EXHIBIT 99.1(5)(a)
Policy - Form 97-56
[LETTERHEAD OF PACIFIC MUTUAL LIFE INSURANCE COMPANY]
LAST SURVIVOR
FLEXIBLE PREMIUM
VARIABLE LIFE INSURANCE POLICY
- BENEFITS WILL VARY BASED ON INVESTMENT EXPERIENCE
- FACE AMOUNT CAN BE DECREASED
READ YOUR POLICY CAREFULLY. This is a legal contract between you, the Owner,
and us, Pacific Mutual Life Insurance Company, a mutual company.
We agree to pay the benefits of this policy according to its provisions.
The consideration for this policy is the application for it, a copy of which is
attached, and payment of the premiums.
VARIABLE ACCOUNT CASH SURRENDER VALUES MAY INCREASE OR DECREASE DEPENDING UPON
VARIABLE ACCOUNT INVESTMENT EXPERIENCE, SUBJECT TO ANY MINIMUM GUARANTEES.
THERE IS NO GUARANTEED VARIABLE ACCOUNT CASH SURRENDER VALUE.
THE AMOUNT OR DURATION OF THE DEATH BENEFIT MAY BE VARIABLE OR FIXED DEPENDING
UPON VARIABLE ACCOUNT INVESTMENT EXPERIENCE. THE AMOUNT OF THE DEATH BENEFIT
WILL NEVER BE LESS THAN THE FACE AMOUNT AS LONG AS YOUR POLICY IS IN FORCE. SEE
THE DEATH BENEFITS OPTIONS PROVISION FOR DETAILS.
POLICY LOAN VALUE IS LESS THAN ONE HUNDRED PERCENT (100%) OF THE POLICY'S CASH
SURRENDER VALUE.
FREE LOOK RIGHT - YOU MAY RETURN THIS POLICY WITHIN (1) 10 DAYS AFTER YOU
RECEIVE IT, (2) 10 DAYS AFTER WE MAIL OR DELIVER A NOTICE OF THE RIGHT OF
WITHDRAWAL, OR (3) 45 DAYS AFTER YOU SIGN THE APPLICATION, WHICHEVER IS LATER.
TO DO SO, DELIVER OR MAIL IT TO US OR OUR AGENT. THIS POLICY WILL THEN BE
DEEMED VOID FROM THE BEGINNING AND WE WILL REFUND THE PREMIUMS PAID.
Signed at our Home Office, 000 Xxxxxxx Xxxxxx Xxxxx, Xxxxxxx Xxxxx, Xxxxxxxxxx
00000.
/s/ XX Xxxxxx
Chairman and Chief Executive Officer
/s/ Xxxxxx X. Xxxxx
Secretary
Form 97-56
POLICY SPECIFICATIONS
BASIC POLICY: LAST SURVIVOR FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE
PREMIUMS: PLANNED PERIODIC PREMIUM PAYMENT = $ 700.00
GUIDELINE SINGLE PREMIUM = $ 9,771.18
GUIDELINE LEVEL PREMIUM = $ 943.00
DEATH BENEFIT OPTION: D
ACCOUNT ALLOCATIONS AVAILABLE:
FIXED EQUITY INCOME MONEY MARKET
GROWTH EQUITY INDEX MULTI-STRATEGY
GROWTH LT MANAGED BOND GOVERNMENT
SECURITIES INTERNATIONAL HIGH YIELD BOND
AGGRESSIVE EQUITY EMERGING MARKETS VAR AC I-O'SEAS EQY
VAR XX XX-CORE GRW VAR AC III-CAP APPR VAR XX XX- ENHNC EQY
BOND & INCOME EQUITY
INTEREST ON THE FIXED ACCOUNT IS GUARANTEED TO BE NOT LESS THAN 4.00% ANNUALLY.
IN ADDITION, ANY EXCESS INTEREST DECLARED BY US WILL BE GUARANTEED FOR ONE YEAR.
POLICY NUMBER: 1234567-0 INSURED #1: XXXXXX XXXXXXXX
POLICY DATE: MAR. 1, 1997 RISK CLASSIFICATION: MALE/NONSMOKER
INITIAL FACE AMOUNT: $100,000 AGE ON POLICY DATE: 35
INSURED #2: XXXX XXXXXXXX
OWNER(S): XXXXXX XXXXXXXX RISK CLASSIFICATION: FEMALE/NONSMOKER
AGE ON POLICY DATE: 35
MONTHLY PAYMENT DATE IS THE 1ST DAY OF EACH POLICY MONTH.
NOTE: IT IS POSSIBLE THAT COVERAGE WILL EXPIRE IF THE ACCUMULATED VALUE IS
INSUFFICIENT TO PAY THE CHARGES ASSESSED ON A MONTHLY PAYMENT DATE. ACCUMULATED
VALUE MAY BE BASED ON THE INVESTMENT RESULTS OF THE SEPARATE ACCOUNT. THE
PAYMENT OF INITIAL AND SUBSEQUENT PREMIUMS WILL NOT GUARANTEE THAT THE POLICY
WILL REMAIN IN FORCE OR THAT THERE WILL BE ANY ACCUMULATED VALUE.
PAGE 3.0
POLICY SPECIFICATIONS 1234567-0
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SUMMARY OF COVERAGES EFFECTIVE ON THE POLICY DATE
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97-56: BASIC COVERAGE FACE AMOUNT: $100,000
INSURED #1: XXXXXX XXXXXXXX
AGE AT ISSUE: 35
RISK CLASSIFICATION: MALE/NONSMOKER
INSURED #2: XXXX XXXXXXXX
AGE AT ISSUE: 35
RISK CLASSIFICATION: FEMALE/NONSMOKER
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PAGE 3.1
POLICY SPECIFICATIONS 1234567-0
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PREMIUM A 6% SALES LOAD OF PREMIUMS PAID IN THE FIRST TEN
LOAD: POLICY YEARS; 4% SALES LOAD OF PREMIUMS PAID
THEREAFTER; A LOAD OF 2.35% FOR PREMIUM TAXES; AND
1.50% FEDERAL TAX.
