THE INSURED XXXXXXX XXX VARIABLE
LIFE INSURANCE
POLICY OWNER XXXXXXX XXX POLICY
INITIAL EQUITABLE
FACE AMOUNT $100,000 VARIABLE LIFE INSURANCE COMPANY
[EVLICO LOGO]
POLICY NUMBER SPECIMEN
EQUITABLE VARIABLE LIFE INSURANCE COMPANY
A Stock Life Insurance Company
Agrees
o To pay the insurance benefits of this policy to the Beneficiary upon receiving
proof of the Insured's death; and
o To provide you (the policy Owner) with the other rights and benefits of this
policy.
These agreements are subject to the provisions of this policy.
The face amount increases at the rate of 3% at the beginning of each policy
year after the first.
THE DEATH BENEFIT OF THIS POLICY DURING THE FIRST POLICY YEAR WILL EQUAL THE
INITIAL FACE AMOUNT SHOWN ON PAGE 3. THEREAFTER, IT MAY INCREASE OR DECREASE
EACH YEAR AS DESCRIBED ON PAGE 4 DEPENDING UPON SEPARATE ACCOUNT INVESTMENT
EXPERIENCE, BUT SHALL NEVER BE LESS THAN THE FACE AMOUNT FOR THE POLICY YEAR IN
WHICH THE INSURED DIES.
THE ACCOUNT VALUE AND THE CASH VALUE OF THIS POLICY WILL VARY FROM DAY TO DAY.
THEY MAY INCREASE OR DECREASE DEPENDING UPON SEPARATE ACCOUNT INVESTMENT
EXPERIENCE.
The amount of the single premium for this policy is shown on page 3.
RIGHT TO EXAMINE POLICY. You may examine this policy and if for any reason you
are not satisfied with it, you may cancel it by returning the policy with a
written request for cancellation to our Administrative Office by the later of:
(a) the 10th day after you receive it; or (b) the 45th day after Part 1 of the
application was signed. If you do this, we will refund the premium that was
paid.
SPECIMEN SPECIMEN
Xxxxx Xxxxx Secretary Xxxxxx X. Xxxxxx President
Single Premium Whole Life Plan. Variable insurance payable upon
death. Guaranteed Minimum Death Benefit. Face amount increases
annually by 3% at the beginning of each policy year after the
first. Non-Participating. Investment experience reflected in
benefits. Investment options described on page 6.
No. 83-10
[EVLICO LOGO]
0000 Xxxxxx xx xxx Xxxxxxxx, Xxx Xxxx, 00000
CONTENTS
Insurance benefits 2
Policy owner and beneficiary 4
Death Benefit 4
Account Value 4
Cash Value 4
Loans 5
The Separate Accounts 5
Investment Options,
allocations, transfers 6
Exchange of Policy 6
General Provisions 7
Payment Options 8
Basis of Values 10
(Net rates of return, variable adjustment amount, benefit base, calculation of
Account Values)
A copy of the application for this policy is at the back of the policy.
IN THIS POLICY:
"We," "our" and "us" mean Equitable Variable Life Insurance Company.
"You" and "your" mean the Owner of the policy at the time an Owner's right is
exercised.
ADMINISTRATIVE OFFICE
The address of our Administrative Office is shown on page 3. You should send
requests to that address unless instructed otherwise.
INSURANCE BENEFITS
The insurance benefits we pay at the insured's death include:
o the Death Benefit described on page 4;
o minus any loan (and loan interest) on the policy.
We will add interest to the resulting amount for the period from the date of
death to the date of payment. It will be computed at the interest rate we are
then paying under the Deposit Option on page 8.
Payment of these benefits may be affected by other provisions of this policy.
See the Suicide Exclusion, Incontestability and Age and Sex clauses on page 7.
Special exclusions or limitations (if any ) are listed on page 3.
No. 83-10 Page 2
THE INSURED XXXXXXX XXX REGISTER DATE JUN 1, 1983
POLICY OWNER XXXXXXX XXX DATE OF ISSUE JUN 1, 1983
INITIAL
FACE AMOUNT $100,000 ISSUE AGE, SEX 35 MALE
POLICY NUMBER SPECIMEN BENEFICIARY XXXXXXXX X. XXX
STATE OF
RESIDENCE SPECIMEN STATE
************************** BENEFITS AND PREMIUMS TABLE *************************
BENEFITS SINGLE PREMIUM
FOR THIS POLICY
LIFE INSURANCE - VARIABLE $71,280.61
THE SINGLE PREMIUM IS $71,280.61 AND IS DUE ON OR BEFORE DELIVERY OF THE POLICY.
THE FOLLOWING DEDUCTIONS ARE MADE FROM THE SINGLE PREMIUM:
ADMINISTRATIVE EXPENSE: $ 200.00
STATE PREMIUM TAX: 1,425.61
THE NET SINGLE PREMIUM AMOUNT ALLOCATED TO THE SEPARATE ACCOUNT(S) IS
$69,655.00.
