EXHIBIT (d)(1)
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THE NORTHWESTERN MUTUAL LIFE INSURANCE COMPANY AGREES TO PAY THE BENEFITS
PROVIDED IN THIS POLICY, SUBJECT TO ITS TERMS AND CONDITIONS. SIGNED AT
MILWAUKEE, WISCONSIN ON THE DATE OF ISSUE.
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/s/ XXXXXX X. XXXXXXXX /s/ XXXXX X. XXXXX
PRESIDENT AND C.E.O. SECRETARY
VARIABLE WHOLE LIFE POLICY WITH EXTRA LIFE PROTECTION
ELIGIBLE FOR ANNUAL DIVIDENDS
Insurance payable at death of Insured. Fixed premiums
payable for period shown on page 3.
Benefits reflect investment results. Variable benefits
described in Sections 5 through 8.
Provided no premium is unpaid as of its due date, the Death Benefit for the
first policy year will be the minimum death benefit shown on page 3, less any
policy debt. The Death Benefit after that may increase or decrease on each
policy anniversary depending on investment results. However, if no premium is
unpaid as of its due date, the Death Benefit will not be less than the minimum
death benefit shown on page 3, less any policy debt.
The cash value under this policy may increase or decrease daily depending on
investment results. There is no guaranteed minimum cash value.
RIGHT TO RETURN POLICY - Please read this policy carefully. The policy may be
returned by the Owner for any reason within (1) ten days after it was received
or (2) forty-five days after the application was signed, whichever is later. The
policy may be returned to your agent or to the Home Office of the Company at 000
Xxxx Xxxxxxxxx Xxxxxx, Xxxxxxxxx, XX 00000. If returned, the policy will be
considered void from the beginning. Any premium paid will then be refunded.
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MM 17 NORTHWESTERN
MUTUAL LIFE(R)
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THIS POLICY IS A LEGAL CONTRACT BETWEEN THE OWNER AND THE
NORTHWESTERN MUTUAL LIFE INSURANCE COMPANY.
READ YOUR POLICY CAREFULLY
GUIDE TO POLICY PROVISIONS
Page
BENEFITS AND PREMIUMS 3
SECTION 1. THE CONTRACT 5
Life Insurance Benefit payable on death of Insured.
Incontestability. Suicide. Definition of dates.
Misstatement of age.
SECTION 2. OWNERSHIP 5
Rights of the Owner. Assignment as collateral.
SECTION 3. PREMIUMS AND REINSTATEMENT 6
Payment of premiums. Grace period of 31 days to pay premiums.
Refund of unused premium at death. How to reinstate the policy
SECTION 4. DIVIDENDS 6
Annual dividends. Paid-up additions and other uses of
dividends. Dividends at death.
SECTION 5. THE SEPARATE ACCOUNT 7
The Separate Account and the Investment Divisions
Allocation of net annual premiums. Transfer of assets.
SECTION 6. DETERMINATION OF VALUES 8
How variable life insurance works. Investment Bases.
SECTION 7. DEATH BENEFIT 9
Determination of Death Benefit. Extra Life Protection.
Variable Insurance Amount.
SECTION 8. CASH VALUES, EXTENDED TERM AND PAID-UP INSURANCE 11
Cash value. What happens if premium is not paid.
Basis of values.
SECTION 9. LOANS 12
Policy loans. Premium loans. Effect of policy debt.
Interest on loans.
SECTION 10. CHANGE OF POLICY 13
SECTION 11. BENEFICIARIES 14
Naming and change of beneficiaries.
Marital deduction provision for spouse of Insured.
Succession in interest of beneficiaries.
SECTION 12. PAYMENT OF POLICY BENEFITS 15
Payment of surrender or death proceeds.
Payment plans for policy proceeds.
Right to increase income under payment plan. Guaranteed payment
tables.
ADDITIONAL BENEFITS (if any) Following page 17
APPLICATION Attached to the policy
MM 17
BENEFITS AND PREMIUMS
DATE OF ISSUE -- JULY 1, 1985
ANNUAL PAYABLE
PLAN AND ADDITIONAL BENEFITS AMOUNT PREMIUM FOR
EXTRA ORDINARY
VARIABLE WHOLE LIFE $1,014.00 LIFE
MINIMUM DEATH BENEFIT $60,000
EXTRA LIFE PROTECTION 40,000*
TOTAL INSURANCE 100,000
* THIS AMOUNT OF EXTRA LIFE PROTECTION IS GUARANTEED FOR THE FIRST 27 POLICY
YEARS UNLESS THIS GUARANTEED PERIOD IS TERMINATED SOONER UNDER SECTION 7.3.
A PREMIUM IS PAYABLE ON THE POLICY DATE AND EVERY 12 MONTHS THEREAFTER.
THE FIRST PREMIUM IS $1,014.00.
THE ALLOCATION OF THE FIRST NET ANNUAL PREMIUM OF $282.60 IS:
MONEY MARKET DIVISION 40%
BOND DIVISION 20%
STOCK DIVISION 20%
MASTER DIVISION 20%
THIS POLICY IS ISSUED IN A SELECT PREMIUM CLASS.
DIRECT BENEFICIARY XXXX X XXX, WIFE OF THE INSURED
OWNER XXXX X XXX, THE INSURED
INSURED XXXX X XXX AGE AND SEX 35 MALE
POLICY DATE JULY 1, 1985 POLICY NUMBER VL 1 700 017
PLAN EXTRA ORDINARY MINIMUM DEATH BENEFIT $ 60,000
VARIABLE WHOLE LIFE EXTRA LIFE PROTECTION 40,000
TOTAL INSURANCE 100,000
MM17 PAGE 3
TABLE OF VALUES
(CASH VALUES ARE NOT GUARANTEED. THEY MAY BE LARGER OR SMALLER
THAN THE CASH VALUES SHOWN. SEE SECTION 8.1.)
END OF TABULAR
POLICY CASH
YEAR JULY 1, VALUES
1 1986 $ 164
2 1987 844
3 1988 1,543
4 1989 2,260
5 1990 3,027
6 1991 3,814
7 1992 4,618
8 1993 5,443
9 1994 6,286
10 1995 7,150
11 1996 8,032
12 1997 8,934
13 1998 9,855
14 1999 10,798
15 2000 11,760
16 2001 12,742
17 2002 13,742
18 2003 14,758
19 2004 15,790
20 2005 16,833
AGE 60 2010 22,227
AGE 65 2015 27,846
AGE 70 2020 33,438
TABULAR CASH VALUES DO NOT REFLECT THE CASH VALUE OF ANY VARIABLE INSURANCE
AMOUNT OR PAID UP ADDITIONS AND DIVIDEND ACCUMULATIONS OR THE AMOUNT OF POLICY
DEBT. VALUES SHOWN AT END OF POLICY YEAR DO NOT REFLECT ANY PREMIUM DUE ON THAT
POLICY ANNIVERSARY.
THE CASH VALUE OF THIS POLICY INCREASES AND DECREASES TO REFLECT THE INVESTMENT
EXPERIENCE OF THE SEPARATE ACCOUNT. THERE IS NO GUARANTEED MINIMUM CASH VALUE.
POLICY NET ANNUAL
YEARS PREMIUM
------ ----------
1 $ 282.60
2-4 778.20
5 and later 807.60
INSURED XXXX X. XXX AGE AND SEX 35 MALE
POLICY JULY 1, 1985 POLICY NUMBER VL 1 700 017
PLAN EXTRA ORDINARY MINIMUM DEATH BENEFIT $ 60,000
VARIABLE WHOLE LIFE EXTRA LIFE PROTECTION 40,000
TOTAL INSURANCE 100,000
PAGE 4
TABLE OF NET SINGLE PREMIUMS
FOR $1.00 OF VARIABLE INSURANCE AMOUNT OR FIXED BENEFIT
OR VARIABLE BENEFIT PAID-UP INSURANCE
END OF NET SINGLE END OF NET SINGLE
POLICY YEAR JULY 1, PREMIUM POLICY YEAR JULY 1, PREMIUM
0 1985 $.25173
1 1986 .26019 36 2021 $ .68574
2 1987 .26892 37 2022 .69929
3 1988 .26890 38 2023 .71262
4 1989 .28712 39 2024 .73864
5 1990 .29659 40 2025 .73828
6 1991 .30630 41 2026 .75052
7 1992 .31623 42 2027 .76238
8 1993 .32641 43 2028 .77391
9 1994 .33683 44 2029 .78517
10 1995 .34748 45 2030 .79621
11 1996 .35837 46 2031 .80702
12 1997 .36951 47 2032 .81756
13 1998 .38089 48 2033 .82774
14 1999 .39252 49 2034 .83745
15 2000 .40440 50 2035 .84665
16 2001 .41653 51 2036 .85536
17 2002 .42888 52 2037 .86362
18 2003 .44143 53 2038 .87153
19 2004 .45416 54 2039 .87921
20 2005 .46704 55 2040 .88679
21 2006 .48007 56 2041 .89444
22 2007 .49324 57 2042 .90238
23 2008 .50655 58 2043 .91083
24 2009 .52002 59 2044 .92014
25 2010 .53364 60 2045 .93048
26 2011 .54739 61 2046 .94199
27 2012 .56124 62 2047 .95457
28 2013 .57516 63 2048 .96778
29 2014 .58909 64 2049 .98068
30 2015 .60301 65 2050 1.0000
31 2016 .61689
32 2017 .63072
33 2018 .64453
34 2019 .65831
35 2020 .67206
INSURED XXXX X XXX AGE AND SEX 35 MALE
POLICY DATE JULY 1, 1985 POLICY NUMBER VL 1 700 017
PLAN EXTRA ORDINARY MINIMUM DEATH BENEFIT $ 60,000
VARIABLE WHOLE LIFE EXTRA LIFE PROTECTION 40,000
TOTAL INSURANCE 100,000
MM 17 PAGE 4A
SECTION 1. THE CONTRACT
1.1 LIFE INSURANCE BENEFIT
The Northwestern Mutual Life Insurance Company will pay a benefit on the
death of the Insured. Subject to the terms and conditions of the policy.
- payment of the Death Benefit determined under Section 7 will be made
after proof of the death of the Insured is received at the Home Office;
and
- payment will be made to the beneficiary or other payee under Sections 11
and 12.
1.2 ENTIRE CONTRACT; CHANGES
This policy with the attached application is the entire contract.
