Common use of READ THIS POLICY CAREFULLY Clause in Contracts

READ THIS POLICY CAREFULLY. It is a legal contract between the Owner and Standard Insurance Company. Pre-existing Condition limitations or exclusions and other limitations or exclusions may apply. The telephone number for the [XYZ] Department of Insurance is [xxx-xx-xxxx]. xxx.xxxxxxxx.xxx STANDARD INSURANCE COMPANY ICC17-B180(07/17) Assignment 19 Benefits Family Care 6 Premium Waiver 6 Presumptive Disability 5 Rehabilitation Program 5 Survivor 8 Total Disability 4 Claims Claim Forms 11 Notice of Claim 11 Payment of Claims 13 Proof of Loss 11 Time of Payment 12 Concurrent Disability 9 DEFINITIONS 20 Exclusions and Limitations 8 Pre-Existing Conditions 10 General Provisions 17 Grace Period 14 Owner 22 Policy Data 3 Policy Termination 15 Premiums Schedule of 3 In General 14 Recurrent Disability 9 Reinstatement 14 Renewal Option After The Termination Date 16 Suspension During Military Service 15 Time Limit On Certain Defenses 18 This refers to the number of days after the start of your disability before you are eligible to receive a disability payment. Insured Policy Effective Date Owner at Issue [XXXX XXX] [July 2, 2016] [The Insured] [00C9999990][35] [Non-Smoker] Policy Number Issue Age Risk Class Termination Date [July 2, 2048] [4A] Occupation Class Benefit Waiting Period [90 days] [Male] Gender Our underwriting experts use risk and occupation class as factors in determining terms of coverage and premium rates. [Mode of Premium Payment: [Special Monthly] Amount: $199.55] There are four premium modes available. The total amount due over a policy year varies by the mode selected. The mode you chose is noted above. The total due over the policy year for this mode and the difference between that total and the net annual premium payment are noted below: Difference between net annual premium and total [Special Monthly] payments: $[113.99]] {*The Net Annual Premium reflects the following discount(s): [Multi-Life Discount 10%] [Student/Resident Discount 10%] [Graduate Medical Education Discount 15%] [Business Owner Discount 10%] [Multi-Product Discount 5%] [Mental Disorder/Substance Abuse Limitation 10%]} This is the maximum amount of time we will pay benefits under your policy. Maximum Benefit Period: [To Age 67] – Determined by Your age when Disability begins; see Schedule of Maximum Benefit Periods on the next page. ICC17-B180(07/17) Page 3 Insured [XXXX XXX] [00C9999990] Policy Number Many additional forms of income protection are available through our wide range of optional riders. Age When Disability Begins Maximum Benefit Period [61 or younger To age 67 62 60 months 63 48 months 64 42 months 65 36 months 66 30 months 67 24 months] Expiration Date: [July 2, 2036] Student Loan Rider [$141.40]** Maximum Monthly Student Loan Benefit: $[ 2,000 ] Student Loan Benefit Waiting Period: [ 90 ] days Student Loan Benefit Expiration Date: [July 2, 2026] {Total Premium for Riders [$988.51]} {* Premium included in base policy premium and any applicable rider premium.} {** Payable to expiration date.} If this policy was issued with an increased premium, exclusion or other modification, you may contact us if there are any changes to your health, occupation, avocation or other risk factor that might allow coverage to be continued without the modification. We will review the information you provide plus any other information available to us regarding all risk factors associated with you as of the time of our review. Using our underwriting rules and guidelines then in effect, we reserve the right to offer any change that we think is most appropriate, as well as the right to decline to make any change, regardless of whether the change in risk factor(s) is directly related to the reason for the policy modification. This refers to your occupation at the time you become disabled. This section also defines regular occupation for specialized physicians and dentists. For example, a presumptive disability could be the total and permanent loss of hearing in both ears. You don’t have to satisfy a benefit waiting period before receiving benefits for a presumptive disability. As you’re recuperating from a disability, you can receive help to return to work full-time. We’ll pay the reasonable costs of a voluntary rehabilitation program, which may include workplace modifications, training and family care expenses.