ADMINISTRATIVE $16 PER MONTH FOR THE FIRST FIVE POLICY YEARS; AND A
CHARGE: MONTHLY CHARGE NOT EXCEEDING $6.00 PER MONTH
THEREAFTER. THE MONTHLY CHARGE WILL BE ZERO AFTER THE
YOUNGEST INSURED REACHES AGE 100.
MORTALITY AND EXPENSE M&E RATE OF $0.0680 PER MONTH PER $1000 OF BASE FACE
RISK CHARGE RATE: AMOUNT FOR POLICY YEARS 1 THROUGH 10; AND ZERO
THEREAFTER. REFER TO CONTRACT FOR DETAILS.
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PAGE 3.2
POLICY SPECIFICATIONS 1234567-0
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SUMMARY OF COVERAGES EFFECTIVE ON THE POLICY DATE
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DEATH BENEFIT OPTION D FACTOR TABLE
BASIC COVERAGE AMOUNT: $100,000
POLICY POLICY
YEAR FACTOR YEAR FACTOR
----------------------------------------------------------------------------
1 1.000 40 1.400
2 1.000 41 1.457
3 1.000 42 1.515
4 1.000 43 1.575
5 1.000 44 1.634
6 1.000 45 1.692
7 1.001 46 1.748
8 1.001 47 1.859
9 1.001 48 1.911
10 1.002 49 1.954
11 1.002 50 1.985
12 1.003 51 2.000
13 1.004 52 2.000
14 1.005 53 2.000
15 1.006 54 2.000
16 1.007 55 2.000
17 1.009 56 2.000
18 1.011 57 2.000
19 1.013 58 2.000
20 1.016 59 2.000
21 1.019 60 2.000
22 1.023 61 2.000
23 1.028 62 2.000
24 1.033 63 2.000
25 1.039 64 2.000
26 1.047 65 2.000
27 1.055 66 2.000
28 1.065 67 2.000
29 1.077 68 2.000
30 1.091 69 2.000
31 1.107 70 2.000
32 1.126 71 2.000
33 1.147 72 2.000
34 1.170 73 2.000
35 1.197 74 2.000
36 1.227 75+ 2.000
37 1.262
38 1.302
39 1.349
PAGE 3.3
POLICY SPECIFICATIONS 1234567-0
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TABLE OF COST OF INSURANCE RATES
GUARANTEED MAXIMUM MONTHLY COST OF INSURANCE RATES PER $1.00 APPLICABLE TO BASE
POLICY COVERING BOTH LIVES.
POLICY MONTHLY POLICY MONTHLY
YEAR RATE YEAR RATE
--------------------------------------------------------------------------------
1 0.000000290 40 0.002063462
2 0.000000944 41 0.002423129
3 0.000001736 42 0.002831915
4 0.000002702 43 0.003287321
5 0.000003901 44 0.003789064
6 0.000005374 45 0.004347886
7 0.000007195 46 0.004982904
8 0.000009368 47 0.005713893
9 0.000011950 48 0.006564256
10 0.000014983 49 0.007551414
11 0.000018582 50 0.008666558
12 0.000022724 51 0.009899061
13 0.000027539 52 0.011236925
14 0.000033158 53 0.012673018
15 0.000039747 54 0.014204253
16 0.000047418 55 0.015836039
17 0.000056509 56 0.017584466
18 0.000067271 57 0.019479708
19 0.000080192 58 0.021582828
20 0.000095324 59 0.024008714
21 0.000112789 60 0.027064052
22 0.000132781 61 0.031418251
23 0.000155055 62 0.038575290
24 0.000179900 63 0.052307245
25 0.000208066 64 0.083333333
26 0.000240634 65 0.083333333
27 0.000279239 66+ 0.000000000
28 0.000325726
29 0.000382564
30 0.000450330
31 0.000529315
32 0.000619341
33 0.000720320
34 0.000831851
35 0.000958197
36 0.001105412
37 0.001280881
38 0.001494129
39 0.001753794
PAGE 4.0
DEFINITIONS
COMPANY or PM or WE or US --- refers to Pacific Mutual Life Insurance Company.
MONTHLY PAYMENT DATE --- is the day each month on which certain policy charges
are deducted from the Accumulated Value. This day is shown on page 3. The first
monthly payment date is the Policy Date.
HOME OFFICE --- means the Company's office located at 000 Xxxxxxx Xxxxxx Xxxxx,
Xxxxxxx Xxxxx, Xxxxxxxxxx 00000.
YOU, YOUR or OWNER --- refers to the owner(s) of this policy as specified in the
application unless changed as provided for in the policy.
POLICY DATE --- is shown on page 3. Policy months, years and anniversaries are
measured from this date.
AGE --- generally means age nearest birthday as of the policy date, increased by
the number of complete policy years elapsed.
EFFECTIVE DATE --- is the date revised coverage begins after a change in the
Face Amount of the base policy or any rider, a change in the target amount of
any benefit, or addition of riders or benefits after the policy date.
EVIDENCE OF INSURABILITY --- is information, including medical information,
satisfactory to the company that is used to determine each insured's risk
classification.
DEBT --- means all unpaid policy loans plus accrued interest on such loans.
FACE AMOUNT --- is the amount used to determine the policy's death benefit. The
initial Face Amount is shown on page 3.
SURVIVOR --- is the insured remaining alive after the first death of the two
insureds that occurs while this policy is in force.
WRITTEN REQUEST --- is a request in writing signed by you that is satisfactory
to PM and filed at its Home Office.
SEPARATE ACCOUNT --- refers to the Pacific Select Exec Separate Account which is
a separate account of PM that consists of subaccounts, which may be referred to
as Variable Accounts. Each Variable Account may invest its assets in a separate
class of shares of a designated investment company or companies.
VARIABLE ACCOUNT --- A separate account of PM or a subaccount of a PM separate
account in which assets of PM are segregated from its assets in PM's general
account and other separate accounts and to which premiums and Accumulated Value
under this policy may be allocated for variable accumulation.
OWNER AND BENEFICIARY
OWNER --- The owner of this policy is shown on the policy specifications pages.