Statements in the application are representations and not warranties. A change
in the policy is valid only if it is approved by an officer of the Company. The
Company may require that the policy be sent to it for endorsement to show a
change. No agent has the authority to change the policy or to waive any of its
terms.
1.3 INCONTESTABILITY
The Company will not contest this policy after it has been in force during
the lifetime of the Insured for two years from the Date of Issue. In issuing the
policy, the Company has relied on the application. While the policy is
contestable, the Company, on the basis of a misstatement in the application, may
rescind the policy or deny a claim.
1.4 SUICIDE
If the Insured dies by suicide within one year from the Date of Issue, the
amount payable by the Company will be limited to the premiums paid.
1.5 DATES
The contestable and suicide periods begin with the Date of Issue. Policy
months, years and anniversaries are computed from the Policy Date. Both dates
are shown on page 3.
1.6 MISSTATEMENT OF AGE OR SEX
If the age or sex of the Insured has been misstated, the amount payable
will be the amount which the premiums paid would have purchased at the correct
age and sex.
1.7 PAYMENTS BY THE COMPANY
All payments by the Company under this policy are payable at its Home
Office.
SECTION 2. OWNERSHIP
2.1 THE OWNER
The Owner is named on page 3. All policy rights may be exercised by the
Owner, his successor or his transferee:
- without the consent of any beneficiary.
- while the Insured is living and, after his death, only as provided in
Sections 11 and 12.
2.2 TRANSFER OF OWNERSHIP
The Owner may transfer the ownership of this policy. Written proof of
transfer satisfactory to the Company must be received at its Home Office. The
transfer will then take effect as of the date it was signed. The Company may
require that the policy be sent to it for endorsement to show the transfer.
2.3 COLLATERAL ASSIGNMENT
The Owner may assign this policy as collateral security. The Company is not
responsible for the validity or effect of a collateral assignment. The Company
will not be responsible to an assignee for any payment or other action taken by
the Company before receipt of the assignment in writing at its Home Office.
The interest of any beneficiary will be subject to any collateral
assignment made either before or after the beneficiary is named.
A collateral assignee is not an Owner. A collateral assignment is not a
transfer of ownership. Ownership can be transferred only by complying with
Section 2.2.
MM 17 5
SECTION 3. PREMIUMS AND REINSTATEMENT
3.1 PREMIUMS
PAYMENT. All premiums after the first are payable at the Home Office or to an
authorized agent. A premium must be paid on or before its due date. A receipt
signed by an officer of the Company will be furnished on request.
FREQUENCY. Premiums may be paid every 3, 6 or 12 months at the published rates
of the Company. A change in premium frequency will take effect when the Company
accepts a premium on a new frequency. Premiums may be paid monthly, or on any
other frequency, with the consent of the Company.
GRACE PERIOD. A grace period of 31 days will be allowed to pay a premium that is
not paid on its due date. The policy will be in full force during this period.
If a premium is paid during the grace period, policy values will be the same as
if the premium had been paid on the premium due date. If the Insured dies during
the grace period, any overdue premium will be paid from the proceeds of the
policy.
If the premium is not paid within the grace period, the policy will
terminate as of the due date unless it continues as extended term insurance or
as paid-up insurance under Section 8.
PREMIUM REFUND AT DEATH. The Company will refund that portion of any premium
paid for a period beyond the date of the Insured's death. The refund will be
part of the policy proceeds.
3.2 REINSTATEMENT
The policy may be reinstated within five years after the due date of the
overdue premium. This may not be done if the policy was surrendered for its cash
value. After reinstatement, the policy will have the same Death Benefit and the
same Investment Base in each Division as if all premiums had been paid when due.
The policy will be reinstated if evidence of insurability is given that is
satisfactory to the Company and upon payment of the greater of:
- all unpaid premiums to the date of reinstatement with interest from the
due date of each premium at an annual effective rate of 6%; or
- 110% of the increase in cash value resulting from reinstatement plus all
unpaid premiums to the date of reinstatement for any Additional Benefits
attached to the policy with interest from the due date of each premium
at an annual effective rate of 6%. The increase in cash value is the
excess of the cash value of the policy upon reinstatement over the cash
value of the policy just before reinstatement.
Any policy debt, with interest at the policy loan interest rate to the date
of reinstatement, must be repaid or reinstated.
SECTION 4. DIVIDENDS
4.1 ANNUAL DIVIDENDS
This policy will share in the divisible surplus of the Company. This
surplus is determined each year. The policy's share will be credited as a
dividend on the policy anniversary.
4.2 USE OF DIVIDENDS
Dividends may be paid in cash or used for one of the following:
- PAID-UP ADDITIONS. Dividends will purchase paid-up additional insurance
as described in Section 4.3. Paid-up additions share in the divisible
surplus.
- DIVIDEND ACCUMULATIONS. Dividends will accumulate at interest. Interest
is credited at an annual effective rate of 3 1/2%. The Company may set a
higher rate.
- PREMIUM PAYMENT. Dividends will be used to reduce premiums. If the
balance of a premium is not paid, or if this policy is in force as fixed
benefit or variable benefit paid-up insurance, the dividend will purchase
paid-up additions.
Other uses of dividends may be made available by the Company.
If no direction is given for the use of dividends, they will purchase
paid-up additions.
4.3 PAID-UP ADDITIONS
If this policy is in force as variable life insurance, dividends may be
used to purchase variable benefit paid-up additions. Each dividend will be
allocated to the Divisions in the same manner as new net annual premiums.
If the policy is in force as fixed benefit paid-up insurance, dividends may
be used to purchase fixed benefit paid-up additions.
4.4 ADDITIONS AND ACCUMULATIONS
Paid-up additions and dividend accumulations increase the policy's cash
value. They are payable as part of the policy's proceeds. The cash value of
variable benefit paid-up additions will vary daily, and the death benefit
annually. However, there is not a minimum death benefit for variable benefit
paid-up additions.
Additions may be surrendered and accumulations may be withdrawn unless they
are used for a loan or for extended term insurance or paid-up insurance under
Section 8.
4.5 DIVIDEND AT DEATH
A dividend for the period from the beginning of the policy year to the date
of the Insured's death will be payable as part of the policy proceeds.
MM 17 6
SECTION 5. THE SEPARATE ACCOUNT
5.1 DESCRIPTION
The Northwestern Mutual Variable Life Account (the Separate Account) has
been established by the Company pursuant to Wisconsin law and is registered as a
unit investment trust under the Investment Company Act of 1940.
The Separate Account has four Divisions--Stock Division, Bond Division,
Money Market Division and Master Division. Assets of the Separate Account are
invested in shares of Northwestern Mutual Variable Life Series Fund, Inc. (the
Fund). The Fund is registered under the Investment Company Act of 1940 as an
open-end, diversified management investment company. The Fund has four
Portfolios--Stock Portfolio, Bond Portfolio, Money Market Portfolio and Master
Portfolio. Assets of each Division of the Separate Account are invested in
shares of the corresponding Portfolio of the Fund. Shares of the Fund are
purchased for the Separate Account at their net asset value. In the future,
additional Divisions may be added to the Separate Account, and additional
Portfolios may be added to the Fund.
Assets will be allocated to the Separate Account to support the operation
of this policy (except when in force as extended term or fixed benefit paid-up
insurance) and other variable life insurance policies. Assets may also be
allocated for other purposes, but not to support the operation of any contracts
or policies other than variable life insurance. Income and realized and
unrealized gains and losses from assets in the Separate Account are credited to
or charged against it without regard to other income, gains or losses of the
Company.
The assets of the Separate Account will be valued on each business day.
They are the property of the Company. The portion of these assets equal to
policy reserves and liabilities will not be charged with liabilities arising out
of any other business the Company may conduct. The Company reserves the right to
transfer assets of the Separate Account in excess of these reserves and
liabilities to its General Account.
The Owner may exchange this policy for a fixed benefit life insurance
policy if the Fund changes its investment advisor or if a Portfolio has a
material change in its investment objectives or restrictions. The Company will
notify the Owner if there is any such change. The Owner may exchange this
policy within 60 days after the notice or the effective date of the change,
whichever is later.
If, in the judgment of the Company, a Portfolio no longer suits the
purposes of this policy due to a change in its investment objectives or
restrictions, the Company may substitute shares of another portfolio of the Fund
or shares of another mutual fund. Any such substitution will be subject to any
required approval of the Securities and Exchange Commission (SEC), the Wisconsin
Commissioner of Insurance or other regulatory authority.
The Company also may, to the extent permitted by applicable laws and
regulations (including any order of the SEC), make changes as follows:
- the Separate Account or a Division may be operated as a management
company under the Investment Company Act of 1940, or in any other form
permitted by law, if deemed by the Company to be in the best interest
of the policyowners.
- the Separate Account may be deregistered under the Investment Company
Act of 1940 in the event registration is no longer required.
- the provisions of this and other policies may be modified to comply
with any other applicable federal or state laws.
In the event of a substitution or change, the Company may make appropriate
endorsement on this and other policies having an interest in the Separate
Account and take other actions as may be necessary to effect the substitution or
change.
5.2 ALLOCATION OF NET ANNUAL PREMIUMS AND DIVIDENDS
The Owner may allocate the net annual premiums to any of the Divisions. The
net annual premium will be allocated on the policy anniversary. Allocations must
be in whole percentages. If a Division is to receive any allocations, the
allocation must be at least 10% of the net annual premium.
The allocation in effect on the Policy Date is shown on page 3. This
allocation applies to the first net annual premium, and it will remain in effect
for later net annual premiums unless changed by the Owner. The Owner may change
the allocation, but the change will not take effect until the first policy
anniversary following receipt of a written request at the Home Office.
A dividend used to purchase variable benefit paid-up additions will be
allocated to the Divisions in the same manner as new net annual premiums.
5.3 TRANSFER OF ASSETS
The Owner may transfer the assets (other than policy debt) supporting the
policy to any of the Divisions. Transfers may be made as often as four times in
a policy year.
The transfer will take effect on the date a written request is received in
the Home Office. A fee may be required.
MM 17 7
SECTION 6. DETERMINATION OF VALUES
6.1 HOW VARIABLE LIFE INSURANCE WORKS
The Death Benefit and cash value provided by this policy are derived from
the net annual premiums credited to the Separate Account and the investment
earnings they generate. These earnings determine a Rate of Return. The Rate of
Return can be either positive or negative because it includes capital gains and
losses (both realized and unrealized), as well as earnings from dividends and
interest.
