.85 29.40 26.95
52 51.00 48.45 45.90 43.35 40.80 38.25 35.70 33.15 30.60 28.05
53 53.00 50.35 47.70 45.05 42.40 39.75 37.10 34.45 31.80 29.15
54 56.00 53.20 50.40 47.60 44.80 42.00 39.20 36.40 33.60 30.80
55 58.00 55.10 52.20 49.30 46.40 43.50 40.60 37.70 34.80 31.90
56 58.00 55.10 52.20 49.30 46.40 43.50 40.60 37.70 34.80 31.90
57 58.00 55.10 52.20 49.30 46.40 43.50 40.60 37.70 34.80 31.90
58 58.00 55.10 52.20 49.30 46.40 43.50 40.60 37.70 34.80 31.90
59 58.00 55.10 52.20 49.30 46.40 43.50 40.60 37.70 34.80 31.90
60 58.00 55.10 52.20 49.30 46.40 43.50 40.60 37.70 34.80 31.90
61 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
62 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
63 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
64 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
65 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
66 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
67 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
68 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
69 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
70 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
71 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
72 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
73 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
74 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
75 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
76 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
77 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
78 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
79 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
80 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
81 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
82 57.00 54.15 51.30 48.45 45.60 42.75 39.90 37.05 34.20 31.35
83 52.00 49.40 46.80 44.20 41.60 39.00 36.40 33.80 31.20 28.60
84 45.00 42.75 40.50 38.25 36.00 33.75 31.50 29.25 27.00 24.75
85 40.00 38.00 36.00 34.00 32.00 30.00 28.00 26.00 24.00 22.00
Years 11-20 are shown on page 22A.
SCC269MT PAGE 22
28
SURRENDER CHARGES PER $1000 OF
INCREASES IN SPECIFIED AMOUNTS (MALE TOBACCO)
Duration
Attained 20 &
Age 11 12 13 14 15 16 17 18 19 Thereafter
--- -- -- -- -- -- -- -- -- -- ----------
50 23.50 21.15 18.80 16.45 14.10 11.75 9.40 7.05 4.70 -0-
51 24.50 22.05 19.60 17.15 14.70 12.25 9.80 7.35 4.90 -0-
52 25.50 22.95 20.40 17.85 15.30 12.75 10.20 7.65 5.10 -0-
53 26.50 23.85 21.20 18.55 15.90 13.25 10.60 7.95 5.30 -0-
54 28.00 25.20 22.40 19.60 16.80 14.00 11.20 8.40 5.60 -0-
55 29.00 26.10 23.20 20.30 17.40 14.50 11.60 8.70 5.80 -0-
56 29.00 26.10 23.20 20.30 17.40 14.50 11.60 8.70 5.80 -0-
57 29.00 26.10 23.20 20.30 17.40 14.50 11.60 8.70 5.80 -0-
58 29.00 26.10 23.20 20.30 17.40 14.50 11.60 8.70 5.80 -0-
59 29.00 26.10 23.20 20.30 17.40 14.50 11.60 8.70 5.80 -0-
60 29.00 26.10 23.20 20.30 17.40 14.50 11.60 8.70 5.80 -0-
61 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
62 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
63 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
64 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
65 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
66 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
67 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
68 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
69 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
70 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
71 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
72 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
73 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
74 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
75 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
76 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
77 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
78 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
79 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
80 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 5.70 -0-
81 28.50 25.65 22.80 19.95 17.10 14.25 11.40 8.55 0.00 -0-
82 28.50 25.65 22.80 19.95 17.10 14.25 11.40 0.00 0.00 -0-
83 26.00 23.40 20.80 18.20 15.60 13.00 0.00 0.00 0.00 -0-
84 22.50 20.25 18.00 15.75 13.50 0.00 0.00 0.00 0.00 -0-
85 20.00 18.00 16.00 14.00 0.00 0.00 0.00 0.00 0.00 -0-
SCD269MT PAGE 22A
29
Part 8. SUMMARY OF POLICY BENEFITS
LIVING BENEFITS Your policy has certain values which are available to you during your
lifetime. These values consist of the cash surrender values or loan values.
You may use these values:
- To provide supplemental income (see page 19).
- As collateral for a loan or as the basis for a policy loan (see page 14).
- To continue some insurance protection if you cannot or do not wish to
continue paying premiums (see pages 5 and 15).
- To obtain cash by surrendering your policy (see page 15).
- To obtain cash by partial withdrawal, (see page 7).
The available Cash Surrender Value of your policy is:
- The Policy Value (see page 11).
MINUS - The Surrender Charge, if any (see page 15).
MINUS - Any Indebtedness (see definition, page 2).
