FLEXIBLE PREMIUM VARIABLE LIFE
INSURANCE CONTRACT
Glenbrook Life and Annuity Company, A Stock Company, Home Office:
Xxxxxxxx Xxxxx, Xxxxxxxxxx, Xxxxxxxx 00000
(800) 755 - 5275
This contract is issued in consideration of your application and the receipt of
your initial premium. Glenbrook Life and Annuity Company will pay the benefits
of this contract, subject to its terms and conditions.
Throughout this contract, "you" and "your" refer to the contract owner(s), who
may be someone other than the insured. "We", "us" and "our" refer to Glenbrook
Life and Annuity Company.
This flexible premium variable life insurance contract provides a death benefit
payable to the beneficiary if the insured dies while this contract is in force.
The death benefit and other values provided by this contract are based on the
investment experience of the variable account, the fixed account earnings, and
other flexible factors. These values may vary based on investment and earnings
experience and are not guaranteed as to a fixed dollar amount.
This contract does not pay dividends.
PLEASE READ YOUR CONTRACT CAREFULLY.
This is a legal contract between the contract owner(s) and Glenbrook Life and
Annuity Company.
Return Privilege
If you are not satisfied with this contract for any reason, you may return it to
us or our agent within 30 days after you receive it. We will refund any premiums
allocated to the variable account, adjusted to reflect investment gain or loss
from the date of allocation to the date of cancellation, in addition to any
premium allocated to the fixed account.
/s/Xxxxxxx X. Xxxxxxx /s/Xxxxx X. Lower, II
Xxxxxxx X. Xxxxxxx Xxxxx X. Lower, II
Secretary Chief Executive Officer
Flexible Premium Variable Life Insurance Contract
Proceeds Payable at Death
Non-Participating
KLUxx
TABLE OF CONTENTS
CONTRACT DATA:....................................................................................................3
* Table of Guaranteed Contract Values
DEFINITIONS:......................................................................................................4
GENERAL PROVISIONS:...............................................................................................5
CONTRACT VALUES:..................................................................................................8
LOAN VALUES:.....................................................................................................12
WITHDRAWAL BENEFITS:.............................................................................................13
PAYMENT OF PROCEEDS:.............................................................................................14
INCOME PAYMENT TABLES:...........................................................................................15
CONTRACT DATA
OWNER(S):..................................................................................................Xxxx Xxx
...........................................................................................................Xxxx Xxx
PRIMARY INSURED:...........................................................................................Xxxx Xxx
Age:........................................................................................................18
Sex:......................................................................................................Male
Rating Classification:................................................................................Standard
CONTRACT NUMBER:.........................................................................................0123456789
CONTRACT DATE:.....................................................................................January 01, 1997
GUARANTEE PERIOD:..........................................................................................Lifetime
GUARANTEE PERIOD EXPIRATION DATE:..............................................................................None
SCHEDULE OF BENEFITS
Specified
Base Coverage Amount Maturity Date
Flexible Premium Variable Life Insurance $100,000.00 None
Death Benefit Option 1
Benefit
Additional Benefits Selected Amount Expiration Date
Primary Insured Term Rider $300,000.00 None
Accidental Death Benefit Rider $100,000.00 January 01, 2044
Children's Level Term Rider $10,000.00 January 01, 2044
Waiver of Monthly Deduction Rider January 01, 2039
Additional Insured Rider (AIR) $100,000.00 None
Name:.............................................Xxxx Xxx
Age:....................................................18
Sex:................................................Female
Rating Classification:............................Standard
Accidental Death Benefit Rider - AIR $100,000.00 January 01, 2044
SCHEDULE OF PREMIUMS
TARGET PREMIUM:.............................................................................................$600.00
MINIMUM ANNUAL PREMIUM:...................................................................................$1,200.00
GUARANTEE PERIOD PREMIUM:.................................................................................$1,800.00
INITIAL REQUIRED PREMIUM - (Quarterly):.....................................................................$300.00
PLANNED PREMIUM AMOUNT - (Quarterly):.......................................................................$450.00
VARIABLE ACCOUNT INFORMATION
VARIABLE ACCOUNT:...................................................Glenbrook Life Variable Life Separate Account B
ALLOCATION OF PREMIUMS:
Allocated
Variable Sub-accounts Amount (%)
VIS Dividend Growth 7%
VIS European Growth 7%
VIS Quality Income Plus 7%
VIS Utilities 6%
VIF Growth and Income 7%
VIF Money Market 7%
The Dreyfus Socially Responsible Growth Fund, Inc. 7%
VIF Small Company Stock 6%
VIP II Contrafund 7%
VIP Growth 7%
VIP High Income 6%
MFS Emerging Growth Series 7%
MFS Limited Maturity Series 6%
American Century VP Balanced 7%
American Century VP International 6%
MINIMUM WITHDRAWAL AMOUNT:....................................................................................$0.00
MINIMUM TRANSFER AMOUNT:......................................................................................$0.00
GENERAL ACCOUNT INFORMATION
FIXED ACCOUNT - MINIMUM GUARANTEED INTEREST RATE:.............................................................3.00%
LOAN CREDITED RATE:...........................................................................................4.00%
MAXIMUM LOAN INTEREST RATE (YEARS 1-10):......................................................................5.00%
(YEARS 11+):.......................................................................4.25%
EXPENSE DEDUCTIONS AND CHARGES
MORTALITY AND EXPENSE RISK ANNUAL RATE:.......................................................................0.60%
MONTHLY ADMINISTRATIVE EXPENSE CHARGE (YEAR 1):............................................................. $20.00
(YEARS 2+):$7.50
PREMIUM EXPENSE CHARGE:.......................................................................................4.00%
PARTIAL WITHDRAWAL SERVICE FEE:...................................................................the lesser of $25
or 2% of the amount withdrawn
SCHEDULE OF SURRENDER CHARGES
A PERCENTAGE OF THE LESSER AMOUNT OF
TOTAL PREMIUMS PAID OR THE TARGET PREMIUM
Contract Surrender
Year Charge
1 - 7 30.00%
8 27.00%
9 24.00%
10 20.00%
11 16.00%
12 12.00%
13 8.00%
14 4.00%
15 0.00%
BENEFICIARY INFORMATION
RELATIONSHIP
BENEFICIARY TO INSURED PERCENTAGE
Xxxx Xxx Son 100%
RELATIONSHIP
CONTINGENT BENEFICIARY TO INSURED PERCENTAGE
Xxxxx Xxx Sister 100%
