RIDER Contract Number: LV1234567
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ACCIDENTAL DEATH BENEFIT
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1. CONSIDERATION. We include this rider as part of this contract based on
the Application signed by the applicant and the deduction of the monthly
cost as stated on page 5-ADB.
2. DATE OF ISSUE OF THIS RIDER. Unless otherwise stated on page 5-ADB, the
date of issue of this rider is the Date of Issue of this contract.
3. THE BENEFIT. We will pay to the beneficiary as part of the Death
Proceeds the Accidental Death Benefit shown on page 5-ADB upon receiving
proof that the death of the Insured:
1) Resulted from accidental bodily injury directly and independently of
all other causes;
2) Occurred within 120 days of the date of injury; and
3) Occurred before this rider terminated.
4. DEATHS NOT COVERED. The Accidental Death Benefit is not payable if the
Insured's death results directly or indirectly, in whole or in part, from:
1) Infirmity or disease of the body or mind; or
2) Infection, unless it is a result of an accidental bodily injury; or
3) Suicide, while sane or insane; o
4) Intentionally self-inflicted injury, while sane or insane; or
5) Committing or attempting to commit a felony;
6) Any act of war, declared or undeclared, or any act incident to war;
or
7) Voluntarily taking, inhaling or absorbing into the body any
hallucinogen, narcotic or other drug except as prescribed by the
Insured's physician; or
8) Operating, descending from, or riding in any aircraft where the
Insured:
a) Is a pilot, officer, or member of the crew of that aircraft; or
b) Is giving or receiving any kind of training or instruction aboard
that aircraft; or
c) Has any duties aboard that aircraft; or
d) Is being flown for the purpose of descent from that aircraft
while in flight.
5. INCONTESTABILITY. We will not contest the Benefit is not payable if the
Insured's death results validity of this rider after it has been in force
directly or indirectly, in whole or in part, from: during the Insured's
lifetime for two years from the
6. TERMINATION. This rider will terminate on the earliest of:
1) The Contract Anniversary after the Insured's 70th birthday;
2) The date this contract terminates; and
3) The date you give Written Notice to cancel this rider.
Signed for Lutheran Brotherhood
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President SAMPLE /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇
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Secretary SAMPLE /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇
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WR3-VA-ADB-1 (97)
Date of Issue of this Rider: MAY 1 , 1997 Contract Number: LV1234567
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ACCIDENTAL DEATH BENEFIT
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INSURED: ▇▇▇▇ ▇▇▇ AGE: 35 SEX: MALE
ACCIDENTAL DEATH BENEFIT $50,000 FORM WR3-VA-ADB-1 (97)
TABLE OF MONTHLY COSTS
BEGINNING
ON RIDER ATTAINED MONTHLY
ANNIVERSARY AGE * COST
MAY 1,
1997 35 $ 2.50
1998 36 2.50
1999 37 2.50
2000 38 2.50
2001 39 2.50
2002 40 2.50
2003 41 2.50
2004 42 2.50
2005 43 2.50
2006 44 2.50
2007 45 2.50
2008 46 2.50
2009 47 3.00
2010 48 3.00
2011 49 3.00
2012 50 3.00
2013 51 3.00
2014 52 3.00
2015 53 3.00
2016 54 3.00
2017 55 3.00
2018 56 3.50
2019 57 3.50
2020 58 3.50
2021 59 3.50
2022 60 4.00
2023 61 4.00
2024 62 4.00
2025 63 4.50
2026 64 4.50
2027 65 5.00
2028 66 5.00
2029 67 5.50
2030 68 6.00
2031 69 6.00
* AGE LAST BIRTHDAY ON RIDER ANNIVERSARY ON OR IMMEDIATELY PRIOR TO MONTHLY
ANNIVERSARY.
WR3-VA-5 page 5-ADB
RIDER Contract Number: LV1234567
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CHILD TERM LIFE INSURANCE BENEFIT
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1. CONSIDERATION. We include this rider as part of this contract based on
the Application signed by the applicant and the deduction of the monthly
cost as stated on page 5-CIB.
2. DEFINITIONS.
2a. Date of Issue of this Rider. Unless otherwise stated on page 5-
CIB, the date of issue of this rider is the Date of Issue of this
contract.
2b. Rider Anniversary. The same month and day for years after issue of
this rider as in the date of issue of this rider.
2c. Child. A Child insured under this rider is:
1) Any child named in the Application for this rider;
2) Any live child born to the Insured after the date of issue of
this rider;
3) Any child legally adopted by the Insured after the date of
issue of this rider and prior to the Rider Anniversary after
the child's 18th birthday; and
4) Any child accepted for coverage under this rider based on
written application made after the date of issue of this rider.
Child does not include a child for whom insurance has been terminated by
Written Notice.
3. THE BENEFIT. We will provide the benefits described below upon each of
the following events:
3a. Death of a Child. We will pay the amount of Child Term Insurance
shown for this rider on page 5-CIB to the Child's beneficiary upon
receiving proof that the death of the Child occurred before:
1) This rider has terminated; and
2) The Rider Anniversary next after the Child's 21st birthday.
3b. Death of the Insured. Upon receiving proof that the death of the
Insured occurred before this rider terminated, any Child Term
Insurance then in force will become Child Paid-Up Term Insurance to
the Rider Anniversary after the Child's 21st birthday. The amount
of Child Paid-Up Term Insurance is the same as the amount of Child
Term Insurance.
4. MONTHLY COST. The monthly cost for this rider is shown on page 5-CIB.
It is deducted only while at least one child is insured under this rider.
If there are no children insured under this rider on the date of birth or
adoption of any child, you must give us Written Notice of birth or adoption
before the sixth Monthly Anniversary after that date. The monthly cost will
then be deducted beginning on the sixth Monthly Anniversary after the date
of birth or adoption. If the required notice is not given, insurance on
that Child will terminate on that sixth Monthly Anniversary.
5. OPTION TO PURCHASE INSURANCE. On the Rider Anniversary after a Child's
21st birthday, that Child will have the option to purchase an insurance
contract on his or her life with no evidence of insurability required. This
option to purchase will be effective for 31 days. If the Child dies while
this option is in effect and before the option has been exercised, we will
pay the amount of Child Term Insurance or Child Paid-Up Term Insurance to
the Child's beneficiary. This option is subject to the following:
1) Written application must be made to us at our Home Office.
2) No premium may be in default on the date of purchase.
3) The new contract's date of issue will be the date of purchase. The
issue age will be the Child's age last birthday on that date.
Premiums will be based on rates in effect on the date of purchase.
4) The new contract will have its own Incontestability and Suicide
provisions measured from the date of issue. As used in those
provisions, the date of issue will be the date of issue of this
rider.
(continued)
WR3-VC-CIB-1 (97)
Contract Number: LV1234567
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CHILD TERM LIFE INSURANCE BENEFIT (continued)
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5. OPTION TO PURCHASE INSURANCE (continued).
5) The amount of the new contract may not exceed five times the amount
of the Child Term Insurance.
6) The new contract may be any life insurance contract that we offer at
the time of purchase.
7) If the new contract is a whole life insurance contract with premiums
payable to at least age 85, then the new contract may contain a
disability waiver benefit rider. However, the disability waiver
benefit rider on the new contract will not cover disability
resulting from injury or disease occurring prior to the date of
purchase.