A change of owner may be made by written request on forms provided by PM. A
change of owner will take place only when recorded at our Home Office. When
recorded, such change will take effect as of the date the written request was
signed. If there are two or more owners, they will own this policy as joint
tenants with right of survivorship unless otherwise stated.
ASSIGNMENT --- This policy may be assigned at any time. PM is not bound by any
assignment unless it is in writing and recorded at our Home Office. We are not
responsible for the validity of any assignment.
BENEFICIARY --- The beneficiary is named by you in the application to receive
the death benefit proceeds. The payment of the death benefit proceeds to any
beneficiary will be subject to any assignment.
A change of beneficiary may be made by written request on forms provided by PM
while either insured is living. The change will take place as of the date the
request is signed.
The interest of a beneficiary who does not survive to receive payment will pass
to the surviving beneficiaries in proportion to their share in the proceeds,
unless otherwise provided. If no beneficiaries survive to receive payment, the
death benefit proceeds will pass to the owner, or the owner's estate if the
owner does not survive to receive payment.
PREMIUMS
PREMIUMS --- This policy will not be in force before the initial premium is
paid. No premium may be less than $50. Premiums may be paid at any time
subject to the limitations described in the Premium Limitation provision.
Premiums are payable either at our Home Office or to an agent of the Company.
Upon written request, we will give you a premium receipt signed by a Company
officer.
Page 5
PREMIUM ALLOCATION --- The initial premium, less the Premium Load, will be
allocated to the Fixed and Variable Accounts according to the premium allocation
specified in the application or your most recent instructions received by us, if
any.
Upon written request, you may change the premium allocation. Subsequent
premiums received by us, less the Premium Load, will be allocated to the Fixed
and Variable Accounts according to your most recent instructions.
PREMIUM LIMITATION --- We reserve the right to require evidence of insurability,
satisfactory to us, for any premium payment that would result in an immediate
increase in the difference between the death benefit and the Accumulated Value.
No premium payment will be accepted after the youngest insured reaches age 100.
In order for this policy to be treated as life insurance under the Internal
Revenue Code, the sum of the premiums paid less a portion of any Withdrawals as
defined in the Internal Revenue Code may not exceed the greater of:
--- the Guideline Single Premium; or
--- the sum of the Guideline Level Premiums to the date of payment.
The amounts of the Guideline Premiums are shown on the policy specifications
pages. The Guideline Premiums will change whenever there is a change in the Face
Amount of insurance or in other policy benefits. Such Guideline Premium changes
will be shown in a supplemental schedule of benefits and premiums that we will
send to you.
The Guideline Premiums are determined according to the rules applicable to this
policy set forth in the Internal Revenue Code. The Guideline Premiums will be
adjusted to conform to any changes in the Internal Revenue Code.
In the event that a premium payment would exceed the Guideline Premium limits,
we reserve the right to refund the excess payment to the owner. Further, we
reserve the right to make distributions from the policy to the extent we deem
it necessary to continue to qualify this policy as life insurance under the
Internal Revenue Code.
In order for this policy to avoid being treated as a Modified Endowment Contract
(MEC), the sum of premiums paid less a portion of any Withdrawals may not exceed
the 7-Pay limit as defined in the Internal Revenue Code. In the event that a
premium payment would exceed the 7-Pay limit, we reserve the right to refund the
excess payment to the owner, unless the owner has previously notified us in
writing that payments that cause this policy to become a MEC may be accepted by
us and applied to the policy.
GRACE PERIOD AND LAPSE --- If the Accumulated Value less debt on a monthly
payment date is not sufficient to cover the current monthly deduction, a grace
period of 61 days will be allowed for the payment of sufficient premium to keep
your policy in force.
We will send a notice at the start of the grace period to you at your last known
address and to any assignee of record. The grace period will end 61 days after
we mail you the notice. The notice will state the due date and the amount of
premium required to keep your policy in force. A minimum of three times the
monthly deduction due when the insufficiency occurred must be paid. Upon receipt
of payment, we will allocate the premium payment, less the Premium Load, to the
Variable Accounts and Fixed Account according to your most recent premium
allocation instructions. Your policy will remain in force during the grace
period. If sufficient premium is not paid by the end of the grace period, a
lapse will occur. We will send you and any assignee of record, a written notice
30 days prior to lapse. Upon lapse, the policy will terminate with no value.
REINSTATEMENT --- If it has not been surrendered, this policy may be reinstated
not more than five years after the end of the grace period. To reinstate this
policy you must provide us with:
--- a written application;
--- evidence of insurability satisfactory to us for each insured living as of
the beginning of the grace period;
--- payment of sufficient premium to cover all monthly deductions that were
due and unpaid during the grace period; plus
--- payment of sufficient premium to keep the policy in force for three
months after the date of reinstatement.
When this policy is reinstated, the Accumulated Value will be equal to the
Accumulated Value on the date of lapse subject to the following. We will
allocate the Accumulated Value and your premium payment, less the Premium Load,
to the Fixed and Variable Accounts according to your most recent premium
allocation instructions.
Page 6
If the policy is reinstated after the first monthly payment date following
lapse, the Accumulated Value will be reduced by the amount of any debt on the
date of lapse and no policy debt will exist on the date of reinstatement. If
the policy is reinstated on the first monthly payment date following lapse, any
debt on the date of lapse will also be reinstated, with the corresponding
portion of the Accumulated Value allocated to the Loan Account as described in
the Policy Loans provision.
The effective date of the reinstated policy will be the first monthly payment
date on or following the date we approve your reinstatement application.
POLICY BENEFITS
DEATH BENEFIT OPTIONS --- The death benefit for this policy will be one of the
following:
OPTION A --- The death benefit is the greater of:
--- the Face Amount; or
--- the Guideline Minimum Death Benefit.
OPTION B --- The death benefit is the greater of:
--- the Face Amount plus the Accumulated Value on the date of death; or
--- the Guideline Minimum Death Benefit.