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TABLE OF GUARANTEED CONTRACT VALUES
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Maximum Annual Primary Accidental Children's Waiver of
Death Cost of Insured Death Level Monthly
Contract Attained Benefit Insurance Term Rider Benefit Term Rider Deductions
Year Age Ratio per $1000 per $1000 per $1000 per $1000 per $1000
1 18 2.50 $1.63 $1.63 $0.68 $6.00 $0.13
2 19 2.50 $1.67 $1.67 $0.68 $6.00 $0.13
3 20 2.50 $1.68 $1.68 $0.69 $6.00 $0.13
4 21 2.50 $1.66 $1.66 $0.71 $6.00 $0.13
5 22 2.50 $1.63 $1.63 $0.73 $6.00 $0.13
6 23 2.50 $1.59 $1.59 $0.75 $6.00 $0.13
7 24 2.50 $1.55 $1.55 $0.76 $6.00 $0.13
8 25 2.50 $1.50 $1.50 $0.76 $6.00 $0.13
9 26 2.50 $1.47 $1.47 $0.74 $6.00 $0.13
10 27 2.50 $1.45 $1.45 $0.72 $6.00 $0.13
11 28 2.50 $1.44 $1.44 $0.71 $6.00 $0.13
12 29 2.50 $1.44 $1.44 $0.70 $6.00 $0.13
13 30 2.50 $1.45 $1.45 $0.70 $6.00 $0.13
14 31 2.50 $1.48 $1.48 $0.70 $6.00 $0.13
15 32 2.50 $1.52 $1.52 $0.71 $6.00 $0.15
16 33 2.50 $1.58 $1.58 $0.71 $6.00 $0.15
17 34 2.50 $1.65 $1.65 $0.72 $6.00 $0.16
18 35 2.50 $1.73 $1.73 $0.73 $6.00 $0.16
19 36 2.50 $1.82 $1.82 $0.74 $6.00 $0.17
20 37 2.50 $1.94 $1.94 $0.75 $6.00 $0.18
21 38 2.50 $2.07 $2.07 $0.76 $6.00 $0.19
22 39 2.50 $2.21 $2.21 $0.77 $6.00 $0.20
23 40 2.50 $2.39 $2.39 $0.78 $6.00 $0.21
24 41 2.43 $2.57 $2.57 $0.79 $6.00 $0.25
25 42 2.36 $2.76 $2.76 $0.80 $6.00 $0.27
26 43 2.29 $2.97 $2.97 $0.81 $6.00 $0.31
27 44 2.22 $3.20 $3.20 $0.82 $6.00 $0.34
28 45 2.15 $3.46 $3.46 $0.84 $6.00 $0.37
28 46 2.09 $3.74 $3.74 $0.85 $6.00 $0.43
30 47 2.03 $4.05 $4.05 $0.87 $6.00 $0.49
31 48 1.97 $4.38 $4.38 $0.89 $6.00 $0.56
32 49 1.91 $4.74 $4.74 $0.91 $6.00 $0.64
33 50 1.85 $5.16 $5.16 $0.93 $6.00 $0.72
34 51 1.78 $5.63 $5.63 $0.96 $6.00 $0.90
35 52 1.71 $6.18 $6.18 $0.98 $6.00 $1.14
36 53 1.64 $6.81 $6.81 $1.01 $6.00 $1.44
37 54 1.57 $7.51 $7.51 $1.04 $6.00 $1.80
38 55 1.50 $8.29 $8.29 $1.07 $6.00 $2.23
39 56 1.46 $9.14 $9.14 $1.10 $6.00 $2.23
40 57 1.42 $10.05 $10.05 $1.13 $6.00 $2.23
41 58 1.38 $11.06 $11.06 $1.17 $6.00 $2.23
42 59 1.34 $12.20 $12.20 $1.23 $6.00 $2.23
43 60 1.30 $13.47 $13.47 $1.30 $6.00 *
44 61 1.28 $14.89 $14.89 $1.34 $6.00 *
45 62 1.26 $16.53 $16.53 $1.39 $6.00 *
46 63 1.24 $18.39 $18.39 $1.45 $6.00 *
47 64 1.22 $20.47 $20.47 $1.51 $6.00 *
48 65 1.20 $22.76 $22.76 ** ** *
49 66 1.19 $25.24 $25.24 ** ** *
50 67 1.18 $27.92 $27.92 ** ** *
51 68 1.17 $30.84 $30.84 ** ** *
52 69 1.16 $34.10 $34.10 ** ** *
53 70 1.15 $37.82 $37.82 ** ** *
54 71 1.13 $42.09 $42.09 ** ** *
55 72 1.11 $47.07 $47.07 ** ** *
56 73 1.09 $52.75 $52.75 ** ** *
57 74 1.07 $59.08 $59.08 ** ** *
58 75 1.05 $65.92 $65.92 ** ** *
59 76 1.05 $73.24 $73.24 ** ** *
60 77 1.05 $81.00 $81.00 ** ** *
61 78 1.05 $89.27 $89.27 ** ** *
62 79 1.05 $98.32 $98.32 ** ** *
63 80 1.05 $108.50 $108.50 ** ** *
64 81 1.05 $120.13 $120.13 ** ** *
65 82 1.05 $133.56 $133.56 ** ** *
66 83 1.05 $148.82 $148.82 ** ** *
67 84 1.05 $165.75 $165.75 ** ** *
68 85 1.05 $184.06 $184.06 ** ** *
69 86 1.05 $203.63 $203.63 ** ** *
70 87 1.05 $224.23 $224.23 ** ** *
71 88 1.05 $245.84 $245.84 ** ** *
72 89 1.05 $268.86 $268.86 ** ** *
73 90 1.05 $293.74 $293.74 ** ** *
74 91 1.04 $321.28 $321.28 ** ** *
75 92 1.03 $352.85 $352.85 ** ** *
76 93 1.02 $392.27 $392.27 ** ** *
77 94 1.01 $448.92 $448.92 ** ** *
78 95 1.01 $542.88 $542.88 ** ** *
79 96 1.01 $727.09 $727.09 ** ** *
80 97 1.01 $783.66 $783.66 ** ** *
81 98 1.01 $879.88 $879.88 ** ** *
82 99 1.01 $990.00 $990.00 ** ** *
83 100+ 1.00 $1000.00 $1000.00 ** ** *
The death benefit at any time will be at least equal to the greater of your
current specified amount or your account value multiplied by the appropriate
death benefit ratio from this table.
(*) Benefit has expired and is no longer available. However, if the insured is
considered disabled under the Waiver of Monthly Deductions provision prior to
the coverage expiration date, monthly deductions will continue to be waived.
(**) Benefit has expired and is no longer available.
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TABLE OF GUARANTEED CONTRACT VALUES - Additional Insured Rider
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Maximum Annual Accidental
Cost of Insurance Death
Contract Attained per $1000 Benefit
Year Age per $1000
1 18 $1.63 $0.55
2 19 $1.67 $0.55
3 20 $1.68 $0.55
4 21 $1.66 $0.55
5 22 $1.63 $0.55
6 23 $1.59 $0.55
7 24 $1.55 $0.55
8 25 $1.50 $0.55
9 26 $1.47 $0.55
10 27 $1.45 $0.53
11 28 $1.44 $0.52
12 29 $1.44 $0.51
13 30 $1.45 $0.51
14 31 $1.48 $0.51
15 32 $1.52 $0.51
16 33 $1.58 $0.51
17 34 $1.65 $0.51
18 35 $1.73 $0.51
19 36 $1.82 $0.51
20 37 $1.94 $0.51
21 38 $2.07 $0.51
22 39 $2.21 $0.51
23 40 $2.39 $0.52
24 41 $2.57 $0.52
25 42 $2.76 $0.53
26 43 $2.97 $0.54
27 44 $3.20 $0.55
28 45 $3.46 $0.56
28 46 $3.74 $0.57
30 47 $4.05 $0.58
31 48 $4.38 $0.59
32 49 $4.74 $0.61
33 50 $5.16 $0.62
34 51 $5.63 $0.64
35 52 $6.18 $0.66
36 53 $6.81 $0.67
37 54 $7.51 $0.69
38 55 $8.29 $0.70
39 56 $9.14 $0.72
40 57 $10.05 $0.75
41 58 $11.06 $0.77
42 59 $12.20 $0.81
43 60 $13.47 $0.84
44 61 $14.89 $0.86
45 62 $16.53 $0.88
46 63 $18.39 $0.90
47 64 $20.47 $0.92
48 65 $22.76 **
49 66 $25.24 **
50 67 $27.92 **
51 68 $30.84 **
52 69 $34.10 **
53 70 $37.82 **
54 71 $42.09 **
55 72 $47.07 **
56 73 $52.75 **
57 74 $59.08 **
58 75 $65.92 **
59 76 $73.24 **
60 77 $81.00 **
61 78 $89.27 **
62 79 $98.32 **
63 80 $108.50 **
64 81 $120.13 **
65 82 $133.56 **
66 83 $148.82 **
67 84 $165.75 **
68 85 $184.06 **
69 86 $203.63 **
70 87 $224.23 **
71 88 $245.84 **
72 89 $268.86 **
73 90 $293.74 **
74 91 $321.28 **
75 92 $352.85 **
76 93 $392.27 **
77 94 $448.92 **
78 95 $542.88 **
79 96 $727.09 **
80 97 $783.66 **
81 98 $879.88 **
82 99 $990.00 **
83 100+ $1000.00 **
(**) Benefit has expired and is no longer available.
DEFINITIONS
When we use the following words, this is what we mean:
AGE The insured's age at the insured's last birthday.
CONTRACT ANNIVERSARY The same day and month as your contract date for each
subsequent year your contract remains in force.
CONTRACT DATE The date from which contract anniversaries, contract years, and
contract months are determined.
Coverage shall become effective on the date when:
* the application has been approved by us;
* the contract has been accepted by you; and
* the initial required premium has been received by us while the insured is
alive.
IN FORCE A term used to describe when the insured's life is covered under the
terms of this contract.
INDEBTEDNESS All contract loans, if any, and accrued loan interest.
INSURED The person whose life is covered under this contract as shown on page 3.
LOAN ACCOUNT An account established for any amounts transferred from the
variable or fixed accounts as a result of loans. The loan account is credited
with interest and is not based on the experience of any separate account.
MONTHLY ACTIVITY DATE The same day of each month as the contract date. If there
is no monthly activity date in a calendar month, the monthly activity date will
be the last day of the current calendar month.
PROCEEDS The amount we are obligated to pay under the terms of this contract
when your contract is surrendered or when the insured dies.
SPECIFIED AMOUNT The specified amount equals the death benefit on the contract
date. Thereafter, it may change in accordance with the terms of this contract.
SURRENDER A term used when the contract is voluntarily terminated by the
contract owner in order to receive the contract proceeds.
TARGET PREMIUM The premium which determines the amount of any surrender charges
applied to this contract.