No other additional benefits will be allowed on the new contract
unless evidence of insurability which meets our standards is
provided.
6. BENEFICIARY. The beneficiary of the insurance on the children is named
in the Application. You may change the beneficiary for a Child by giving us
Written Notice while the Child is living. If the owner dies and the Child
has attained age 18, the Child may change the beneficiary by making a
written request to us. If the owner dies and the Child has not attained age
18, the Child's legal guardian may change the beneficiary by making a
written request to us.
The change will become effective if we receive the notice or request at our
Home Office and we acknowledge the change. The effective date of the change
will be the date the notice or request was signed. We will not be liable
for any payment made or action taken by us before we receive the notice or
request.
7. INCONTESTABILITY. With respect to each Child named in an application
for coverage under this rider, we will not contest the validity of this
rider after it has been in force during the lifetime of that Child for two
years from its effective date. This provision will apply from the date this
rider is reinstated with regard to statements made in the application for
reinstatement.
8. REINSTATEMENT. This rider may be reinstated if the contract is
reinstated. To reinstate this rider we require evidence of each Child's
insurability which meets our standards. Paragraph 7 Incontestability will
apply from the date the rider is reinstated with regard to statements made
in the application for reinstatement.
9. SURRENDER OF CHILD PAID-UP TERM INSURANCE. If this rider is in force as
Child Paid-Up Term Insurance, you may surrender the Child Paid-Up Term
Insurance for, its accumulated value by giving Written Notice while the
Child is living. The surrender will be effective on the date the notice is
signed. The accumulated value is the net single premium for the Child Paid-
Up Term Insurance. Values are not less than the minimum values required by
law. Information on applicable accumulated values will be furnished upon
request.
If we receive Written Notice to surrender the Child Paid-Up Term Insurance
within 30 days after a Rider Anniversary, the accumulated value will not be
less than it was on that anniversary.
10. TERMINATION. This rider will terminate on the earlier of:
1) The Rider Anniversary after the 100th birthday of the Insured;
2) The date this contract terminates; and
3) The date you give Written Notice to cancel this rider.
However, if this contract terminates due to the death of the Insured, this
rider will remain in force until all Child Paid-Up Term Insurance under this
rider terminates.
Signed for Lutheran Brotherhood
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President SAMPLE /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇
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Secretary SAMPLE /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇
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WR3-VC-CIB-2 (97)
Date of Issue of this Rider: MAY 1 , 1997 Contract Number: LV1234567
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CHILD TERM LIFE INSURANCE BENEFIT
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FORM WR3-VC-CIB-1 (97)
CHILD TERM INSURANCE
BIRTH TO 15 DAYS $0
15 DAYS TO 6 MONTHS $5,000
6 MONTHS TO RIDER ANNIVERSARY
AFTER 21ST BIRTHDAY $10,000
MONTHLY COST: $4.50
MONTHLY COST APPLIES ONLY WHILE AT LEAST ONE CHILD IS INSURED UNDER THIS
RIDER. SEE PARAGRAPH 4 OF FORM WR3-VC-CIB-1 (97)
WR3-VC-5 page 5-CIB
RIDER
Contract Number: LV1234567
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GUARANTEED INCREASE OPTION BENEFIT
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1. CONSIDERATION. We include this rider as part of this contract based on
the Application signed by the applicant and the deduction of the monthly
cost as stated on page 5-GIO.
2. DEFINITIONS.
2a. Date of Issue of this Rider. Unless otherwise stated on page 5-
GIO, the date of issue of this rider is the Date of Issue of this
contract.
2b. Rider Anniversary. The same month and day for years after issue of
this rider as in the date of issue of this rider.
3. THE BENEFIT.
1) You may increase the Face Amount of this contract as provided in
Paragraph 4 Increase Option.
2) We will pay the amount of any Term Insurance (see Paragraph 5) in
force under this rider to the beneficiary as part of the Death
Proceeds upon receiving proof that the death of the Insured occurred
before this rider terminated.
4. INCREASE OPTION.
4a. Increase in Face Amount. An option to increase the Face Amount of
this contract will become effective on each Fixed Increase Option
Date and each Additional Increase Option Date (see paragraphs 4c
and 4d) if less than the Maximum Number of Options have been used
to increase the Face Amount. Each option will be in effect for 90
days after the effective date of the option but will terminate
earlier upon:
1) The date the Face Amount is increased under this rider; or
2) The date this rider terminates.
4b. Maximum Number of Options. The Maximum Number of Options that may
be used to increase the Face Amount is the number of Fixed Increase
option Dates occurring after the date of issue of this rider.
4c. Fixed Increase Option Dates. Fixed Increase Option Dates occur on
the Rider Anniversary after the 25th, 28th, 31st, 34th, 37th, 40th
and 43rd birthdays of the Insured.
4d. Additional Increase Option Dates. An Additional Increase Option
Date occurs upon each of the following events which takes place
between the date of issue of this rider and the Rider Anniversary
after the Insured's 43rd birthday:
1) Marriage of the Insured;
2) Birth of each live child born to the Insured; and
3) Legal adoption of a child by the Insured.
4e. Conditions of Increase. The Face Amount of this contract may be
increased with no evidence of insurability required. The increase
is subject to the following:
1) You must make written application to us at our Home Office.
2) Premium Class for the increase in Face Amount will be the same
as for this rider.
3) The amount of the increase must be at least $10,000 and may not
exceed the Option Amount for this rider as shown on page 5-GIO.
4) The Cash Surrender Value of this contract must be sufficient to
cover the Monthly Deduction on the effective date of the
increase (unless the Death Benefit Guarantee is in force).
5) The Initial Monthly Charge for Increases will be charged on the
effective date of the increase and then on each Monthly
Anniversary until 180 charges have been made.
6) A new schedule of Decrease Charges will apply to the increase
in Face Amount.
(continued)
WR3-VG-GIO-1 (97)
Contract Number: LV1234567
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GUARANTEED INCREASE OPTION BENEFIT (continued)
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4e. Conditions of Increase (continued).
7) A new Death Benefit Guarantee Premium for this contract will be
determined if the Death Benefit Guarantee is in effect on the
effective date of the increase.
8) The effective date of the increase will be the date shown on the
supplementary contract schedule that we will mail to you.
5. TERM INSURANCE. We will provide Term Insurance on the Insured's life
during the period while at least one Increase Option is in effect. (Periods
during which Increase Options are in effect are specified in Paragraph 4a.)
The amount of insurance will be the Option Amount for this rider as shown on
page 5-GIO.
6. INCONTESTABILITY. We will not contest the validity of this rider after
it has been in force during the Insured's lifetime for two years from the
date of issue of this rider.
7. TERMINATION. This rider will terminate on the earliest of:
1) The date 90 days following the Rider Anniversary after the Insured's
43rd birthday;
2) The date the cumulative total of options used to increase the Face
Amount equals the Maximum Number of Options;
3) The date this contract terminates; and
4) The date you give Written Notice to cancel this rider.