OPTION C --- The death benefit is the greater of:
--- the Face Amount plus the sum of the premiums paid to the date of death
minus the sum of any partial withdrawals taken and any other distribution of
the Accumulated Value to the date of death; or
--- the Guideline Minimum Death Benefit.
OPTION D --- The death benefit is the greater of:
--- the Face Amount times the death benefit factor for the current policy
year as shown on the policy specifications pages; or
--- the Guideline Minimum Death Benefit.
The owner elects the Death Benefit Option in the application. If no option is
elected, Option A is the automatic option. The original election of the Death
Benefit Option may not be changed until after completion of the fifth policy
year. Thereafter, the Death Benefit Option may be changed to Option A or B upon
written request at a maximum of once per policy year. Changes to Option C or D
will not be permitted. After any such change, the Face Amount will be that
amount which results in the death benefit after the change being equal to the
death benefit before the change. The change will be effective on the monthly
payment date on or next following the day the written request is received by us
at PM's Home Office.
Unless specified otherwise by you in writing, any request for a death benefit
option change will not be processed if the option change would cause the policy
to be treated as a MEC.
THE GUIDELINE MINIMUM DEATH BENEFIT at any time is the Accumulated Value
multiplied by the Death Benefit Percentage shown below:
Death Benefit Death Benefit
Age Percentage Age Percentage
0-40 250% 60 130%
41 243 61 128
42 236 62 126
43 229 63 124
44 222 64 122
45 215 65 120
46 209 66 119
47 203 67 118
48 197 68 117
49 191 69 116
50 185 70 115
51 178 71 113
52 171 72 111
53 164 73 109
54 157 74 107
55 150 75-90 105
56 146 91 104
57 142 92 103
58 138 93 102
59 134 >93 101
The age is the age of the younger insured at issue, increased by the number of
complete policy years elapsed.
PM reserves the right to reduce the Guideline Minimum Death Benefit by requiring
partial withdrawals be made in order to maintain the net amount at risk at a
level that will not exceed three times the Death Benefit on the Policy Date.
The net amount at risk is the difference between the Death Benefit and the
Accumulated Value.
This policy is intended to qualify as a life insurance contract under the
Internal Revenue Code for Federal tax purposes, and the death benefit under this
policy is intended to qualify for the income tax exclusion under the Internal
Revenue Code. To that end, the provisions of this policy, including any other
rider, benefit, or endorsement, are to be interpreted to ensure such tax
qualification, notwithstanding any other provisions to the contrary.
Page 7
If at any time the premiums paid under this policy exceed the amount allowable
for such tax qualification, such excess amount shall be removed from the policy
as of the date of its payment, and any appropriate adjustment in the death
benefit shall be made as of such date. This excess amount shall be refunded to
the Owner no later than 60 days after the end of the applicable contract year.
We shall adjust the excess amount refunded for interest from the date of its
payment or for changes in Accumulated Value attributable to the excess amount.
If the excess amount is not refunded by then, the death benefit under this
policy shall be increased retroactively and prospectively so that at no time is
this death benefit ever less than the amount needed to ensure such tax
qualification. To the extent that the death benefit as of any time is increased
by this provision, appropriate adjustments shall be made retroactively in any
cost of insurance or supplemental benefits as of that time that are consistent
with such an increase.
Unless specified otherwise by you in writing, it is intended that this policy
will not be treated as a Modified Endowment Contract (MEC) under the Internal
Revenue Code. To that end, the provisions of this policy, including any other
rider, benefit or endorsement, are to be interpreted to prevent the policy from
being subject to such treatment, notwithstanding any other provisions to the
contrary.
If at any time the premiums or other amounts paid under the policy exceed the
limit for avoiding such MEC treatment, unless otherwise specified in writing by
you that such MEC treatment is acceptable, such excess amount shall be removed
from the policy as of the date of its payment, and any appropriate adjustment in
the policy's death benefit shall be made as of such date. This excess amount
shall be refunded to the owner no later than 60 days after the end of the
applicable contract year. We shall adjust the excess amount refunded for
interest from the date of its payment or for changes in Accumulated Value
attributable to the excess amount. If this excess amount is not refunded by
then, the death benefit under the policy shall be increased retroactively and
prospectively to the minimum amount necessary (e.g., to the end of any test
period) so that at no time is this death benefit ever less than the amount
needed to avoid such MEC treatment. To the extent that the death benefit as of
any time is increased by this provision, appropriate adjustments shall be made,
retroactively or otherwise, in any cost of insurance or supplemental benefits as
of that time that are consistent with such an increase.
DEATH BENEFIT PROCEEDS --- When we receive proof that both insureds' deaths
occurred while this policy was in force, we will pay the death proceeds in
effect for this policy as of the date of the survivor's death. If both insureds
die either simultaneously or in circumstances where it is not clear which
insured died first, the older of the two insureds will be deemed to be the
survivor. Proof of death of each insured should be sent to the Home Office or
to an agent of the Company within 90 days of death.
We will pay the death benefit proceeds to the beneficiary. The death benefit
proceeds are equal to the death benefit provided by your policy, as of the date
of death, less any debt and less any due and unpaid monthly deductions occurring
during the grace period. The actual death benefit proceeds paid are subject to
the conditions and adjustments defined in other policy provisions, such as
General Provisions, Withdrawals and Policy Loans.
We will pay interest on death benefit proceeds from the date of the Survivor's
death to the date of payment at a rate not less than 4%, or if higher, the
interest rate required by the state in which this policy is issued.
DECREASE PROVISION --- Subject to PM's approval, the owner may decrease the
Face Amount of insurance if such request is made:
--- while either or both insureds are living;
--- after the first policy year;
--- no more often than once in any policy year; and
--- in writing while this policy is in force.
The effective date of the decreased Face Amount will be the first monthly
payment date on or following the date the written request is received by us.
A supplemental schedule of benefits and premiums will be issued. This schedule
will include the following information:
--- the effective date of the decreased Face Amount;
--- the amount of the decrease and the decreased Face Amount; and
--- the new Guideline Premiums.