If the Rate of Return were to equal 4% each and every year, the policy's
cash value each year would equal the value for that year shown in the table of
Tabular Cash Values on page 4. Likewise, the Death Benefit would always equal
the minimum death benefit shown on page 3, plus the amount of Extra Life
Protection then if force. This is because 4% is the earnings rate the Company
assumed when it calculated the net annual premiums and Tabular Cash Values.
If the rate of Return in a given year is greater than 4%, the earnings in
excess of 4% are converted to paid-up variable life insurance. If the rate of
Return in a given year is less than 4% the result is negative paid-up variable
life insurance. The total amount of paid-up variable life insurance is called
the Variable Insurance Amount.
The Variable Insurance Amount is zero during the first policy year. On each
policy anniversary, the positive (or negative) paid-up variable life insurance
is added to (or subtracted from) the Variable Insurance Amount for the prior
year. If the resulting Variable Insurance Amount is positive, the policy's cash
value on the policy anniversary will be greater than the amount shown on page 4,
and the positive Variable Insurance Amount will contribute to the Extra Life
Protection. On the other hand, if the Variable Insurance Amount is negative, the
policy's cash value on the policy anniversary will be less than the Tabular Cash
Value shown on page 4. The Death Benefit, however, will be equal to the minimum
death benefit shown on page 3, plus the amount of Extra Life Protection in
force, unless premiums are not paid when due or there is policy debt.
In this policy, amounts used in calculations may be negative. When a
negative amount is added, the result is the same as if the corresponding
positive amount had been subtracted.
6.2 VALUATION PERIOD
Each business day, together with any non-business day or consecutive
non-business days immediately preceding it, will constitute a valuation period.
A business day is any day on which the New York Stock Exchange is open for
trading.
6.3 NET INVESTMENT FACTOR
The Net Investment Factor for a valuation period for a particular Division
is obtained by dividing (a) by (b) and then subtracting (c) where:
(a) is: - the value of a Fund share in the corresponding Portfolio at the
close of the current valuation period; plus
- the per share amount of any investment income and capital gains
distributed by the Fund for the current valuation period; minus
- any amount per share charged against the Division in the valuation
period for taxes.
(b) is: the value of the share at the close of business of the preceding
valuation period.
(c) is: a charge not exceeding .00001367 for each day in the valuation
period. This is the equivalent of a charge not exceeding .50% per
year for mortality and expense risks and other contingencies.
6.4 DIVISION INDEX
The Division Index for the valuation period which included the first day on
which there were assets in the Division was 1.000000. The Index for each
subsequent valuation period is the Division Index for the immediately preceding
valuation period multiplied by the Net Investment Factor for the subsequent
valuation period. The Index for a valuation period applies to each day in that
period.
6.5 RATE OF RETURN
The Rate of Return for a Division is equal to the change in the Division
Index over the applicable period divided by the Division Index at the beginning
of such period.
The Rate of Return for policy debt is the interest earned on one dollar
over the applicable period, assuming an annual effective interest rate
equivalent to the policy loan interest rate or rates in effect during that
period, less a charge by the Company for expenses and taxes.
6.6 INVESTMENT ADJUSTMENT RATE
The Investment Adjustment Rate for a Division or policy debt is equal to
its Rate of Return less the interest earned on one dollar over the applicable
period assuming an annual effective rate of 4%. The Investment Adjustment Rate
for a Division may be positive or negative.
MM 17 8
6.7 INVESTMENT ADJUSTMENT
The Investment Adjustment for each Investment Base is equal to (a) the
Investment Adjustment Rate for the corresponding Division multiplied by the
average Investment Base plus (b) the Investment Adjustment Rate for policy debt
multiplied by the average amount of policy debt allocated to the Investment
Base.
6.8 INTERIM VALUE ADJUSTMENT
The Interim Value Adjustment is the accumulation of all Investment
Adjustments made during the period for which the Interim Value Adjustment is
calculated. On each policy anniversary it is applied as a Net Single Premium to
increase (or decrease) the Variable Insurance Amount. However, any Interim Value
Adjustment attributable to variable benefit paid-up additions is applied
as a Net Single Premium to increase (or decrease) such additions.
6.9 INVESTMENT BASES
The Investment Bases will be determined at the end of each policy year and
at any other time it is necessary to recognize requests by the Owner for
transfers of assets, policy loan increases or repayments, or other transactions
concerning policy values.
The Investment Base in a Division is:
- its portion of the current Tabular Cash Value; plus
- its portion of the current Net Single Premium for the Variable Insurance
Amount in effect; plus
- its portion of the current Net Single Premium for the amount of variable
benefit paid-up additions; plus
- its contribution to the current Interim Value Adjustment; less
- its portion of the current policy debt. Policy debt and repayments will
be allocated in proportion to the sum of the current Tabular Cash Value,
current Net Single Premiums and current Interim Value Adjustment in each
Investment Base.
The Investment Bases cease to exist if the policy continues in force as
extended term insurance or fixed benefit paid-up insurance.
SECTION 7. DEATH BENEFIT
7.1 BENEFIT
The Death Benefit when all premiums due have been paid will equal:
- the minimum death benefit; plus
- the amount of Extra Life Protection then in force; less
- any policy debt; plus
- the amount of any dividend accumulations and any dividend at death.
The minimum death benefit is shown on page 3. The Death Benefit will be
increased by that portion of any premium paid for a period beyond the date of
the Insured's death. The Death Benefit, if the Insured dies during the grace
period, will be the amount determined above decreased by any due and unpaid
premium. All values will be determined as of the date of death.
The amount payable on death when all premiums due have not been paid and
the policy is in force after the grace period is determined under Section 8.
7.2 EXTRA LIFE PROTECTION
DESCRIPTION. Extra Life Protection consists of one year term insurance,
positive Variable Insurance Amount, and variable benefit paid-up additions.
Each dividend is used to purchase variable benefit paid-up additions. These
additions and positive Variable Insurance Amount reduce the amount of one year
term insurance. At first, Extra Life Protection is all one year term insurance.
The amount of one year term insurance will vary from policy year to policy year
to reflect investment results. The amount of one year term insurance is zero
when Extra Life Protection is all variable benefit paid-up additions and
positive Variable Insurance Amount.
The amount of Extra Life Protection and the period for which that amount is
guaranteed are shown on page 3. The amount of Extra Life Protection will be the
sum of variable benefit paid-up additions and positive Variable Insurance Amount
when that sum exceeds the amount of Extra Life Protection shown on page 3.
MM17 9
After the guaranteed period has expired, Extra Life Protection will
continue to be at least the amount shown on page 3 so long as premiums are paid
when due unless:
- the amount of Extra Life Protection is reduced by the Owner under Section
7.3; or
- the amount of Extra Life Protection is reduced by the Company.
POSSIBLE REDUCTION FOR POLICY YEAR BY COMPANY AND OWNER'S RIGHT TO CONTINUE
EXISTING PROTECTION. If, on any policy anniversary after the guaranteed period
has expired, the sum of variable benefit paid-up additions and positive Variable
Insurance Amount is less than the amount of Extra Life Protection shown on page
3, the Company may reduce the term insurance portion of Extra Life Protection
for the policy year. The Company will notify the Owner of the amount of the
reduction. For the policy year the Owner then may increase the Extra Life
Protection up to the amount shown on page 3 by paying an additional premium. The
additional premium will not be more than 110% of the net premium for an amount
of one year term insurance equal to the amount by which the Extra Life
Protection is to be increased. The net premium will be based on the Insured's
attained age, the Commissioners 1980 Standard Ordinary Mortality Table for the
sex of the Insured, and an annual effective interest rate of 4%. The additional
premium will be due on the date stated in the notice sent by the Company to the
Owner on the policy anniversary. The right of the Owner to continue the amount
of Extra Life Protection will terminate as of the first policy anniversary on
which the Owner fails to pay an additional premium when due, or, if earlier,
when the Owner reduces the Extra Life Protection under Section 7.3.
7.3 REDUCTION OF EXISTING PROTECTION BY OWNER
If the Owner surrenders any variable benefit paid-up additions or directs
that dividends be used other than for paid-up additions:
- any one year term insurance in force will terminate;
- any remaining guaranteed period of Extra Life Protection will terminate;
and
- the right to continue the amount of Extra Life Protection under Section
7.2 will terminate.
The amount of Extra Life Protection thereafter will be the sum of positive
Variable Insurance Amount and variable benefit paid-up additions remaining in
force.
7.4 VARIABLE INSURANCE AMOUNT
The Company will determine at the beginning of each policy year the
Variable Insurance Amount for that year. It remains at a constant amount during
the year and may be positive or negative. It is zero during the first policy
year.
The Variable Insurance Amount for a policy year is the sum of the Variable
Insurance Amount for the past year plus the amount of paid-up variable life
insurance as determined on the policy anniversary. The amount of paid-up
variable life insurance, which may be positive or negative, is determined by
dividing (a) by (b) where:
(a) equals the Interim Value Adjustment for the past policy year, less that
portion of the Interim Value Adjustment attributable to additions. (See
Section 7.5.)
(b) equals the Net Single Premium per $1.00 of Variable Insurance Amount at
the end of the policy year.
7.5 VARIABLE BENEFIT PAID-UP ADDITIONS
If variable benefit paid-up additions have been purchased by dividends, the
Company will determine at the beginning of each policy year the amount of
insurance provided by the additions for that year. The amount of such insurance
for a policy year is the sum of the amount for the past year plus an additional
amount determined on the policy anniversary. The additional amount, which may be
positive or negative, is determined by dividing (a) by (b) where:
(a) equals the sum of the portion of Interim Value Adjustment attributable
to existing additions and the amount of the current dividend to be used
to purchase additions.
(b) equals the Net Single Premium per $1.00 of Variable Insurance Amount at
the end of the policy year.
The amount of insurance provided by dividends remains constant during the
year, unless additions are surrendered.
MM 17 10
SECTION 8. CASH VALUE, EXTENDED TERM INSURANCE
AND PAID-UP INSURANCE
8.1 CASH VALUE
The cash value on any date when all premiums due have been paid or when the
policy is in force as variable benefit paid-up insurance under Section 8.3 will
be equal to the sum of the Investment Bases on that date. If premiums are not
paid on this policy on an annual basis, the cash value will reflect a
reduction for any premiums due later in the policy year. See Sections 6.9 and
8.6. The cash value on any date during the grace period will be equal to the sum
of the Investment Bases on the due date, adjusted for the sum (positive or
negative) of the Investment Adjustments since the due date, and adjusted for any
increase or decrease in policy debt since the due date.