Signed for Lutheran Brotherhood
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President SAMPLE /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇
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Secretary SAMPLE /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇
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WR3-VG-GIO-2 (97)
Date of Issue of this Rider: MAY 1, 1997 Contract Number: LV1234567
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GUARANTEED INCREASE OPTION BENEFIT
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FORM WR3-VG-GIO-1 (97)
INSURED: ▇▇▇▇ ▇▇▇
AGE: 35 SEX: MALE
OPTION AMOUNT $50,000
PREMIUM CLASS: NON-TOBACCO
MONTHLY COST IS DEDUCTED TO THE CONTRACT ANNIVERSARY AFTER AGE 43.
WR3-VG-5 page 5-GIO
RIDER Contract Number: LV1234567
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COST OF LIVING BENEFIT
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1. CONSIDERATION. We include this rider as part of this contract based on
the Application signed by the applicant and the deduction of the monthly
cost as stated on page 5-COL.
2. DATE OF ISSUE OF THIS RIDER. Unless otherwise stated on page 5-COL, the
date of issue of this rider is the Date of Issue of this contract.
3. THE BENEFIT. This rider increases the Face Amount of this contract.
Increases are effective on each Contract Anniversary after the date of issue
of this rider, provided this rider is then in force. The amount of the
increase is determined on each Contract Anniversary. It is the smallest of:
1) The CPI Increase;
2) 10% of the Eligible Face Amount on the day before the increase,
rounded to the nearest $1,000. The Eligible Face Amount is that
part of the Face Amount with Premium Class which is not rated; and
3) $100,000.
However, no increase will be made if the amount determined above is less
than $1,000. The Premium Class for the increase in Face Amount will be the
same as for this contract.
4. THE CPI INCREASE. The CPI Increase is equal to:
1) The percentage increase in Consumer Price Index from the Base Index
Month to the Current Index Month; multiplied by
2) The Eligible Face Amount on the day before the increase.
The CPI Increase is rounded to the nearest $1,000. If this increase before
rounding is less than $5OO, the CPI Increase for that Contract Anniversary
will be zero. The index used is the Consumer Price Index for All Urban
Consumers. If this index is discontinued or changed we will use a similar
index.
5. INDEX MONTHS. The Current Index Month is the third calendar month
before the Contract Anniversary. The Base Index is the month one year
before the Current Index Month.
6. PREMIUM INCREASE. The increase in Face Amount will increase the monthly
Cost of Insurance for this contract. Your premium billing will be increased
by the greater of:
1) The percentage increase in Face Amount; and
2) The increase in the Death Benefit Guarantee Premium due to the
increase in Face Amount. This amount will be zero if the Death
Benefit Guarantee is not in effect on the effective date of the
increase in Face Amount.
We will mail you a supplemental contract schedule one month before any
Contract Anniversary in which an increase will occur. You may reject the
increase in Face Amount by giving Written Notice before that Contract
Anniversary.
7. INCONTESTABILITY. We will not contest the validity of this rider after
it has been in force during the Insured's lifetime for two years from the
date of issue of this rider.
8. TERMINATION. This rider will terminate on the earliest of:
1) The Expiration Date for this rider shown on page 5-COL;
2) The date this contract terminates;
3) The date you reject an increase in Face Amount under this rider;
4) The date you decrease the Face Amount;
5) The date the sum of the increases in Face Amount due to this rider
equals or exceeds two times the Initial Face Amount; and
6) The date you give Written Notice to cancel this rider.
(continued )
WR3-VL-COL-1 (97)
Contract Number: LV1234567
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COST OF LIVING BENEFIT (continued)
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9. REINSTATEMENT. If this rider terminates other than under paragraphs 8(l)
and 8(5), it may be reinstated any time before the Expiration Date for this
rider. To reinstate we require evidence of insurability which meets our
standards. The effective date of the reinstatement is the Monthly
Anniversary on or next after the date the application for reinstatement is
approved by us. Paragraph 7 Incontestability will apply from the date of
reinstatement with regard to statements made in the application for
reinstatement.
Signed for Lutheran Brotherhood
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President SAMPLE /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇
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Secretary SAMPLE /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇
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WR3-VL-COL-2 (97)
Date of Issue of this Rider: MAY 1 , 1997 Contract Number: LV1234567
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COST OF LIVING BENEFIT
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FORM WR3-VL-COL-1 (97)
INSURED: ▇▇▇▇ ▇▇▇
AGE: 35 SEX: MALE
EXPIRATION DATE: MAY 1, 2017
MONTHLY COST: NONE
WR3-VL-5 page 5-COL
RIDER Contract Number: LV1234567
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SPOUSE ADJUSTABLE TERM LIFE INSURANCE BENEFIT
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1. CONSIDERATION. We include this rider as part of this contract based on
the Application signed by the applicant and the deduction of the monthly
cost as stated on page 5-SIB.
2. DEFINITIONS.
2a. Date of Issue of this Rider. Unless otherwise stated on page 5-
SIB, the date of issue of this rider is the Date of Issue of this
contract.
2b. Rider Anniversary. The date of issue of this rider and the same
month and day for years after issue of this rider as in the date of
issue of this rider.
2c. Spouse. The Spouse is the Insured's Spouse named on page 5-SIB.
2d. ▇▇▇▇▇▇'s Attained Age. The Spouse's Attained Age on any day is the
Spouse's age last birthday on the Rider Anniversary on or
immediately prior to that day.
3. SPOUSE MEMBERSHIP. We accept the Spouse as an adult member of the
Society. Rights and privileges of membership are set forth in the Bylaws of
the Society or in the Application. These rights and privileges are separate
from the ownership of this contract. Membership rights and privileges
cannot be assigned.
4. THE BENEFIT. Upon receiving proof that the death of the Spouse occurred
before this rider terminated, we will pay to the Spouse's beneficiary the
amount of Spouse Term Insurance shown on page 5-SIB.
5. MONTHLY COST. The monthly cost of this benefit to be deducted on each
Monthly Anniversary is the sum of:
1) The Spouse Cost of Insurance. This amount is determined on each
Monthly Anniversary. It is equal to the Spouse Cost of Insurance
Rate multiplied by the amount of Spouse Term Insurance divided by
1,000;
2) The Spouse Initial Monthly Charge. This is a charge per $1,000 of
the initial amount of Spouse Term Insurance. However, if the initial
amount of Spouse Term Insurance is decreased, the charge will be
based on the amount of Spouse Term Insurance remaining after the
decrease. The charge is made on the date of issue of this rider and
then on each Monthly Anniversary until a total of 180 charges have
been made. The charge per $1,000 is shown on page 5-SIB; and
3) Any Spouse Initial Monthly Charge for Increases. This is a charge
per $1,000 of increase in Spouse Term Insurance. However, if the
increased insurance is later decreased, the charge will be based on
the amount of the increase in Spouse Term Insurance remaining in
force after the decrease. The charge is made on the effective date
of the increase and then on each Monthly Anniversary until 180
charges have been made. The charge is based on the Spouse's
Attained Age on the date of increase. The charge per $1,000 is
shown on page 5-SIB.
WR3-VS-SIB-1 (97)
Contract Number: LV1234567
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SPOUSE ADJUSTABLE TERM LIFE INSURANCE BENEFIT (continued)
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6. SPOUSE COST OF INSURANCE RATE. We will determine the Spouse Cost of
Insurance Rate monthly. The rate is based on the Spouse's Premium Class,
sex, Issue Age, Attained Age and amount of Spouse Term Insurance.