Page 8
The request for a decrease in the face amount will be subject to the Guideline
Premiums Limitation as defined in the Internal Revenue Code. This may result in
a refund of premiums and/or the distribution of Accumulated Value in order to
maintain compliance with such limitations. Such request will not be allowed if
the resulting Guideline Premiums could cause an amount in excess of the Net Cash
Surrender Value to be distributed from the policy. The Face Amount of this
policy may not be decreased to less than our minimum issue limit in effect on
the date of the request.
Unless specified otherwise by you in writing, no request for a face amount
decrease will be processed if the decrease would cause the policy to be treated
as a MEC.
ACCUMULATED VALUE
ACCUMULATED VALUE --- The Accumulated Value on any date is the sum of your
policy's Accumulated Value in the Fixed and Variable Accounts, plus the amount
set aside in the Loan Account to secure any policy debt and any interest
credited thereon.
The amount set aside to secure debt in the Loan Account on each policy
anniversary is equal to the amount of debt. During each policy year, the amount
in the Loan Account on any date is:
--- the amount in the Loan Account on the prior anniversary increased by
interest;
--- plus any loan taken since the prior anniversary increased by interest;
and
--- minus any loan amount repaid since the prior anniversary increased by
interest.
FIXED ACCOUNT --- The Accumulated Value in the Fixed Account on any date is:
--- the Accumulated Value in the Fixed Account on the prior monthly payment
date increased by interest;
--- plus the amount of any premiums less Premium Load received and allocated
to the Fixed Account since the last monthly payment date, increased by
interest;
--- minus the monthly deduction and other deductions due, if any, and
assessed against the Fixed Account increased by interest;
--- minus the amount of any withdrawals, or transfers from the Fixed Account,
including transfers to the Loan Account, since the last monthly payment date,
increased by interest; and
--- plus the amount of any transfer to the Fixed Account, including transfers
from the Loan Account, since the last monthly payment date, increased by
interest.
VARIABLE ACCOUNTS --- Assets in the Variable Accounts are divided into
accumulation units, which are a measure of value used for bookkeeping purposes.
We credit your policy with accumulation units in each Variable Account as a
result of:
--- the amount of any premiums less Premium Load received and allocated to
the Variable Account; and
--- transfers of Accumulated Value to the Variable Account, including
transfers from the Loan Account.
We debit accumulation units in each Variable Account as a result of:
--- transfers from the Variable Account, including transfers to the Loan
Account;
--- withdrawals from the Variable Account; and
--- the monthly deduction and other deductions due, if any, and assessed
against the Variable Account.
To determine the number of accumulation units debited or credited in connection
with a transaction, we divide the dollar amount of the transaction by the unit
value of the affected Variable Account.
The unit value of each Variable Account is determined on each Valuation Date.
The number of units in each Variable Account will not change because of
subsequent changes in unit value.
To calculate the unit value of a Variable Account on any Valuation Date, we
adjust the unit value from the previous Valuation Date for:
--- the investment performance of the Variable Account;
--- any dividends or distributions paid to the Variable Account;
--- charges, if any, that may be assessed by us for income taxes attributable
to the operation of the Variable Account.
A Valuation Date is each day required by applicable law and currently includes
each day that both the New York Stock Exchange is open for trading and Pacific
Mutual's administrative offices are open. If any transaction or event is
scheduled to occur on a day that is not a Valuation Date, such transaction or
event will be deemed to occur on the next following Valuation Date unless
otherwise specified.
Page 9
To determine your Accumulated Value in each Variable Account, we multiply the
number of units in the Variable Account by the unit value of such account.
INTEREST --- We will credit interest on the Accumulated Value in the Fixed
Account at a rate not less than .32737% per month, compounded monthly. This is
equivalent to an annual effective rate of 4%. At our discretion, we may credit
a higher rate of interest periodically. We will credit interest on the amount
in the Loan Account at a rate of .32737% per month, compounded monthly. This is
equivalent to an annual effective rate of 4%.
On each policy anniversary, any interest earned and held in the Loan Account
will be transferred to the Fixed and Variable Accounts in accordance with your
most recent premium allocation instructions.
TRANSFERS --- While your policy is in force, you may, upon written request,
transfer your Accumulated Value, or a part of it, among the Fixed and Variable
Accounts subject to the following. No transfer may be made if the policy is in
a grace period and the required premium has not been paid. Only one transfer
from the Fixed Account may be made in any twelve month period.
Transfers from the Fixed Account to the Variable Accounts will be limited to the
greater of 25% of the Accumulated Value in the Fixed Account or $5,000 in any
year. Transfers from the Variable Accounts to the Fixed Account may be made
only during the policy month preceding each policy anniversary.
No charges are currently imposed upon a transfer. We reserve the right at a
future date to limit the size of transfers and remaining balances, to assess
transfer charges and to limit the number and frequency of transfers.
POLICY CHARGES
MONTHLY DEDUCTION --- A Monthly Deduction for a policy month is due on each
monthly payment date and is equal to the sum of the following items:
--- the monthly Cost of Insurance Charge;
--- the Administrative Charge;
--- the Mortality and Expense Risk Charge; and
--- the monthly charge of any riders or benefits.
The Monthly Deduction will be charged proportionately to the Accumulated Value
in each Variable Account and the Fixed Account on the monthly payment date.
COST OF INSURANCE CHARGE --- Beginning on the policy date and monthly
thereafter, there will be a charge equal to the Cost of Insurance applicable to
the policy face amount.
The monthly Cost of Insurance Charge for the death benefit payable under this
policy is determined as follows: (1) is multiplied by the result of (2) minus
(3), where:
--- (1) is the applicable monthly Cost of Insurance Rate;
--- (2) is the death benefit at the beginning of the policy month divided by
1.00327374; and
--- (3) is the Accumulated Value at the beginning of the policy month before
the Monthly Deduction due, including any interest credited to the Loan
Account.
COST OF INSURANCE RATES --- The Cost of Insurance Rates are based on the
policy's duration and on the two insureds' ages and risk classifications on the
policy date. The current monthly Cost of Insurance Rates will be determined by
us. These rates will not exceed the guaranteed maximum monthly Cost of Insurance
Rates shown on the policy specifications pages. Any changes in the Cost of
Insurance Rates will apply uniformly to all pairs of insureds of the same ages,
risk classifications and duration under this policy.