TERMINATE A term used to describe when the insured's life is no longer covered
under any of the terms of this contract.
VARIABLE SUB-ACCOUNTS The variable account is divided into variable
sub-accounts. Each variable sub-account invests solely in the shares of the
mutual fund or mutual portfolio underlying that variable sub-account.
WRITTEN REQUEST A request in writing signed by you on a form agreeable to us.
GENERAL PROVISIONS
THE CONTRACT Your contract is issued in consideration of the application and the
payment of an initial required premium.
Your contract, any riders and endorsements, the application, and any
supplemental applications are the entire contract between you and us. A copy of
the application is included. Any supplemental applications will also be attached
to and made a part of the contract. Any statements made in the application and
any supplemental applications either by you or by the insured will, in the
absence of fraud, be considered representations and not warranties. Also, any
written statement made either by you or by the insured will not be used to void
your contract nor defend against a claim under your contract unless the
statement is contained in the application or any supplemental applications.
Only our officers may change the contract or waive a right or requirement. No
agent or other person may do this.
VARIABLE ACCOUNT The variable account for this contract is that shown on page 3.
This account is a separate investment account to which we allocate assets
contributed under this and certain other life insurance contracts. We will have
exclusive and absolute ownership and control of the assets of our separate
accounts. The assets of the variable account will be available to cover the
liabilities of our general account only to the extent those assets exceed the
liabilities of that variable account arising under the variable life insurance
contracts supported by that variable account.
The assets of the variable account will be valued at least as often as any
contract benefits vary, but at least monthly. Our determination of the value of
an accumulation unit by the method described in this policy will be conclusive.
VARIABLE ACCOUNT TRANSFERS Upon request and as long as this contract is in
force, you may transfer amounts among the variable sub-accounts. You may make 12
transfers each contract year without charge. Subsequent transfers in any
contract year may be assessed a $10 transfer fee, to be deducted proportionately
from each variable sub-account and the fixed account. The minimum amount that
may be transferred among variable sub-accounts is subject to the minimum
transfer amount which is shown on page 3. We reserve the right to waive the
transfer fees and restrictions contained in this contract.
VARIABLE ACCOUNT MODIFICATIONS We reserve the right, subject to applicable law,
to make additions to, deletions from, or substitutions for the mutual fund
shares underlying the variable sub-accounts of the variable account. We will not
substitute any shares attributable to your interest in a variable sub-account of
the variable account without notice to you and prior approval of the Securities
and Exchange Commission, to the extent required by the Investment Company Act of
1940.
We reserve the right to establish additional variable sub-accounts of the
variable account, each of which would invest in shares of another portfolio of
the mutual fund or another mutual fund. You may then instruct us to allocate
premiums paid or transfers to such variable sub-accounts, subject to any terms
set by us or the mutual fund. In the event of any such substitution or change,
we may by endorsement, make such changes as may be necessary or appropriate to
reflect such substitution or change.
If we deem it to be in the best interests of persons having voting rights under
these contracts, the variable account may be operated as a management company
under the Investment Company Act of 1940 or it may be deregistered under such
Act in the event such registration is no longer required.
FIXED ACCOUNT At any time while this contract is in force, you may allocate
premiums to a fixed account which will earn interest at the current rate,
declared by us, in effect at the time of allocation or transfer from an existing
variable sub-account. Interest is credited daily to monies in the fixed account
during the life of the contract. The rates we declare to be in effect are
effective annual interest rates. We credit interest at a rate which compounds
over one year to the interest rate we declare. We will credit interest as of the
date money is allocated or transferred to the fixed account. The interest rate
may increase or
decrease but will never be less than that shown on page 3.
FIXED ACCOUNT TRANSFERS Transfers from the fixed account may be done once each
year within 60 days following the contract anniversary. Transfer requests
received at any other time will not be processed. There is no minimum amount
which must be transferred from the fixed account. However, the maximum amount
which may be transferred from the fixed account in any contract year is the
greater of:
* 25% of your account value in the fixed account at the time of the transfer or
withdrawal in a contract year; or * the amount transferred from the fixed
account in the prior contract year; or * $500.
BENEFICIARY When we receive due proof of the insured's death, we will pay the
proceeds of this contract to the beneficiary or beneficiaries who are named in
the application for this contract unless you subsequently change the
beneficiary. In that event, we will pay the proceeds to the beneficiary named in
your last change of beneficiary request as provided for in this contract.
If a primary or contingent beneficiary dies before the insured, that
beneficiary's interest in this contract ends with that beneficiary's death. Only
those beneficiaries who survive the insured will be eligible to share in the
proceeds. If no beneficiary survives the insured, we will pay the proceeds of
this contract to you, if living, otherwise to your estate.
CHANGE OF OWNER OR BENEFICIARY If you have reserved the right to change the
owner or beneficiary, you can file a written request with us to make such a
change. If you have not reserved the right to change the beneficiary, the
written consent of the irrevocable beneficiary(s) will be required.
Your written request will not be effective until it is recorded in our home
office records. After it has been recorded, it will take effect as of the date
you signed the request. However, if the insured dies before the request has been
recorded, the request will not effect those proceeds we may have paid before
your request was recorded in our home office records.
REINSTATEMENT Prior to the death of the insured and if this contract has not
been surrendered, this contract may be reinstated provided:
* you make your request within five years of the date the contract entered a
grace period; * satisfactory evidence of insurability is submitted; * any
indebtedness is repaid; and * sufficient premium is paid to:
* cover all monthly deduction amounts unpaid during the grace period;
and * keep the contract in force for three months after the date of
reinstatement.
The specified amount of the reinstated contract cannot exceed the specified
amount at the time of lapse. The account value on the reinstatement date will
reflect:
* the account value at the time of termination; and
* premiums paid at the time of reinstatement.
Withdrawal charges will continue to be based on the original contract date.
EXCHANGE OPTION If this contract is in force, you may exchange it during the
first two years after the contract date or within two years of an increase in
specified amount, for a contract in which values do not vary with the investment
experience of the variable account. This exchange will be implemented by
transferring your account value to the fixed account and removing your future
right to allocate funds to the variable account. We may require you to return
this contract to us before this exchange will be processed. This transfer will
not be subject to the excess transfer fee described earlier in this contract.
ANNUAL REPORT We will send you, at least once a year, an annual report which
provides information on the current status of your contract. This information
will include items such as:
* the current death benefit;
the current account value and cash surrender value;
any amount of indebtedness;
any monthly deductions since the last report;
any partial withdrawals and withdrawal charges since the last report; any
premium payments since the last report; and, the current interest rate
being credited to the fixed account.
If you ask us, we will send you an additional report, at any time during the
contract year. We may charge you for this report but the charge will not be more
than $25. We will tell you what the current charge is before sending the report.
In addition, we will send you any shareholder reports of the variable funds or
any other notices, reports or documents required by law.
Suicide Exclusion If the insured dies by suicide while sane or self-destruction
while insane within two years from the contract date, our liability will be
limited to an amount equal to the account value less any indebtedness. If the
insured dies by suicide while sane or self-destruction while insane within two
years of the effective date of any increase in specified amount, our liability
with respect to the increase will be limited to the cost of insurance for the
increase.
Incontestability We cannot contest this contract after it has been in force
during the lifetime of the insured for two years after the contract date. Any
increase in the specified amount for which evidence of insurability was obtained
will be incontestable only after the increase has been in force, during the
lifetime of the insured, for two years from the effective date of the increase.
Misstatement of Age or Sex If the age or sex of the insured has been misstated,
any proceeds will be adjusted to the amount which the initial target premium
would have purchased at the correct age and sex.
Assignment You may assign an interest in this contract as collateral or security
for a loan. However, we are not responsible for the soundness of an assignment.
No assignment will bind us unless it is written and acknowledged by us in
writing.
Life Insurance Qualification This contract is intended to qualify for treatment
as a life insurance contract under the Internal Revenue Code as it now exists or
may later be amended. We reserve the right to amend this contract to comply with
future changes in the Code and its Regulations. We will promptly provide you
with a copy of any amendment.
Taxation Currently, no charge is made to the variable account for federal income
taxes that may be attributable to the operations of the variable account.
However, the Company may make such a charge in the future. Charges for other
taxes, if any, attributable to the variable account or this class of contracts
may also be made.
Nonparticipating This contract will not share in our surplus distributions.
Termination This contract will terminate upon the earliest of the following
events:
surrender of the contract; or
the end of the grace period; or
the death of the insured.
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CONTRACT VALUES
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Premium Payments The initial required premium amount shown on page 3 is due by
the contract date and must be paid in advance. This contract will not be in
effect before this amount is received. We will send reminder notices for the
planned premium payments you have selected as shown on page 3. However, all
premiums are subject to our minimum requirements to keep the contract in force.