The Premium Class for the initial amount of Spouse Term Insurance is shown
on page 5-5lB. The Premium Class for any increase in Spouse Term Insurance
will be determined on the effective date of the increase. The Cost of
Insurance Rate for the initial amount of Spouse Term Insurance and for any
increase in Spouse Term Insurance with the same Premium Class as shown on
page 5-SIB will not exceed the rates shown on page 5-SIB. However, for any
amount of Spouse Term Insurance with a rated Premium Class, the maximum cost
is increased in one or both of the following ways, as specified on page 5-
SIB:
1) The maximum Spouse Cost of Insurance Rate is multiplied by a
percentage rating.
2) An extra monthly amount is added to the Spouse Cost of Insurance.
We may charge less than the maximum rate. Any change in Spouse Cost of
Insurance Rates will be based on the initial amount of Spouse Term Insurance
and any requested increases in Spouse Term Insurance and will apply to all
Spouses of the same Premium Class, sex, Issue Age and attained age.
7. INCREASE IN SPOUSE TERM INSURANCE. You may increase the amount of
Spouse Term Insurance any time before the Rider Anniversary next after the
Spouse's 85th birthday. The increase is subject to the following:
1) You must make written application to us at our Home Office.
2) We will require evidence of insurability which meets our standards.
3) The increase must be at least $25,000.
4) The Cash Surrender Value of this contract must be sufficient to
cover the Monthly Deduction on the effective date of the increase
(unless the Death Benefit Guarantee is in force).
5) The Spouse Initial Monthly Charge for Increases (see Paragraph 5(3))
will be charged on the effective date of the increase and then on
each Monthly Anniversary until 180 charges have been made.
6) A new Death Benefit Guarantee Premium for this contract will be
determined if the Death Benefit Guarantee is in effect on the
effective date of the increase.
7) The effective date of the increase will be the date shown on the
supplemental contract schedule that we will mail to you.
Paragraph 11 Incontestability and Paragraph 12 Exclusion: Suicide will apply
to the increase from its effective date with regard to statements made in
the application for increased insurance.
8. DECREASE IN SPOUSE TERM INSURANCE. You may decrease the amount of
Spouse Term Insurance at any time. The decrease is subject to the
following:
1) You must give Written Notice.
2) The decrease will be applied, in successive order, against:
a) The most recent increase in the amount of Spouse Term Insurance;
b) The next most recent increase(s); then
c) The initial amount of Spouse Term Insurance.
3) The remaining amount of Spouse Term Insurance must not be less than
$25,000.
4) A new Death Benefit Guarantee Premium for this contract will be
determined if the Death Benefit Guarantee is in effect on the
effective date of the decrease.
5) The effective date of the decrease will be the Monthly Anniversary
on or next after the date we receive Written Notice. That date will
be shown on the supplemental contract schedule that we will mail to
you.
WR3-VS-SIB-2 (97)
Contract Number: LV1234567
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SPOUSE ADJUSTABLE TERM LIFE INSURANCE BENEFIT (continued)
----------------------------------------------------------------------------
9. CONVERSION PRIVILEGE. You may convert this rider to any life insurance
contract, other than term insurance, that we offer at the time of
conversion. The new contract will be on the life of the Spouse with no
evidence of insurability required. Conversion is subject to the following:
1) Written application must be made to us at our Home Office and this
rider must be surrendered.
2) Conversion must be made while this rider is in force and before the
Rider Anniversary after the 75th birthday of the Spouse. However,
if the Insured dies at any time while this rider is in force, you
may convert this rider within 90 days of the date of the Insured's
death. If the Insured is the owner of this contract, then the
Spouse may convert this rider within 90 days of the date of the
Insured's death.
3) No premium may be in default at the time of conversion.
4) The new contract's date of issue will be the date of conversion.
The issue age will be the Spouse's age last birthday on that date.
Premiums will be based on rates in effect on the date of conversion.
5) The new contract will have its own Incontestability and Suicide
provisions measured from the date of issue. As used in those
provisions, if an increase in Spouse Term Insurance is converted,
the date of issue will be the effective date of the increase.
Otherwise, the date of issue will be the date of issue of this
rider.
6) The new contract will be issued on the same Premium Class as this
rider. If any exclusion rider applies to this rider, the new
contract will also have such an exclusion rider.
7) The amount of the new contract may not exceed the amount of the
Spouse Term Insurance.
10. MISSTATEMENT OF AGE OR SEX. If the Spouse's age or sex has been
misstated, contract values will be adjusted to the amounts that would have
been provided based on the correct age and sex, using the ratio of the most
recent Spouse Cost of Insurance Rates applied on this contract to the
current rates based on the correct age and sex.
11. INCONTESTABILITY. We will not contest the validity of this rider after
it has been in force during the lifetime of the Spouse for two years from
the date of issue of this rider.
If the amount of Spouse Term Insurance is increased according to Paragraph
7, this provision will apply to the increase from its effective date with
regard to statements made in the application for increased insurance. This
provision will apply from the date this rider is reinstated with regard to
statements made in the application for reinstatement.
12. EXCLUSION: SUICIDE. If the Spouse dies by suicide, while sane or
insane, within two years after the date of issue of this rider, the benefit
of this rider is limited to the sum of the monthly cost deductions made for
this rider.
If the Spouse dies by suicide, while sane or insane, within two years after
the effective date of an increase in the amount of Spouse Term Insurance
according to Paragraph 7, the benefit with respect to the increase is
limited to the sum of the monthly cost deductions made for the increase.
13. REINSTATEMENT. This rider may be reinstated if the contract is
reinstated. To reinstate this rider we require evidence of the Spouse's
insurability which meets our standards. Paragraph 11 Incontestability will
apply from the date the rider is reinstated with regard to statements made
in the application for reinstatement.
WR3-VS-SIB-3 (97)
Contract Number: LV1234567
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SPOUSE ADJUSTABLE TERM LIFE INSURANCE BENEFIT (continued)
---------------------------------------------------------------------------
14. BENEFICIARY. The beneficiary of this rider is named in the
Application. You may change the beneficiary by giving us Written Notice
while the Spouse is living. The change will become effective if we receive
the notice or request at our Home Office and we acknowledge the change. The
effective date of the change will be the date the notice or request was
signed. We will not be liable for any payment made or action taken by us
before we receive the notice or request.
15. TERMINATION. This rider will terminate on the earliest of:
1) The Expiration Date for this rider shown on page 5-SIB;
2) The date this contract terminates;
3) The date this rider is converted; and
4) The date you give Written Notice to cancel this rider.
However, if this contract terminates due to the death of the Insured, this
rider will remain in force until the earlier of:
1) 90 days after the date of the Insured's death, and
2) The date this rider is converted.
Signed for Lutheran Brotherhood
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President SAMPLE /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇
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Secretary SAMPLE /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇
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WR3-VS-SIB-4 (97)
Date of Issue of this Rider: MAY 1 , 1997 Contract Number: LV1234567
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SPOUSE ADJUSTABLE TERM LIFE INSURANCE BENEFIT
----------------------------------------------------------------------------
SPOUSE: ▇▇▇▇ ▇▇▇ FORM WR3-VS-SIB-1 (97)
SPOUSE AGE: 35 SPOUSE SEX: FEMALE
SPOUSE TERM INSURANCE: $50,000
PREMIUM CLASS: NON-TOBACCO
SPOUSE INITIAL MONTHLY CHARGE: $V.VV PER $1,000 OF SPOUSE TERM INSURANCE,
CHARGED ONLY IN THE FIRST 180 MONTHLY
DEDUCTIONS ON OR AFTER THE DATE OF ISSUE OF
THIS RIDER.