MORTALITY AND EXPENSE RISK CHARGE --- The Mortality and Expense Risk Charge is
to compensate us for the risk we assume that mortality and expenses will be
greater than estimated. The Mortality and Expense Risk Charge consists of the
following:
--- a maximum monthly charge of .00025 (.30% annually) in the first 20 policy
years; and .000083333 (.10% annually) thereafter, multiplied by the result of
the Accumulated Value in the Fixed and Variable Accounts at the beginning of
the policy month less the Cost of Insurance Charge and less the monthly
charge for any riders or benefits.
--- a monthly charge equal to the rates shown in the policy specifications
pages, multiplied by the Face Amount of the policy at issue.
ADMINISTRATIVE CHARGE --- Beginning on the policy date and monthly thereafter,
there will be an Administrative Charge against the Accumulated Value. The
amount of this charge will not exceed the amount shown on the policy
specifications pages. The monthly charge will be set to zero after the youngest
insured reaches age 100.
Page 10
If you already own a policy under PM form 97-56, we will waive the
Administrative Charges of this policy while Administrative Charges are being
paid under the other policy, if the insureds of both policies are the same.
However, we will deduct a charge of $200 from the initial premium of this
policy.
PREMIUM LOAD --- A Premium Load will be charged each time a premium is paid to
cover state premium tax, federal tax and contribute towards covering our sales
and distribution expenses. The Premium Load consists of the following:
--- a sales load equal to 6% in the first ten policy years and 4% thereafter;
--- a charge of 2.35% for state premium taxes; and
--- a charge of 1.50% for federal taxes.
The Premium Load associated with each premium will be immediately deducted from
the premium paid.
We reserve the right to increase the Premium Load with respect to the load for
state premium taxes and federal taxes. We will only increase the Premium Load
if the effective taxes paid by us increase.
WITHDRAWAL FEE --- A withdrawal fee of $25 will be deducted from the Accumulated
Value each time a partial withdrawal occurs. The withdrawal fee will be deducted
from the Fixed and Variable Accounts in the same proportion as the partial
withdrawal.
OTHER DEDUCTIONS --- In addition to the charges imposed under Premium Load and
elsewhere, we reserve the right to make a charge for federal, state or local
taxes that may be attributable to the Variable Accounts or to our operations
with respect to this policy if we incur any such taxes.
SURRENDER AND WITHDRAWAL OF VALUES
SURRENDER --- Upon written request while either insured is living you may
surrender this policy for its Net Cash Surrender Value. The policy will
terminate on the date the request is received at the Home Office.
NET CASH SURRENDER VALUE --- The Net Cash Surrender Value is the Cash Surrender
Value less any policy debt.
CASH SURRENDER VALUE --- The Cash Surrender Value is the Accumulated Value.
WITHDRAWALS --- Withdrawals of the Net Cash Surrender Value may be taken as
follows:
Upon written request on or after the first policy anniversary while either
insured is living, you may withdraw a portion of the Net Cash Surrender Value of
this policy as a partial withdrawal. The Withdrawal Fee described above will
apply.
A partial withdrawal may cause a decrease in the Face Amount if the Death
Benefit Option is A or D. The Face Amount will be reduced by the excess, if any,
of the Face Amount over the result of (a) minus (b) where:
--- (a) is the death benefit immediately prior to the partial withdrawal; and
--- (b) is the amount of the partial withdrawal.
However, for the first withdrawal in each of the first 15 policy years, the Face
Amount will be reduced only to the extent that the withdrawal exceeds the lesser
of $10,000 or 10% of the Cash Surrender Value.
Partial withdrawals will be subject to the following conditions: The amount of
each withdrawal must be at least $500 and the Net Cash Surrender Value remaining
after each withdrawal must be at least $500. Also, if there is any policy debt
at the time of each withdrawal, the amount of the withdrawal is limited to the
excess, if any, of the Cash Surrender Value immediately prior to the withdrawal
over the result of the debt divided by 90%.
The amount of each withdrawal will be allocated proportionately to the
Accumulated Value in the Fixed and Variable Accounts unless otherwise requested
by you. If the survivor dies after the request for a withdrawal is sent to us
and prior to the withdrawal being paid, the amount of the withdrawal will be
deducted from the death benefit proceeds.
Unless specified otherwise by you in writing, no request for a partial
withdrawal will be processed if the partial withdrawal would cause the policy to
be treated as a MEC.
Page 11
INCOME BENEFITS
INCOME BENEFITS --- Surrender or withdrawal benefits may be used to purchase a
lifetime monthly income. Death benefits may be used to purchase a monthly income
for the lifetime of the beneficiary. Monthly income payments will automatically
be guaranteed to continue for at least ten years, unless another form of payment
is requested. Under the automatic form of payment, if the income recipient dies
before the end of the ten-year period, payments will continue to the end of the
ten-year period to a person designated by the income recipient in writing.
Other options of monthly income benefits are available upon request. We may
require evidence of the income recipient's survival when monthly income payments
have been made for more than ten years.
The purchase rates for the monthly income will be set periodically by the
Company. However, under the automatic form, the monthly income bought by each
$1000 of benefit amount will always be at least as large as that shown below.
Single-Life Single-Life
10-Years Certain 10-Years Certain
Age Monthly Income Age Monthly Income
30 $3.12 54 $4.15
32 3.17 56 4.30
34 3.23 58 4.47
36 3.29 60 4.66
38 3.35 62 4.87
40 3.42 64 5.10
42 3.50 66 5.36
44 3.58 68 5.65
46 3.67 70 5.97
48 3.78 72 6.32
50 3.89 74 6.69
52 4.01 75 6.89
Monthly income amounts for ages not shown are halfway between the two amounts
for the nearest two ages which are shown.
Guaranteed amounts for ages under 30 are the same as those for age 30;
guaranteed amounts for ages over 75 are the same as those for age 75. Amounts
shown are based on 1983 Table a mortality with interest at 3%. This benefit is
not available if the income would be less than $100 a month.