READ THIS POLICY CAREFULLY. It is a legal contract between the Owner and Standard Insurance Company. Pre-existing Condition limitations or exclusions and other limitations or exclusions may apply. The telephone number for the [XYZ] Department of Insurance is [xxx-xx-xxxx]. xxx.xxxxxxxx.xxx STANDARD INSURANCE COMPANY ICC17-B180(07/17) Assignment 19 Benefits Family Care 6 Premium Waiver 6 Presumptive Disability 5 Rehabilitation Program 5 Survivor 8 Total Disability 4 Claims Claim Forms 11 Notice of Claim 11 Payment of Claims 13 Proof of Loss 11 Time of Payment 12 Concurrent Disability 9 DEFINITIONS 20 Exclusions and Limitations 8 Pre-Existing Conditions 10 General Provisions 17 Grace Period 14 Owner 22 Policy Data 3 Policy Termination 15 Premiums Schedule of 3 In General 14 Recurrent Disability 9 Reinstatement 14 Renewal Option After The Termination Date 16 Suspension During Military Service 15 Time Limit On Certain Defenses 18 This refers to the number of days after the start of your disability before you are eligible to receive a disability payment. Insured Policy Effective Date Owner at Issue [XXXX XXX] [July 2, 2016] [The Insured] [00C9999990][35] [Non-Smoker] Policy Number Issue Age Risk Class Termination Date [July 2, 2048] [4A] Occupation Class Benefit Waiting Period [90 days] [Male] Gender Our underwriting experts use risk and occupation class as factors in determining terms of coverage and premium rates. [Mode of Premium Payment: [Special Monthly] Amount: $199.55] There are four premium modes available. The total amount due over a policy year varies by the mode selected. The mode you chose is noted above. The total due over the policy year for this mode and the difference between that total and the net annual premium payment are noted below: Difference between net annual premium and total [Special Monthly] payments: $[113.99]] {*The Net Annual Premium reflects the following discount(s): [Multi-Life Discount 10%] [Student/Resident Discount 10%] [Graduate Medical Education Discount 15%] [Business Owner Discount 10%] [Multi-Product Discount 5%] [Mental Disorder/Substance Abuse Limitation 10%]} Commencement Date [91st] day of Disability This is the maximum amount of time we will pay benefits under your policy. Maximum Benefit Period: [To Age 67] – Determined by Your age when Disability begins; see Schedule of Maximum Benefit Periods on the next page. ICC17-B180(07/17) Page 3 Insured [XXXX XXX] [00C9999990] Policy Number Many additional forms of income protection are available through our wide range of optional riders. Age When Disability Begins Maximum Benefit Period [61 or younger To age 67 62 60 months 63 48 months 64 42 months 65 36 months 66 30 months 67 24 months] Expiration Date: [July 2, 2036] Student Loan Rider [$141.40]** Maximum Monthly Student Loan Benefit: $[ 2,000 ] Student Loan Benefit Waiting Period: [ 90 ] days Student Loan Benefit Expiration Date: [July 2, 2026] {Total Premium for Riders [$988.51]} {* Premium included in base policy premium and any applicable rider premium.} {** Payable to expiration date.} If this policy was issued with an increased premium, exclusion or other modification, you may contact us if there are any changes to your health, occupation, avocation or other risk factor that might allow coverage to be continued without the modification. We will review the information you provide plus any other information available to us regarding all risk factors associated with you as of the time of our review. Using our underwriting rules and guidelines then in effect, we reserve the right to offer any change that we think is most appropriate, as well as the right to decline to make any change, regardless of whether the change in risk factor(s) is directly related to the reason for the policy modification. This refers to your occupation at the time you become disabled. This section also defines regular occupation for specialized physicians and dentists. For example, a presumptive disability could be the total and permanent loss of hearing in both ears. You don’t have to satisfy a benefit waiting period before receiving benefits for a presumptive disability. As you’re recuperating from a disability, you can receive help to return to work full-time. We’ll pay the reasonable costs of a voluntary rehabilitation program, which may include workplace modifications, training and family care expenses.