SPOUSE SPOUSE
BEGINNING SPOUSE'S COST OF INITIAL MONTHLY
ON RIDER ATTAINED INSURANCE CHARGE FOR
ANNIVERSARY AGE RATE * INCREASES #
MAY 1,
1997 35 $ 0.12 $ 0.04
1998 36 0.13 0.04
1999 37 0.14 0.04
2000 38 0.15 0.04
2001 39 0.16 0.04
2002 40 0.18 0.05
2003 41 0.19 0.05
2004 42 0.21 0.05
2005 43 0.22 0.05
2006 44 0.24 0.05
2007 45 0.25 0.05
2008 46 0.27 0.05
2009 47 0.29 0.05
2010 48 0.31 0.05
2011 49 0.33 0.05
2012 50 0.36 0.06
2013 51 0.38 0.06
2014 52 0.42 0.06
2015 53 0.45 0.06
2016 54 0.49 0.06
* MAXIMUM MONTHLY COST PER $1,000 INSURANCE FOR NON-TOBACCO PREMIUM CLASS,
BASED ON COMMISSIONERS 1980 STANDARD ORDINARY MORTALITY TABLE. AGE AT ISSUE
IS AGE LAST BIRTHDAY.
# MONTHLY CHARGE PER $1,000 OF INCREASE IN SPOUSE TERM INSURANCE, CHARGED
ONLY IN THE FIRST 180 MONTHLY DEDUCTIONS ON OR AFTER THE EFFECTIVE DATE OF
THE INCREASE.
EXPIRATION DATE: MAY 1, 2062
WR3-VS-5 page 5-SIB
Date of Issue of this Rider: MAY 1 , 1997 Contract Number: LV1234567
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SPOUSE ADJUSTABLE TERM LIFE INSURANCE BENEFIT (continued)
----------------------------------------------------------------------------
SPOUSE: ▇▇▇▇ ▇▇▇ FORM WR3-VS-SIB-1 (97)
SPOUSE AGE: 35 SPOUSE SEX: FEMALE
SPOUSE TERM INSURANCE: $50,000
SPOUSE SPOUSE
BEGINNING SPOUSE'S COST OF INITIAL MONTHLY
ON RIDER ATTAINED INSURANCE CHARGE FOR
ANNIVERSARY AGE RATE * INCREASES #
MAY 1,
2017 55 $ 0.53 $ 0.06
2018 56 0.56 0.06
2019 57 0.60 0.06
2020 58 0.64 0.06
2021 59 0.68 0.06
2022 60 0.73 0.07
2023 61 0.79 0.07
2024 62 0.87 0.07
2025 63 0.96 0.07
2026 64 1.07 0.07
2027 65 1.18 0.07
2028 66 1.30 0.07
2029 67 1.42 0.07
2030 68 1.55 0.07
2031 69 1.69 0.07
2032 70 1.85 0.07
2033 71 2.05 0.07
2034 72 2.29 0.07
2035 73 2.59 0.07
2036 74 2.92 0.07
2037 75 3.30 0.07
2038 76 3.71 0.07
2039 77 4.14 0.07
2040 78 4.61 0.07
2041 79 5.14 0.07
2042 80 5.73 0.07
2043 81 6.41 0.xx
2044 82 7.20 0.xx
2045 83 8.09 0.xx
046 84 9.07 0.xx
2047 85 10.13 0.xx
* MAXIMUM MONTHLY COST PER $1,000 INSURANCE FOR NON-TOBACCO PREMIUM CLASS,
BASED ON COMMISSIONERS 1980 STANDARD ORDINARY MORTALITY TABLE. AGE AT ISSUE
IS AGE LAST BIRTHDAY.
# MONTHLY CHARGE PER $1,000 OF INCREASE IN SPOUSE TERM INSURANCE, CHARGED
ONLY IN THE FIRST 180 MONTHLY DEDUCTIONS ON OR AFTER THE EFFECTIVE DATE OF
THE INCREASE.
WR3-VS-5 Cl page 5-SIB Continued
Date of Issue of this Rider: MAY 1 , 1997 Contract Number: LV1234567
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SPOUSE ADJUSTABLE TERM LIFE INSURANCE BENEFIT (continued)
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SPOUSE: ▇▇▇▇ ▇▇▇ FORM WR3-VS-SIB-1 (97)
SPOUSE AGE: 35 SPOUSE SEX: FEMALE
SPOUSE TERM INSURANCE: $50,000
SPOUSE SPOUSE
BEGINNING SPOUSE'S COST OF INITIAL MONTHLY
ON RIDER ATTAINED INSURANCE CHARGE FOR
ANNIVERSARY AGE RATE * INCREASES #
MAY 1,
2048 86 $ 11.26 $
2049 87 12.46
2050 88 13.74
2051 89 15.09
2052 90 16.54
2053 91 18.11
2054 92 19.87
2055 93 21.94
2056 94 24.60
2057 95 28.41
2058 96 xx.xx
2059 97 xx.xx
2060 98 xx.xx
2061 99 xx.xx
* MAXIMUM MONTHLY COST PER $1,000 INSURANCE FOR NON-TOBACCO PREMIUM CLASS,
BASED ON COMMISSIONERS 1980 STANDARD ORDINARY MORTALITY TABLE. AGE AT ISSUE
IS AGE LAST BIRTHDAY.
# MONTHLY CHARGE PER $1,000 OF INCREASE IN SPOUSE TERM INSURANCE, CHARGED
ONLY IN THE FIRST 180 MONTHLY DEDUCTIONS ON OR AFTER THE EFFECTIVE DATE OF
THE INCREASE.
WR3-VS-5 C2 page 5-SIB Continued
RIDER
Contract Number: LV1234567
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WAIVER OF SELECTED AMOUNT BENEFIT
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1. CONSIDERATION. We include this rider as part of this contract based on
the Application signed by the applicant and the deduction of the monthly
cost as stated on page 5-WSA.
2. DATE OF ISSUE OF THIS RIDER. Unless otherwise stated on page 5-WSA, the
date of issue of this rider is the Date of Issue of this contract.
3. THE BENEFIT. Upon receiving proof that Total Disability has continued
for six consecutive months, we will credit premiums to this contract on each
Monthly Anniversary during the Benefit Period while Total Disability
continues. The premium credited on a Monthly Anniversary will be equal to
the greater of:
1) One-twelfth of the Selected Amount on the date Total Disability
began; and
2) The amount which provides the Monthly Deduction for that Monthly
Anniversary.
In addition, for each Monthly Anniversary that occurred during the Benefit
Period but before we received proof of Total Disability, we will credit the
greater of:
1) A premium equal to one-twelfth of the Selected Amount on the date
Total Disability began; and
2) A Net Premium equal to the Monthly Deduction on that Monthly
Anniversary.
This amount will be credited on the day your claim for waiver is approved by
us.
Unless this contract terminates due to excess loan, each premium credited
will continue this contract in force until the next Monthly Anniversary.
4. BENEFIT PERIOD.
1) If the Insured has a Total Disability at Age 5, the Benefit Period
starts at Age 5 and continues until Age 100.