POLICY LOANS
POLICY LOANS --- You may obtain loans by written request while this policy is in
force on the sole security of the amount in the Loan Account for this policy.
AMOUNT AVAILABLE --- The amount available for a loan is equal to 100% of the
Accumulated Value in the Fixed Account plus 90% of the Accumulated Value in the
Variable Accounts. The minimum amount of a loan must be at least $500.
PM may defer granting a loan for up to six months from the date of request.
However, we will not defer payment of any loan if it is to be used to pay the
premium on any policy currently in force and issued by the company.
LOAN INTEREST --- Interest will accrue daily and is payable in arrears at the
annual rate of:
--- 4.50% for years one through ten; and
--- 4.25% for years eleven and after.
Any loan interest not paid when due will be added to the loan principal and bear
interest at the same rate of interest.
LOAN ACCOUNT --- When a loan is taken, an amount equal to the loan is
transferred from the Fixed and Variable Accounts into the Loan Account to secure
the loan. Unless you request otherwise, loan amounts will be deducted from the
Fixed and Variable Accounts on a proportionate basis, up to the amount
available. We will credit interest monthly on amounts in the Loan Account at a
rate equivalent to an annual effective rate of 4%.
On each policy anniversary, if the amount in the Loan Account exceeds policy
debt, the excess will be transferred from the Loan Account to the Fixed and
Variable Accounts according to your most recent instructions. If policy debt
exceeds the amount in the Loan Account, an amount equal to such excess will be
transferred from the Fixed and Variable Accounts on a proportionate basis to the
Loan Account.
REPAYMENT --- Loans may be repaid at any time prior to lapse of this policy. An
amount equal to the portion of any loan repaid, but not more than the amount in
the Loan Account, will be transferred from the Loan Account to the Fixed and
Variable Accounts according to your most recent instructions.
Any payment we receive from you while you have a loan will be first considered a
premium payment, unless you tell us in writing it is a loan payment.
Page 12
GENERAL PROVISIONS
ENTIRE CONTRACT --- This policy is a contract between the Owner and PM. This
policy, the attached copy of the initial application, any applications for
reinstatement, all subsequent applications to change the policy, any
endorsements, riders or benefits are the entire contract.
Only the Chief Executive Officer, President or Secretary of PM is permitted to
change this contract or waive any of its terms. The change must be in writing.
All statements in the application shall, in the absence of fraud, be deemed
representations and not warranties. PM will not use any statement to contest
this policy or defend a claim on grounds of misrepresentation unless the
statement is in the application or any subsequent applications.
INCONTESTABILITY --- Except for failure to pay premiums, this policy cannot be
contested after the expiration of the following time period:
--- The initial Face Amount cannot be contested with respect to a given
insured after the policy has been in force during that insured's lifetime for
two years from the policy date.
If this policy has been reinstated, it cannot be contested with respect to a
given insured after it has been in force during that insured's lifetime for two
years from the date of reinstatement. Except for failure to pay premiums, in no
event will a contest be made after reinstatement unless there is a material
misrepresentation in the reinstatement application.
This policy will terminate upon successful contest with respect to either
insured.
PARTICIPATING --- The current dividend scale is zero and it is not expected that
dividends will be paid. Any dividends that do become payable will be paid in
cash annually.
SUICIDE EXCLUSION --- If either insured dies by suicide, while sane or insane,
within two years of the policy date, no death benefit proceeds will be paid.
Instead, we will return the sum of the premiums paid, less the sum of any debt,
any partial withdrawal amounts, and any dividends paid by us in cash.
MISSTATEMENT --- If there is a misstatement of either insured's age or sex in
the application, the Face Amount shall be adjusted as follows in order to
reflect the correct age or sex. The adjusted Face Amount shall equal (a) times
(b) divided by (c) where:
(a) is the Face Amount before this adjustment;
(b) is the monthly Cost of Insurance Rate actually used to calculate Cost of
Insurance Charges in the policy year in which the misstatement is discovered,
based on the misstated age or sex; and
(c) is the monthly Cost of Insurance Rate for the policy year in which the
misstatement is discovered, based on the correct age and sex.
For all policy months after the policy month in which the misstatement is
discovered, the Accumulated Value will be calculated using Cost of Insurance
Charges, Rider Charges and Benefit Charges based on the correct age and sex.
The Accumulated Value for the policy months through the month in which the
misstatement is discovered will not be recalculated. Mortality and Expense Risk
Charges will not be recalculated.
If unisex Cost of Insurance Rates apply, no adjustment will be made for a
misstatement of sex.
REPORTS --- A report will be mailed to you at the end of each policy quarter to
your last known address. This report will include the following information for
the policy quarter:
--- the Accumulated Value;
--- the Cash Surrender Value;
--- the current death benefit;
--- transactions that occurred during the policy quarter;
--- existing debt;
--- changes in the Guideline Premiums; and
--- any information required by law.
In addition to the above reports, we will send you annual financial statements
for the Separate Account and annual and semi-annual financial statements for the
designated investment company or companies in which the Separate Account
invests, the latter of which will include a list of the portfolio securities of
the investment company, as required by the Investment Company Act of 1940 and/or
any other reports as required by federal securities law.
Page 13
POLICY ILLUSTRATIONS --- Upon request we will give you an illustration of the
future benefits under this policy based upon both guaranteed and current cost
factor assumptions. However, if you ask us to do this more than once in any
policy year, we reserve the right to charge you a fee, not to exceed $25.00, for
this service.
BASIS OF VALUES --- A detailed statement showing how values are determined has
been filed with the state insurance department. No values are less than the
minimums required by the Standard Nonforfeiture Law and by the law in the state
in which this policy is delivered. All guaranteed values and the guaranteed
maximum monthly Cost of Insurance Rates are based on the 1980 CSO Mortality
Table (ANB) and interest at the rate of 4% per year. For policies that are
issued on a unisex basis, the 1980 CSO Mortality Table B (ANB) applies.
OWNERSHIP OF ASSETS --- We have the exclusive and absolute control of our
assets, including all assets in the Separate Account.