READ THIS POLICY CAREFULLY. It is a legal contract between the Owner and Standard Insurance Company. Pre-existing Condition limitations or exclusions and other limitations or exclusions may apply. The telephone number for the [XYZ] Department of Insurance is [xxx-xx-xxxx]. xxx.xxxxxxxx.xxx STANDARD INSURANCE COMPANY ICC17-B180(07/17For a noncancelable policy, this section will be replaced with new language that states the policy is noncancelable and guaranteed renewable to age 67. We can’t change the policy or its premium. Xxxxxxxxx X. Xxxxx Corporate Secretary B180(7/17) Assignment 19 Benefits Family Care 6 Premium Waiver 6 Presumptive Disability 5 Rehabilitation Program 5 Survivor 8 Total Disability 4 Claims Claim Forms 11 Notice of Claim 11 Payment of Claims 13 Proof of Loss 11 Time of Payment 12 Concurrent Disability 9 DEFINITIONS 20 Exclusions and Limitations 8 Pre-Existing Conditions 10 General Provisions 17 Grace Period 14 Owner 22 Policy Data 3 Policy Termination 15 Premiums Schedule of 3 In General 14 Recurrent Disability 9 Reinstatement 14 Renewal Option After The Termination Date Date. 16 Suspension During Military Service 15 Time Limit On Certain Defenses 18 This refers to the number of days after the start of your disability before you are eligible to receive a disability payment. Insured Policy Effective Date Owner at Issue [XXXX XXX] [July 2, 2016] [The Insured] [00C9999990][35] [Non-Smoker] Policy Number Issue Age Risk Class Termination Date [July 2, 2048] [4A] Occupation Class Benefit Waiting Period [90 days] [Male] Gender B180(7/17) Our underwriting experts use risk and occupation class as factors in determining terms of coverage and premium rates. This refers to the number of days that you must be disabled before you are eligible to receive a [XXXX XXX] [July 2, 2016] [ The Insured] [July 2, 2048] [90 Days] [0000000000] Policy Number [3P] Occupation Class [Female] Gender disability benefit. Mode of Premium Payment: [Special Monthly] Amount: [$199.55249.98] There are four premium modes available. The total amount due over a policy year varies by the mode selected. The mode you chose is noted above. The total due over the policy year for this mode and the difference between that total and the net annual premium payment are noted below: Difference between net annual premium and total [Special Monthly] payments: $[113.99142.86]] {*The Net Annual Premium reflects the following discount(s): [Multi-Life Discount 10%] [Student/Resident Discount 10%] [Graduate Medical Education Discount 15%] [Business Owner Discount 10%] [Multi-Product Discount 5%] [Mental Disorder/Substance Abuse Limitation 15% 10%]} % Commencement Date 91st day of Disability This is the maximum $[5,000] amount of time we will pay benefits under your policy. Maximum Benefit Period: [To Age 67] – Determined by Your age when Disability begins; see Schedule of Maximum Benefit Periods on the next page. ICC17-B180(07/17B180(7/17) Page 3 Insured [XXXX XXX] [00C99999900000000000] Policy Number Many additional forms of income protection Some added benefits are available through our wide range of optional ridersincluded automatically under the GME program. Age When Disability Begins Maximum Benefit Period [61 or younger To age 67 62 60 months 63 48 months 64 42 months 65 36 months 66 30 months 67 24 months] months Others, such as the Student Loan Rider, are optional. Expiration Date: [July 2October 13, 20362043] provisions are incorporated into the base policy form rather than attached as a rider. Catastrophic Disability Benefit Rider $[5,000.00] Per Month [$174.04] Student Loan Rider [$141.40]** Maximum Monthly Student Loan Benefit: $[ 2,000 ] 2,500.00 [$225.37]** Student Loan Benefit Waiting Period: [ 90 ] days Student Loan Benefit Expiration Date: [July 2, 2026] {Total Premium for Riders [$988.51]} {90 days 10/13/2031 Applicants may choose to add a Student Loan Rider and/or Catastrophic Disability Benefit Rider. * Premium included in base policy premium and any applicable rider premium.} {. ** Payable to expiration date.} . If this policy was issued with an increased premium, exclusion or other modification, you may contact us if there are any changes to your health, occupation, avocation or other risk factor that might allow coverage to be continued without the modification. We will review the information you provide plus any other information available to us regarding all risk factors associated with you as of the time of our review. Using our underwriting rules and guidelines then in effect, we reserve the right to offer any change that we think is most appropriate, as well as the right to decline to make any change, regardless of whether the change in risk factor(s) is directly related to the reason for the policy modification. This refers B180(7/17) Page 3A We agree to your occupation at pay benefits according to the time terms of this policy if you become disabled. This section also defines regular occupation Disabled while this policy is in force and you give us Proof Of Loss for specialized physicians and dentists. For example, a presumptive disability could be the total and permanent loss of hearing in both ears. You don’t have to satisfy a benefit waiting period before receiving any benefits for which you submit a presumptive disabilityclaim. As In this policy you’re recuperating from a disability, you can receive help /your mean the Insured; we/us/our mean Standard Insurance Company. Other defined terms have initial capital letters and are defined in the DEFINITIONS section or in the provisions in which they first appear and to return to work full-time. We’ll pay the reasonable costs of a voluntary rehabilitation program, which may include workplace modifications, training and family care expensesthey primarily pertain.