*************** INVESTMENT ALLOCATION OF NET SINGLE PREMIUM AMOUNT**************
SEPARATE ACCOUNT I 50%
SEPARATE ACCOUNT II 50%
****************************TABLE OF FACE AMOUNTS *****************************
POLICY FACE POLICY FACE POLICY FACE
YEAR AMOUNT YEAR AMOUNT YEAR AMOUNT
1 $100,000 9 $126,678 17 $160,472
2 103,000 10 130,478 18 165,286
3 106,090 11 134,392 19 170,245
4 109,273 12 138,424 20 175,352
5 112,551 13 142,577 AGE 60 209,379
6 115,928 14 146,854 AGE 62 222,130
7 119,406 15 151,260 AGE 65 242,728
8 122,988 16 155,798 AGE 70 281,388
******* ADMINISTRATIVE OFFICE: EQUITABLE VARIABLE LIFE INSURANCE COMPANY *******
SPECIMEN REGIONAL SERVICE CENTER
000 XXXXXXXX XX.
CITY, STATE 10001
V83-10-3 PAGE 3
0030L/Pg.28
THE INSURED XXXXXXX XXX REGISTER DATE JUN 1, 1983
INITIAL
FACE AMOUNT $100,000 DATE OF ISSUE JUN 1, 1983
POLICY NUMBER SPECIMEN ISSUE AGE, SEX 35 MALE
******************************* TABULAR VALUES *********************************
THE ACCOUNT VALUE AND CASH VALUE OF THIS POLICY MAY BE GREATER OR LESS THAN
AMOUNTS SHOWN AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT
SEE PAGE 4 FOR ACCOUNT VALUE AND CASH VALUE PROVISIONS
TABULAR VALUES AT ENDS OF POLICY YEARS
END OF TABULAR TABULAR
POLICY YEAR ACCOUNT VALUES CASH VALUES
1 $ 72,366 $ 66,509
2 75,182 69,740
3 78,105 73,127
4 81,138 76,677
5 84,285 80,398
6 87,548 84,296
7 90,931 88,380
8 94,439 92,660
9 98,076 97,145
10 101,845 101,845
11 105,752 105,752
12 109,799 109,799
13 113,991 113,991
14 118,332 118,332
15 122,826 122,826
16 127,478 127,478
17 132,291 132,291
18 137,271 137,271
19 142,422 142,422
20 147,749 147,749
AGE 60 177,186 177,186
AGE 62 190,354 190,354
AGE 65 211,722 211,722
AGE 70 251,930 251,930
THESE VALUES DO NOT REFLECT LOANS. VALUES NOT SHOWN WILL BE FURNISHED ON
REQUEST.
V83-10-3A PAGE 3A
ak/0177L
TABLE OF NET SINGLE PREMIUMS
For $1.00 of Variable Adjustment Amount or Paid-Up Whole Life Increasing
Insurance. Values shown are applicable on policy anniversaries. The net single
premium as of a date during a policy year shall be determined by interpolation
between the values applicable on the immediately preceding and immediately
following anniversaries.
Age of Age of Age of Age of Age of
Insured Net Insured Net Insured Net Insured Net Insured Net
(Nearest Single (Nearest Single (Nearest Single (Nearest Single (Nearest Single
Birthday) Premium Birthday) Premium Birthday) Premium Birthday) Premium Birthday) Premium
---------- ------- --------- ------- --------- ------- --------- -------- --------- -------
MALE INSURED
------------
1 $.51971 21 $.61724 41 $.73320 61 $.85165 81 $ .93500
2 .52393 22 .62256 42 .73935 62 .85696 82 .93783
3 52832 23 .62793 43 .74551 63 .86215 83 .94052
4 .53278 24 .63335 44 .75167 64 .86727 84 .94309
5 53732 25 .63883 45 .75782 65 .87226 85 .94556
6 .54193 26 .64436 46 .76397 66 .87715 86 .94793
7 .54662 27 .64995 47 .77011 67 .88190 87 .95023
8 .55137 28 .65560 48 .77622 68 .88652 88 .95248
9 .55619 29 .66129 49 .78231 69 .89099 89 .95470
10 .56107 30 .66704 50 .78838 70 .89532 90 .95690
11 .56600 31 .67284 51 .79440 71 .89950 91 .95910
12 .57098 32 .67869 52 .80039 72 .90354 92 .96133
13 .57601 33 .68460 53 .80632 73 .90746 93 .96360
14 .58106 34 .69055 54 .81222 74 .91128 94 .96595
15 .58614 35 .69655 55 .81805 75 .91501 95 .96845
16 .59125 36 .70259 56 .82383 76 .91864 96 .97119
17 .59638 37 .70867 57 .82955 77 .92218 97 .97423
18 .60154 38 .71477 58 .83519 78 .92560 98 .97751
19 .60673 39 .72090 59 .84076 79 .92888 99 .98064
20 .61196 40 .72705 60 .84625 80 .93202 100 1.00000
FEMALE INSURED
--------------
1 $.49309 21 $.58614 41 $.69655 61 $.81805 81 $ .91501
2 .49707 22 .59125 42 .70259 62 .82383 82 .91864
3 .50122 23 .59638 43 .70867 63 .82955 83 .92218
4 .50544 24 .60154 44 .71477 64 .83519 84 .92560
5 .50975 25 .60673 45 .72090 65 .84076 85 .92888
6 .51412 26 .61196 46 .72705 66 .84625 86 .93202
7 .51856 27 .61724 47 .73320 67 .85165 87 .93500
8 .52307 28 .62256 48 .73935 68 .85696 88 .93783
9 .52765 29 .62793 49 .74551 69 .86216 89 .94052
10 .53228 30 .63335 50 .75167 70 .86727 80 .94309
11 .53696 31 .63883 51 .75782 71 .87226 91 .94556
12 .54168 32 .64436 52 .76397 72 .87715 92 .94793
13 .54645 33 .64995 53 .77011 73 .88190 93 .95023
14 .55127 34 .65560 54 .77622 74 .88652 94 .95248
15 .55614 35 .66129 55 .78231 75 .89099 95 .95470
16 .56105 36 .66704 56 .78838 76 .89532 96 .95690
17 .56600 37 .67284 57 .79440 77 .89950 97 .95910
18 .57098 38 .67869 58 .80039 78 .90354 98 .96133
19 .57601 39 .68460 59 .80632 79 .90746 99 .96360
20 .58106 40 .69055 60 .81222 80 .91128 100 .96595
101 .96845
102 .97119
103 .97423
104 .97751
105 .98064
106 1.00000
V83-10-3B Page 3B
POLICY OWNER AND BENEFICIARY
OWNER. The Owner of this policy is the Insured unless otherwise stated in the
application, or later changed. As Owner, you can exercise all the rights in this
policy while the Insured is living. You do not need the consent of anyone who
has only a conditional or future ownership interest in this policy.
BENEFICIARY. The Beneficiary is as stated in the application, unless later
changed. If two or more persons are named, those surviving the Insured will
share equally unless otherwise stated.
We will pay any benefit for which there is no stated Beneficiary living at the
death of the Insured to the children of the Insured who then survive, in equal
shares. If none survive, we will pay the estate of the Insured.
CHANGES. While the Insured is living, you may change the Owner or Beneficiary by
written notice in a form satisfactory to us. The change will take effect on the
date you sign the notice, except that it will not apply to any payment we make
or other action we take before we receive the notice at our Administrative
Office. If you change the Beneficiary, any previous arrangement you made under
the Payment Options provision on page 8 is cancelled.
ASSIGNMENT. You may assign this policy, but we will not be bound by an
assignment unless it is in writing and we have received it at our Administrative
Office. Your rights and those of any other person referred to in this policy
will be subject to the assignment. We assume no responsibility for the validity
of any assignment.