You may make premium payments at any time and in any amount while the contract
is in force, subject to certain conditions. Unless you request otherwise in
writing, any premiums we receive other than the planned premiums shown on page
3, while a contract loan exists, will be applied as a repayment of indebtedness
first, and then as a premium payment.
Premium payments may be made at any time and in any amount necessary to avoid
termination of this contract.
Premium Limitations We will not accept any premium payment causing this contract
not to qualify as a life insurance contract under the Internal Revenue Code. If
this occurs, in order for us to accept this premium, we must receive from you a
written request to increase your specified amount to an amount able to sustain
the additional premium. Your request to increase your specified amount will
require evidence of insurability and approval by us.
In addition, we will not accept any premium payment causing this contract to
become a modified endowment contract under the Internal Revenue Code. We will
conduct a test at least once each year in which premiums are paid and refund any
excess premiums with interest at the current interest rate being applied to the
fixed account. In order for us to accept premiums in excess of the Internal
Revenue Code guidelines, we must first receive from you written acknowledgment
of your understanding that the contract will become a modified endowment
contract. We will take any necessary action within 60 days following the
contract anniversary.
Premium Allocation All premiums received will be allocated to the variable
sub-accounts and the fixed account, in whole percentages according to the
premium allocation specified on the application, on the date we receive the
final requirement to put the contract in force.
All premium payments not requiring underwriting will be allocated to the
variable sub-accounts and the fixed account as of the date payments are received
at our home office. Premium payments requiring underwriting will be allocated
once underwriting approval is received. Upon underwriting approval, an amount
equal to the accumulated value which would have been earned had the premium been
invested in the money market account since the date of receipt of the premium,
will be allocated according to the initial premium allocation specified on the
application or your most recent written instructions. You may change your
premium allocation upon written request.
We reserve the right to allocate premium payments to the fixed account during
the return privilege period described on page 1 of this contract. Transfer of
premiums from the fixed account at the end of the return privilege period will
not be considered one of your 12 free transfers allowed in a contract year.
Grace Period This contract will terminate 61 days after a monthly activity date
on which:
the cash surrender value is less than zero; and
the guarantee period shown on page 3 and described below has expired or
been terminated; and the three year continuation period described below has
expired or the required premium for the three year continuation period has
not been paid.
This 61 day period is the grace period. We will notify you and any assignee, at
the last known address, of the premium amount required to continue this
contract, at least 61 days before the end of the grace period. The premium
required will be no greater than an amount required to pay three monthly
deduction amounts as of the day the grace period began. If this premium is not
paid by the end of the grace period, this contract will terminate.
Minimum Annual Premium The minimum annual premium as of the contract date is
shown on page 3. We will recalculate the minimum annual premium whenever an
additional benefit is changed, added to, or deleted from the contract, or the
contract's specified amount is changed.
The start date and amount of your new minimum annual premium will be sent to you
in the form of an endorsement to the contract.
Guarantee Period Premium The guarantee period premium as of the contract date is
shown on page 3. We will recalculate the guarantee period premium whenever an
additional benefit is changed, added to, or deleted from the contract, or the
contract's specified amount is changed.
The start date and amount of your new guarantee period premium will be sent to
you in the form of an endorsement to the contract.
Three Year Continuation Period Except as provided in any Waiver of Monthly
Deductions Rider attached to this contract, the three year continuation period
will be in effect until the end of the third contract year. On any monthly
activity date while the three year continuation period is in effect, we
guarantee the contract will remain in force if:
the cumulative premiums paid; less
partial withdrawals and any indebtedness; is greater than or equal to
the cumulative minimum premium.
The cumulative minimum premium will be calculated by dividing the minimum annual
premium shown on page 3, by 12, and multiplying by the number of contract months
since issue. If the minimum annual premium was changed, as described in the
minimum annual premium provision, each minimum annual premium will be divided by
12, multiplied by the respective number of contract months it was in effect, and
totalled to obtain the cumulative minimum premium.
Guarantee Period The contract will not be terminated during the guarantee period
even if the cash surrender value is zero. The guarantee period is the period you
have selected in your application and will expire on the date shown on page 3.
The guarantee period will be terminated prior to the guarantee period expiration
date if on any monthly activity date:
the cumulative premiums paid; less partial withdrawals and any
indebtedness; is less than the cumulative guarantee period premium.
The cumulative minimum premium will be calculated by dividing the guarantee
period premium shown on page 3, by 12, and multiplying by the number of contract
months since issue. If the guarantee period premium was changed, as described in
the guarantee period premium provision, each guarantee period premium will be
divided by 12, multiplied by the respective number of contract months it was in
effect, and totalled to obtain the guarantee period premium. We reserve the
right to establish diversification guidelines in the future if necessary.
The guarantee period will apply to the specified amount which is shown on page 3
and to any subsequent increases in coverage which are approved after the
contract date.
Accumulation Unit and Accumulation Unit Value Amounts which you allocate to a
variable sub-account of the variable account are used to purchase accumulation
units in that variable sub-account. The accumulation unit value for each
variable sub-account at the end of any valuation period is calculated by
multiplying the accumulation unit value at the end of the immediately preceding
valuation period by the variable sub-account's net investment factor for the
valuation period. The accumulation unit values may go up or down. Additions or
transfers to a variable sub-account of the variable account will increase the
number of accumulation units for that variable sub-account. Withdrawals,
transfers, transfer fees, contract loans, monthly deduction amounts, or other
fees deducted from a variable sub-account will decrease the number of
accumulation units for that variable sub-account.
The number of accumulation units to be added to or deducted from a variable
sub-account equals the dollar amount of the transaction divided by the
accumulation unit value for the valuation period.
Accumulated Value Your accumulated value in any variable sub-account equals:
the number of accumulation units in that variable sub-account on the
valuation day; multiplied by that variable sub-account's accumulation unit
value on the valuation day.
Net Investment Factor For each variable sub-account, the "net investment factor"
for a valuation period is (A) divided by (B), minus (C) where:
(A) is the sum of:
1. the net asset value per share of the mutual fund underlying the
variable sub-account determined as of the end of the current valuation period;
plus
2. the per share amount of any dividend or capital gain distributions
made by the mutual fund underlying the variable sub-account during the current
valuation period.
(B) is the net asset value per share of the mutual fund underlying the variable
sub-account determined as of the end of the immediately preceding valuation
period.
(C) is the mortality and expense risk annual rate divided by 365 and multiplied
by the number of calendar days in the current valuation period. The mortality
and expense risk annual rate is shown on page 3.
Valuation Period and Valuation Date A "valuation period" is the time interval
between the close of regular trading of the New York Stock Exchange on
consecutive valuation dates. A "valuation date" is any date the New York Stock
Exchange is open for trading.
Monthly Deduction Amount The monthly deduction amount will be taken
proportionately from your variable sub-accounts and the fixed account on each
monthly activity date, and is equal to:
the cost of insurance charge; plus the monthly administrative expense
charge; plus the monthly charges for additional benefits selected, if any.
Cost of Insurance Charges The maximum cost of insurance charge for any monthly
activity date is equal to:
the death benefit; minus
the account value on the monthly activity date, prior to assessing the
monthly deduction amount; the result is divided by 1000 and multiplied by
the maximum annual cost of insurance rate divided by 12.
We can use cost of insurance charges that are lower than the maximum annual cost
of insurance shown on page 3. Charges will be determined based on our
expectation as to future experience. Any change we make will be on a uniform
basis for all insureds with the same age, sex, and rating classification whose
coverage has been in force for the same length of time. No change in rating
classification or cost will occur due to deterioration of the insured's health.
Monthly Administrative Expense Charge The monthly administrative expense charge
for any monthly activity date is equal to that shown on page 3. The monthly
administrative expense charge shown is deducted each month during the contract
years indicated.
Premium Expense Charge A premium expense charge will be deducted from each
premium received prior to being allocated to the variable or fixed account. This
charge, shown on page 3, is a percentage of the premium received.
Account Value Your account value on the contract date equals the initial premium
paid less the premium expense charge, less the monthly deduction amount for the
first policy month. Your account value on each subsequent monthly activity date
equals:
the sum of your accumulated values in each variable sub-account; plus the
value of your fixed account; plus the value of your loan account, if any;
minus the monthly deduction amount.
On any day other than your monthly activity date, your account value equals:
the sum of your accumulated values in each variable sub-account; plus the
value of your fixed account; plus the value of your loan account, if any.
