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
LAST SURVIVOR This is a Joint and Last Survivor Benefit Agreement for the
DEATH BENEFIT Certificate which summarizes changes in coverage under the
AGREEMENT Group Contact. The provisions summarized 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 ATTAINED MONTHLY COST OF ATTAINED MONTHLY COST OF
AGE INSURANCE RATE AGE INSURANCE RATE AGE INSURANCE RATE
[0 - 35 - 70 0.5020
1 - 36 - 71 0.6663
2 - 37 - 72 0.8666
3 - 38 - 73 1.1163
4 - 39 - 74 1.4171
5 - 40 - 75 1.7732
6 - 41 - 76 2.1831
7 - 42 - 77 2.6479
8 - 43 - 78 3.1709
9 - 44 - 79 3.7616
10 - 45 - 80 4.4380
11 - 46 - 81 5.2163
12 - 47 - 82 6.1130
13 - 48 - 83 7.1314
14 - 49 - 84 8.2628
15 - 50 - 85 9.4909
16 - 51 - 86 10.8022
17 - 52 - 87 12.1851
18 - 53 - 88 13.6300
19 - 54 - 89 15.1452
20 - 55 - 90 16.7381
21 - 56 - 91 18.4406
22 - 57 - 92 20.3084
23 - 58 - 93 22.4784
24 - 59 - 94 25.2634
25 - 60 - 95 29.2770
26 - 61 - 96 35.7275
27 - 62 - 97 46.8583
28 - 63 - 98 66.0868
29 - 64 - 99 81.9135]
30 - 65 0.0267
31 - 66 0.0884
32 - 67 0.1642
33 - 68 0.2559
34 - 69 0.3660
For the purposes of this table, Attained Age is based upon the age of the
younger Insured.
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