CONTRACT INFORMATION
First Insured [Xxxx Xxx] Certificate Number [NV-12345678]
Issue Age/Sex [65] [Male] Contract Date [January 1, 1999]
Rating Class [Standard] [Non-Tobacco]
Second Insured [Xxxx Xxx] Initial Death Benefit [$60,252.00]
Issue Age/Sex [65] [Female] Initial Payment [$30,000.00]
Rating Class [Standard] [Non-Tobacco] Initial Fixed Account
Guaranteed Interest Rate [4.00%]
Additional Agreements
[
Last Survivor Death Benefit Agreement]
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON
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LAST SURVIVOR This is a Joint and Last Survivor Benefit Agreement for the
DEATH BENEFIT Certificate which summarizes changes in coverage under the
Group Contact. The provisions summarized AGREEMENT herein
modify those in Your Certificate of coverage. If this
Agreement is attached to Your Certificate, coverage is
extended to two Insureds. The Insured individuals are those
shown on the Contract Information page of the Certificate.
The Death Benefit under a Certificate is payable if the
surviving Insured dies while coverage under the Group
Contract is in force and before the Maturity Date. The
surviving Insured is the Insured who is living upon the
death of the other Insured under this Certificate. No Death
Benefit is payable upon the death of the first Insured to
die.
DEFINITIONS
The Attained Age is an Insured's age on his or her last
birthday.
THE BENEFIT
In determining the Death Benefit, the applicable percentage
of the Account Value is based upon the Attained Age of the
younger Insured.
GUARANTEED DEATH BENEFIT
The Guaranteed Death Benefit will be in effect until the
date shown in the table below:
YOUNGER INSURED'S ISSUE AGE EXPIRY DATE OF GUARANTEED DEATH BENEFIT
0-39 25 Years from the Contract Date
40-59 15 Years from the Contract Date
60-85 10 Years from the Contract Date
MATURITY BENEFIT
The Maturity Date provision will be based upon the Attained
Age of the younger Insured.
REINSTATEMENT
You may reinstate the coverage under this Certificate
subject to the Reinstatement provision provided that: both
Insureds are alive; or one Insured is alive and the
termination of coverage without value occurred after the
death of the first Insured.
MISSTATEMENT OF AGE OR SEX, ASSIGNMENT
The Misstatement of Age or Sex and Assignment provisions
apply to either Insured.
OWNER
During the lifetime of both Insureds, the rights and
privileges stated in the Certificate may be exercised only
by You, the Owner.
BENEFICIARY
The Beneficiary is as named in the application on the
Contract Date of the Certificate, and may be changed from
time to time. The interest of any Beneficiary who dies
before the surviving Insured will terminate at the death of
that Beneficiary.
If no Beneficiary designation is in effect at the surviving
Insured's death, or if there is no designated Beneficiary
then living, You will be the Beneficiary. However, if the
surviving Insured was the Owner, the executors or
administrators of the Insured's estate will be the
Beneficiary.
CHANGE OF OWNERSHIP OR BENEFICIARY
You may change the Owner or any Beneficiary by Written
Request during the lifetime of either Insured. The change
will take effect as of the date the request is signed after
We acknowledge receipt in writing, whether or not the Owner
or an Insured are living at the time of acknowledgment. The
change will be subject to any assignment, and to any payment
made or action taken by Us before acknowledgment.
INCONTESTABILITY AFTER TWO YEARS
The Incontestability After Two Years provision applies to
both Insureds.
Before the end of the second year from the Contract Date of
a Certificate, We will send a notice to You requesting
notification of the death of any Insured. Failure to notify
Us of the death of either Insured will not avoid a contest
of the Group Contract.
SUICIDE WITHIN TWO YEARS
The Suicide Within Two Years provision applies to either
Insured.
COST OF INSURANCE RATE
The Cost of Insurance Rate is based on the Attained Age, sex
and rating classification of both Insureds. Pages 21 and
page 22 of this Certificate, which contain the Guaranteed
Monthly Maximum Cost of Insurance Rates, are hereby deleted
and replaced with the following:
The Guaranteed Monthly Maximum Cost of Insurance Rates are
based on the exact age and rating classification of each
Insured using the Xxxxxxx Method and the 1980 Commissioners
Standard Ordinary Mortality Table, age last birthday, on a
smoker/non-smoker basis.
A Table of the Guaranteed Monthly Maximum Cost of Insurance
Rates applicable to the Insureds named in Your application
has been printed on the Contract Information page of a
Certificate.
ACCELERATED DEATH BENEFIT
After the death of the first Insured, the Death Benefit may
be accelerated, subject to the conditions of the Accelerated
Death Benefit provision.
PAYMENT OF PROCEEDS
The Proceeds of this Certificate will be subject first to
the interest of an assignee, to whom payment will be made in
one sum. We will pay any remaining Proceeds to You before
the surviving Insured's death, and to the Beneficiary after
the surviving Insured's death.
Payment to the Beneficiary will be made only if We receive
proof, satisfactory to Us, of the death of both Insureds.
Unless otherwise provided, payment will be made in equal
shares to those Beneficiaries entitled to receive the
Proceeds.
TERMINATION OF AN INSURED'S COVERAGE
Coverage under this Agreement will terminate when one of the
following events occur:
- the surviving Insured dies;
- an Insured's coverage matures;
- the date an Insured's coverage ends without value; or
- the date an Insured's coverage is surrendered for its
Surrender Value.
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THIS AGREEMENT AND THE CERTIFICATE
This Agreement is made a part of Your Certificate if We have
listed it on the Contract Information page of the
Certificate.
EFFECTIVE DATE
This Agreement takes effect on the Contract Date shown on
the Contract Information page for the Certificate.
/s/ Xxxxxx X Xxxxx
PRESIDENT
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TABLE OF GUARANTEED MONTHLY MAXIMUM COST OF INSURANCE RATES
PER $1,000 OF INSURANCE NET AMOUNT OF RISK
[MALE] [STANDARD] [NON-TOBACCO] ISSUE AGE [65]
[FEMALE] [STANDARD] [NON-TOBACCO] ISSUE AGE [65]
Attained Monthly Cost of
Age Insurance Rate
[0 -
1 -
2 -
3 -
4 -
5 -
6 -
7 -
8 -
9 -
10 -
11 -
12 -
13 -
14 -
15 -
16 -
17 -
18 -
19 -
20 -
21 -
22 -
23 -
24 -
25 -
26 -
27 -
28 -
29 -
30 -
31 -
32 -
33 -
34 -
35 -
36 -
37 -
38 -
39 -
40 -
41 -
42 -
43 -
44 -
45 -
46 -
47 -
48 -
49 -
50 -
51 -
52 -
53 -
54 -
55 -
56 -
57 -
58 -
59 -
60 -
61 -
62 -
63 -
64 -
65 0.0267
66 0.0884
67 0.1642
68 0.2559
69 0.3660
70 0.5020
71 0.6663
72 0.8666
73 1.1163
74 1.4171
75 1.7732
76 2.1831
77 2.6479
78 3.1709
79 3.7616
80 4.4380
81 5.2163
82 6.1130
83 7.1314
84 8.2628
85 9.4909
86 10.8022
87 12.1851
8 13.6300
89 15.1452
90 16.7381
91 18.4406
92 20.3084
93 22.4784
94 25.2634
95 29.2770
96 35.7275
97 46.8583
98 66.0868
99 81.9135]
For the purposes of this table, Attained Age is based upon the age of the
younger Insured.
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