The cash value of any extended term insurance, fixed benefit paid-up
insurance, or fixed benefit paid-up additions will be the net single premium for
that insurance at the attained age of the Insured less any policy debt. If
extended term insurance or fixed benefit paid-up insurance is surrendered within
31 days after a policy anniversary, the cash value will not be less than the
cash value on that anniversary.
The cash value of the policy will include the amount of any dividend
accumulations.
8.2 EXTENDED TERM INSURANCE
If any premium is unpaid at the end of the grace period, the policy will be
in force as fixed benefit extended term insurance. The amount of this term
insurance will be the Death Benefit, determined under section 7.1, at the end of
the last valuation period prior to the due date of the unpaid premium adjusted
for any change in policy debt. The term insurance will start as of the due date
of the unpaid premium. The period of term insurance will be determined by using
the cash value as of the last day of the grace period as a net single premium at
the attained age of the Insured. If the term insurance would extend to or beyond
age 100, or if this policy is issued in a classified premium class, fixed
benefit paid-up insurance will be provided instead. Extended term insurance does
not share in divisible surplus.
8.3 PAID-UP INSURANCE
Fixed benefit or variable benefit paid-up insurance may be selected in
place of extended term insurance. A written request must be received at the Home
Office no later than three months after the due date of the unpaid premium. The
minimum death benefit is not in effect for paid-up insurance.
The amount of fixed benefit paid-up insurance will be determined by using
the cash value plus the policy debt, both as of the last day of the grace
period, as a Net Single Premium at the attained age of the Insured. However, if
a portion of the cash value is attributable to variable benefit paid-up
additions, that portion will be applied to purchase fixed benefit paid-up
additions. The variable benefit paid-up additions will no longer be in force.
Variable benefit paid-up insurance may be selected provided the cash value
of the policy is at least $1,000 as of the end of the last valuation period just
prior to the due date of the unpaid premium. The amount of variable benefit
paid-up insurance until the first policy anniversary following the due date of
the unpaid premium will be determined by using the cash value plus the policy
debt, both as of the end of the last valuation period just prior to the due date
of the unpaid premium, as a net single premium at the attained age of the
Insured. Thereafter, the amount of variable benefit paid-up insurance will be
determined on each policy anniversary. The amount of variable benefit paid-up
insurance for a policy year is the amount in force at the end of the prior year
plus the amount of paid-up variable life insurance as determined on the policy
anniversary. The amount of paid-up variable life insurance, which may be
positive or negative, is determined by dividing (a) by (b) where:
(a) equals the Interim Value Adjustment for the past policy year
(or, for the policy year following that in which a premium
remained unpaid, the Interim Value Adjustment for the period
between the due date of the unpaid premium and the end of the
policy year), less that portion of the Interim Value
Adjustment attributable to additions.
(b) equals the Net Single Premium per $1.00 of Variable Insurance
Amount on the policy anniversary.
Any policy debt will continue on paid-up insurance. Paid-up insurance will
share in divisible surplus.
8.4 SURRENDER
The Owner may surrender this policy for its cash value. A written surrender
of all claims, satisfactory to the Company, will be required. The date of
surrender will be the date of receipt at the Home Office of the written
surrender. The policy will terminate, and the cash value will be determined, as
of the end of the last valuation period prior to the date of surrender, or, in
the case of extended term insurance or fixed benefit paid-up insurance, as of
the date of surrender. The Company may require that the policy be sent to it.
The Company may defer paying the cash value of extended term or fixed
benefit paid-up insurance for up to six months from the date of surrender. If
payment is deferred for 30 days or more, interest will be paid on the cash value
at an annual effective rate of 4% from the date of surrender to the date of
payment.
MM 17 11
8.5 DEFERRAL OF PAYMENTS
During any period when:
- the sale of securities or the determination of a Division Index is not
reasonably practicable because
(i) the New York Stock Exchange is closed, or
(ii) conditions are such that, under rules and regulations adopted by
the SEC, trading is deemed to be restricted or an emergency is
deemed to exist, or
- the SEC, by order, permits deferral for the protection of the Company's
policyowners;
the Company reserves the right:
- to defer determination of cash values and payment of the cash value;
- to defer payment of loan;
- to defer determination of a change in the Variable Insurance Amount or
other variable amounts payable on death, and, if such determination has
been deferred, to defer payment of any portion of the Death Benefit
equal to the Variable Insurance Amount or such other variable amounts;
and
- if payment of all or part of the Death Benefit is deferred, to defer
application of the Death Benefit to a payment plan under Section 12.
8.6 TABULAR CASH VALUES
Tabular Cash Values are shown on page 4 for the end of the policy years
indicated. These values assume that all premiums due have been paid for the
number of years stated. They do not reflect the cash value of any Variable
Insurance Amount, amounts resulting from dividends, or policy debt. When a
Tabular Cash Value is derived for the purpose of determining a cash value, a
deduction will be made for any portion of the policy year for which premiums
have not been paid. Tabular Cash Values during a policy year will also reflect
time elapsed in that year.
Values for policy years not shown are calculated on the same basis as those
on page 4. A list of these values will be furnished on request. All values are
at least as great as those required by the state in which this policy is
delivered.
8.7 BASIS OF VALUES
Tabular Cash Values are the reserves for the minimum death benefit
calculated by using the net annual premiums shown on page 4. These and the Net
Single Premiums are based on the Commissioners 1980 Standard Ordinary Mortality
Table for the sex of the Insured, except that for the first ten years of any
period of extended term insurance, the Commissioners 1980 Extended Term
Insurance Table for the sex of the Insured is used. Interest is based on an
annual effective rate of 4%. Calculations assume the continuous payment of
premiums and the immediate payment of claims.
SECTION 9. LOANS
9.1 POLICY AND PREMIUM LOANS
The Owner may obtain a loan from the Company in an amount that, when added
to existing policy debt, is not more than the loan value. The making of a policy
loan will have a permanent effect on the cash values and the Death Benefit
payable under the policy. While this policy is in force as variable life
insurance, loans will decrease and repayments will increase the Investment Bases
as described in Section 6.9.
POLICY LOAN. The loan may be obtained on written request. No loan will be made
if the policy is in force as extended term insurance. If the policy is in force
as fixed benefit paid-up insurance, the Company may defer making the loan for up
to six months.
PREMIUM LOAN. If the premium loan provision is in effect on this policy, a loan
will be made to pay an overdue premium. If the loan value is not large enough to
pay the overdue premium, a premium will be paid for any other frequency
permitted by this policy for which the loan value is large enough. The Owner may
elect or revoke the premium loan provision by written request received at the
Home Office.
9.2 LOAN VALUE
The loan value in the first two policy years is 75% of the sum of the cash
value and any existing policy debt on the date of the loan. The loan value after
that is 90% of the sum of the cash value and any existing policy debt on the
date of the loan.
9.3 POLICY DEBT
Policy debt consists of all outstanding loans and accrued interest. It may
be paid to the Company at any time. Any policy debt will be deducted from the
policy proceeds.
If the cash value decreases to zero, this policy will terminate unless a
sufficient portion of the policy debt is repaid. Termination occurs 31 days
after a notice has been mailed to the Owner and to any assignee on record at the
Home office. The notice will state the amount that must be repaid to keep the
policy in force.
MM 17 12
9.4 LOAN INTEREST
The Specified Rate loan interest option or the Variable Rate loan interest
option is elected on the application. The Owner may change this election at any
time, but the change will not take effect until the January 1st following
receipt of a written request at the Company's Home Office.
Interest accrues and is payable on a daily basis from the date of the loan
on policy loans and from the premium due date on premium loans. Unpaid interest
is added to the loan.
9.5 SPECIFIED RATE LOAN INTEREST OPTION
Interest is payable at an annual effective rate of 8%.
9.6 VARIABLE RATE LOAN INTEREST OPTION
Interest is payable at an annual effective rate that is set by the Company
annually and applied to new or outstanding policy debt during the year beginning
each January 1. The highest loan interest rate that may be set by the Company is
the greater of 5% or a rate based on the Xxxxx'x Corporate Bond Yield
Averages--Monthly Average Corporates for the immediately preceding October. This
Average is published by Xxxxx'x Investors Services, Inc. If it is no longer
published, the highest loan interest rate will be based on some other similar
average established by the insurance supervisory official of the state in which
this policy is delivered.
The loan interest rate set by the Company will not exceed the maximum rate
permitted by the laws of the state in which this policy is delivered. The loan
interest rate may be increased only if the increase the annual effective rate
is at least 1/2%. The loan interest will be decreased if the decrease in the
annual effective rate is at least 1/2%.
SECTION 10. CHANGE OF POLICY
10.1 EXCHANGE OF POLICY
Within 24 months after the Date of Issue shown on page 3, provided premiums
are duly paid, the Owner may exchange this policy without evidence of
insurability for a similar fixed benefit life insurance policy issued by the
Company on the life of the Insured.
To effect the change the Owner must send this policy, a completed
application for change, and any required payment to the Home Office of the
Company. The change will be effective on the later of the date of the
application or the date the required items are received at the Home Office.
The new policy will have the same face amount, policy date and issue age as
this one, and the premiums and cash values will be the same as those for
policies issued on the Date of Issue of this policy.
Any Additional Benefit included in this policy will be included with the
new policy only to the extent that such provisions were being offered with the
new policy on the Date of Issue of this policy.
10.2 CHANGE OF PLAN
The Owner may change this policy to any permanent life insurance plan
agreed to by the Owner and the Company by:
- paying the required costs; and
- meeting any other conditions set by the Company.
10.3 CHANGE OF INSURED
EXCHANGE. The Owner may exchange this policy for a new policy on the life of a
new insured by:
- paying the required costs; and
- meeting any other conditions set by the Company, including the
following:
a. on the date of exchange, the new insured's age may not be more
than 75;
b. the proposed new insured must be insurable; and
c. the Owner must have an insurable interest in the life of the new
insured.
DATE OF EXCHANGE. The date of exchange will be the later of:
- the date the request to exchange is received in the Company's Home
Office; or
- the date of the medical examination (or the non-medical application).