READ THIS POLICY CAREFULLY. It is a legal contract between the Owner and Standard Insurance Company. Pre-existing Condition limitations or exclusions and other limitations or exclusions may apply. The telephone number for the [XYZ] Department of Insurance is [xxx-xx-xxxx]. xxx.xxxxxxxx.xxx STANDARD INSURANCE COMPANY ICC17-B180(07/17) Assignment 19 Benefits Family Care 6 Premium Waiver 6 Presumptive Disability 5 Rehabilitation Program 5 Survivor 8 Total Disability 4 Claims Claim Forms 11 Notice of Claim 11 Payment of Claims 13 Proof of Loss 11 Time of Payment 12 Concurrent Disability 9 DEFINITIONS 20 Exclusions and Limitations 8 Pre-Existing Conditions 10 General Provisions 17 Grace Period 14 Owner 22 Policy Data 3 Policy Termination 15 Premiums Schedule of 3 In General 14 Recurrent Disability 9 Reinstatement 14 Renewal Option After The Termination Date 16 Suspension During Military Service 15 Time Limit On Certain Defenses 18 This refers to the number of days after the start of your disability before you are eligible to receive a disability payment. Insured Policy Effective Date Owner at Issue [XXXX XXX] [July 2, 2016] [The Insured] [00C9999990][35] [Non-Smoker] Policy Number Issue Age Risk Class Termination Date [July 2, 2048] [4A] Occupation Class Benefit Waiting Period [90 days] [Male] Gender Our underwriting experts use risk and occupation class as factors in determining terms of coverage and premium rates. [Mode of Premium Payment: [Special Monthly] Amount: $199.55] There are four premium modes available. The total amount due over a policy year varies by the mode selected. The mode you chose is noted above. The total due over the policy year for this mode and the difference between that total and the net annual premium payment are noted below: Difference between net annual premium and total [Special Monthly] payments: $[113.99]] {*The Net Annual Premium reflects the following discount(s): [Multi-Life Discount 10%] [Preferred Occupation Discount 10%] [Student/Resident Discount 10%] [Graduate Medical Education Discount 15%] [Business Owner Discount 10%] [Multi-Product Discount 5%] [Mental Disorder/Substance Abuse Limitation 10%]} This is the maximum amount of time we will pay benefits under your policy. Maximum Benefit Period: [To Age 67] – Determined by Your age when Disability begins; see Schedule of Maximum Benefit Periods on the next page. ICC17-B180(07/17) Page 3 Insured [XXXX XXX] [00C9999990] Policy Number Many additional forms of income protection are available through our wide range of optional riders. Age When Disability Begins Maximum Benefit Period [61 or younger To age 67 62 60 months 63 48 months 64 42 months 65 36 months 66 30 months 67 24 months] Expiration Date: [July 2, 2036] Student Loan Rider [$141.40]** Maximum Monthly Student Loan Benefit: $[ 2,000 1,500 ] Student Loan Benefit Waiting Period: [ 90 ] days Student Loan Benefit Expiration Date: [July 2, 2026] {Total Premium for Riders [$988.51]} {* Premium included in base policy premium and any applicable rider premium.} {** Payable to expiration date.} If this policy was issued with an increased premium, exclusion or other modification, you may contact us if there are any changes to your health, occupation, avocation or other risk factor that might allow coverage to be continued without the modification. We will review the information you provide plus any other information available to us regarding all risk factors associated with you as of the time of our review. Using our underwriting rules and guidelines then in effect, we reserve the right to offer any change that we think is most appropriate, as well as the right to decline to make any change, regardless of whether the change in risk factor(s) is directly related to the reason for the policy modification. This refers to your occupation at the time you become disabled. This section also defines regular occupation for specialized physicians and dentists. For example, a presumptive disability could be the total and permanent loss of hearing in both ears. You don’t have to satisfy a benefit waiting period before receiving benefits for a presumptive disability. As you’re recuperating from a disability, you can receive help to return to work full-time. We’ll pay the reasonable costs of a voluntary rehabilitation program, which may include workplace modifications, training and family care expenses.