The available Loan Value of your policy is:
- 90% of the Cash Surrender Value, less six months of Monthly
Deductions (see page 15).
DEATH The amount payable to the beneficiary is the total of the following amounts
PROCEEDS determined on the date of the Insured's death:
- The death benefit amount of this policy (see page 10).
PLUS - Any additional insurance on the Insured's life provided by an
extra benefit rider (see page 3).
MINUS - Any Indebtedness (see definition, page 2).
MINUS - Any Monthly Deductions due (see page 11).
EXTRA The extra benefits, if any, listed on page 3 are fully described in the extra benefit
BENEFIT RIDERS riders that are attached to this policy.
Part 9. YOUR RIGHTS
During the Insured's lifetime and unless otherwise provided in this policy, you
have the exclusive right to assign this policy, to receive every benefit and to
exercise every right, privilege and option this policy grants or that we allow.
Some of your rights are:
- To change the owner or beneficiary. (Change of Owner and Beneficiary,
page 5).
- To transfer money between Accounts. (Transfers, page 8)
- To withdraw cash. (Partial Withdrawals, page 7).
- To surrender this policy. (Nonforfeiture Options, page 15).
- To stop premium payments but keep the policy in force. (Continuation
of Coverage, page 6).
- To change the frequency of premium payments. (Premiums, page 5).
- To change the Specified Amount. (Increase or Decrease in The Specified
Amount, page 10).
- To change the Death Benefit Option. (Change in the Death Benefit
Option, page 10).
- To borrow on the life insurance base policy. (Policy Loans, page 14).
- To reinstate the policy after lapse. (Reinstatement, page 6).
- To receive policy benefits as income. (Settlement Options, pages 19,
and 20).
To exercise any of these rights, or to apply for the proceeds or any benefits
under this policy, communicate with our nearest representative or directly with
our home office. Please notify us promptly of any change of address.
BR726 PAGE 23
30
PEOPLES BENEFIT LIFE INSURANCE COMPANY
Home Office located at: 4333 Edgewood Road N.E., Cedar Rapids, Iowa 52499
FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE POLICY
TERMINAL ILLNESS ACCELERATED DEATH BENEFIT
PREMIUMS PAYABLE TO MATURITY DATE OR UNTIL PRIOR DEATH OF INSURED
PROCEEDS, IF ANY, PAYABLE AT DEATH OR MATURITY DATE
NON-PARTICIPATING
SOME BENEFITS REFLECT INVESTMENT RESULTS
INDEX
Page Page
Annual Report...............................7 Loan Values...................................14
Assignment..................................4 Loan Interest.................................14
Basis Used for Calculations................15 Misstatement of Age or Sex.....................5
Beneficiary.................................5 Monthly Deduction.............................11
Cash Surrender Value.......................15 Nonforfeiture Options.........................15
Change of Owner or Beneficiary..............5 Non-participating..............................5
Change of Specified Amount.................10 Partial Withdrawals............................7
Continuation of Coverage....................6 Payment Intervals (Premiums)...................5
Contract....................................4 Payment of Proceeds...........................19
Cost of Insurance..........................12 Policy Loans..................................14
Death Benefit Options......................10 Policy Value..................................11
Definitions.................................2 Policy Specifications..........................3
Exchange Privilege..........................7 Premiums.......................................5
Extended Maturity Date.....................13 Reduced Paid-Up Insurance.....................15
Fixed Account Value........................12 Reinstatement..................................6
General Provisions..........................4 Separate Account...............................8
Grace Period................................6 Settlement Options............................19
Guaranteed Cost of Insurance Rates.........18 Specified Amount..............................10
Illustrative Reports........................5 Sub-Account Value.............................12
Incontestability............................4 Suicide Exclusion..............................4
Indebtedness................................2 Surrender Charge..............................15
Interest from Date of Death................11 Terminal Illness Accelerated Death Benefit....16
Interest Rate..............................12 Transfers......................................8
Unit Value.....................................9
- - PLEASE EXAMINE YOUR POLICY AND THE ATTACHED COPY OF THE APPLICATION
CAREFULLY. CONTACT YOUR AGENT IF YOU DESIRE ADDITIONAL SERVICE OR
INFORMATION.
- - IF YOU CHANGE YOUR ADDRESS, PLEASE NOTIFY US AT THE HOME OFFICE GIVING
YOUR FULL NAME AND POLICY NUMBER.
- - YOUR POLICY IS A VALUABLE ASSET. FOR YOUR OWN PROTECTION, LET US ADVISE
YOU REGARDING ANY SUGGESTION TO TERMINATE OR EXCHANGE THIS POLICY.
B726