CONTRACT DATA CONTRACT NUMBER 9999999. BENEFICIARY As stated in the application or in the last beneficiary designation filed with us ANNUITANT Jxxx X. Xxx OWNER As stated in the application or in the last ownership designation filed with us CONTRACT DATE May 01, 2011 ISSUE AGE [35] MATURITY DATE May 01, 2061 SEX [Male] MONTHLY LIFE INCOME FACTOR [$7.46 per $1,000 of Maturity Proceeds] REDETERMINATION DATES [May 01, 2019] and subsequent Contract Anniversaries GUARANTEED PAYMENT PERIOD [120 Months]
CONTRACT DATA CONTRACT NUMBER 9999999. BENEFICIARY INSURED As stated in the application or in the Xxxx Xxx OWNER INITIAL The insured SPECIFIED AMOUNT $100,000 ISSUE AGE CONTRACT DATE 35 Sept 01, 2000 SEX MATURITY DATE* Male Sept 01, 2065 MINIMUM SPECIFIED AMOUNT $100,000 GUARANTEED MONTHLY PREMIUM DURING GUARANTEED PAYMENT PERIOD $XX.XX** GUARANTEED PAYMENT PERIOD AGENCY First five years following the contract date. 0001 FIXED ACCOUNT GUARANTEED INTEREST RATE 4.0% LOAN INTEREST RATE 6.0% * Coverage may expire prior to the maturity date if the cash surrender value or premium payments are insufficient as described in Section 4.8, Grace Period ** This amount will change if you increase the specified amount or add any additional benefits provided by riders.
SECTION 1: CONTRACT DATA (continued) DATE PREPARED:09/01/2000 INSURED CONTRACT NUMBER Xxxx Xxx 9999999 PLANNED PREMIUM PAYMENT: $1,000.00 ANNUALLY GUARANTEED MINIMUM DEATH BENEFIT RIDER PREMIUM: For Option A: $XXX.XX monthly MONTHLY SPECIFIED RISK COST OF FORM NO. BENEFIT DESCRIPTION AMOUNT CLASS INSURANCE J155 Coverage Option A: Death $100,000* Non-Tobacco See Table D Benefit equals the specified amount at the time of death. (Effective Sept 01, 2000) R186 Guaranteed Minimum Death $100,000 Non-Tobacco ----------- Benefit Rider** (Effective Sept 01, 2000) R187 Additional Life Insurance Rider $100,000 Non-Tobacco See Rider Rider (Effective Sept 01, 2000) R188 Other Insured Term Life $25,000 Non-Tobacco See Rider Insurance Rider*** (Effective Sept 01, 2000) * This is the initial specified amount on the contract date. The specified amount may be changed as provided in Section 5, Contract Change Provisions. ** The expiration date of this rider is the contract anniversary on which the Insured is age 65. ***The expiration date of this rider with respect to each Other Insured is the earlier of the Insured's maturity date or the contract anniversary on which that Other Insured is age 100.
SECTION 1: CONTRACT DATA (continued) DATE PREPARED:09/01/2000 INSURED CONTRACT NUMBER Xxxx Xxx 9999999 PREMIUM EXPENSE CHARGE 6.35% deducted from each premium payment MONTHLY EXPENSE CHARGE $7.50 per month plus Current [0.00] per $1,000 Guaranteed $.05 per $1,000 MORTALITY AND EXPENSE RISK CHARGE 0.50% annually PARTIAL SURRENDER FEE The partial surrender fee is the lesser of: (a) 2% of the amount surrendered; or (b) $25.00. SURRENDER CHARGE TABLE OF SURRENDER CHARGES CONTRACT AMOUNT AT YEAR END OF YEAR 0-1 $1058.00 2 $2208.00 3 $2185.00 4 $2139.00 5 $2116.00 6 $2070.00 ...