DEATH BENEFIT
The Death Benefit equals:
o the face amount shown on page 3 for the policy year in which the Insured
dies.
o plus the sum, if positive, of the Variable Adjustment Amounts, for each
separate account under this policy in which you have a cash value, for
the policy year in which the Insured dies.
However, the Death Benefit will in no event be less than the amount of Paid-up
Whole Life Increasing Insurance that could be purchased by the Account Value at
the Insured's death on the basis of the Table of Net Single Premiums on page 3B.
See page 10 for a description of how the Variable Adjustment Amount for each
separate account is determined.
ACCOUNT VALUE
The policy's Account Value will vary daily with the performance of the separate
accounts in which you have an Account Value under this policy. See page 11 for a
description of how the Account Value is determined.
CASH VALUE
You may give up this policy for its net cash value at any time while the Insured
is living. The net cash value is the cash value minus any loan and loan
interest.
We will determine the net cash value on the date we receive your signed request
for it at our Administrative Office. The policy will terminate on the date you
send the policy and the request to us.
CASH VALUE. The policy's cash value will vary daily with the performance of the
separate accounts in which you have a cash value under this policy.
During the first ten policy years the cash value on any date will be equal to
the product of (1) and (2), where:
(1) is the Account Value on that date; and
(2) is the Tabular Cash Value divided by the Tabular Account Value for that
date.
Tabular Account Values and Tabular Cash Values are shown on page 3A.
After the tenth policy year, the cash value will equal the Account Value.
V83-10-3B Page 4
LOANS
You may get a loan on this policy while it has a loan value. This policy will be
the sole security for the loan.
The amount of the loan may not be more than the loan value. A loan must be at
least $100 more than any existing loan and loan interest. Any existing loan and
loan interest will be deducted from the new loan.
A loan, whether you repay it or not, will have a permanent effect on the
Variable Adjustment Amounts, Death Benefit, Account Value and cash value under
this policy.
We will allocate loans to the separate accounts based on your net cash value in
each separate account as of the dates the loans are made. we will allocate loan
repayments to the separate accounts based on the amount of your outstanding
loans as to each separate account as of the dates the repayments are made.
LOAN VALUE. The loan value is 90% of the policy's cash value.
LOAN INTEREST. Interest on a loan accrues daily, at an annual rate of 5%.
Interest is due on each policy anniversary. If the interest is not paid when
due, it will be added to the loan and bear interest at the loan rate.
When a loan plus loan interest first exceeds the cash value, we will mail to you
and any assignee of record at last known addresses a notice that the policy will
terminate if such excess amount is not repaid within 31 days after we mailed
such notice.
REPAYMENT. You may repay a loan and loan interest in whole or in part at any
time while the Insured is living and this policy is in effect. We will deduct
any existing loan and loan interest from any benefits we pay at the Insured's
death.
THE SEPARATE ACCOUNTS
We established and we maintain Separate Accounts I and II under the laws of New
York State. Realized and unrealized gains and losses from the assets of Separate
Accounts I and II are credited or charged against such accounts without regard
to our other income, gains, or losses. Assets are put in Separate Accounts I and
II to support this policy and other variable life insurance policies. Assets may
be put in Separate Accounts I and II for other purposes, but not to support
contracts or policies other than variable life insurance.
We expect the investments in Separate Account I will be, primarily, common
stocks and other equity-type investments. We expect the investments in Separate
Account II will be, primarily, short-term (not to exceed one year) money market
instruments, such as: United States (U.S.) government and U.S. government agency
securities; bank money instruments; time deposits; certificates of deposit; high
grade commercial paper, including master demand notes; and repurchase agreements
covering U.S. government obligations and certificates of deposit. But, we may
invest the assets of Separate Accounts I and II in any legal investments. We
will rely upon our own and outside counsel for advice in this regard.
Instead of making direct investments, we may also operate either Separate
Account I or II as a unit investment trust, or other form. We would invest all
or part of such account's assets in shares or units of a fund. We, an affiliate,
or The Equitable Life Assurance Society of the United States would be the
investment adviser and would invest the assets of the fund as above.
The assets of Separate Accounts I and II are our property. The portion of the
assets of Separate Accounts I and II equal to the reserves and other policy
liabilities with respect to such separate accounts will not be chargeable with
liabilities arising out of any other business we conduct. We may transfer assets
of such separate accounts in excess of such reserves and liabilities to our
general account.
We will value the assets of Separate Accounts I and II on each business day. A
business day is any day on which the New York Stock Exchange is open for
trading.
We have the right to create new separate accounts. We have the right to withdraw
assets of a class of policies to which this policy belongs from either
V83-10-5 Page 5
THE SEPARATE ACCOUNTS CONTINUED
separate account and put them in another separate account. If we do this, we
will withdraw the same percentage of each investment in such separate account,
but will avoid odd lots and fractions. We also have the right to combine any two
or more separate accounts. The term "Separate Account I" or "Separate Account
II" in this policy shall then refer to any other separate account in which the
assets of a class of policies to which this policy belongs were placed.
We have the right to:
1. register or deregister either separate account under the Investment Company
Act of 1940;
2. run either separate account under the direction of a committee, and to
discharge such committee at any time; and
3. restrict or eliminate any voting rights of policyowners, or other persons
who have voting rights as to either separate account.
CHANGES OF INVESTMENT ADVISER OR INVESTMENT POLICY. Unless otherwise required by
law or regulation, the investment adviser or any investment policy may not be
changed without our consent. If required by law or regulation, the investment
policy of either separate account will not be changed unless approved by the
Superintendent of Insurance of New York State or deemed approved in accordance
with such law or regulation. If so required, we have filed the process for
getting such approval with the insurance supervisory official of the
jurisdiction in which this policy is delivered.
INVESTMENT OPTIONS
ALLOCATION OF NET SINGLE PREMIUM. We will allocate to each separate account as
of the Register Date a percentage of the Net Single Premium Amount shown on page
3. Such allocation will be based on the allocation percentages designated in the
application for this policy.
TRANSFER OF ACCOUNT VALUES. You may ask us to transfer all or part of your
Account Value in one of the separate accounts to the other. Only two such
transfers may be made in a policy year. We will make the transfer as of the date
we receive your written request for it at our Administrative Office.