Specified Amount The specified amount for this contract is shown on page 3, and
is equal to the death benefit on the contract date. If a partial withdrawal is
taken, a death benefit option change occurs, or an increase in specified amount
is made, the specified amount will change as described in the partial
withdrawal, death benefit option changes, or premium limitations provisions of
this contract, respectively.
Specified Amount Changes At any time after the first contract year, you may
request in writing an increase or decrease of your specified amount. A request
to change your specified amount will take effect on the next valuation date
following the date we approve the request.
A request to decrease your specified amount will first be applied against the
most recent increase amount, if any, then successively to each prior increase,
and then to the initial specified amount. The specified amount in force after
any decrease may not be less than the minimum we have established. A request to
increase your specified amount will require a new application and evidence of
insurability.
We will provide to you an endorsement showing the start date of any increase or
decrease and the new specified amount. For increases in specified amount, we
will also provide a table of surrender charges based on the increased specified
amount and new target premium. We reserve the right to limit the amount and
frequency of any increases or decreases in specified amount.
Death Benefit The death benefit is determined by the death benefit option that
currently exists on your contract, as shown on page 3. Available death benefit
options on this contract are:
option 1; the death benefit equals the existing specified amount.
option 2; the death benefit equals the existing specified amount, plus your
account value.
We will pay the death benefit less any indebtedness, and less any unpaid monthly
deduction amounts occurring during a grace period, if the insured dies while
this contract is in force, subject to the terms of this contract. Written due
proof that the insured has died must be received at our home office prior to
paying a death benefit.
In any event, your death benefit will be at least equal to the greater of your
current specified amount or your account value multiplied by the death benefit
ratio on page 3.
Interest from Date of Death If the proceeds under this contract are not paid
within thirty days after we receive due proof of the death of the insured, we
will also pay interest on the proceeds. Interest will accrue at the legal rate
of interest and will accrue from the date of death until the claim is paid.
Death Benefit Option Changes At any time after the first contract year, you may
request to change the death benefit option by writing to us. If you ask to
change from option 2 to option 1, the specified amount will be increased by the
amount of the account value. If you ask to change from option 1 to option 2, the
specified amount will decrease by the amount of the account value.
Any change will take effect on the next valuation date following the date we
receive your request. We will provide to you an endorsement showing the actual
start date of the death benefit option change and the new specified amount. We
reserve the right to limit the frequency of death benefit option changes made
under this contract.
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LOAN VALUES
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Contract Loan At any time while this contract is in force, you can borrow up to
the available loan value of your contract. The maximum loan value is 90% of your
cash value, less 100% of any existing loans as of the date of the loan.
Unless you specify otherwise, all loan amounts will be transferred
proportionately from the variable sub-accounts and the fixed account to the loan
account. However, we will not withdraw amounts from the fixed account equalling
more than the total loan multiplied by the ratio of the fixed account to your
account value immediately prior to the loan. Loans have priority over the claims
of any other person and your contract is sole security for all loans.
Credited Interest The loan account will be credited with interest at a rate
equal to the loan credited rate shown on page 3.
Loan Interest Interest will accrue daily by a rate not to exceed the maximum
loan interest rate shown on page 3. Interest payments are due on the contract
anniversary. If unpaid, interest is added to the amount of the loan and will
itself bear interest at the rate described in this provision. On each contract
anniversary, the difference between the total indebtedness and the balance in
the loan account will be transferred proportionately from the variable
sub-accounts and the fixed account to the loan account.
Loan Repayment You can repay all or part of a loan and loan interest at any time
while this contract is in force. The loan repayment will be allocated among the
variable sub-accounts and the fixed account in the same percentage as premiums
are allocated, unless you specify otherwise. If you do not repay your loans, we
will deduct all loans and loan interest from the amounts we pay.
Loan Limit Your contract will become overloaned when loans and loan interest
exceed the cash value. We will terminate this contract when it becomes
overloaned. We will not terminate a contract which becomes overloaned until 61
days after notice has been mailed to the last known address of the owner.
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WITHDRAWAL BENEFITS
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Cash Surrender Value You may terminate your contract for its cash surrender
value, which may be paid in cash or under an income plan. Your cash surrender
value is equal to the cash value less any indebtedness. Your cash value is equal
to the account value less any applicable surrender charges shown on page 3. In
addition, any request to terminate your contract will include a refund of
surrender charges in excess of any existing Securities and Exchange Commission
limits.
Termination will be effective on the date we receive your written request. We
may require that your contract accompany your written request before making any
payment. When you terminate your contract for its cash surrender value, your
contract will terminate.
Partial Withdrawals You may request a partial withdrawal of your account value
once each year after the first contract anniversary by writing to us. Your
partial withdrawal will be effective on the next valuation date. The minimum
partial withdrawal amount is shown on page 3, and the maximum partial withdrawal
amount may not reduce the account value to less than $500. When a partial
withdrawal is made, the amount of the withdrawal and a partial withdrawal
service fee is deducted from your account value. The amount of the partial
withdrawal service fee is shown on page 3.
You may specify how much of your partial withdrawal you wish taken from each
variable sub-account or from the fixed account. However, you may not withdraw
from the fixed account more than the total withdrawal times the ratio of the
fixed account to your account value immediately prior to the withdrawal. Unless
you indicate otherwise, we will withdraw funds and the partial withdrawal
service fee proportionately from the variable sub-accounts and the fixed account
in the same proportion your account value in each account bears to your account
value immediately prior to the withdrawal.
Any contract with Death Benefit Option 1 will also have a reduction in specified
amount, in addition to a reduction in account value. The specified amount will
be reduced by the amount of the partial withdrawal.
We will send you an endorsement to reflect the effects of the partial
withdrawal, including any change in the specified amount. We may ask you to
return your contract to us to make this change. The partial withdrawal and the
reduction in specified amount will be effective as of the next valuation date
following the date we receive your request.
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PAYMENT OF PROCEEDS
-------------------------------------------------------------------------------
Deferment of Payments We will pay any amounts due from the variable account
under this contract within seven days of receiving a written request for a
transfer, contract loan, termination, partial withdrawal, or death benefit, as
well as, any other required documentation, unless:
the New York Stock Exchange is closed for other than usual weekends or
holidays, or trading on such Exchange is restricted;
an emergency exists as defined by the Securities and Exchange Commission;
or the Securities and Exchange Commission permits delay for the protection
of contract holders.
Payee Rights You will be the payee for the cash surrender value unless you name
a different payee. The beneficiary will be the payee for the death proceeds.
When we pay the proceeds, we may ask that you give this contract back to us. If
the insured has died, you or the beneficiary must give us due proof of death.
You may choose payment as a single payment or an income plan. Before the
proceeds are due, you may choose or change an income plan selection by writing
to us. Once we accept the change, it takes effect as of the date you signed the
request. This change is subject to any action we take before we accept it. After
the proceeds are due, the payee may choose an income plan if:
you have not made a prior choice which is still in effect; and the proceeds are
due in a single sum and have not been paid.
No surrenders or partial withdrawals are permitted after payments under an
income plan have started.
Payout Start Date The payout start date is the date the cash surrender value or
death benefit is applied to an income plan.
Income Plans An income plan is a series of payments on a scheduled basis to the
payee. The proceeds will be applied to your income plan choice from the
following list:
1. Life Income with Guaranteed Payments We will make payments for as long as
the payee lives. If the payee dies before the selected number of guaranteed
payments have been made, we will continue to pay the remainder of the guaranteed
payments.
2. Joint and Survivor Life Income with Guaranteed Payments We will make
payments for as long as either the payee or joint payee, named at the time of
income plan selection, lives. If both the payee and the joint payee die before
the selected number of guaranteed payments have been made, we will continue to
pay the remainder of the guaranteed payments.
We reserve the right to make available other income plans.
Payout Terms and Conditions The income payments are subject to the following
terms and conditions:
If the proceeds are less than $3,000, or not enough to provide an initial
payment of at least $20, we reserve the right to:
*change the payment frequency to make the payment at least $20; or
*terminate the contract and pay you the proceeds in a lump sum.
If you choose an income plan which depends on any person's life, we may
require: * proof of age and sex before income payments begin; and * proof
that the payee or joint payee is still alive before we make each payment.
--------------------------------------------------------------------------------
INCOME PAYMENT TABLES
--------------------------------------------------------------------------------
The initial income payment will be at least the amount based on the adjusted age
of the payee(s) and the tables below, less any federal income taxes which are
withheld. The adjusted age is the actual age on the payout start date reduced by
one year for each six full years between January 1, 1983 and the payout start
date. Income payments for ages and guaranteed payment periods not shown below
will be determined on a basis consistent with that used to determine those that
are shown. The Income Payment Tables are based on 3.0% interest and the 1983a
Annuity Mortality Tables.