2) If Total Disability begins after Age 5, but before Age 60, the
Benefit Period starts on the date Total Disability begins and
continues until Age 100.
3) If Total Disability begins at or after Age 60, but before Age 65,
the Benefit Period starts on the date Total Disability begins and
continues until the later of:
a) Age 65 of the Insured; and
b) The date two years after Total Disability begins.
5. DEFINITION OF AGE. For purposes of this rider, "Age 5," "Age 60," "Age
65" and "Age 100" mean the Contract Anniversary after the Insured's 5th,
60th, 65th, and 100th birthday, respectively.
6. DEFINITION OF TOTAL DISABILITY. Total Disability is a disability of the
Insured:
1) Which begins before Age 65;
2) Which results from accidental bodily injury sustained or disease
which first appears while both this contract and this rider are in
force; and
3) Which completely prevents the Insured from engaging in an Occupation
for gain or profit. During the first 24 months of disability,
Occupation is the Insured's regular occupation when disability
begins. After this, it is any occupation for which the Insured is
or becomes qualified by reason of education, training or experience.
However:
a) If the Insured is a full-time student under age 18 when Total
Disability begins, Occupation for gain or profit means attending
school outside the home. This definition applies until the
disabled Insured reaches age 18, or for 24 months if later.
b) If the Insured is primarily a homemaker when Total Disability
begins, Occupation for gain or profit means performing household
duties.
WR3-VW-WSA-1 (97)
Contract Number: LV1234567
----------------------------------------------------------------------------
WAIVER OF SELECTED AMOUNT BENEFIT (continued)
----------------------------------------------------------------------------
7. PRESUMPTIVE TOTAL DISABILITY. Total Disability is presumed upon the
total and permanent loss before Age 65, of:
1) Use of both hands or both feet; or
2) Use of one hand and one foot; or
3) Sight in both eyes.
This presumption will continue for 60 months from the date of loss.
However, benefits are payable only as provided in Paragraph 3 The Benefit.
After the 60 month period, Total Disability is no longer presumed.
8. RISKS NOT ASSUMED. No premiums will be credited under this
rider if the Total Disability results from:
1) Intentionally self-inflicted injury, while sane or insane; or
2) Any act of war, declared or undeclared, or any act incident to war.
9. NOTICE AND PROOF OF CLAIM. Written notice and proof of claim must be
given to us at our Home Office within one year after the end of each period
for which we are liable. However, failure to give proof within one year
will not affect the claim if proof is given as soon as is reasonably
possible.
10. PROOF OF CONTINUANCE OF TOTAL DISABILITY. Proof of continuance of
Total Disability, at your expense, will be required at reasonable intervals.
If you do not give proof, no further premiums will be credited under this
rider. After premiums have been credited for two full years, we will not
require proof more than once a year. As part of any proof we may require
the Insured, at our expense, to have an examination by a physician whom we
will name.
11. BENEFITS AFTER PREMIUM IN DEFAULT. No premiums will be credited under
this rider until your claim for waiver is approved.
If a premium is in default, your claim for waiver will be approved only if:
1) Total Disability began before the end of the grace period of the
first premium in default;
2) Written notice of claim is given within one year from the end of the
grace period of the first premium in default, or as soon as
reasonably possible; and
3) All other conditions of this rider are met.
If Total Disability began during the grace period of the first premium in
default, no claim will be considered until the required premium is paid.
12. CONTRACT BENEFITS NOT REDUCED. Premiums credited under this rider will
not reduce any other contract benefits. Accumulated Values and all other
benefits will be the same as if the credited premiums had been paid in cash.
13. PREMIUMS NOT CREDITED. We will not credit the amount of monthly cost
deductions for an Additional Benefit on this contract or for a requested
increase in coverage on any person insured under this contract if the Total
Disability is a result of accidental bodily injury sustained or disease
which first appears before the date of issue of that Additional Benefit or
the effective date of the increase.
14. TERMINATION. This rider will terminate on the earliest of:
1) The date the Insured reaches Age 65 or the end of the Benefit
Period, if later;
2) The date this contract terminates; and
3) The date you give Written Notice to cancel this rider.
Signed for Lutheran Brotherhood
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President SAMPLE /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇
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Secretary SAMPLE /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇
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WR3-VW-WSA-2 (97)
Date of Issue of this Rider: MAY 1 , 1997 Contract Number: LV1234567
----------------------------------------------------------------------------
WAIVER OF SELECTED AMOUNT BENEFIT
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INSURED: ▇▇▇▇ ▇▇▇ FORM WR3-VW-WSA-1 (97)
AGE: 35 SEX: MALE SELECTED AMOUNT: $1,200.00
TABLE OF MONTHLY COSTS
BEGINNING
ON RIDER ATTAINED MONTHLY
ANNIVERSARY AGE * COST #
MAY 1,
1997 35 3.0%
1998 36 3.0
1999 37 3.0
2000 38 3.0
2001 39 3.0
2002 40 3.5
2003 41 3.5
2004 42 3.5
2005 43 4.0
2006 44 4.5
2007 45 4.5
2008 46 5.0
2009 47 5.0
2010 48 5.0
2011 49 5.0
2012 50 6.0
2013 51 6.5
2014 52 8.0
2015 53 10.0
2016 54 12.5
2017 55 15.0
2018 56 18.0
2019 57 23.0
2020 58 27.0
2021 59 30.0
2022 60 7.0
2023 61 6.0
2024 62 5.0
2025 63 5.0
2026 64 5.0
* AGE LAST BIRTHDAY ON RIDER ANNIVERSARY ON OR IMMEDIATELY PRIOR TO MONTHLY
ANNIVERSARY.
# PERCENTAGE OF THE GREATER OF (1) THE SUM OF THE MONTHLY COST OF INSURANCE,
THE MONTHLY ADMINISTRATIVE CHARGES, ANY INITIAL MONTHLY CHARGES FOR
INCREASES AND THE MONTHLY COST OF ANY OTHER ADDITIONAL BENEFITS AND (2) ONE-
TWELFTH OF THE SELECTED AMOUNT.
WR3-VW-5 page 5-WSA
RIDER Contract Number: LV1234567
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ACCELERATED BENEFITS
--------------------------------------------------------------------------
We include this rider as part of this contract. If you so elect, we will
pay the Accelerated Benefit according to the provisions of this rider. If
we pay you an Accelerated Benefit, the amount of insurance and the
Accumulated Value for this contract will be reduced or eliminated.
BENEFIT PAYMENTS UNDER THIS RIDER MAY BE TAXABLE. CONSULT YOUR TAX ADVISOR.
1. DEFINITIONS.
la. Doctor. A physician having the designation M.D. or a doctor of
osteopathy having the designation D.O. acting within the legal scope
of his or her license. Doctor does not include you or the Insured or
a member of your family or the Insured's family.
lb. Nursing Home. A facility or that part of one which provides room,
board and inpatient care and:
1) Is licensed by the state in which it operates;
2) Provides nursing services under the supervision of a Doctor or a
registered graduate nurse (RN), licensed practical nurse (LPN)
or licensed vocational nurse (LVN);
3) Has an RN, LPN or LVN on duty or on call at all times and at
least one RN, LPN or LVN who is employed full time on the day
shift; and
4) Keeps a daily medical record of each patient.