EXCHANGE OF POLICY
You may exchange this policy for a policy of permanent fixed benefit insurance
on the life of the Insured. You may make such an exchange within 18 months after
the Date of Issue shown on page 3. We will not require evidence of insurability.
We will require:
1. That this policy be in effect on the date of exchange; and
2. Repayment of any loan and loan interest on this policy.
The date of exchange will be the later of: (a) the date you send us this policy
and the signed request on our form for such exchange; or (b) the date we receive
at our Administrative Office any sum due to be paid for such exchange.
THE NEW POLICY. The new policy will be the "Single Premium Life Plan" policy
being offered by The Equitable Life Assurance Society of the United States
(Equitable) on the Date of Issue of this policy. It is a policy of permanent
fixed benefit life insurance. The new policy will have a face amount equal to
the initial face amount of this policy. It will have the same Register Date,
Date of Issue, and Issue Age as this policy. The single premium for the new
policy will be based on Equitable's rates in effect on its Register Date for the
same class of risk as under this policy.
Upon request you will be told the amount of the single premium for the new
policy, and of any extra sum required or allowance to be made for a premium or
cash value adjustment that takes appropriate account of the premiums and cash
values under this policy and under the new policy. If so required, we have filed
a detailed statement of the method of computing such an adjustment with the
insurance supervisory official of the jurisdiction in which this policy is
delivered.
V83-10-5 Page 6
GENERAL PROVISIONS
THE CONTRACT. This insurance is granted in consideration of payment of the
single premium for this policy shown on page 3. This policy and the application
(a copy of which is attached at issue) constitute the entire contract. The
rights conferred by this policy are in addition to those provided by applicable
Federal and State laws and regulations.
The contract may not be modified, nor may any of our rights or requirements be
waived, except in writing signed by our President, one of our Vice Presidents,
or by our Secretary or Treasurer.
INCONTESTABILITY. All statements made in the application are representations and
not warranties. We have the right to contest the validity of this policy based
on material misstatements made in the application. However, this policy will
become incontestable after it has been in effect during the lifetime of the
Insured for two years from the Date of Issue shown on page 3.
AGE AND SEX. If the Insured's age or sex has been misstated, any benefits will
be those that the premium paid would have purchased at the correct age and sex.
SUICIDE EXCLUSION. If the Insured commits suicide, while sane or insane, within
two years after the Date of Issue shown on page 3, our liability will be limited
to the payment of a single sum equal to the premium paid, minus any loan and
loan interest.
POLICY PERIODS AND ANNIVERSARIES. Policy years and policy anniversaries are
measured from the Register Date. If the end of a policy year is indicated by an
age, it ends on the policy anniversary nearest the birthday on which the Insured
reaches that age.
REPORTS. Each policy year after the first we will give you a report showing the
Death Benefit, the Account Value and the cash value as of the first day of such
year. The amount of any existing loan and the accrued loan interest for the
previous policy year will also be shown. We will also give you such other
reports as may be required by law.
BASIS OF COMPUTATION. Account Values, reserves and net single premiums are based
on the Commissioners 1958 Standard Ordinary Mortality Table. Continuous
functions are used with interest compounded annually at 4%.
The cash values are equal to or more than those required by law. If so required,
we have filed a detailed statement of the method of computing cash values with
the insurance supervisory official of the jurisdiction in which this policy is
delivered. The Tabular Account Value at the end of each policy year equals the
tabular reserve. Our expense and mortality results will not adversely affect the
dollar amount of insurance benefits or Account Values or cash values.
DETERMINATION AND PAYMENT OF VARIABLE BENEFITS. We will make payments under this
policy as follows:
o A cash value will be paid within 7 days after we receive your policy and
request at our Administrative Office;
o A loan will be paid within 7 days after we receive your request at our
Administrative Office; and
o The insurance benefits will be paid within 7 days after we receive at our
Administrative Office proof of the Insured's death and all other
requirements deemed necessary before such payment may be made.
We may not be able to sell securities or determine the value of the assets of
the separate accounts if: (1) the New York Stock Exchange is closed; (2) the
Securities and Exchange Commission requires trading to be restricted or declares
an emergency; or (3) the Securities and Exchange Commission by order permits us
to defer payments for the protection of our policy owners. During such times we
may defer:
1. Determination of Account Values;
2. Determination and payment of cash values;
3. Payment of loans;
4. Determination of a change in a Variable Adjustment Amount, and payment of
any portion of the Death Benefit equal to the Variable Adjustment Amount;
5. Any requested transfer of Account Value; and
6. Use of insurance benefits under the Payment Options.
V83-10-7 Page 7
PAYMENT OPTIONS
Payments under these options will not be affected by the investment
experience of any separate account after proceeds are applied
under such options.
Instead of having the insurance benefits or net cash value paid immediately in
one sum, you can choose another form of payment for all or part of them. If you
do not arrange for this before the Insured dies, the Beneficiary will have this
right when the Insured dies. Arrangements you make, however, cannot be changed
by the Beneficiary after the Insured's death. The options are:
1. DEPOSIT OPTION: Left on deposit for a period mutually agreed upon, with
interest paid at the end of each month, each 3 months, each 6 months or
each 12 months, as chosen.
2. INSTALMENT OPTIONS:
A. FIXED PERIOD: Paid in equal instalments for a specified number of
years (not more than 30). The instalments will not be less than those
shown in the Table of Guaranteed Payments on page 9.
B. FIXED AMOUNT: Paid in instalments as mutually agreed upon until the
amount applied, together with interest on the unpaid balance, is used
up.
3. LIFE INCOME OPTIONS:
Paid as a monthly income for life in an amount we determine but not less
than shown in the Table of Guaranteed Payments on page 9. We guarantee
payments for life and in any event for 10 years, 20 years, or until the
payments we make equal the amount applied (called "refund certain"),
according to the "certain" period chosen.
4. OTHER: We will apply the sum under any other option requested that we make
available at time of the Insured's death or net cash value withdrawal.
We guarantee interest under Option 1 at the rate of 3% a year and under Option 2
at 3-1/2% a year, or such higher rates as we may determine. We may allow excess
interest under Options 1 and 2.
The payee under an option may name and change a successor payee for any amount
we would otherwise pay the payee's estate.
Any arrangements involving more than one of the options, or a payee who is not a
natural person (for example, a corporation) or who is a fiduciary, must have our
approval. Also, details of all arrangements will be subject to our rules at the
time the arrangement takes effect. These include rules on: the minimum amount we
will apply under an option and minimum amounts for installment payments;
withdrawal or commutation rights; naming payees and successor payees; and
proving age and survival.