Income Plan 1 - Life Income with Guaranteed Payments for 120 Months
==============================================================================================================================
Monthly Income Payment for each $1,000 Applied to this Income Plan
==============================================================================================================================
Payee's Payee's Payee's
Age Male Female Age Male Female Age Male Female
------------------- ---------------------- ---------------- ---------------------- ---------------- ==========================
35 $3.43 $3.25 49 $4.15 $3.82 63 $5.52 $4.97
36 3.47 3.28 50 4.22 3.88 64 5.66 5.09
37 3.51 3.31 51 4.29 3.94 65 5.80 5.22
38 3.55 3.34 52 4.37 4.01 66 5.95 5.35
39 3.60 3.38 53 4.45 4.07 67 6.11 5.49
40 3.64 3.41 54 4.53 4.14 68 6.27 5.64
41 3.69 3.45 55 4.62 4.22 69 6.44 5.80
42 3.74 3.49 56 4.71 4.29 70 6.61 5.96
43 3.79 3.53 57 4.81 4.38 71 6.78 6.13
44 3.84 3.58 58 4.92 4.46 72 6.96 6.31
45 3.90 3.62 59 5.02 4.55 73 7.13 6.50
46 3.96 3.67 60 5.14 4.65 74 7.31 6.69
47 4.02 3.72 61 5.26 4.75 75 7.49 6.88
48 4.08 3.77 62 5.39 4.86
=================== ====================== ================ ====================== ================ ==========================
Income Plan 2 - Joint and Survivor Life Income with Guaranteed Payments for 120 Months
==============================================================================================================================
Monthly Income Payment for each $1,000 Applied to this Income Plan
==============================================================================================================================
Female Payee's Age
---------- ------------ ----------- ---------- ---------- ---------- ---------- --------- ===============
Male
Payee's 35 40 50 55 60 65 70 75
Age 45
-------------------- ---------- ------------ ----------- ---------- ---------- ---------- ---------- --------- ===============
35 $3.09 $3.16 $3.23 $3.28 $3.32 $3.36 $3.39 $3.40 $3.42
40 3.13 3.22 3.31 3.39 3.46 3.51 3.56 3.59 3.61
45 3.17 3.28 3.39 3.50 3.60 3.69 3.76 3.81 3.85
50 3.19 3.32 3.45 3.60 3.74 3.87 3.98 4.07 4.14
55 3.21 3.37 3.55 3.75 3.98 4.23 4.47 4.70 4.88
65 3.24 3.39 3.57 3.80 4.07 4.37 4.71 5.04 5.34
70 3.24 3.40 3.59 3.83 4.13 4.48 4.90 5.36 5.81
75 3.25 3.41 3.61 3.86 4.17 4.56 5.04 5.61 6.22
==================== ========== ========== ========== ========== =========== ========== ============ =========== =============
GLENBROOK LIFE AND ANNUITY COMPANY
(HEREIN CALLED "WE" OR "US")
AMENDATORY ENDORSEMENT FOR WAIVER OF MONTHLY DEDUCTIONS RIDER
GENERAL The "contract" is the contract to which this rider is attached. The
owner of the contract is called "you". This rider is part of your contract and
will stay in force while the contract remains in force or until the coverage
expiration date of this rider.
If all named owners and contingent owners have died or if there is no owner
named, the owner of this rider is the insured, if living. Write to us if you
wish to discontinue this rider.
AGE The insured's age at their last birthday.
COVERAGE EXPIRATION DATE Except as defined in this rider, coverage under this
rider will expire on the earliest of the following dates:
the date the contract expires;
the date we receive written notice from you that you do not want this rider
to stay in force; or the contract anniversary on which the insured's age is
60.
MONTHLY COST OF INSURANCE While this rider remains in force, the monthly cost of
insurance for this rider is deducted on the monthly activity date. This
deduction is taken from the contract value of the contract and is the product
of: the total monthly deduction amount for the contract, excluding the monthly
cost of insurance charge for this rider; and the Waiver of Monthly Deductions
monthly cost of insurance rate per $10 of deductions waived, divided by 10. The
Waiver of Monthly Deductions monthly cost of insurance rates per $10 of
deductions waived are based on the insured's attained age, sex, and rating
class.
Any increases in the Waiver of Monthly Deductions cost of insurance rates for
special class risks are shown on page 3 of the contract or on an endorsement to
page 3.
THE BENEFIT Except as stated in the Proof of Continuance of Disability
provision, all monthly deduction amounts which become due are waived if the
insured becomes disabled before age 60 and when we receive due proof of
disability in a timely manner. All benefits of the contract will be the same as
if you had made the payments which are waived.
The monthly deduction amount which will be waived includes only those portions
of the total monthly deduction amount for which a charge for this rider was
deducted on the monthly activity date on or immediately prior to the date of
disability.
PREMIUMS AND DEDUCTIONS DURING DISABILITY During the first 180 days of
disability, premiums large enough to keep the contract in force must be paid, as
provided in the three year continuation period, guarantee period, and grace
period provisions of the contract. If the insured becomes disabled during a
grace period, we will not waive the unpaid premium due.
If the disability continues more than 180 days, you must provide us with due
proof of disability. We will then credit the contract value with the sum of the
monthly deduction amounts taken, plus interest at the current interest rate
being applied to the fixed account, for the months since the insured became
disabled until the time you provided us with due proof. After the insured has
been disabled 180 days, premiums will not be required to keep the contract in
force as long as the disability continues.
DEFINITION OF DISABILITY Disabled means the insured has a disability which: was
caused by injury or disease; began on or after the contract date of this rider
and prior to the coverage expiration date on which the insured's age is 60; has
lasted for at least 180 consecutive days; and is not described in the Causes of
Disability Not Covered provision of this rider.
As a result of the disability, the insured must:
be kept from doing work for which the insured is reasonably suited by education,
training, or experience; or have a total and permanent loss of:
- the sight of both eyes; - the use of both hands; - the use of both
feet; or - the use of one hand and one foot.
CAUSES OF DISABILITY NOT COVERED The insured will not be said to be disabled if
the disability is caused by any intentionally self-inflicted injury, or a war,
or any act of war. "War" means armed aggression by one or more countries which
is opposed on the orders of any other country, group of countries, or
international body. "Act of War" means any act peculiar to armed forces' actions
in time of war.
PROOF OF DISABILITY Before monthly deduction amounts are waived, you must
provide due proof that the insured is disabled. Due proof must be received:
prior to the insured's death;
while the insured is disabled; and
within one year from the date the insured became disabled.
If you are medically unable to provide due proof to us as defined above, we will
still waive monthly deduction amounts once due proof is received by us. We will
waive monthly deduction amounts as if you had provided due proof to us as
defined above. If you were able to provide due proof to us as defined above, but
failed to, we will waive only:
the monthly deduction amounts due during the 12 months prior to the
date you provided us due proof; and the monthly deduction amounts
which become due after the date you provided us due proof.
We may ask for medical exams by doctors of our choice, at our expense, as part
of the due proof required.
PROOF OF CONTINUANCE OF DISABILITY We may require due proof that the insured is
still disabled. We may ask for this due proof at reasonable times during the
first two years in which the insured is disabled, and once a year thereafter.
You must give us immediate notice when the insured recovers from disability.
If the insured is no longer disabled, or if you do not provide us with due proof
when we ask for it:
no more monthly deduction amounts will be waived; and you will be
responsible for paying any premium amount necessary to keep your
contract in force.
PREMIUMS UPON RECOVERY The minimum annual premium, guarantee period, and the
three year continuation period are described in the contract. If the three year
continuation period was in effect at the end of the first 180 days of
disability, it will be in effect again when the insured recovers from
disability. The three year continuation period will be in effect from the date
of recovery until the earlier of the end of the third contract year, not
counting any time the insured has been disabled.
REINSTATEMENT We will reinstate this rider if it has stopped and you meet the
requirements of the reinstatement provision of the contract.
MISSTATEMENT OF AGE OR SEX If the age or sex of the insured has been misstated,
the benefit will be adjusted to an amount which your initial target premium
would have purchased at the correct age and sex.
INCONTESTABILITY We may not contest this benefit once it has been in force
during the lifetime of the insured for two years from the contract date, not
counting any time the insured has been disabled, except for payments due but not
made.
/s/Xxxxxxx X. Xxxxxxx /s/Xxxxx X. Lower, II
Xxxxxxx X. Xxxxxxx Xxxxx X. Lower, II
Secretary Chief Executive Officer
Glenbrook Life and Annuity Company
(herein called "we" or "us")
Amendatory Endorsement for Accelerated Death Benefit Rider
IF AN ACCELERATED PAYMENT IS MADE BY US, THE SPECIFIED AMOUNT, DEATH BENEFIT,
BENEFIT AMOUNT, ACCOUNT VALUE, OR OUTSTANDING LOANS, IF APPLICABLE, WILL BE
REDUCED ON A PRO RATA BASIS FOR YOUR CONTRACT. A QUALIFIED TAX ADVISER SHOULD BE
CONSULTED BEFORE REQUESTING AN ACCELERATED DEATH BENEFIT PAYMENT.