THE NEW POLICY. The new policy will take effect on the date of exchange. When
the new policy takes effect, this policy terminates. The policy date of the new
policy will be the later of:
- the Policy Date of this policy; or
- the first anniversary of this policy after the date of birth of the new
insured.
The contestable and suicide periods in the new policy start on the date of
exchange.
The new amount of insurance will be set so that the cash value of this
policy and the cash value of the new policy are the same on the date of
exchange. If either policy has no cash value, the amount will be set so that the
premiums are the same.
Any policy debt or assignment of this policy will continue on the new
policy.
MM 17 13
SECTION 11. BENEFICIARIES
11.1 DEFINITION OF BENEFICIARIES
The term "beneficiaries" as used in this policy includes direct
beneficiaries, contingent beneficiaries and further payees.
11.2 NAMING AND CHANGE OF BENEFICIARIES
BY OWNER. The Owner may name and change the beneficiaries of death proceeds:
- while the Insured is living.
- during the first 60 days after the date of death of the Insured, if the
Insured just before his death was not the Owner. No one may change this
naming of a direct beneficiary during this 60 days.
BY DIRECT BENEFICIARY. A direct beneficiary may name and change the contingent
beneficiaries and further payees of his share of the proceeds:
- if the direct beneficiary is the Owner;
- if, at any time after the death of the Insured, no contingent beneficiary
or further payee of that share is living; or
- if, after the death of the Insured, the direct beneficiary elects a
payment plan. The interest of any other beneficiary in the share of that
direct beneficiary will end.
These direct beneficiary rights are subject to the Owner's rights during
the above 60 days.
BY SPOUSE (MARITAL DEDUCTION PROVISION).
- POWER TO APPOINT. The spouse of the Insured will have the power alone and
in all events to appoint all amounts payable to the spouse under the
policy if:
a. the Insured just before his death was the Owner; and
b. the spouse is a direct beneficiary; and
c. the spouse survives the Insured.
- TO WHOM SPOUSE CAN APPOINT. Under this power, the spouse can appoint:
a. to the estate of the spouse; or
b. to any other persons as contingent beneficiaries and further payees.
- EFFECT OF EXERCISE. As to the amounts appointed, the exercise of this
power will:
a. revoke any other designation of beneficiaries;
b. revoke any election of payment plan as it applies to them; and
c. cause any provision to the contrary in Section 11 or 12 of this policy
to be of no effect.
EFFECTIVE DATE. A naming or change of a beneficiary will be made on receipt at
the Home Office of a written request that is acceptable to the Company. The
request will then take effect as of the date that it was signed. The Company is
not responsible for any payment or other action that is taken by it before the
receipt of the request. The Company may require that the policy be sent to it to
be endorsed to show the naming or change.
11.3 SUCCESSION IN INTEREST OF BENEFICIARIES
DIRECT BENEFICIARIES. The proceeds of this policy will be payable in equal
shares to the direct beneficiaries who survive and receive payment. If a direct
beneficiary dies before he receives all or part of his full share, the unpaid
part of his share will be payable in equal shares to the other direct
beneficiaries who survive and receive payment.
CONTINGENT BENEFICIARIES. At the death of all of the direct beneficiaries, the
proceeds, or the present value of any unpaid payments under a payment plan, will
be payable in equal shares to the contingent beneficiaries who survive and
receive payment. If a contingent beneficiary dies before he receives all or part
of his full share, the unpaid part of his share will be payable in equal shares
to the other contingent beneficiaries who survive and receive payment.
FURTHER PAYEES. At the death of all of the direct and contingent beneficiaries,
the proceeds, or the present value of any unpaid payments under a payment plan,
will be paid in one sum:
- in equal shares to the further payees who survive and receive payment; or
- if no further payees survive and receive payment, to the estate of the
last to die of all of the direct and contingent beneficiaries.
OWNER OR HIS ESTATE. If no beneficiaries are alive when the Insured dies, the
proceeds will be paid to the Owner or to his estate.
11.4 GENERAL
TRANSFER OF OWNERSHIP. A transfer of ownership of itself will not change the
interest of a beneficiary.
CLAIMS OF CREDITORS. So far as allowed by law, no amount payable under this
policy will be subject to the claims of creditors of a beneficiary.
SUCCESSION UNDER PAYMENT PLANS. A direct or contingent beneficiary who succeeds
to an interest in a payment plan will continue under the terms of the plan.
MM17 14
SECTION 12. PAYMENT OF POLICY BENEFITS
12.1 PAYMENT OF PROCEEDS
Proceeds that are payable due to the death of the Insured will be paid
under the payment plan that takes effect on the date of death. The Interest
Income Plan (Option A) will be in effect if no payment plan has been elected.
Interest will accumulate from the date of death until a payment plan is elected
or the proceeds are withdrawn in cash.
Proceeds from the surrender of this policy will be paid in cash or under a
payment plan that is elected.
12.2 PAYMENT PLANS
INTEREST INCOME PLAN (OPTION A). The proceeds will earn interest which may be
received each month or accumulated. The first payment is due one month after the
date on which the plan takes effect. Interest that has accumulated may be
withdrawn at any time. Part or all of the proceeds may be withdrawn at any time.
INSTALLMENT INCOME PLANS. Payments will be made each month on the terms of
the plan that is elected. The first payment is due on the date that the plan
takes effect.
- SPECIFIED PERIOD (OPTION B). The proceeds with interest will be paid over
a period of from one to 30 years. The present value of any unpaid
installments may be withdrawn at any time.
- SPECIFIED AMOUNT (OPTION D). Payments of not less than $10.00 per $1,000
of proceeds will be made until all of the proceeds with interest have
been paid. The balance may be withdrawn at any time.
LIFE INCOME PLANS. Payments will be made each month on the terms of the plan
that is elected. The first payment is due on the date that the plan takes
effect. Proof of the date of birth, acceptable to the Company, must be furnished
for each person on whose life the payments are based.
- SINGLE LIFE INCOME (OPTION C). Payments will be made for a chosen period
and, after that, for the life of the person on whose life the payments
are based. The choices for the period are:
a. zero years;
b. 10 years;
c. 20 years; or
d. a refund period which continues until the sum of the payments that
have been made is equal to the proceeds that were placed under the
plan.
- JOINT AND SURVIVOR LIFE INCOME (OPTION E). Payments are based on the
lives of two persons. Level payments will be made for a period of 10
years and, after that, for as long as one or both of the persons are
living.
- OTHER SELECTIONS. The Company may offer other selections under the Life
Income Plans.
- WITHDRAWAL. The present value of any unpaid payments that are to be made
for the chosen period (Option C) or the 10 year period (Option E) may be
withdrawn only after the death of all of the persons on whose lives the
payments are based.
- LIMITATIONS. A direct or contingent beneficiary who is a natural person
may be paid under a Life Income Plan only if the payments depend on his
life. A corporation may be paid under a Life Income Plan only if the
payments depend on the life of the Insured or, after the death of the
Insured, on the life of his spouse or his dependent.
PAYMENT FREQUENCY. On request, payments will be made once every 3, 6 or 12
months instead of each month.
TRANSFER BETWEEN PAYMENT PLANS. A beneficiary who is receiving payment under a
plan which includes the right to withdraw may transfer the amount withdrawable
to any other plan that is available.
MINIMUM PAYMENT. The Company may limit the election of a payment plan to one
that results in payments of at least $50.
If payments under a payment plan are or become less than $50, the Company
may change the frequency of payments. If the payments are being made once every
12 months and are less than $50, the Company may pay the present value or the
balance of the payment plan.
12.3 PAYMENT PLAN RATES
INTEREST INCOME AND INSTALLMENT INCOME PLANS. Proceeds will earn interest at
rates declared each year by the Company. None of these rates will be less than
an annual effective rate of 3 1/2%. Interest of more than 3 1/2% will increase
the amount of the payments or, for the Specified Amount Plan (Option D),
increase the number of payments. The present value of any unpaid installments
will be based on the 3 1/2% rate of interest.
The Company may offer guaranteed rates of interest higher than 3 1/2% with
conditions on withdrawal.
LIFE INCOME PLANS. Payments will be based on rates declared by the Company.
These rates will provide at least as much income as would the Company's rates,
on the date that the payment plan takes effect, for a single premium immediate
annuity contract, with no charge for issue expenses. Payments under these rates
will not be less than the amounts that are described in Minimum Payment Rates.
MINIMUM PAYMENT RATES. The minimum payment rates for the Installment Income
Plans (Option B and D) and the Life Income Plans (Options C and E) are shown in
the Minimum Payment Rate Table.
MM17 15
The Life Income Plan payment rates in that table depend on the sex and on
the adjusted age of each person on whose life the payments are based. The
adjusted age is:
- the age on the birthday that is nearest to the date on which the payment
plan takes effect; plus
- the age adjustment shown below for the number of policy years that have
elapsed from the Policy Date to the date that the payment plan takes
effect. A part of a policy year is counted as a full year.
----------------------------------------------------------
POLICY POLICY
YEARS AGE YEARS AGE
ELAPSED ADJUSTMENT ELAPSED ADJUSTMENT
----------------------------------------------------------
1 to 10 +8 31 to 35 -1
11 to 15 +6 36 to 40 -2
16 to 20 +4 41 to 45 -3
21 to 25 +2 46 to 50 -4
26 to 30 0 51 or more -5
----------------------------------------------------------
12.4 EFFECTIVE DATE FOR PAYMENT PLAN
A payment plan that is elected will take effect on the date of death of the
Insured if:
- the plan is elected by the Owner for death proceeds; and
- the election is received at the Home Office while the Insured is living.
In all other cases, a payment plan that is elected will take effect:
- on the date the election is received at the Home Office; or
- on a later date, if requested.
12.5 PAYMENT PLAN ELECTIONS
FOR DEATH PROCEEDS BY OWNER. The Owner may elect payment plans for death
proceeds:
- while the Insured is living.
- during the first 60 days after the date of death of the Insured, if the
Insured just before his death was not the Owner. No one may change this
election made during those 60 days.
FOR DEATH PROCEEDS BY DIRECT OR CONTINGENT BENEFICIARY. A direct or contingent
beneficiary may elect payment plans for death proceeds payable to him if no
payment plan that has been elected is in effect. This right is subject to the
Owner's rights during the above 60 days.