Choices (or any later changes) under these options will be made and will take
effect in the same way as a change of Beneficiary. Amounts applied under these
options will not be subject to the claims of creditors or to legal process, to
the extent permitted by law.
V83-10-7 Page 8
TABLE OF GUARANTEED PAYMENTS
MINIMUM AMOUNT FOR EACH $1,000 OF ORIGINAL SUM
OPTION 2
FIXED PERIOD INSTALLMENTS
-------------------------
Number
of Years' Monthly Annual
Installments Instalment Instalment
------------ ---------- ----------
1 $84.70 $1000.00
2 43.08 508.60
3 29.21 344.86
4 22.28 263.04
5 18.12 213.99
6 15.36 181.32
7 13.38 158.01
8 11.91 140.56
9 10.76 127.00
10 9.84 116.18
11 9.09 107.34
12 8.47 99.98
13 7.94 93.78
14 7.49 88.47
15 7.11 83.89
16 6.77 79.89
17 6.47 76.37
18 6.20 73.25
19 5.97 70.47
20 5.76 67.98
21 5.57 65.74
22 5.40 63.70
23 5.24 61.85
24 5.10 60.17
25 4.97 58.62
26 4.84 57.20
27 4.73 55.90
28 4.63 54.69
29 4.54 53.57
30 4.45 52.53
If installments are paid every 3 months, they will be 25.32% of the annual
installments. If they are paid every 6 months, they will be 50.43% of the annual
installments.
OPTION 3
MONTHLY LIFE INCOME
-------------------
10 Years Certain 20 Years Certain Refund Certain
---------------- ---------------- --------------
AGE Male Female Male Female Male Female
--- ---- ------ ---- ------ ---- ------
50 $4.50 $3.96 $4.27 $3.89 $ 4.28 $3.87
51 4.58 4.02 4.32 3.94 4.35 3.93
52 4.67 4.09 4.38 4.00 4.42 3.99
53 4.75 4.16 4.44 4.06 4.50 4.05
54 4.85 4.24 4.50 4.12 4.58 4.11
55 4.94 4.32 4.56 4.18 4.66 4.18
56 5.04 4.40 4.62 4.24 4.74 4.25
57 5.15 4.49 4.68 4.31 4.83 4.33
58 5.26 4.58 4.74 4.38 4.93 4.41
59 5.37 4.68 4.81 4.45 5.03 4.49
60 5.49 4.78 4.86 4.52 5.13 4.58
61 5.62 4.89 4.92 4.59 5.24 4.67
62 5.75 5.00 4.98 4.66 5.35 4.77
63 5.88 5.12 5.04 4.73 5.48 4.88
64 6.03 5.25 5.09 4.80 5.60 4.99
65 6.17 5.39 5.14 4.88 5.74 5.10
66 6.32 5.53 5.19 4.95 5.88 5.22
67 6.48 5.68 5.24 5.01 6.03 5.35
68 6.64 5.83 5.28 5.08 6.18 5.49
69 6.80 6.00 5.32 5.14 6.35 5.64
70 6.97 6.17 5.35 5.20 6.53 5.79
71 7.15 6.34 5.38 5.26 6.71 5.96
72 7.32 6.53 5.41 5.30 6.91 6.13
73 7.50 6.72 5.43 5.35 7.12 6.32
74 7.67 6.92 5.45 5.38 7.34 6.52
75 7.85 7.12 5.47 5.42 7.58 6.73
76 8.02 7.32 5.48 5.44 7.82 6.96
77 8.19 7.53 5.49 5.46 8.09 7.21
78 8.36 7.75 5.50 5.48 8.38 7.47
79 8.52 7.96 5.50 5.49 8.67 7.75
80 8.67 8.16 5.51 5.50 9.00 8.05
81 8.81 8.36 5.51 5.51 9.34 8.39
82 8.94 8.55 5.51 5.51 9.70 8.73
83 9.06 8.73 5.51 5.51 10.10 9.12
84 9.16 8.90 5.51 5.51 10.52 9.53
85 & over 9.26 9.05 5.51 5.51 10.96 9.97
Amounts for Monthly Life Income are based on age nearest birthday when
income starts. Amounts for ages not shown will be furnished on request.
V83-10-9 Page 9
BASIS OF VALUES
ACTUAL NET RATE OF RETURN (ACTUAL NRR). For each separate account, the Actual
Net Rate of Return for a policy year reflects the account's:
o investment income;
o plus realized and unrealized capital gains;
o minus realized and unrealized capital losses;
o minus any charge for taxes or amounts set aside as a reserve for taxes;
o minus a charge not exceeding .25% per year for investment management
expenses; and
o minus a charge not exceeding .50% per year for mortality, expenses and other
risks.
The Actual NRR for a period less than a year will be calculated in a consistent
manner.
BASE NET RATE OF RETURN (BASE NRR). The Base NRR is 4% per year. (It is a
pro-rata part of 4% for periods of less than a year.)
If the Actual NRR for all separate accounts always equals the Base NRR, then:
o the Death Benefit will always equal the Face Amount; and
o the Account Value at the end of each policy year will equal the Tabular
Account Value shown on page 3A.
VARIABLE ADJUSTMENT AMOUNT (VAA). The VAA for a policy year is the amount of
insurance in effect for that policy year due to investment performance in past
years. On each policy anniversary we will determine a new VAA for the next
policy year. We will do this independently for each separate account, taking
into account the Actual NRR for the last policy year.
For the first policy year the VAA for each separate account is zero. For later
policy years, the VAA for each separate account will equal the sum of the VAA
Change Amounts for all prior policy years, including the current year, increased
at 3% compound interest from the Register Date to the current policy
anniversary. A VAA does not change during a policy year.
VAA CHANGE AMOUNT. For each policy year after the first, the VAA Change Amount
for each separate account may be positive or negative. It will equal the product
of the following Items (a) and (b) divided by the product of Items (c) and (d).
(a) The Actual NRR for the separate account minus the Base NRR for that policy
year.
(b) The Benefit Base for the separate account as of the last policy
anniversary.
(c) The Net Single Premium per $1.00 of VAA for the current policy anniversary
as shown on page 3B.