Definitions
Accelerated Benefit - The amount of the specified amount or benefit amount
requested by the owner.
Net Accelerated Payment - The amount of the accelerated benefit which is paid to
the owner.
Insured - The insured or any additional insured rider under the contract.
Owner - The owner of the contract. The owner is referred to as 'you'.
Contract - The contract to which this rider is attached.
Terminally Ill - An illness or physical condition of the insured or any
additional insured rider that, notwithstanding appropriate medical care, will
result in a life expectancy of 12 months or less.
Effective Date If the insured is terminally ill as a result of an illness, a
payment under this rider is not available unless the illness occurred at least
30 days after the date coverage begins under the contract. If the insured is
terminally ill as a result of an accident, a payment under this rider is
available if the accident occurred after coverage under the contract began.
General This rider provides for an accelerated payment of a portion of the
specified amount available under the contract and a portion of the benefit
amounts available under the primary insured term rider and the additional
insured rider. After a payment has been made, the specified amount, the death
benefit, benefit amount, account value, and any policy loan will be reduced on a
pro rata basis. We will mail you an endorsement to your contract which reflects
the new values. The availability of this benefit is not meant to provide
involuntary access to proceeds which are ultimately payable to the beneficiary.
We will pay you the benefits due under this rider upon receipt of a written
request from you and due proof that the insured has been diagnosed as terminally
ill. Due proof includes, but is not limited to, a statement signed by a licensed
physician that the insured has been diagnosed as terminally ill.
We reserve the following rights:
1. To require, at our expense, an exam by a physician of our choice
in order to confirm that the insured is terminally ill; and
2. To request documents which support the terminally ill diagnosis from
the insured's attending physician. These documents include, but are not
limited to, clinical, radiological, histological and/or laboratory
evidence.
Accelerated Benefit Payment The maximum amount which you may accelerate is the
lesser of:
* 50% of the specified amount available under the contract and 50% of the
benefit amount available under the riders in force on the day we
receive your acceleration request; and
* $250,000 for all policies issued by us which cover the insured.
You must request an amount of at least $10,000. Only one acceleration for each
insured will be allowed. If the insured dies before the payment is made, the
death benefit payable under the contract will be paid to the beneficiary.
Net Accelerated Payment The amount of the actual payment to the owner is called
the net accelerated payment. The amount of this payment will be calculated as of
the day the written request for acceleration was received by us.
The amount of specified amount or benefit amount which you request to accelerate
will be reduced by:
* a 12 month interest discount which reflects the early payment of
amounts held under the contract,
* an administrative fee up to $250; and
* a pro rata amount of any outstanding loan and accrued loan interest.
The interest discount used to calculate the payment will be based on the greater
of:
* the current yield on 90 day treasury bills; or
* the current maximum statutory adjustable policy loan interest rate.
A detailed statement which describes the method we use to determine the net
accelerated payment has been filed with the Insurance Department of the state in
which this rider has been issued. You may request a copy of this statement from
us.
Irrevocable Beneficiaries Each irrevocable beneficiary must sign a written
consent to the payment of an accelerated benefit before such payments may be
made to the owner of the contract. The written consent must be received at our
home office in a form acceptable to us on the date the benefit is requested.
Termination This rider will terminate on the earliest of the following dates:
* the date that the net accelerated payment has been paid; * the date the
contract terminates; or * the date we receive a written request from you to
terminate this rider.
Misstatement of Age or Sex If the insureds age or sex shown on the application
is wrong, the net accelerated payment we pay will be based on the amount of
coverage which the initial target premium paid would have purchased at the
correct age and sex.
Incontestability We may not contest this rider once it has been in force while
the insured is alive for two years from the contract date, except for payments
due but not made.
Suicide Exclusion We reserve the right to request that the owner return the
difference between the net accelerated payment and the payments made for
coverage under the contract if the insured dies from suicide while sane or
self-destruction while insane within two years of contract date and the amount
of the net accelerated payment was greater than the payments made for coverage
under the contract.
/s/Xxxxxxx X. Xxxxxxx /s/Xxxxx X. Lower, II
Xxxxxxx X. Xxxxxxx Xxxxx X. Lower, II
Secretary Chief Executive Officer
Glenbrook Life and Annuity Company
(herein called "we" or "us")
Amendatory Endorsement for Accidental Death Benefit Rider
General The "contract" is the contract to which this rider is attached. The
owner of the contract is called "you". This rider is part of your contract and
will stay in force while the contract remains in force or until the coverage
expiration date of this rider.
If all named owners and contingent owners have died or if there is no owner
named, the owner of this rider is the insured, if living. Write to us if you
wish to discontinue this rider.
Age The insured's age at their last birthday.
Coverage Expiration Date Except as defined in this rider, coverage under this
rider will expire on the earliest of the following dates:
* the date the contract expires;
* the date we receive written notice from you that you do not want
this rider to stay in force; or
* the contract anniversary on which the insured's age is 65.
The Benefit As shown on page 3 of the contract, we will pay the amount of
benefit in force to the beneficiary if you provide us due proof that:
* the insured died solely from accidental injury; * death took place within 90
days from the date of this injury; * death took place prior to the contract
anniversary on which the insured's age is 65; and * the cause of death is not
described in the Risks Not Covered provision of this rider.
Where allowed by law, we may have an autopsy performed at our own expense before
we make a payment.
Risks Not Covered We will not pay if death was caused by:
* suicide while sane or self-destruction while insane;
* disease, infirmity of the body or mind, or treatment for any of these;
* voluntarily:
- taking a drug, unless ordered by a qualified doctor; - taking a
poison; or - inhaling a gas, unless in the course of employment;
* committing or attempting to commit an assault or felony;
* being in or falling from an air craft or space craft. This does not
apply if the insured was riding as a passenger in an air craft or space
craft being used:
- commercially to transport passengers for hire; or
- by a private business or government to transport its personnel or
guests; or
* war or any act of war.
"Passenger" excludes one who receives training or has a duty on an air craft or
space craft even if the training or duty does not relate to the trip. "War"
means armed aggression by one or more countries which is opposed on the orders
of any other country, group of countries, or international body. "Act of War"
means any act peculiar to armed forces' actions in time of war.
Reinstatement We will reinstate this rider if it has stopped and you meet the
requirements of the reinstatement provision of the contract.
Misstatement of Age or Sex If the age or sex of the insured has been misstated,
the benefit will be adjusted to the amount which your intitial target premium
would have purchased at insured's correct age and sex.
Incontestability We may not contest this benefit after it has been in force
during the lifetime of the insured for two years from the contract date, except
for payments due but not made.
/s/Xxxxxxx X. Xxxxxxx /s/Xxxxx X. Lower, II
Xxxxxxx X. Xxxxxxx Xxxxx X. Lower, II
Secretary Chief Executive Officer
Glenbrook Life and Annuity Company
(herein called "we" or "us")
Amendatory Endorsement for Additional Insured Rider
General The "contract" is the contract to which this rider is attached. The
"insured" referred to in this rider is the additional insured(s) named in the
contract. The owner of the contract is called "you". This rider is part of your
contract and will stay in force while the contract remains in force or until the
coverage expiration date of this rider.
Write to us if you wish to discontinue this rider.
Age The insured's age at their last birthday.
Coverage Expiration Date Except as defined in this rider, coverage under this
rider will expire on the earliest of the following dates:
* the date the contract expires;
* the date we receive written notice from you that you do not want this
rider to stay in force; or
* the date you buy a new contract to replace it as described in the
conversion privilege provision of this rider.
Monthly Cost of Insurance While this rider remains in force, the monthly cost of
insurance for this rider is deducted on the monthly activity date. This
deduction is taken from the contract value of the contract and is determined as
follows:
* multiply the number of thousands of benefit in force by the monthly
cost of insurance rate per $1,000, based on the insured's attained age,
sex, and rating class. Any increases in the cost of insurance rates for
special class risks are shown on page 3 of the contract or on an
endorsement to page 3; and
* add any extra monthly charges per $1,000 of coverage. These charges
are shown on page 3 of the contract or on an endorsement to page 3.
The guaranteed maximum monthly cost of insurance rates are shown on pages 3 of
the contract. We may use cost of insurance rates lower than the guaranteed rates
to calculate contract values.