READ THIS POLICY CAREFULLY. It is a legal contract between the Owner and Standard Insurance Company. Pre-existing Condition limitations or exclusions and other limitations or exclusions may apply. The telephone number for the [XYZ] Department of Insurance is [xxx-xx-xxxx]. xxx.xxxxxxxx.xxx xxx.xxxxxxxx.xxx] STANDARD INSURANCE COMPANY ICC17-B180(07/17) Xxxxxxxxx X. Xxxxx Corporate Secretary We want you to be satisfied with the policy we deliver to you. If you decide within 30 days that you don’t want the policy, we’ll cancel it with no questions asked and refund your premium. Assignment 19 Benefits Family Care 6 Premium Waiver 6 Presumptive Disability 5 Rehabilitation Program 5 Survivor 8 Total Disability 4 Claims Claim Forms 11 Notice of Claim 11 Payment of Claims 13 Proof of Loss 11 Time of Payment 12 Concurrent Disability 9 DEFINITIONS 20 Exclusions and Limitations 8 Pre-Existing Conditions 10 General Provisions 17 Grace Period 14 Owner 22 Policy Data 3 Policy Termination 15 Premiums Schedule of 3 In General 14 Recurrent Disability 9 Reinstatement 14 Renewal Option After The Termination Date 16 Suspension During Military Service 15 Time Limit On Certain Defenses 18 ICC17-B180GSI(07/17) This refers to the number of days after the start of your disability that you must be disabled before you are eligible to receive a disability paymentbenefit. Insured Policy Effective Date Owner at Issue [XXXX XXX] [00C9999990] Policy Number Policy Effective Date [July 2, 2016] [35] Issue Age Owner at Issue [The Insured] [00C9999990][35] [Non-Smoker] Policy Number Issue Age Risk Class Termination Date [July 2, 2048] [4A] Occupation Class Benefit Waiting Period [90 days] [Male] Neutral Gender Our underwriting experts use risk and occupation class as factors in determining terms of coverage and premium rates. [Mode of Premium Payment: [Special Monthly] Amount: $199.55[ 207.47] There are four premium modes available. The total amount due over a policy year varies by the mode selected. The mode you chose is noted above. The total due over the policy year for this mode and the difference between that total and the net annual premium payment are noted below: Difference between net annual premium and total [Special Monthly] payments: $[113.99[ 118.51]] {*The Net Annual Premium reflects the following discount(s): a discount of [Multi-Life Discount 10%] [Student/Resident Discount 10%] [Graduate Medical Education Discount 15%] [Business Owner Discount 10%] [Multi-Product Discount 5%] [Mental Disorder/Substance Abuse Limitation 10%]} 25]%. This is the maximum amount of time we will pay benefits under your policy. Maximum Benefit Period: [To Age 67] – Determined by Your age when Disability begins; see Schedule of Maximum Benefit Periods on the next page. ICC17-B180(07/17B180GSI(07/17) Page 3 Insured [XXXX XXX] [00C9999990] Policy Number Many additional forms of income protection are available through our wide range of optional riders. Insured [XXXX XXX] [00C9999990] Policy Number Schedule of Maximum Benefit Periods Age When Disability Begins Maximum Benefit Period [61 or younger To age 67 62 60 months 63 48 months 64 42 months 65 36 months 66 30 months 67 24 months 68 24 months 69 21 months 70 18 months 71 16months 72 15 months 73 14 months 74 13 months 75 or older 12 months] Expiration Date: Indexed Cost of Living Rider [July 2, 20363%] Student Loan [6%] [$428.66] Catastrophic Disability Benefit Rider $[5,000.00] Per Month [$166.00] Basic Residual Disability Rider [$141.40]** Maximum Monthly Student Loan Benefit: 235.26] Enhanced Residual Disability Benefit Rider [$ xx.xx] Short Term Residual Disability Benefit Rider [$[ 2,000 xx.xx] Student Loan Own Occupation Benefit Waiting Period: [ 90 Rider [$371.08] days Student Loan Benefit Expiration Date: Regular Occupation Extension Rider [July 2, 2026$xx.xx] {Total Premium for Riders and Other [$988.511,201.00]} {* Premium included in base policy premium and any applicable rider premium.} {** Payable to expiration date.} If this policy was issued with an increased premium, exclusion or other modification, you may contact us if there are any changes to your health, occupation, avocation or other risk factor that might allow coverage to be continued without the modification. We will review the information you provide plus any other information available to us regarding all risk factors associated with you as of the time of our review. Using our underwriting rules and guidelines then in effect, we reserve the right to offer any change that we think is most appropriate, as well as the right to decline to make any change, regardless of whether the change in risk factor(s) is directly related to the reason for the policy modification. This refers ICC17-B180GSI(07/17) Page 3A We agree to your occupation at pay benefits according to the time terms of this policy if you become disabled. This section also defines regular occupation Disabled while this policy is in force and you give us Proof Of Loss for specialized physicians and dentists. For example, a presumptive disability could be the total and permanent loss of hearing in both ears. You don’t have to satisfy a benefit waiting period before receiving any benefits for which you submit a presumptive disabilityclaim. As In this policy you’re recuperating from a disability, you can receive help /your mean the Insured; we/us/our mean Standard Insurance Company. Other defined terms have initial capital letters and are defined in the DEFINITIONS section or in the provisions in which they first appear and to return to work full-time. We’ll pay the reasonable costs of a voluntary rehabilitation program, which may include workplace modifications, training and family care expensesthey primarily pertain.