(d) The sum to which One Dollar will increase at 3% compound interest from the
Register Date to the current policy anniversary.
BENEFIT BASE. For each separate account, the Benefit Base on the Register Date
is the product of the following Items (1) and (2):
(1) The Allocation Percentage designated in the application for this policy.
(2) The Net Single Premium Amount shown on page 3.
On policy anniversaries, the Benefit Base for a separate account is the sum of
the following Items (1) and (2), minus Item (3):
(1) The Tabular Account Value on that anniversary, multiplied by the following
amount immediately before that anniversary: The Benefit Base in that
separate account divided by the sum of the Benefit Bases for all separate
accounts in which you have an Account Value.
(2) The Net Single Premium for the VAA for that separate account on that
anniversary.
(3) Any outstanding loan, plus interest for the separate account as of that
policy anniversary.
V83-10-9 Page 10
BASIS OF VALUES (CONTINUED)
The Net Single Premium Amount, Tabular Account and Cash Values and Net Single
Premiums for the VAA are shown on pages 3, 3A and 3B, respectively.
For each separate account, the VAA Change Amount will also reflect the effect
of:
1. All new policy loans and repayments during the previous policy year; and
2. All transfers of Account Value to or from that separate account during the
previous policy year.
CALCULATION OF ACCOUNT VALUES. The Account Value of this policy on the Register
Date is the net single premium shown on page 3. The Account Value of this policy
on any date after the Register Date is the sum of your Account Values in each
separate account on that date. Your Account Value in each separate account on
any date is the sum of the following Items (1), (2) and (3):
(1) The Tabular Account Value on that date, multiplied by the following amount
immediately before that date: The Account Value in that separate account
divided by the sum of your Account Values in all of the separate accounts.
(2) The Net Single Premium on that date for the current VAA for that separate
account.
(3) If the date is not a policy anniversary, the product of the following
Items (a) and (b):
(a) The Actual NRR for that separate account minus the Base NRR for the
time elapsed since the last policy anniversary.
(b) The Benefit Base for that separate account on the last policy
anniversary.
For each separate account, the Account Value will also reflect the effect of:
1. All new policy loans and repayments since the last policy anniversary; and
2. All transfers of Account Value to or from that separate account since the
last policy anniversary.
If for any reason the Account Value in a separate account is zero, we will
cancel the VAA and any policy loan as to such separate account and reallocate
them to the other separate account.
TABULAR ACCOUNT AND CASH VALUES (TAV and TCV). The tables of TAV's and TCV's on
page 3A show them at the end of the first 20 policy years and at certain
attained ages. We will determine the TAV and TCV on other dates in a consistent
manner with allowance for time elapsed. Any TAV's and TCV's not shown will be
furnished on request.
No. 83-10 Page 11
--------------------------------------------------------------------------------
PART 1 OF AN APPLICATION FOR INDIVIDUAL VARIABLE LIFE INSURANCE TO |_|JUV.
EQUITABLE VARIABLE LIFE INSURANCE COMPANY (EVLICO) |_|OPAI
--------------------------------------------------------------------------------
1. PROPOSED INSURED
a. Print name as it is to appear on policy.
_______RICHARD_____________________________ROE__________________________________
First Middle Initial Last
b. |X| Mr. |_| Miss |_| Mrs. |_| Ms. |_| Other Title_______________
c. List all current occupations -- Give Titles(s) and Duties
_______________VICE PRESIDENT -- HEAD OF________________________________________
_______________ACCOUNTING DEPT__________________________________________________
d. Date of Birth 5 1 1948
---------------------- ----
Month Day Year
e. Age Nearest Birthday ___35___
f. Place of Birth: State of ___NEW YORK___
g. Residence: State of ___NEW YORK___
h. |X| Male |_| Female
2. PLAN* INITIAL FACE AMOUNT
|_| Variable Whole Life
|_| Variable Increasing Protection Life ___$ 100,000____
INVESTMENT ALLOCATION (WHOLE NUMBERS ONLY)
Separate Account I Separate Account II
50% + 50% = 100%
________________________ _________________
3. OPTIONAL BENEFITS
|_| Accidental Death Benefit* (Specify Amount): $____________
|_| Disability Premium Waiver*
|_| Option to Purchase Add'l Ins. (Issue ages to 37 only): $____________
Term Riders:
Decreasing Term Per Month
|_| Family Income: ______Years $____________
|_| Mortgage Prot.: ______Years Initial Amt.: $____________
Level Term -- Yearly Renewable
|_| On Insured: $____________
|_| On Additional Insured (See page 2): $____________
|_| Increasing Term
|_| Children's Term (See page 2): $__________Units_______________
*If Proposed Insured is a Child (Issue Age 0-14) see Limitations on p.2.
4. BENEFICIARY FOR INSURANCE ON PROPOSED INSURED. Include FULL
NAME and RELATIONSHIP to Proposed Insured.
XXXXXXXX XXX -- WIFE
________________________________________________________________________________
________________________________________________________________________________
Unless otherwise requested, the contingent beneficiary will be the surviving
children of the Insured, in equal shares. If none survive, payment will be made
to the Insured's estate.
THE BENEFICIARY UNDER ANY TERM INSURANCE on an Additional Insured or on a Child
will be as stated in the riders for those benefits, unless otherwise designated
in Special Instructions.
5. OWNER Owner's Soc. Sec. or Tax No. |0|0|0|0|0|0|0|0|0| |
The Owner is |X| Proposed Insured
|_| Applicant for Child (See 10.c.)
|_| Other (Give Full Name):
____________________________________________________________________________
If "Other", complete the following:
|_| Mr. |_| Miss |_| Mrs. |_| Ms. |_| Other Title_____________
Relationship to Insured_____________________________________________________
Specify a successor Owner if desired
____________________________________________________________________________
If the Proposed Insured or the Applicant for a Child is not the Owner and if
all persons designated die before the Insured, the Owner will be the estate
of the last of such persons to die except where the Insured is a Child (see
Note in 10.c.).