FOR SURRENDER PROCEEDS. The Owner may elect payment plans for surrender
proceeds. The Owner will be the direct beneficiary.
12.6 INCREASE OF MONTHLY INCOME
A direct beneficiary who is to receive proceeds under a payment plan may
increase the amount of the monthly payments. This is done by the payment of an
annuity premium to the Company at the time the payment plan elected under
Section 12.5 takes effect. The amount that will be applied under the payment
plan will be the net premium. The net premium is the annuity premium less a
charge of not more than 2% and less any premium tax. The net premium will be
applied under the same payment plan and at the same rates as the proceeds. The
Company may limit this net premium to an amount that is equal to the direct
beneficiary's share of the proceeds payable under this policy.
MINIMUM PAYMENT RATE TABLE
MINIMUM MONTHLY INCOME PAYMENTS PER $1,000 PROCEEDS
INSTALLMENT INCOME PLANS (OPTIONS B AND D)
-------------------------------------------------------------------------------
PERIOD MONTHLY PERIOD MONTHLY PERIOD MONTHLY
(YEARS) PAYMENT (YEARS) PAYMENT (YEARS) PAYMENT
-------------------------------------------------------------------------------
1 $84.65 11 $9.09 21 $5.56
2 43.05 12 8.46 22 5.39
3 29.19 13 7.94 23 5.24
4 22.27 14 7.49 24 5.09
5 18.12 15 7.10 25 4.96
6 15.35 16 6.76 26 4.84
7 13.38 17 6.47 27 4.73
8 11.90 18 6.20 28 4.63
9 10.75 19 5.97 29 4.53
10 9.83 20 5.75 30 4.45
-------------------------------------------------------------------------------
MM 17 16
MINIMUM PAYMENT RATE TABLES
MINIMUM MONTHLY INCOME PAYMENTS PER $1,000 PROCEEDS
LIFE INCOME PLANS (OPTIONS C AND E)
------------------------------------------------------------------------------------------------------------------
SINGLE LIFE MONTHLY PAYMENTS (OPTION C)
------------------------------------------------------------------------------------------------------------------
MALE CHOSEN PERIOD (YEARS) FEMALE CHOSEN PERIOD (YEARS)
ADJUSTED ----------------------------------------------- ADJUSTED ----------------------------------------------
AGE* XXXX 00 00 REFUND AGE* ZERO 10 20 REFUND
------------------------------------------------------------------------------------------------------------------
55 $ 5.39 $ 5.24 $ 4.85 $ 5.00 55 $ 4.75 $ 4.70 $ 4.53 $ 4.57
56 5.51 5.34 4.91 5.09 56 4.85 4.78 4.59 4.64
57 5.63 5.45 4.97 5.19 57 4.94 4.87 4.66 4.72
58 5.77 5.56 5.03 5.29 58 5.05 4.97 4.73 4.81
59 5.91 5.68 5.10 5.39 59 5.16 5.07 4.80 4.90
60 6.06 5.80 5.16 5.50 60 5.27 5.17 4.87 4.99
61 6.22 5.93 5.21 5.62 61 5.40 5.28 4.94 5.09
62 6.39 6.07 5.27 5.74 62 5.53 5.40 5.01 5.20
63 6.58 6.21 5.33 5.87 63 5.67 5.52 5.08 5.31
64 6.77 6.35 5.38 6.01 64 5.82 5.66 5.15 5.43
65 6.99 6.50 5.43 6.16 65 5.97 5.80 5.22 5.55
66 7.21 6.66 5.48 6.31 66 6.14 5.95 5.28 5.69
67 7.46 6.83 5.52 6.47 67 6.31 6.10 5.35 5.83
68 7.72 7.00 5.56 6.65 68 6.50 6.27 5.40 5.99
69 7.97 7.17 5.60 6.83 69 6.70 6.45 5.46 6.15
70 8.23 7.35 5.63 7.03 70 6.90 6.63 5.51 6.32
71 8.49 7.53 5.66 7.23 71 7.11 6.82 5.55 6.51
72 8.76 7.71 5.68 7.45 72 7.33 7.02 5.59 6.71
73 9.03 7.89 5.70 7.69 73 7.55 7.22 5.62 6.92
74 9.30 8.07 5.72 7.94 74 7.79 7.43 5.65 7.15
75 9.57 8.25 5.73 8.21 75 8.02 7.64 5.68 7.39
76 9.85 8.43 5.74 8.49 76 8.26 7.85 5.69 7.65
77 10.11 8.60 5.74 8.80 77 8.48 8.05 5.71 7.92
78 10.38 8.77 5.75 9.13 78 8.72 8.26 5.72 8.21
79 10.64 8.93 5.75 9.48 79 8.94 8.45 5.73 8.52
80 10.90 9.08 5.75 9.85 80 9.16 8.84 5.74 8.85
81 11.13 9.21 5.75 10.26 81 9.36 8.81 5.74 9.21
82 11.36 9.34 5.75 10.70 82 9.53 8.96 5.75 9.57
83 11.55 9.44 5.75 11.17 83 9.70 9.10 5.75 9.97
84 11.75 9.54 5.75 11.70 84 9.85 9.22 5.75 10.39
85 and over 11.92 9.61 5.75 12.26 85 and over 9.98 9.33 5.75 10.81
------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------
JOINT AND SURVIVOR MONTHLY PAYMENTS (OPTION E)
------------------------------------------------------------------------------------------------------------------
MALE FEMALE ADJUSTED AGE*
ADJUSTED ----------------------------------------------------------------------------------------------------
AGE* 55 60 65 70 75 80 85 and over
------------------------------------------------------------------------------------------------------------------
55 $ 4.33 $ 4.55 $ 4.76 $ 4.94 $ 5.08 $ 5.17 $ 5.22
60 4.45 4.73 5.03 5.30 5.53 5.68 5.76
65 4.54 4.89 5.28 5.68 6.04 6.29 6.43
70 4.61 5.01 5.49 6.04 6.57 6.97 7.20
75 4.66 5.09 5.65 6.32 7.04 7.65 8.02
80 4.68 5.14 5.74 6.51 7.39 8.20 8.72
85 and over 4.69 5.16 5.78 6.60 7.57 8.52 9.15
------------------------------------------------------------------------------------------------------------------
*See Section 12.3.
MM 17 17
EXHIBIT (e)
SUPPLEMENT TO APPLICATION
FOR VARIABLE LIFE INSURANCE
NORTHWESTERN MUTUAL LIFE INSURANCE COMPANY
INSURED Xxxx X. Xxx
----------------------------------
APPLICATION NUMBER 000 009
-----------------------
201. Allocation of Net Premium
Money Market Division 40 % (Whole percentages
Bond Division 20 % only,
Stock Division 20 % minimum of 10% in
Master Division 20 % Division selected.)
===========
100 %
202. I acknowledge receipt of the prospectus for Variable Life Insurance dated
July 1, 1985
-----------------.
203. I UNDERSTAND THAT THE DEATH BENEFIT FOR THE VARIABLE LIFE INSURANCE POLICY
APPLIED FOR MAY INCREASE OR DECREASE TO REFLECT THE INVESTMENT EXPERIENCE
OF THE NORTHWESTERN MUTUAL VARIABLE LIFE ACCOUNT, BUT WILL NOT BE LESS THAN
THE FACE AMOUNT PROVIDED ALL PREMIUMS ARE PAID AS OF THEIR DUE DATE AND
PROVIDED THERE IS NO POLICY DEBT.
204. I UNDERSTAND THAT THE CASH VALUES FOR THE VARIABLE LIFE INSURANCE POLICY
APPLIED FOR MAY INCREASE OR DECREASE TO REFLECT THE INVESTMENT EXPERIENCE
OF THE NORTHWESTERN MUTUAL VARIABLE LIFE ACCOUNT AND ARE NOT GUARANTEED AS
TO FIXED DOLLAR AMOUNT. THERE ARE NO GUARANTEED MINIMUM CASH VALUES.
205. I believe that a Variable Life Insurance policy is consistent with my
investment objectives and financial needs.
I understand that an illustration of benefits, including death benefits and
cash values, is available upon request to compare:
- a Variable Whole Life policy based on a hypothetical investment return
of 0%, 4% and 8% (or alternatively 0%, 6%, and 12%).
- a fixed benefit Whole Life policy issued by the Northwestern Mutual
Life Insurance Company based on the same gross premium as the Variable
Whole Life policy.
206. Owner's Address
[X] Insured's address in 3A or:
[ ]
----------------------------------------------------------
Xxxxxx & Xx. xx X.X.X.
----------------------------------------------------------
Xxxx Xxxxx Zip Code
(Signed) Xxxx X. Xxx
--------------------------------------- ------------------------------------
Signature of Insured or Informant Signature of Applicant
(if other than Applicant)
Signed at Milwaukee, WI Date 7/1/85
------------------------------ -------------------------------
Based on the information furnished by the Applicant or Informant in this
application, I certify that I have reasonable ground for believing the purchase
of the policy applied for is suitable for the Applicant. I further certify that
a current Prospectus was delivered and that no written sales materials other
than those furnished by the Home Office were used.
Signature of Licensed Agent (Signed) Xxxx X. Weestern
-----------------------------------------------------
(Registered Representative)
General Agent's Approval
-------------------------------------------------------
Registered Principal's Approval
-------------------------------------------------
(Completed in H.O.)
LIFE INSURANCE OR ANNUITY APPLICATION TO No. -----------------
682709 THE NORTHWESTERN MUTUAL LIFE INSURANCE COMPANY [ ] Life & Disability
MILWAUKEE, WISCONSIN Insurance
-----------------------------------------------------------------------------------------------------------------------
1. INSURED Sex:
or Annuitant Xxxx X. Xxx [X] Male
(Please Print) First Middle Initial Last [ ] Female
-----------------------------------------------------------------------------------------------------------------------
2. APPLICANT, if other
than insured Relationship
(Please Print)_____________________________________________________________________ to Insured __________________
First Middle Initial Last
If Business Organization: [ ] Corporation [ ] Partnership [ ] Other type of Business (specify)
-----------------------------------------------------------------------------------------------------------------------
3A. PRESIDENT of Insured: Print 3B. PREMIUM PAYER Send premium notices to:
Street No. [X] Insured [ ] Owner [ ] Applicant
or R.F.D. 0000 Xxxx Xx.