READ THIS POLICY CAREFULLY. It is a legal contract between the Owner and The Standard Life Insurance CompanyCompany of New York. Pre-existing Condition limitations or exclusions and other limitations or exclusions may apply. The telephone number for By B180GSI(9/16)NY We want you to be satisfied with the [XYZ] Department of Insurance is [xxx-xx-xxxx]policy we deliver to you. xxx.xxxxxxxx.xxx STANDARD INSURANCE COMPANY ICC17-B180(07/17) If you decide within 30 days that you don’t want the policy, we’ll cancel it with no questions asked and refund your premium. Assignment 19 Benefits Family Care 6 Premium Waiver 6 Presumptive Disability 5 Rehabilitation Program 5 Survivor 8 6 Total Disability 4 Claims Claim Forms 11 9 Notice of Claim 11 9 Payment of Claims 13 11 Proof of Loss 11 9 Time of Payment 12 10 Concurrent Disability 9 8 DEFINITIONS 20 18 Exclusions and Limitations 8 Pre-Existing Conditions 10 7 General Provisions 17 15 Grace Period 14 12 Owner 22 19 Policy Data 3 Policy Termination 15 13 Premiums Schedule of 3 In General 14 12 Recurrent Disability 9 8 Reinstatement 14 12 Renewal Option After The Termination Date 16 Date. 14 Suspension During Military Service 15 13 Time Limit On Certain Defenses 18 16 B180GSI(9/16)NY This refers to the number of days after the start of your disability that you must be disabled before you are eligible to receive a disability paymentbenefit. Insured Policy Effective Date Owner at Issue [XXXX XXX] [00C9999990] Policy Number Policy Effective Date [July 2, 2016] [35] Issue Age Owner at Issue [The Insured] [00C9999990][35] [Non-Smoker] Policy Number Issue Age Risk Class Termination Date [July 2, 2048] [4A] Occupation Class Benefit Waiting Period [90 days] [Male] Neutral Gender Our underwriting experts use risk and occupation class as factors in determining terms of coverage and premium rates. [Mode of Premium Payment: [Special Monthly] Amount: $199.55[ 207.47] There are four premium modes available. The total amount due over a policy year varies by the mode selected. The mode you chose is noted above. The total due over the policy year for this mode and the difference between that total and the net annual premium payment are noted below: Difference between net annual premium and total [Special Monthly] payments: $[113.99[ 118.51]] {*The Net Annual Premium reflects the following discount(s): a discount of [Multi-Life Discount 10%] [Student/Resident Discount 10%] [Graduate Medical Education Discount 15%] [Business Owner Discount 10%] [Multi-Product Discount 5%] [Mental Disorder/Substance Abuse Limitation 10%]} 25]%. This is the maximum amount of time we will pay benefits under your policy. Commencement Date [91st] day of Disability Maximum Benefit Period: [To Age 67] – Determined by Your age when Disability begins; see Schedule of Maximum Benefit Periods on the next page. ICC17-B180(07/17) B180GSI(9/16)NY Page 3 Insured [XXXX XXX] [00C9999990] Policy Number Many additional forms of income protection are available through our wide range of optional riders. Insured [XXXX XXX] [00C9999990] Policy Number Schedule of Maximum Benefit Periods Age When Disability Begins Maximum Benefit Period [61 or younger To age 67 62 60 months 63 48 months 64 42 months 65 36 months 66 30 months 67 24 months 68 24 months 69 21 months 70 18 months 71 16months 72 15 months 73 14 months 74 13 months 75 or older 12 months] Expiration Date: Indexed Cost of Living Rider [July 2, 20363%] Student Loan [6%] [$428.66] Catastrophic Disability Benefit Rider $[5,000.00] Per Month [$166.00] Basic Residual Disability Rider [$141.40]** Maximum Monthly Student Loan Benefit: $[ 2,000 ] Student Loan Benefit Waiting Period: [ 90 ] days Student Loan Benefit Expiration Date: [July 2, 2026235.26] {Total Premium for Riders and Other [$988.511,201.00]} {* Premium included in base policy premium and any applicable rider premium.} {** Payable to expiration date.} If this policy was issued with an increased premium, exclusion or other modification, you may contact us if there are any changes to your health, occupation, avocation or other risk factor that might allow coverage to be continued without the modification. We will review the information you provide plus any other information available to us regarding all risk factors associated with you as of the time of our review. Using our underwriting rules and guidelines then in effect, we reserve the right to offer any change that we think is most appropriate, as well as the right to decline to make any change, regardless of whether the change in risk factor(s) is directly related to the reason for the policy modification. This refers to your occupation at the time you become disableddisabled as stated in the policy. This section also defines regular occupation for specialized physicians and dentists. For exampleIf you are presumptively disabled, a presumptive you can continue to work and earn an income and still be eligible for disability could be benefits. Presumptively disabled may refer to the total and permanent loss of hearing in both ears, for example. You don’t have to satisfy a benefit waiting period before receiving benefits for a presumptive disability. As you’re recuperating from a disability, you can receive help to return to work full-timetime by participating in a rehabilitation program that is approved by us. We’ll pay the reasonable costs of a voluntary rehabilitation program, which may include workplace modifications, training and family care expenses. Specialists (AOABOS) or American Dental Association (ADA), then that specialty will be deemed your Regular Occupation. If you are unemployed at the time Disability begins, then the last occupation in which you worked at least 30 hours per week will be deemed your Regular Occupation. If you are retired at the time Disability begins, then being retired will be deemed your Regular Occupation.

