Exhibit 99.1A(5)(a)
[FARM BUREAU LOGO] SOUTHERN FARM BUREAU
LIFE INSURANCE COMPANY
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Xxxx Xxxxxx Xxx 00 - Xxxxxxx, Xxxxxxxxxxx 00000 - 000-000-0000
AGREEMENT PROVIDING WAIVER OF MONTHLY DEDUCTIONS
ON INSURED'S TOTAL DISABILITY
BENEFIT
On receipt of due proof of the Insured's total disability while this agreement
is in force, We will waive monthly deductions during such total disability. If
the Insured becomes totally disabled, We will waive the Monthly Deductions
starting with the one on the Monthly Deduction Day next following the date total
disability began. If total disability began on a Monthly Deduction Day, We will
waive the Monthly Deduction on that day as well.
If We have deducted any Monthly Deductions since total disability began, We will
restore them to the accumulated value of this policy as of the date the
deductions were taken. We will not waive or restore any Monthly Deduction if the
Monthly Deduction Day on which it was deducted is more than one year before the
date We receive Your Written Notice and proof of the Insured's total disability.
However, failure to give notice and proof within such time will not void any
claim if notice and proof was given as soon as reasonably possible.
MONTHLY COST OF INSURANCE FOR THIS AGREEMENT
The Cost of Insurance for this agreement is included in the Monthly Deduction
for the policy to which it is attached. It is determined by the following
procedure:
a) Divide the Death Benefit of the policy on the Monthly Deduction Day by
1.0032737.
b) Reduce the result (a) by the amount of the Accumulated Value of the
policy on the Monthly Deduction Day.
c) Multiply the difference (b) by .001.
d) Multiply (c) by the appropriate cost of insurance rate for waiver of
monthly deductions per $1,000.
The cost of insurance rate for waiver of monthly deductions is shown on the
policy Schedule Page or on an endorsement to the Policy Schedule Page.
DEFINITION OF TOTAL DISABILITY
Total disability means disability which:
(a) results from bodily injury or disease;
(b) begins while this agreement is in force and before the lnsured's
attained age 60;
(c) exists continuously for at least six consecutive months; and
(d) prevents the Insured from engaging in any occupation for which he or
she is or becomes reasonably qualified by education, training, or
experience.
FORM L507 1
The total and irrecoverable loss of any of the following will be considered
total disability:
(a) sight of both eyes;
(b) use of both hands;
(c) use of both feet; or
(d) use of one hand and one foot.
DISABILITIES NOT COVERED
Monthly Deductions will not be waived under this agreement if total
disability results from any of the following causes:
(a) bodily injury occurring or disease contracted or commencing prior to
the effective date of this agreement;
(b) intentionally self-inflicted injury;
(c) any act of war, declared or undeclared; or
(d) military, naval, or air service of any country or international
organization at war, declared undeclared.
NOTICE AND PROOF OF DISABILITY
Written notice of a claim and proof of total disability must be received at the
Home Office:
(a) during the lnsured's lifetime;
(b) during the continuance of total disability; and
(c) not later than six months after this agreement terminates.
CONTINUANCE OF DISABILITY
We may require proof of continuance of total disability, including examination
of the Insured by a physician other than the Insured. After total disability has
continued for two years, such proof will not be required more often than once a
year. Waiver of Monthly Deductions will cease if:
(a) proof of the continuance of total disability is not furnished;
(b) the Insured refuses to submit to an examination as required; or
(c) the Insured ceases to be totally disabled.
Premiums becoming due on the policy after waiver under this agreement has ceased
must be paid to Us.
INCONTESTABILITY
We will not contest liability under this agreement after it has been in force
for two years from its effective date, except for nonpayment of the Cost of
Insurance for this agreement.
FORM L507 2
TERMINATION
This agreement will terminate on the earliest of the following:
(a) the end of the grace period for any premium which remains unpaid on
either the policy or this agreement;
(b) the lnsured's attained age 60, if the Insured is not then totally
disabled;
(c) when the Insured ceases to be totally disabled, if the Insured is
totally disabled on the attained age 60;
(d) on the surrender, maturity, expiry, exchange, or other termination of
the policy; or
(e) the premium due date next following receipt at the Home Office of
Written Notice to the Company requesting termination.
If a Monthly Cost of Insurance for this agreement is paid for any period after
termination of the agreement, Our only liability will be to refund any Monthly
Cost of Insurance so deducted.
GENERAL PROVISIONS
This agreement is issued in consideration of the application and of the payment
of premiums. It is made a part of the policy to which it is attached.
The effective date of this agreement is the policy date, unless this agreement
was made a part of the policy after the policy date. In that event, the
effective date of this agreement is shown on the Schedule Page or on an
endorsement to the Schedule Page.
The benefits provided by this agreement are subject to the terms and conditions
of this agreement and the policy.
/s/ X.X. Xxxxxx
Secretary
FORM L507 3