6. MAILING ADDRESS |_| Business (Give Full Name) |x| Residence
|1|0|0| |S|P|E|C|M|E|N| |A|V|E| | | | | | | | | | | | | | | | |
--------------------------------------------------------------
No. Street Apt.
|N|E|W| |Y|O|R|K| | | | | | | | | | | | | | | | | | | | | | | |
--------------------------------------------------------------
City
|N|E|W| |Y|O|R|K| | | | | | | | | | | | | | | | | | |1|0|0|0|1|
--------------------------------------------------------------
State Zip
7. *PREMIUM PAYMENT PLAN
|_| Annual |_| Semi-Annual |_|Quarterly
|_| Monthly |_| System-Matic (Attach S-M Form)
|_| Military Allotment: Branch _____________________________
Register Date________________________
|_| Salary Allotment: Register Date__________________________
Unit Name_____________________________________________________
Unit/Sub-Unit No. if established:
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Divisible by |_| 2 |_| 4 |_| Hold Premium $________________
Payroll No._________________
8. SUITABILITY
a. Have you the Proposed Insured and the Purchaser if
other than the Proposed Insured received a Prospectus
for the policy applied for?
Yes |x| No |_|
Date of Prospectus ______SPECIMEN______
Date of any supplement ______SPECIMEN______
b. Do you understand that, under the policy applied for (exclusive of any
optional benefits), the amount of death benefit above the guaranteed
minimum death benefit and the entire amount of the cash value may
increase or decrease depending upon investment experience?
|X| Yes |_| No
c. With this in mind, is the policy in accord with your insurance
objectives and your anticipated financial needs?
|X| Yes |_| No
9. SPECIAL INSTRUCTIONS
a. |_| Preliminary Term (PT) period of _______ days
ending ___________________ . PT Premium $______
Mo. Day. Yr.
b. |_| Date to save insurance age: _____________
c. |_| Other:
* ISSUE VARIABLE
_________________________________________
SINGLE PREMIUM WHOLE LIFE PLAN.
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
--------------------------------------------------------------------------------
NOTE: UPON REQUEST, WE WILL FURNISH ILLUSTRATIONS OF BENEFITS, INCLUDING DEATH
BENEFITS AND CASH VALUES, FOR (A) THE VARIABLE LIFE INSURANCE POLICY APPLIED FOR
AND (B) A FIXED BENEFIT LIFE INSURANCE POLICY FOR THE SAME PREMIUM.
--------------------------------------------------------------------------------
EV4-200N 1
10.COMPLETE IF PROPOSED INSURED IS A CHILD (ISSUE AGES 0-14).
a. Will there be more life insurance in effect on the Child
than on any older child in the family? |_| Yes |_| No
If yes, explain: ___________________________________________
_____________________________________________________________
b. APPLICANT-COMPLETE IF OTHER THAN THE CHILD.
i. _________________________________________________________
First Name Middle Initial Last Name
ii. |_| Mr. |_| Miss |_| Mrs. |_| Ms. |_| Other Title_______
xxx.Xxxx of Birth___________________________________19____
Month Day Year
iv. |_| Male |_| Female
v. Relationship to Child:___________________________________
vi. Total Life Insurance now in effect: $ _________________
c. OWNER. If the Applicant is to be the Owner, after the
Applicant's death the Child will be the Owner unless
otherwise designated in Special Instructions (in any such
designation include Owner's FULL NAME, RELATIONSHIP to
Child, and Social Security or Tax Number).
NOTE: Consider designating an adult secondary Owner to
reduce the chance of a minor Child becoming the Owner. If
all persons designated die before the Child, the Owner will
be the Child.
d. OPTIONAL BENEFIT ON APPLICANT.
|_| Supplemental Protective Benefit. Give Applicant's:
i. Age Nearest ii. Place of
Birthday ____________________ Birth____________________
State
iii.Height______Ft.____In. Weight______lbs.
iv. Occupations-Give Title(s) and Duties:___________________________________
____________________________________________________________________________
ALSO ANSWER QUESTIONS ON PAGE 3 AS TO APPLICANT.
e. LIMITATIONS ON CHILD'S ADB AND DPW BENEFITS. If the Accidental Death Benefit
is applied for on the Child, the benefit is payable only if the Child dies
after the Child's first birthday.
If the Disability Premium Waiver Benefit is applied for on the Child, the
benefit is effective only if the Child becomes totally disabled on or after
the Child's 5th birthday.
--------------------------------------------------------------------------------
11. COMPLETE FOR CHILDREN'S TERM RIDER.
Give Names of Children below and answer the Questions on page 3 as to each
Child.
CHILDREN PROPOSED FOR INSURANCE:
NOTE: To be eligible, children (including stepchildren and legally adopted
children) must not yet have reached their 18th birthday. Coverage does
not begin until a child is 15 days old. DATE OF BIRTH
|Sex| Mo.| Day| Yr.
________________________________________________________________________________
First Name Middle Initial Last Name
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
12. COMPLETE FOR LEVEL TERM YEARLY RENEWABLE RIDER ON ADDITIONAL INSURED.
Complete below and answer the Questions on page 3 as to the Additional Insured.
PROPOSED ADDITIONAL INSURED
a. Print name as it is to appear on the Policy.
________________________________________________________________________________
First Middle Initial Last
b. List all current occupations -- Give Title(s) and Duties.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
x. Xxxx of Birth: Mo.____________ Day___________ Yr. 19_______
d. Age Nearest Birthday _______________________________________
e. Place of Birth: State of __________________________________
f. Residence: State of________________________________________
g. |_| Male |_| Female
h. Owner's Relationship to Additional Insured:_________________
________________________________________________________________
--------------------------------------------------------------------------------
13. COMPLETE IF USING EXISTING OPTION TO PURCHASE INSURANCE.
i. Existing Individual Policy No. _____________________________
ii. Option Date__________ iii. Option Amount: $________________
iv. |_| Regular Option or
|_| Option on Birth or Adoption of Child
Child's Name___________________________________________
Date of Birth or Adoption______________________________
v. If applying for Disability Premium Waiver, is Proposed Insured now totally
disabled as defined in the Disability Premium Waiver provision of the above
policy? |_| Yes |_| No
This application is made under a provision in the policy indicated above
permitting the purchase of individual life insurance (the "Option Provision").
If this application is made within the time allowed and in accordance with the
other terms in the Option Provision, including timely payment of the full first
premium for the option insurance, then the option insurance shall take effect
upon the terms of the policy EVLICO would issue. Otherwise, the option insurance
shall not take effect.
Answer the Questions on page 3 only if evidence of insurability is required in
connection with an optional benefit or any excess of the insurance amount
applied for over the insurance amount permitted by the Option Provision (the
option insurance).