---------------------------------------------- [ ] Other
City Milwaukee State WI ------------------------------------------
---------------------------- -------------- Name
County Milwaukee Zip Code 53200 at: [X] Insured's address See 3A) or:
-------------------------- ----------
This address will be used for all of Insured's policies. ----------------------------------------------------
------------------------------------------------------------ Street & No. or R.F.D.
4A. Insured's Date of Birth 7 1 50 ------------------------------- -------------------
Mo. Day Year City State
------------------------------------------------------------
4B. Place of Birth: (State or Country if other than U.S.A.) ------------------------------- -------------------
Milwaukee, WI Country Zip Code
Unless directed otherwise, any notices will be sent
to the Owner at the Insured's address.
-----------------------------------------------------------------------------------------------------------------------
5. Has application or informal inquiry ever been made to the Northwestern Mutual for annuity, life or disability
insurance on the life of the Insured? [ ] Yes [X] No If "Yes," Last Policy Number is_________________________
-----------------------------------------------------------------------------------------------------------------------
COMPLETE QUESTION 6 IF EXERCISING ADDITIONAL PURCHASE BENEFIT OPTION
-----------------------------------------------------------------------------------------------------------------------
6A. Number of policy under which this privilege is being 6B. Is application? [ ] Regular Purchase
exercised? [ ] Advance Purchase (See 6C).
-----------------------------------------------------------------------------------------------------------------------
6C. If an ADVANCE PURCHASE, event is the following:
[ ] (1) Marriage Name of [ ] Spouse [ ] Child ________________________________________________________
First Middle Initial Last
[ ] (2) Birth of Child Place and Date of Marriage, Birth or Final Decree of Legal Adoption:
[ ] (3) Adoption of Child _______________________________________________________________
City County State Mo. Day Yr.
-----------------------------------------------------------------------------------------------------------------------
7A. Plan and Amount applied for: 7B. ADDITIONAL BENEFITS (Check those desired):
[X] Life Insurance
[ ] WAIVER OF PREMIUM
Extra Ordinary Variable Life $ 100,000 [ ] $ ______ OF ACCIDENTAL DEATH
--------------------------------------- ------------ [ ] ADDITIONAL PURCHASE $ _____ PER OPTION
Plan Amount [ ] PAYOR BENEFIT
[ ] INDEXED PROTECTION
[ ] LIFE PLAN WITH TERM BENEFIT [ ] OTHER, SPECIFY ___________________________
Basic policy ______________________ $ __________
Plan Amount If any additional benefits cannot be approved,
should the policy be issued without the
benefit?
Term __________________________________ $___________ [ ] Yes [ ] No
Benefit & Years Amount ----------------------------------------------------------
8. SPECIAL DATING:
[ ] Annuity (Flexible Premium Annuity, Single PREPAID: [ ] Short Term to __________________________
Premium Retirement Annuity, Retirement Income) Mo. Day Yr.
[ ] Date to Save Age [ ] Backdate to _______________
________________________ _______________________ Mo. Day Yr.
Plan Age at Maturity
NON PREPAID: Specified Future Date __________________
Complete [ ] To provide monthly income of $ _________ Mo. Day Yr.
only [ ] To provide monthly income based on a
one [ ] Date to Save Age [ ] Backdate to _______________
Mo. Day Yr.
__________________ premium of $ ________________ -----------------------------------------------------------
Mode 9. Shall the PREMIUM LOAN provision, if available become
operative according to its terms? [X] Yes [ ] No
-----------------------------------------------------------------------------------------------------------------------
LIFE INSURANCE or ANNUITY (CONTINUED)
------------------------------------------------------------------------------------------------------------------------------------
10A. ANNUAL DIVIDENDS until otherwise directed will: 10B. POLICY LOAN INTEREST RATE OPTION:
[ ] Be used to reduce current premium. [ ] 8%
[X] Purchase paid-up additions. [X] Variable Rate. (Not available on all plans, or in
[ ] Accumulate at interest. Substitute Form W-9 Arkansas, District of Columbia, Kentucky, Montana,
{Form 15-1272X) is required. S. Carolina)
[ ] Be cash.
------------------------------------------------------------------------------------------------------------------------------------
11A. DIRECT BENEFICIARY: (Print Name) 12. The Owner will be: (Select ONLY ONE of the choices
Xxxx X. Xxx A through G. Consider the choice of item E, F and G,
-------------------------------------------------------------- especially if the Insured is under age 15.)
[X] A. The Insured.
-------------------------------------------------------------- [ ] B. The Applicant.
Relationship to Insured: [ ] C. Other, (Print Name)
-------------------------------------- ------------------------------
First Middle Initial Last
11B. CONTINGENT BENEFICIARY: (Print Name)
----------------------------------------------------
-------------------------------------------------------------- Relationship to Insured
-------------------------------------------------------------- [ ] D. See Attached Supplement Form.
Relationship to Insured: [ ] E. The Applicant. If the Applicant dies before the
-------------------------------------- Insured, the Insured will be the Owner.
[ ] F. The Applicant. If the Applicant dies before the
NOTE: Item 1 or 2 may be selected to supplement the contingent Insured, the Owner will be:
beneficiary designation or may be used to designate children or
brothers and sisters as contingent beneficiaries without -------------------------------------------------
specifically naming them. Item 3 may be used to supplement Item First Middle Initial Last
1, 2 or any contingent beneficiary designation.
_____________________________. If both die before
[X] (1) and any (other) children of the Insured. Relationship to Insured
[ ] (2) and any (other) brothers and sisters of the Insured the Insured, the Insured will be the Owner.
born of the marriage of or legally adopted by ___________
and __________ prior to the Insured's death. [ ] G. The Applicant until the Insured attains the age
[ ] (3) any amount a deceased contingent beneficiary would of ______ years. If the Applicant dies before the
have received, if living, will be payable when due in Insured, the Owner will be:
one sum in equal shares to his or her then living
children. (The word "children" includes child and any -------------------------------------------------
legally adopted child.) First Middle Initial Last
11C. FURTHER PAYEES: (Print Name) ______________________________ until the Insured
Relationship to Insured
-------------------------------------------------------------- attains such age. Upon the Insured attaining
such age, or if both die before the Insured, the
-------------------------------------------------------------- Insured will be the Owner.
Relationship to Insured:
--------------------------------------
[ ] SEE ATTACHED SUPPLEMENT FORM.
------------------------------------------------------------------------------------------------------------------------------------
13. PREMIUM PAYABLE: 14. Has the premium for the policy applied for been paid
to the agent in exchange for the Conditional Insurance
[X] Annually [ ] Semiannually [ ] Quarterly [ ] Single Agreement with the same number as the application?
[ ] Monthly (Variable Life only) [X] Yes [ ] No
------------------------------------------------------------------------------------------------------------------------------------
15. Will the insurance (or annuity) applied for replace insurance (or annuities) on the Insured's (or Annuitant's) life in this
Company or elsewhere? If "Yes," agent should explain and submit required papers. [ ] Yes [X] No
------------------------------------------------------------------------------------------------------------------------------------
THE INSURED CONSENTS TO THIS APPLICATION AND DECLARES THAT THE ANSWERS AND STATEMENTS ON BOTH SIDES OF THIS PAGE ARE CORRECTLY
RECORDED, COMPLETE AND TRUE TO THE BEST OF HIS KNOWLEDGE AND BELIEF. STATEMENTS IN THIS APPLICATION ARE REPRESENTATIONS AND NOT
WARRANTIES.
It is agreed that: (3) If the policy is issued in an extra premium class,
(1) If the premium is not paid when the application is signed, no acceptance of the policy will amend it so that extended term
insurance will be in effect. The insurance will take effect at the insurance can be in force only if:
time the policy is delivered and the premium is paid, if: - the Company gives its consent; or
- the loan value is not large enough to grant to premium
- the Insured is living at that time; and loan.
- the answers and statements in the application are then true
to the best of the knowledge and belief of the Insured. If a premium is not paid within the grace period an extended
term insurance cannot be in force, paid-up insurance will be
(2) If the premium is paid when the application is taken, no life selected.
insurance will have been in effect if Section I of the Conditional
Insurance Agreement applies. (4) No agent is authorized to make or alter contracts or to
waive any of the Company's rights or requirements.
/s/ Xxxx X. Xxx
------------------------------------------------------------------- -------------------------------------------------------------
Signature of INSURED or Annuitant (if other than Applicant and Signature of APPLICANT
15 yrs. of age and over)
Signed at Milwaukee, WI Date July 1 85 /s/ Xxxx X. Western
----------------------------------------------- ---------------------- ------------------------------------------
City, County & State Month Day Year Signature of LICENSED AGENT
THE NORTHWESTERN MUTUAL LIFE INSURANCE COMPANY
--------------------------------------------------------------------------------
TO BE COMPLETED BY THE INSURED OR INFORMANT
-----------------------------------------------------------------------------------------------------------
INSURED (Please Print) Xxxx X. Xxx
-----------------------------------------------------------------------------------------------------------
First Middle Initial Last
-----------------------------------------------------------------------------------------------------------------------------------
If submitted for purpose other than a new insurance application, please indicate:
[ ] Policy Change [ ] Conversion [ ] Adding _________ Benefit [ ] Reinstatement [ ] Rating Reduction
for Policy(ies) Number _________________________________________________________________________________________________________
[ ] Payor Benefit for Applicant (Payor)_____________________________________________________ Relationship to Insured _______________
First Middle Initial Last
Payor's Date of Birth ___________________________ Policy Number ________________________________________________________________
------------------------------------------------------------------------------------------------------------------------------------
20. Have you ever had life, disability, or hospital insurance COMPLETE QUESTIONS 27-31 IF INSURED AGE 10 OR OLDER
declined, rated, modified, cancelled, or not renewed? 27. Are you a member of, or do you contemplate joining any
(If "Yes" explain in REMARKS) [ ] Yes [X] No branch of the Armed Forces, the R.O.T.C., the National
----------------------------------------------------------------- Guard or any other component of the Armed Forces Re-
21. When was your last previous examination or application serve either on an active or inactive status?
for life, disability, or accidental death insurance? (If "Yes," complete Military Section 90-5) [ ] Yes [X] No
Month Year Company -----------------------------------------------------------------
----------------------------------------------------------------- 28. Except as a fare paying passenger on a regularly sched-
22. Indicate below whether any other Life Insurance on your uled flight, have you flown within the past 3 years, or
Life is individual (Ind) or Group (Grp) and identify In do you contemplate flying in the future?