Nursing Home does not include that part of any facility which is
primarily:
1) A sheltered living accommodation, a residence home or a similar
living arrangement; or
2) A home or facility for the treatment of alcoholism, drug
addiction or mental illness.
1c. Calculation Rate. The Calculation Rate on any day is the greater
of:
1) The yield on 90-day Treasury bills on that day; and
2) The maximum statutory adjustable policy loan interest rate on
that day.
2. EFFECTIVE DATE OF THIS RIDER. Unless a different date is
shown above, the effective date of this rider is the Date of Issue of
this contract.
3. THE BENEFIT. We will pay an Accelerated Benefit if you give us Written
Notice requesting the benefit and we receive proof satisfactory to us that
the Insured:
1) Has a life expectancy of twelve months or less; or
2) Has been confined in a Nursing Home, due to a condition which
usually requires continuous confinement, for at least six
consecutive months and confinement is expected to continue for the
lifetime of the Insured.
Proof must include certification by a Doctor. We may, at our expense,
require independent medical verification.
You may elect to receive all or part of the Eligible Amount (see Paragraph
4) as an Accelerated Benefit. Payment of an Accelerated Benefit is subject
to the Conditions of Payment (Paragraph 7). The benefit will be paid in a
lump sum. With our approval, you may instead elect to have the Accelerated
Benefit paid in equal periodic payments over a fixed period. The minimum
periodic payment is $500. If the Insured dies before all periodic payments
have been made, we will pay to the beneficiary the present value of the
remaining payments, calculated based on the same interest rate as that used
to determine the periodic payments.
WR3-VX-ACCB-1 (97)
Contract Number: LV1234567
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ACCELERATED BENEFITS (continued)
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4. ELIGIBLE AMOUNT. The amount available as an Accelerated Benefit will be
the present value of:
1) The amount that would be payable under this contract upon the death
of the Insured;
2) Expected future dividends;
Less
3) Expected future costs of insurance;
4) Expected future charges against this contract; and
5) An administrative fee of $150.
Present values will be calculated using the reduced life expectancy of the
Insured and an interest rate not greater than the Calculation Rate. The
Eligible Amount will be calculated on the date we receive satisfactory proof
that the Insured meets the requirements for the benefit (see Paragraph 3).
Items 2, 3 and 4 will be determined using the scales in effect on that date.
THE ELIGIBLE AMOUNT WILL BE LESS THAN THE AMOUNT THAT WOULD BE PAYABLE UPON
THE DEATH OF THE INSURED.
5. EFFECT OF ACCELERATION. If you elect to have all of the Insured's
Eligible Amount paid as an Accelerated Benefit, this contract will terminate
on the date the benefit is paid. Any riders on this contract that provide
insurance on the life of any other person will be administered according to
the rider provisions regarding the death of the Insured.
If only a portion of the Eligible Amount is paid as an Accelerated Benefit,
this contract will remain in force and the cost of insurance, amount of
insurance, amount of any loan balance and Accumulated Value of the contract
will be reduced. The amount of insurance, loan balance and accumulated value
in each subaccount will be reduced by the same percentage as the percentage
of the Eligible Amount that you elect to receive as an Accelerated Benefit.
The new cost of insurance will be that which would have been charged for the
new face amount based on the Date of Issue of this contract and the
Insured's issue age. Any insurance not included in the calculation of the
Eligible Amount will not be affected. We will send you information showing
the new cost of insurance, amount of insurance, contract loan amount and
Accumulated Value. Existing provisions for premium payments will continue.
If you elect to have only a portion of the Eligible Amount paid as an
Accelerated Benefit, you may make later requests for additional Accelerated
Benefits.
6. OTHER INSUREDS. If a rider on this contract provides life insurance on
a person other than the Insured, that insurance may be used to provide an
Accelerated Benefit on that person if we receive proof satisfactory to us
that he or she:
1) Has a life expectancy of twelve months or less; or
2) Has been confined in a Nursing Home, due to a condition which
usually requires continuous confinement, for at least six
consecutive months and confinement is expected to continue for the
lifetime of that person.
Proof must include certification by a Doctor. We may, at our expense,
require independent medical verification.
WR3-VX-ACCB-2 (97)
Contract Number: LV1234567
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ACCELERATED BENEFITS (continued)
----------------------------------------------------------------------------
6. OTHER INSUREDS (continued). The Accelerated Benefit for any person
other than the Insured is subject to the provisions and conditions of this
rider except that:
1) The Eligible Amount is the present value of:
a) The amount of life insurance provided on that person;
Less
b) Expected future monthly costs or other charges for that
person's life insurance; and
c) An administrative fee of $150.
Present values will be calculated using the reduced life expectancy
of that person and an interest rate not greater than the
Calculation Rate. The Eligible Amount for that person will be
calculated on the date we receive satisfactory proof that he or she
meets the requirements for the benefit. Item (b) will be
determined using the scales in effect on that date.
2) If you elect to have all of that person's Eligible Amount paid as an
Accelerated Benefit, all insurance on that person's life will
terminate on the date the benefit is paid. If only a portion of the
Eligible Amount is paid as an Accelerated Benefit, the rider will
remain in force and the monthly cost and amount of insurance for the
rider will be reduced. The amount of insurance will be reduced by
the same percentage as the percentage of the person's Eligible
Amount that you elect to receive as an Accelerated Benefit.
Insurance provided on the Insured or on any other person will not be
affected. We will send you information for the rider showing the
new monthly cost and the new amount of insurance.
7. CONDITIONS OF PAYMENTS. Payment of an Accelerated Benefit is subject to
the following conditions:
1) This contract must be in force.
2) Any assignee, irrevocable beneficiary or other party with ownership
rights must consent to payment of the Accelerated Benefit.
3) Election of an Accelerated Benefit is voluntary. You may not elect
an Accelerated Benefit if:
a) You are required by law to use this rider to meet the claims of
creditors; or
b) You are required by a government agency to use this benefit in
order to apply for, obtain or keep a government benefit or
entitlement.
4) The Accelerated Benefit payable for any person must be at least
$10,000 or, if smaller, that person's entire Eligible Amount.
5) If you elect to have only part of any person's Eligible Amount paid
as an Accelerated Benefit, the amount of insurance remaining in
force on that person after payment of the benefit must be at least
$10,000.
8. TERMINATION. This rider will terminate on the earlier of:
1) The date this contract is terminated; and
2) The date you give Written Notice to cancel this rider.
Signed for Lutheran Brotherhood
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President SAMPLE /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇
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Secretary SAMPLE /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇
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WR3-VX-ACCB-3 (97)
RIDER Contract Number: LV1234567
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LUTHERAN CHARITY BENEFIT
--------------------------------------------------------------------------
We include this rider as part of this contract. If, upon the death of a
person insured under this contract, we pay Charitable Death Proceeds of at
least $1,000 to a Lutheran Charitable Organization, then we will also pay a
Charitable Amount to that organization.
1. CHARITABLE AMOUNT. The Charitable Amount that we will pay to a Lutheran
Charitable Organization is the lesser of:
1) 10% of the Charitable Death Proceeds paid to that organization; and
2) $25,000.
However, if the amount determined above is less than $100, then no
Charitable Amount is payable to that organization.