COMPLIANCE --- We reserve the right to make any change to the provisions of this
policy to comply with, or give you the benefit of, any federal or state statute,
rule, or regulation, including but not limited to requirements for life
insurance contracts under the Internal Revenue Code or any state.
We will provide you with a copy of any such change, and will also file such a
change with the insurance supervisory official of the state in which this policy
is delivered. You have the right to refuse any such change.
PAYMENTS
VARIABLE ACCOUNTS --- We will calculate the Net Cash Surrender Value on
surrender, partial withdrawals, and loan proceeds based on allocations made to
the Variable Accounts, and unless transfers are restricted, transfers between
Variable Accounts or from Variable Accounts to the Fixed Account based on
allocations made to the Variable Accounts as of the end of the Valuation Date on
or next following the day on which such instructions are received. We will
calculate death benefit proceeds based on allocations made to the Variable
Accounts as of the end of the Valuation Date on or next following the day on
which the survivor's death occurs. We will pay such amounts and will effect a
transfer between Variable Accounts within seven days after we receive all the
information needed to process a payment or transfer.
However, we may postpone the calculation or payment of such a payment or
transfer of amounts based on investment performance of the Variable Accounts if:
The New York Stock Exchange is closed on other than customary weekend and
holiday closings or trading on the New York Stock Exchange is restricted as
determined by the Securities and Exchange Commission (SEC); or
An emergency exists, as determined by the SEC, as a result of which disposal
of securities is not reasonably practicable to determine the value of the
Account assets; or
The SEC by order permits postponement for the protection of policy owners.
FIXED ACCOUNT --- As to amounts allocated to the Fixed Account, we may defer
payment of any Net Cash Surrender Value on surrender, partial withdrawals, or
loan amounts or defer transfers from the Fixed Account for up to six months
after we receive a request for it. We will credit interest, at a rate of at
least 4% annually, on any Net Cash Surrender Value or withdrawal benefit derived
from the Fixed Account that we defer for 30 days or more. However, we will not
defer payment of any such amounts if they are to be used to pay the premium on
any policy issued by the company.
SEPARATE ACCOUNT PROVISIONS
SEPARATE ACCOUNT --- We established the Separate Account and maintain it under
the laws of California. The Separate Account is divided into subaccounts, called
Variable Accounts. Realized and unrealized gains and losses from the assets of
each Variable Account are credited or charged against it without regard to our
other income, gains, or losses. Assets may be put in our Separate Account to
support this policy and other variable life insurance policies. Assets may be
put in our Separate Account for other purposes, but not to support contracts or
policies other than variable life contracts or policies.
The assets of our Separate Account are our property. The portion of its assets
equal to the reserves and other policy liabilities with respect to our Separate
Account will not be chargeable with liabilities arising out of any other
business we conduct. We may transfer assets of a Variable Account in excess of
the reserves and other liabilities with respect to that account to another
Variable Account or to our general account. All obligations arising under the
policy are general corporate obligations of Pacific Mutual. We do not hold
ourselves out to be trustees of the Separate Account assets.
Page 14
VARIABLE ACCOUNTS --- Each Variable Account may invest its assets in a separate
class of shares of a designated investment company or companies. The Variable
Accounts of our Separate Account that were available for your initial
allocations, are shown on the policy specifications pages. The allocations that
you initially choose are shown on the copy of the application attached to this
Policy. From time to time we may make other Variable Accounts available to you.
We will provide you with written notice of all material details including
investment objectives and all charges.
We reserve the right, subject to compliance with the law then in effect, to:
--- change or add designated investment companies;
--- add, remove or combine Variable Accounts;
--- add, delete or make substitutions for the securities that are held or
purchased by the Separate Account or any Variable Account;
--- register or deregister any Variable Account under the Investment Company
Act of 1940;
--- to change the classification of any Variable Account;
--- operate any Variable Account as a managed investment company or as a unit
investment trust;
--- combine the assets of any Variable Account with other separate accounts
or subaccounts thereof of PM or an affiliate thereof;
--- transfer the assets of any Variable Account to other separate accounts or
subaccounts thereof of PM or an affiliate thereof;
--- run any Variable Account under the direction of a committee, board, or
other group;
--- restrict or eliminate any voting rights of policy owners with respect to
any Variable Account, or other persons who have voting rights as to any
Variable Account. Also, unless required by law or regulation, an investment
policy may not be changed without our consent;
--- change the allocations permitted under the policy;
--- terminate and liquidate any Variable Account; and
--- comply with law.
If any of these changes result in a material change in the underlying
investments of a Variable Account of our Separate Account, we will notify you of
such change.
We will not change the investment policy of the Separate Account without
following the filing and other procedures of the Insurance Commissioner in the
State of California and without following the filing and other procedures
established by insurance regulators of the state of issue.
Page 15
INDEX
SUBJECT PAGE
Accumulated Value................... 9
Administrative Charge............... 11
Age................................. 5
Assignment.......................... 5
Basis of Values..................... 14
Beneficiary......................... 5
Cash Surrender Value................ 11
Compliance.......................... 14
Cost of Insurance Rates............. 10
Decrease Provision.................. 8
Definitions......................... 5
Dividends........................... 13
Face Amount......................... 3
General Provisions.................. 13
Grace Period and Lapse.............. 6
Income Benefits..................... 12
Incontestability.................... 13
Interest............................ 9
Misstatement........................ 13
Mortality and Expense Risk Charge... 10
Other Deductions.................... 11
Owner............................... 3, 5
Payments............................ 14
Policy Benefits..................... 7
Policy Date......................... 3, 5
Policy Illustrations................ 14
Policy Loans........................ 12
Premium Limitation.................. 6
Premium Load........................ 10
Premiums............................ 5
Reinstatement....................... 6
Reports............................. 14
Suicide Exclusion................... 13
Surrender Charge.................... 11
Transfers........................... 10
Variable Accounts................... 9, 14, 15
Withdrawals......................... 12
Withdrawal Fee...................... 11
[LETTERHEAD OF PACIFIC MUTUAL LIFE INSURANCE COMPANY]
Form 96-56