Force (I), Pending (P) or Contemplated (C). (If "Yes," completed Aviation Section 90-5 [ ] Yes [X] No
If none check: [X] NONE -----------------------------------------------------------------
----------------------------------------------------------------- 29. Have you within the past 2 years participated in or do
Ind or Life Insurance Accidental Death I, P, you contemplate participating in racing (automobile,
Insurer Grp Amount Amount or C snowmobile, motorcycle, boat or go-kart) scuba or skin
----------------------------------------------------------------- diving, sky diving, hang gliding, mountain climbing or
----------------------------------------------------------------- rodeos?
----------------------------------------------------------------- (If "Yes," complete Avocation Section 90-6) [ ] Yes [X] No
----------------------------------------------------------------- -----------------------------------------------------------------
----------------------------------------------------------------- 30. A. What is your Automobile Driver's License Number?
----------------------------------------------------------------- # W0000000000 State Wis.
----------------------------------------------------------------- ------------------------- -------------------------
23. Marital Single, Widowed or, [ ] I do not drive an automobile.
Status: [ ] or Divorced [X] Married B. In the past 3 years have you been in a motor vehicle
----------------------------------------------------------------- accident, charged with a moving violation or any motor
24. Citizen of: [X] U.S.A. [ ] Other ___________________ vehicle law, or had your license restricted or revoked?
If other: Visa Type __________________ Visa No. _____________ (If "Yes" explain in C., D. and/or REMARKS) [ ] Yes [X] No
----------------------------------------------------------------- C. Moving Violations within the past 3 years:
25. Do you contemplate leaving the United States of -----------------------------------------------------------------
America for travel or residence? Type and Details
(If "Yes" explain in REMARKS) [ ] Yes [X] No Date (Speeding, Reckless Driving, Action (Citation, Accident
----------------------------------------------------------------- Driving While Intoxicated) Fine) (Yes or No)
26. A. What is your occupation(s)? attorney -----------------------------------------------------------------
-------------------------------
What are your duties? ____________________________________
__________________________________________________________
If applying for disability income, are you now actively
at work with no medical restrictions?
(If "No" explain in REMARKS) [ ] Yes [ ] No -----------------------------------------------------------------
B. Employer(s) XYZ Corporation D. Details of any Accidents: (Include date, citations,
----------------------------------------------- damage amounts, injuries.)
Name
750 Street
-----------------------------------------------
Street & No. or R.F.D.
Xxxxxxxxx XX 00000
-----------------------------------------------
City State Zip Code
C. How long so employed? 5 yrs.
-----------------
(If less than 2 years, explain in REMARKS)
------------------------------------------------------------------------------------------------------------------------------------
REMARKS:
------------------------------------------------------------------------------------------------------------------------------------
I declare that my answers and statements are correctly recorded, complete and true to the best of my knowledge and belief.
Statements in this application are representations and not warranties.
Date _____________________________ ___________________________________________________________________
Month Day Year Signature of Insured (or Informant)
(Signature not required if reverse side, 90-4 also completed)
-----------------------------------------------------------------------------------------------------
INSURED
(if not given on Form 90-3) -----------------------------------------------------------------------------------------------------
First Middle Initial Last
------------------------------------------------------------------------------------------------------------------------------------
NONMEDICAL APPLICATIONS ONLY
------------------------------------------------------------------------------------------------------------------------------------
31. A. Have you smoked cigarettes in the past 10 years? 36. Have you ever requested or received a pension, benefits
[ ] Yes [X] No or payment because of any injury, sickness or disability?
B. Present cigarette smokers: [ ] Yes [X] No
(1) How many cigarettes do you smoke per day? ---------------------------------------------------------------
(Number of cigarettes not number of packs) _______ 39. FAMILY HISTORY: Diabetes, cancer, high blood pressure,
(2) How many years have you smoked? _______ heart or kidney disease, mental illness or suicide?
C. Past cigarette smokers: [ ] Yes [X] No
(1) How many cigarettes do you smoke per day? ---------------------------------------------------------------
(Number of cigarettes not number of packs) _______ Age, if Living Cause of Death Age of Death
(2) How many years have you smoked? _______ --------------------------------------------------
(3) When did you quit smoking? _______ Father 59
D. Are you using tobacco in any other form? ---------------------------------------------------------------
If "Yes," specify ___________________ [ ] Yes [X] No Mother 58
---------------------------------------------------------------- ---------------------------------------------------------------
32. Are you now using any medication or drugs? Brothers and Sisters
[ ] Yes [X] No ---------------------------------------------------------------
---------------------------------------------------------------- 40. A. Have you lost weight in the past year? [ ] Yes [X] No
33. HAVE YOU EVER BEEN TREATED FOR OR EVER HAD ANY INDICATION If "Yes,", loss was ________lbs.
OF: B. How long have you been at your present weight? 3 yrs.
A. Disorder of eyes, ears, nose or throat? [ ] Yes [X] No ---------
---------------------------------------------------------------- C. Height 5 ft. 11 in. D. Weight 175 lbs.
B. Dizzy or fainting spells, seizures or convulsions, --- ---- -----
recurrent headache, paralysis or stroke, mental or E. Did agent measure? [ ] Yes [X] No
nervous disorder? [ ] Yes [X] No F. Did agent weight? [ ] Yes [X] No
---------------------------------------------------------------- ---------------------------------------------------------------
C. Persistent shortness of breath, cough, blood spitting; 42. If the Insured is under age 1, what was the weight at
bronchitis, asthma, emphysema, tuberculosis or other birth? ________ lbs ________ ozs.
lung or respiratory disorder? [ ] Yes [X] No ---------------------------------------------------------------
---------------------------------------------------------------- 43. Do you have a personal physician? [ ] Yes [X] No
D. Chest pain, discomfort or tightness, palpitation, high
blood pressure, rheumatic fever, heart murmur, heart Name
attack or other disorder of the heart or blood vessels? -------------------------------------------------------
[ ] Yes [X] No Address
---------------------------------------------------------------- ----------------------------------------------------
E. Jaundice, intestinal bleeding; ulcer, hernia, colitis, Date last seen Reason
diverticulitis, hemorrhoids, recurrent indigestion or ---------------- --------------------
other disorder of the stomach, intestines, liver, gall Mo. Day Yr.
bladder or pancreas? [ ] Yes [X] No ---------------------------------------------------------------
---------------------------------------------------------------- REMARKS. GIVE DETAILS OF "YES" ANSWERS. IDENTIFY QUESTION
F. Sugar, albumin, blood in urine; venereal disease; stone NUMBER. STATE SIGNS, SYMPTOMS AND DIAGNOSIS OF ILLNESS AND
or other disorder of kidney, bladder, prostate or NAME AND ADDRESS OF ANY ATTENDING PHYSICIAN.
reproductive organs? [ ] Yes [X] No ---------------------------------------------------------------
----------------------------------------------------------------
G. Diabetes; thyroid or other endocrine disorders?
[ ] Yes [X] No
----------------------------------------------------------------
H. Rheumatism, arthritis, gout, or disorder of the muscles
or bones, spine, back or joints? [ ] Yes [X] No
----------------------------------------------------------------
I. Deformity, lameness or amputation? [ ] Yes [X] No
----------------------------------------------------------------
J. Disorder of skin, lymph glands, cyst, tumor or cancer?
[ ] Yes [X] No
----------------------------------------------------------------
K. Allergies; anemia or other disorder of the blood?
[ ] Yes [X] No
----------------------------------------------------------------
L. Alcohol or drug habit? [ ] Yes [X] No
----------------------------------------------------------------
34. OTHER THAN ABOVE, HAVE YOU WITHIN THE PAST 5 YEARS:
A. Had any physician or practitioner examine, advise or
treat you? [ ] Yes [X] No
----------------------------------------------------------------
B. Been a patient in a hospital, clinic or medical facility?
[ ] Yes [X] No
----------------------------------------------------------------
C. Had EKG, X-ray, other test? [ ] Yes [X] No
----------------------------------------------------------------
D. Been advised to have any test, hospitalization or
surgery which was not completed? [ ] Yes [X] No
----------------------------------------------------------------
35. Have you ever had military service deferment, rejection or
discharge because of a physical or mental condition?
[ ] Yes [X] No
------------------------------------------------------------------------------------------------------------------------------------
I declare that my answers and statements on both sides of this page are correctly recorded, complete and true to the best of my
knowledge and belief. Statements in this application are representations and not warranties.
/s/ Xxxx X. Xxx
---------------------------------------------------------------
Signature of Insured (or Informant)
Signed at Milwaukee, WI On 1 1 85 /s/ Vorm M. Western
-------------------------- -------------------- ---------------------------------------------------------------
City State Mo Day Year Signature of Licensed Agent
[NORTHWESTERN MUTUAL LIFE(R) LOGO]
IT IS RECOMMENDED THAT YOU . . .
READ YOUR POLICY.
NOTIFY YOUR NML AGENT OR THE COMPANY AT
000 X. XXXXXXXXX XXXXXX, XXXXXXXXX, WIS. 53202,
OF AN ADDRESS CHANGE.
CALL YOUR NML AGENT FOR INFORMATION --
PARTICULARLY ON A SUGGESTION
TO TERMINATE OR EXCHANGE THIS POLICY
FOR ANOTHER POLICY OR PLAN.
ELECTION OF TRUSTEES
The members of The Northwestern Mutual Life Insurance Company are its
policyholders of insurance policies and deferred annuity contracts. The members
exercise control through a Board of Trustees. Elections to the Board are held
each year at the annual meeting of members. Members are entitled to vote in
person or by proxy.
VARIABLE WHOLE LIFE POLICY WITH EXTRA LIFE PROTECTION
ELIGIBLE FOR ANNUAL DIVIDENDS
Insurance payable at death of Insured.
Fixed premiums payable for period shown on page 3.
Benefits reflect investment results.
Variable benefits described in Sections 5 through 8.
Provided no premium is unpaid as of its due date, the Death Benefit for the
first policy year will be the minimum death benefit shown on page 3, less any
policy debt. The Death Benefit after that may increase or decrease on each
policy anniversary depending on investment results. However, if no premium is
unpaid as of its due date, the Death Benefit will not be less than the minimum
death benefit shown on page 3, less any policy debt.
The cash value under this policy may increase or decrease daily depending on
investment results. There is no guaranteed minimum cash value.
MM 17