2. LUTHERAN CHARITABLE ORGANIZATION. A legally incorporated nonprofit
organization which:
1) Qualifies as a charitable organization under Internal Revenue Code
Section 170(c), or its successor; and
2) Identifies itself as Lutheran.
3. CHARITABLE DEATH PROCEEDS. The amount we pay as a result of the death
of any person insured under this contract to a Lutheran Charitable
Organization designated as a beneficiary of that person's life insurance.
4. MULTIPLE CHARITABLE BENEFICIARIES. If Charitable Death Proceeds under
this contract are paid to more than one Lutheran Charitable Organization and
the total of Charitable Amounts determined as in Paragraph I would exceed
$25,000, then we will pay pro rata amounts to each organization such that
the total of Charitable Amounts that we pay on the death of a person insured
under this contract is equal to $25,000.
5. MULTIPLE CONTRACTS. If Charitable Death Proceeds are paid under more
than one Lutheran Brotherhood contract upon the death of the Insured and the
total of Charitable Amounts payable under all contracts as determined in
Paragraph 1 would exceed $25,000, then we will pay pro rata amounts to each
organization such that the total Charitable Amounts that we pay to Lutheran
Charitable Organizations upon the death of any insured person is equal to
$25,000.
Signed for Lutheran Brotherhood
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President SAMPLE /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇
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Secretary SAMPLE /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇
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WR3-VY-LCB-1 (97)
AMENDATORY AGREEMENT Contract Number: LV1234567
----------------------------------------------------------------------------
AVIATION EXCLUSION
----------------------------------------------------------------------------
1. CONFLICT WITH OTHER PROVISIONS. This agreement takes precedence over
any provision of this contract with which it is in conflict.
2. DESIGNATED INSURED. This agreement applies only to the Designated
Insured(s) named for this agreement on page 5-AVEX.
3. EXCLUSION. The amount payable upon the death of a Designated Insured is
limited if that person's death is a result of operating, descending from, or
riding in any aircraft where the Designated Insured:
1) Is a pilot, officer, or member of the crew of that aircraft; or
2) Is giving or receiving any kind of training or instruction aboard
that aircraft; or
3) Has any duties aboard that aircraft; or
4) Is being flown for the purpose of descent from that aircraft while in
flight.
4. LIMITED DEATH PROCEEDS. If a Designated Insured dies as in Paragraph 3,
the amount payable upon that person's death is limited as follows:
1) If that person is named as Insured on page 3 of this contract, then
the amount payable is limited to the greater of:
a) The reserve for this contract less any Debt; and
b) The premiums paid on this contract less the sum of:
i) The monthly cost deductions made for any riders which
provide coverage on a person other than the Designated
Insured;
ii) Any Partial Surrenders; and
iii) Any Debt.
2) If that person is covered only under a rider attached to this
contract, then the amount payable is limited to the sum of the
monthly cost deductions made for the rider covering that person.
In no case will this agreement increase the amount otherwise payable under
this contract. Any amount payable will be paid in a lump sum.
5. SCOPE OF THIS AGREEMENT. If this contract is changed or converted, this
agreement will be included in the new contract.
Signed for Lutheran Brotherhood
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President SAMPLE /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇
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Secretary SAMPLE /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇
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W-VA-Amend.AVEX (97)
Contract Number: LV1234567
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AVIATION EXCLUSION
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FORM W-VA-AMEND.AVEX (97)
DESIGNATED INSURED: ▇▇▇▇ ▇▇▇
W-VA-5 page 5-AVEX
AMENDATORY AGREEMENT Contract Number: LV1234567
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ARMED FORCES AVIATION EXCLUSION
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1. CONFLICT WITH OTHER PROVISIONS. This agreement takes precedence over
any provision of this contract with which it is in conflict.
2. DESIGNATED INSURED. This agreement applies only to the Designated
Insured(s) named for this agreement on page 5-AFAE.
3. EXCLUSION. The amount payable upon the death of a Designated Insured is
limited if that person's death is a result of operating, descending from, or
riding in any aircraft where the Designated Insured:
1) Is a pilot, officer, or member of the crew of that aircraft; or
2) Is giving or receiving any kind of training or instruction aboard
that aircraft; or
3) Is being flown for the purpose of descent from that aircraft while
in flight.
This exclusion will apply only while the Designated Insured is:
1) Acting as an advisor; or
2) On full or part-time duty; or
3) In training,
for the armed forces of one or more countries.
4. LIMITED DEATH PROCEEDS. If a Designated Insured dies as in Paragraph 3,
the amount payable upon that person's death is limited as follows:
1) If that person is named as Insured on page 3 of this contract, then
the amount payable is limited to the greater of:
a) The reserve for this contract less any Debt; and
b) The premiums paid on this contract less the sum of:
i) The monthly cost deductions made for any riders which
provide coverage on a person other than the Designated
Insured;
ii) Any Partial Surrenders; and
iii) Any Debt.
2) If that person is covered only under a rider attached to this
contract, then the amount payable is limited to the sum of the
monthly cost deductions made for the rider covering that person.
In no case will this agreement increase the amount otherwise payable under
this contract. Any amount payable will be paid in a lump sum.
5. SCOPE OF THIS AGREEMENT. If this contract is changed or converted, this
agreement will be included in the new contract.
Signed for Lutheran Brotherhood
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President SAMPLE /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇
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Secretary SAMPLE /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇
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W-VF-Amend.AFAE (97)
Contract Number: LV1234567
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ARMED FORCES AVIATION EXCLUSION
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FORM W-VF-AMEND.AFAE (97)
DESIGNATED INSURED: ▇▇▇▇ ▇▇▇
W-VF-5 page 5-AFAE
AMENDATORY AGREEMENT Contract Number: LV1234567
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SURVIVAL PROVISION
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1. CONFLICT WITH OTHER PROVISIONS. This agreement takes precedence over
any provision of this contract with which it is in conflict.
2. SURVIVAL PROVISION. Payment of proceeds will be made to the
beneficiaries according to the provisions of this contract. However, to
determine who will receive the proceeds on the death of any person insured
under this contract, any beneficiary of that person who dies simultaneously
with that person or within a specified number of days after that person will
be deemed to have died before that person. The number of days is on the
request form for this agreement.
3. TERMINATION. You may terminate this agreement by Written Notice.
Signed for Lutheran Brotherhood
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President SAMPLE /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇
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Secretary SAMPLE /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇
W-VS-Amend.Surv Prov (97)
AMENDATORY AGREEMENT
Contract Number: LV1234567
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PRIMARY BENEFICIARY SURVIVAL PROVISION
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1. CONFLICT WITH OTHER PROVISIONS. This agreement takes precedence over
any provision of this contract with which it is in conflict.
2. PRIMARY BENEFICIARY SURVIVAL PROVISION. Payment of proceeds will be
made to the beneficiaries according to the provisions of this contract.
However, to determine who will receive the proceeds on the death of any
person insured under this contract, any primary beneficiary of that person
who dies simultaneously with that person or within a specified number of
days after that person will be deemed to have died before that person. The
number of days is on the request form for this agreement.
3. TERMINATION. You may terminate this agreement by Written Notice.
Signed for Lutheran Brotherhood
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President SAMPLE /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇
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Secretary SAMPLE /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇
W-VP-Amend.PBSP (97)
▇▇-▇▇\s-6\1997\riders.doc
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