The Benefit As shown on page 3 of the contract, we will pay the amount of
benefit in force to the beneficiary if you provide us due proof that the insured
died on or prior to the coverage expiration date of this rider.
Change of Benefit Amount At anytime after the first contract year, you may
request an increase or decrease in the benefit amount. A request to change your
benefit amount will take effect on the next valuation date following the date we
approve the request.
A request to decrease your benefit amount will first be applied against the most
recent increase amount, if any, then successively to each prior increase, and
then to the initial benefit amount. The benefit amount in force after any
decrease may not be less than the minimum we have established. A request to
increase your benefit amount will require a new application and evidence of
insurability.
We will provide to you an endorsement showing the start date of any increase or
decrease and the new benefit amount. For increases in the benefit amount, we
will also provide a table of surrender charges based on the increased benefit
amount and new target premium. We reserve the right to limit the amount and
frequency of any increases or decreases in benefit amount.
The monthly cost of insurance rates applying to the increased amount are based
on the rating class shown or an endorsement to page 3.
Conversion Privilege While this rider is in force, you may buy a new contract on
the life of the insured. To get a new contract on the insured, you must provide
us with a written application and pay the required premium for the new contract
within 31 days from the date of your request. The new contract will start on the
first day past the date the benefit amount on the insured expires. This date is
called the "new contract date". The premiums due on the new contract will be
based on the insured age and sex on the new contract date, the same risk
characteristics as this rider, and the rates in effect for the new contract at
that time. The new contract must:
* have cash values;
* be available on the new contract date for the amount chosen and for
the same risk characteristics as this rider;
* have a death benefit at least as large as the minimum we establish, but
not more than the benefit amount in force under this rider.
The new contract will be the same as other like contracts also starting on the
new contract date except that the provisions on incontestability and suicide
exclusion will be measured from the contract date of this rider, and the rating
class for the insured on the new contract will have the same risk
characteristics as this rider.
We will not ask for proof that the insured is insurable for the death benefit of
the new contract. If an additional benefit is requested, it will not start until
we give our approval. If the insured is not insurable for the additional
benefits, we will start a new contract without the additional benefits.
While this rider is in force, we will pay a death benefit equal to the amount we
would have paid under this rider if the insured dies within 31 days from the
date the insured's benefit expires, and the insured has not used this conversion
privilege.
Reinstatement We will reinstate this rider if it has stopped and you meet the
requirements of the reinstatement provision of the contract.
Misstatement of Age or Sex If the age or sex of the insured has been misstated,
the benefit will be adjusted to the amount which the most recent monthly cost of
insurance deduction would have purchased at the correct age and sex.
Incontestability Except for increases in the amount of benefit, we may not
contest this benefit after it has been in force during the lifetime of the
insured for two years from the contract date, except for payments due but not
made. We may not contest any increase in the benefit amount once it has been in
force during the lifetime of the insured for two years from the start date of
the increase.
Suicide Exclusion If the insured dies by suicide while sane or self-destruction
while insane within two years from the contract date, our liability will be
limited to an amount equal to the monthly deductions taken for this rider and
this rider will terminate. If the insured dies by suicide while sane or
self-destruction while insane within two years of the effective date of any
increase in benefit amount, our liability with respect to the increase will be
limited to the monthly deductions taken for the increase and this rider will
terminate.
/s/Xxxxxxx X. Vellota /s/Xxxxx X. Lower, II
Xxxxxxx X. Xxxxxxx Xxxxx X. Lower, II
Secretary Chief Executive Officer
Glenbrook Life and Annuity Company
(herein called "we" or "us")
Amendatory Endorsement for Children's Level Term Rider
General The "contract" is the contract to which this rider is attached. The
owner of the contract is called "you". This rider is part of your contract and
will stay in force while the contract remains in force or until the coverage
expiration date of this rider.
If all named owners and contingent owners have died or if there is no owner
named, the owner of this rider is the insured, if living, or children who are
living after the death of the insured.
Write to us if you wish to discontinue this rider.
Age The insured's age and each insured child's age at their last birthday.
Coverage Expiration Date Except as defined in this rider, coverage under this
rider will expire on the earliest of the following dates:
* the date the contract expires;
* the date we receive written notice from you that you do not want
this rider to stay in force; or
* the contract anniversary on which the insured's age is 65.
Definition of Insured and Child The "insured" is the individual covered under
the terms of the contract. "Child" means each child, stepchild, or child adopted
by law who is:
* named in the application and accepted by us;
* born to the insured after the contract date of this rider; or
* adopted by law by the insured:
- after the contract date of this rider; and
- prior to the child reaching age 18.
A child who is less than 15 days old, or never leaves the hospital due to
disability or death, will not be insured.
The Benefit As shown on page 3, we will pay the amount of benefit in force to
the payee for each child insured under this rider. We will pay the benefit to
the payee if you give us due proof that the child died on or prior to the
earlier of:
* the contract anniversary on which the child's age is 25; or
* the coverage expiration date of this rider.
Change of Benefit Amount A decrease of the benefit amount will take effect on
the monthly activity day on or following the date we receive the request. The
number of units remaining in force after any decrease cannot be less than the
minimum we establish.
Paid-Up Benefit Each child will have paid-up term insurance if the insured dies
while this rider is in force, all due premium payments have been made, and the
death of the insured was not caused by suicide while sane or self-destruction
while insane within two years from the contract date of this rider. The paid-up
benefit amount will be the amount of benefit in force at the time of the
insured's death. The paid-up term insurance will expire on each child at the
earlier of:
* the contract anniversary on which the child's age is 25; or
* the contract anniversary on which the insured's age would have been 65.
Beneficiary The beneficiary is called the "payee". The death proceeds of this
rider are paid to the payee. Unless changed by the owner, the payee is the
owner, if living. If the owner is deceased, the payee is the insured, if living,
or the children who are living after the death of the insured. The payee for the
benefits of this rider need not be the same as for the other benefits of the
contract.
Conversion Privilege While this rider is in force, you may buy a new contract
on the life of each
child insured under this rider when the rider expires, or a child may buy a new
contract on their own life when their coverage expires on the contract
anniversary on which the child's age is 25.
To get a new contract on a child, you must provide us with a written application
and pay the required premium for the new contract within 31 days from the date
the child's benefit expires. The new contract will start on the first day past
the date the death benefit on the child expires. This date is called the "new
contract date". The premiums due on the new contract will be based on the
child's age and sex on the new contract date, the same risk characteristics as
this rider, and the rates in effect for the new contract at that time. The new
contract must:
* have cash values;
* be available on the new contract date for the amount chosen and for
the same risk characteristics as this rider;
* have a death benefit not exceeding $5,000 for each $1,000 of death
benefit expiring on the child; and
* have a death benefit at least as large as the minimum we establish.
The new contract will be the same as other like contracts also starting on the
new contract date except that the provisions on incontestability and suicide
exclusion will be measured from the contract date of this rider, and the rating
class for each child on the new contract will have the same risk characteristics
as this rider.
We will not ask for proof that a child is insurable for the death benefit of the
new contract. If an additional benefit is requested, it will not start until we
give our approval. If the child is not insurable for the additional benefits, we
will start a new contract without the additional benefits.
While this rider is in force, we will pay a death benefit equal to the amount we
would have paid under this rider if a child dies within 31 days from the date
the child's benefit expires, and the child has not used this conversion
privilege.
Reinstatement We will reinstate this rider if it has stopped and you meet the
requirements of the reinstatement provision of the contract and give us due
proof that all children insured under this rider are still insurable.
Misstatement of Age or Sex If the age or sex of the insured or any insured child
has been misstated, the benefit will be adjusted to take into account the
insured's correct age and sex. The child's insurance will then expire on the
earlier of the contract anniversary on which the child's correct age is 25, or
on which the insured's correct age is 65.
Incontestability We may not contest this benefit on a child after it has been in
force during the lifetime of the insured for two years from its contract date,
except for payments due but not made.
Suicide Exclusion If the insured dies by suicide while sane or self-destruction
while insane within two years from the contract date of this rider, each child
may choose to buy a new contract on their own life. The death benefit of each
new contract will be equal to the death benefit expiring on each child's life.
The provisions of and premiums for each new contract will be the same as those
described in the conversion privilege provision of this rider. The new contract
date will be the date each application is signed.
Each child choosing to buy a new contract must write to us within 60 days of the
date of the insured's death. If no one writes to us within 60 days after the
insured's death, we will only pay a refund of the premiums made for this rider
and this rider will terminate on the date of the insured's death.
/s/Xxxxxxx X. Xxxxxxx /s/Xxxxx X. Lower, II
Xxxxxxx X. Xxxxxxx Xxxxx X. Lower, II
Secretary Chief Executive Officer