READ THIS POLICY CAREFULLY. It is a legal contract between the Owner and Standard Insurance Company. Pre-existing Condition limitations or exclusions and other limitations or exclusions may apply. The telephone number for the [XYZxxx.xxxxxxxx.xxx] Department of Insurance is [xxx-xx-xxxx]. xxx.xxxxxxxx.xxx STANDARD INSURANCE COMPANY ICC17-B180(07/17be replaced with new language that states the policy is noncancelable and guaranteed renewable to age 65 or 67. We can’t change the policy or its premium. Xxxxxxxxx X. Xxxxx Corporate Secretary B180GSI(7/17) Assignment 19 Benefits Family Care 6 Premium Waiver 6 Presumptive Disability 5 Rehabilitation Program 5 Survivor 8 Total Disability 4 Claims Claim Forms 11 Notice of Claim 11 Payment of Claims 13 Proof of Loss 11 Time of Payment 12 Concurrent Disability 9 DEFINITIONS 20 Exclusions and Limitations 8 Pre-Existing Conditions 10 General Provisions 17 Grace Period 14 Owner 22 Policy Data 3 Policy Termination 15 Premiums Schedule of 3 In General 14 Recurrent Disability 9 Reinstatement 14 Renewal Option After The Termination Date Date. 16 Suspension During Military Service 15 Time Limit On Certain Defenses 18 B180GSI(7/17) Our underwriting experts use risk and occupation class as factors in determining terms of coverage and premium rates. This refers to the number of days after the start of your disability that you must be disabled before you are eligible to receive a disability paymentbenefit. This is the maximum amount of time we will pay benefits under your policy. Insured Policy Effective Date Owner at Issue [XXXX XXX] [00C9999990] Policy Number Policy Effective Date [July 2, 2016] [35] Issue Age Owner at Issue [The Insured] [00C9999990][35] [Non-Smoker] Policy Number Issue Age Risk Class Termination Date [July 2, 2048] [4A] Occupation Class Benefit Waiting Period [90 days] [Male] Neutral Gender Our underwriting experts use risk and occupation class as factors in determining terms of coverage and premium rates. [Mode of Premium Payment: [Special Monthly] Amount: $199.55[ 207.47] There are four premium modes available. The total amount due over a policy year varies by the mode selected. The mode you chose is noted above. The total due over the policy year for this mode and the difference between that total and the net annual premium payment are noted below: Difference between net annual premium and total [Special Monthly] payments: $[113.99[ 118.51]] {*The Net Annual Premium reflects the following discount(s): a discount of [Multi-Life Discount 10%25]%. Commencement Date [91st] [Student/Resident Discount 10%] [Graduate Medical Education Discount 15%] [Business Owner Discount 10%] [Multi-Product Discount 5%] [Mental Disorder/Substance Abuse Limitation 10%]} This is the maximum amount day of time we will pay benefits under your policy. Disability Maximum Benefit Period: [To Age 67] – Determined by Your age when Disability begins; see Schedule of Maximum Benefit Periods on the next page. ICC17-B180(07/17B180GSI(7/17) Page 3 Insured [XXXX XXX] [00C9999990] Policy Number Many additional forms of income protection are available through our wide range Insured [XXXX XXX] [00C9999990] Policy Number Schedule of optional riders. Maximum Benefit Periods Age When Disability Begins Maximum Benefit Period [61 or younger To age 67 62 60 months 63 48 months 64 42 months 65 36 months 66 30 months 67 24 months 68 24 months 69 21 months 70 18 months 71 16months 72 15 months 73 14 months 74 13 months 75 or older 12 months] Expiration Date: range of optional riders. Indexed Cost of Living Rider [July 2, 20363%] Student Loan [6%] [$428.66] Catastrophic Disability Benefit Rider $[5,000.00] Per Month [$166.00] Basic Residual Disability Rider [$141.40]** Maximum Monthly Student Loan Benefit: $[ 2,000 ] Student Loan Benefit Waiting Period: [ 90 ] days Student Loan Benefit Expiration Date: [July 2, 2026235.26] {Total Premium for Riders and Other [$988.511,201.00]} {* Premium included in base policy premium and any applicable rider premium.} {** Payable to expiration date.} If this policy was issued with an increased premium, exclusion or other modification, you may contact us if there are any changes to your health, occupation, avocation or other risk factor that might allow coverage to be continued without the modification. We will review the information you provide plus any other information available to us regarding all risk factors associated with you as of the time of our review. Using our underwriting rules and guidelines then in effect, we reserve the right to offer any change that we think is most appropriate, as well as the right to decline to make any change, regardless of whether the change in risk factor(s) is directly related to the reason for the policy modification. into the base policy form rather than attached as a rider. This refers to your occupation at the time you become disableddisabled as stated in the policy. This section also defines regular occupation for specialized physicians and dentists. For exampleIf you are presumptively disabled, a presumptive you can continue to work and earn an income and still be eligible for disability could be benefits. Presumptively disabled may refer to the total and permanent loss of hearing in both ears, for example. You don’t have to satisfy a benefit waiting period before receiving benefits for a presumptive disability. As you’re recuperating from a disability, you can receive help to return to work full-timefull- time by participating in a rehabilitation program that is approved by us. We’ll pay the reasonable costs of a voluntary rehabilitation program, which may include workplace modifications, training and family care expenses. Specialists (AOABOS) or American Dental Association (ADA), then that specialty will be deemed your Regular Occupation. If you are unemployed at the time Disability begins, then the last occupation in which you worked at least 30 hours per week will be deemed your Regular Occupation. If you are retired at the time Disability begins, then being retired will be deemed your Regular Occupation.