________________________________________________________________________________
EV4-200N NO. SPECIMEN 2
OTHER INFORMATION -- AS TO EACH PERSON PROPOSED FOR INSURANCE, ANSWER QUESTIONS
14 AND 15. ALSO ANSWER QUESTIONS 16, 17 AND 18 IF NON-MEDICAL.
14. HAS ANY PERSON PROPOSED FOR INSURANCE:
a. Within the last two years, been convicted of two or more moving violations
or driving under the influence of alcohol or drugs, or had a driver's
license suspended or revoked? (Give full details -- including dates, types
of violation, and reason for license suspension or revocation.)
|_| Yes |X| No
b. Any plan to travel or reside outside the U.S.? (Give full details.)
|_| Yes |X| No
c. Any other life insurance now in effect or application now pending? (State
companies and amounts.)
|_| Yes |X| No
15. HAS ANY PERSON PROPOSED FOR INSURANCE:
a. Within the last year flown other than as a passenger or plan to do so?
|_| Yes |X| No
If yes: Total flying time at present__________ Hours;
Last 12 mos.________Hours; Next 12 mos._______Est. Hours.
(Complete Aviation Supplement for competitive, test,
stunt or military flying, or crop dusting.)
b. Engaged within the last year, or any plan to engage in motor racing on land
or water, underwater diving, sky diving, ballooning, hang-gliding or
parachuting? (If yes, complete Avocation Supplement.) |_| Yes |X} No
c. Ever had an application for life or health insurance declined, that
required an extra premium or was otherwise modified? (Give full details.)
|_| Yes |X| No
d. Replaced or changed any existing insurance or annuity (or any plan to do
so) assuming the insurance applied for will be issued? (State companies,
plans and amts.) |_| Yes |X| No
16. Proposed Insured: Height 6 Ft. 1 In. Weight 185 lbs.
_______ ________ ______
Additional Insured: Height Ft. In. Weight lbs.
_______ ________ ______
17. HAS ANY PERSON PROPOSED FOR INSURANCE:
a. Ever been treated for or had any indication of heart trouble, stroke, high
blood pressure, chest pain, diabetes, tumor or cancer? (Give full details.)
|_| Yes |X| No
b. Within the last 5 years, consulted a physician, or been examined or treated
at a hospital or other medical facility? (Include medical check-ups in the
last 2 years. Do not include colds, minor virus infections, minor injuries,
or normal pregnancy.) (Give full details.)
|X| Yes |_| No
18. HAS ANY PERSON PROPOSED FOR INSURANCE:
a. Within the last ten years repeatedly used barbiturates, amphetamines,
hallucinatory drugs or narcotics? (Give full details.)
|_| Yes |X| No
b. Within the last ten years received counseling or treatment regarding the
use of alcohol or drugs? (Give full details.)
|_| Yes |X|No
19. DETAILS. For each yes answer give Question number, name of person(s)
affected and full details. For 17 and 18 also include conditions, dates,
durations, treatment and results, and names and addresses of physicians and
medical facilities.
No. Name of Person Affected Details
________________________________________________________________________________
--------------------------------------------------------------------------------
17.b. |XXXXXXX XXX MEDICAL CHECK-UP 4/1/82 NORMAL.
________________________________________________________________________________
DR. XXXX XXXXX 100 SPECIMEN ST. NEW YORK, N.Y. 10001
_______________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
20. COMPLETE IF FIRST PREMIUM IS PAID BEFORE THE POLICY IS DELIVERED:
Have the undersigned read and do they agree to the conditions of EVLICO's
Temporary Insurance Agreement, including (i) the requirement that all of the
conditions in that Agreement must be met before any insurance takes effect, and
(ii) the $250,000 insurance amount limitation? |_| YES |_| NO (If "No," a
premium may not be paid before the policy is delivered.)
AMOUNT PAID: $___________. (Draw checks to order of EVLICO.)
AGREEMENT. The signers of this application agree that:
(1) The statements and answers in all parts of this application are true and
complete to the best of my knowledge and belief. EVLICO may rely on them in
acting on this application.
(2) EVLICO's Temporary Insurance Agreement states the conditions that must be
met before any insurance takes effect, if the full first premium for the
policy applied for is paid before the policy is delivered.
(3) Except as stated in the Temporary Insurance Agreement, no insurance shall
take effect on this application: (a) until a policy is delivered and the
full first premium for it is paid while the Proposed Insured is living; (b)
before any Register Date specified in this application; and (c) unless to
the best of my knowledge and belief the statements and answers in all parts
of this application continue to be true and complete, without material
change, as of the time such premium is paid.
(4) No agent or medical examiner has authority to modify this Agreement or the
Temporary Insurance Agreement, nor to waive any EVLICO's rights or
requirements. EVLICO shall not be bound by any information unless it is
stated in application Part 1, 1A or 2.
---------------------------------------------------------------------------
SIGNATURE OF AGENT
______/s/ Xxxx X. Agent______
IT IS UNDERSTOOD THAT UNDER THE POLICY APPLIED FOR (EXCLUSIVE OF ANY OPTIONAL
BENEFITS) THE AMOUNT OF THE DEATH BENEFIT ABOVE THE FACE AMOUNT, AND THE CASH
VALUE, MAY INCREASE OR DECREASE BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE
ACCOUNT AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT.
Dated at ______NEW YORK,____N.Y.____________on____6/1_____19__83__
City State
__X /s/ Xxxxxxx Xxx_____________________________________________________________
Signature of Proposed Insured or of Applicant if Proposed Insured is a Child,
Issue Age 0-14.
________________________________________________________________________________
Signature of Additional Insured if required.
________________________________________________________________________________
Signature of Purchaser if not Proposed Insured or Applicant.
(If corp. show firm's name and signature of authorized officer.)
EV4-200N 3
________________________________________________________________________________
EQUITABLE
VARIABLE LIFE INSURANCE COMPANY
[EVLICO LOGO]
Home Office: 0000 Xxxxxx xx xxx Xxxxxxxx, Xxx Xxxx, Xxx Xxxx 00000
VARIABLE
LIFE
INSURANCE
POLICY
Single Premium Whole Life Plan. Variable insurance payable upon death.
Guaranteed Minimum Death Benefit. Face amount increases annually by 3%
at the beginning of each policy year after the first.
Non-Participating. Investment experience reflected in benefits.
Investment options described on page 6.
No. 83-10