READ THIS POLICY CAREFULLY. It is a legal contract between the Owner and Standard Insurance Company. Pre-existing Condition limitations or exclusions and other limitations or exclusions may apply. The telephone number for the [XYZ] Department of Insurance is [xxx-xx-xxxx]. xxx.xxxxxxxx.xxx STANDARD INSURANCE COMPANY ICC17-B180(07/17) Xxxxxxxxx X. Xxxxx Corporate Secretary Assignment 19 Benefits Family Care 6 Premium Waiver 6 Presumptive Disability 5 Rehabilitation Program 5 Survivor 8 Total Disability 4 Claims Claim Forms 11 Notice of Claim 11 Payment of Claims 13 Proof of Loss 11 Time of Payment 12 Concurrent Disability 9 DEFINITIONS 20 Exclusions and Limitations 8 Pre-Existing Conditions 10 General Provisions 17 Grace Period 14 Owner 22 Policy Data 3 Policy Termination 15 Premiums Schedule of 3 In General 14 Recurrent Disability 9 Reinstatement 14 Renewal Option After The Termination Date 16 Suspension During Military Service 15 Time Limit On Certain Defenses 18 Insured Policy Effective Date Owner at Issue [XXXX XXX] [July 2, 2016] [The Insured] [00C9999990][28] [Non-Smoker] Policy Number Issue Age Risk Class Termination Date [July 2, 2048] [4P] Occupation Class Benefit Waiting Period [90 days] [Male] Gender This refers to the number of days after the start of your disability before you are eligible to receive a disability payment. Insured Policy Effective Date Owner at Issue [XXXX XXX] [July 2, 2016] [The Insured] [00C9999990][35] [Non-Smoker] Policy Number Issue Age Risk Class Termination Date [July 2, 2048] [4A] Occupation Class Benefit Waiting Period [90 days] [Male] Gender Our underwriting experts use risk and occupation class as factors in determining terms of coverage and premium rates. [Mode of Premium Payment: [Special Monthly] Amount: $199.55] There are four premium modes available. The total amount due over a policy year varies by the mode selected. The mode you chose is noted above. The total due over the policy year for this mode and the difference between that total and the net annual premium payment are noted below: Difference between net annual premium and total [Special Monthly] payments: $[113.99104.71]] {*The Net Annual Premium reflects the following discount(s): [Multi-Life Discount 10%] [Student/Resident Discount 10%] [Graduate Medical Education Discount 15%] [Business Owner Discount 10%] [Multi-Product Discount 5%] [Mental Disorder/Substance Abuse Limitation 15% 10%]} % This is the maximum amount of time we will pay benefits under your policy. Maximum Benefit Period: [To Age 67] – Determined by Your age when Disability begins; see Schedule of Maximum Benefit Periods on the next page. ICC17-B180(07/17) Page 3 Insured [XXXX XXX] [00C9999990] Policy Number Many additional forms of income protection Some added benefits are available through our wide range of optional ridersincluded automatically under the GME program. Age When Disability Begins Maximum Benefit Period [61 or younger To age 67 62 60 months 63 48 months 64 42 months 65 36 months 66 30 months 67 24 months] Expiration Date: Others, such as the Student Loan Rider, are optional. * 0 [July 2, 2036$364.04] [Catastrophic Disability Benefit Rider $[5,000.00] Per Month] [$198.50] [Student Loan Rider [$141.40205.74]** Maximum Monthly Student Loan Benefit: $[ 2,000 2,500 ] Student Loan Benefit Waiting Period: [ 90 ] days Student Loan Benefit Expiration Date: [July 2, 2026]] {Total Premium for Riders [$988.51]} {* Premium included in base policy premium and any applicable rider premium.} {. ** Payable to expiration date.} . If this policy was issued with an increased premium, exclusion or other modification, you may contact us if there are any changes to your health, occupation, avocation or other risk factor that might allow coverage to be continued without the modification. We will review the information you provide plus any other information available to us regarding all risk factors associated with you as of the time of our review. Using our underwriting rules and guidelines then in effect, we reserve the right to offer any change that we think is most appropriate, as well as the right to decline to make any change, regardless of whether the change in risk factor(s) is directly related to the reason for the policy modification. This refers ICC17-B180(07/17) Page 3A Applicants may choose to your occupation at the time you become disabled. This section also defines regular occupation for specialized physicians and dentists. For example, add a presumptive disability could be the total and permanent loss of hearing in both ears. You don’t have to satisfy a benefit waiting period before receiving benefits for a presumptive disability. As you’re recuperating from a disability, you can receive help to return to work full-time. We’ll pay the reasonable costs of a voluntary rehabilitation program, which may include workplace modifications, training and family care expensesStudent Loan Rider and/or Catastrophic Disability Benefit Rider.