EXHIBIT 99.d(4)
COUNTRY INVESTORS LIFE ASSURANCE COMPANY TERM INSURANCE AGREEMENT
0000 X. Xxxxxxx Xxxxxx FOR CHILDREN'S INSURANCE
X.X. Xxx 0000, Xxxxxxxxxxx, Xxxxxxxx 00000-0000
Supplemental Agreement attached to and made a part of this policy in
consideration of the application and payment of its cost of insurance. The cost
of insurance for this benefit is the monthly deduction shown on the Policy
Schedule for this Agreement. This Agreement will remain in force as long as the
monthly deductions for this policy continue to include the cost of insurance for
this benefit.
1. INSURED CHILD: Insured Child means:
a) Any child or legally adopted child of the Insured named in the
application for this policy or this Agreement; and
b) Any child who, after the date of application, becomes the legal
responsibility of the Insured by birth or legal adoption prior to
the child's 18th birthday.
2. DEATH BENEFIT: We will pay the Death Benefit for this Children's Insurance
Agreement upon receipt of due proof of death of an Insured Child. Death must
occur while this Agreement is in force and must have occurred:
a) After that Insured Child became 14 days old;
b) Before the Monthly deduction Day immediately following that
Insured Child's 23rd birthday; and
c) While this Agreement and this policy were in force with respect
to such Insured Child.
The number of units of Death Benefit is shown on Page 1 (Policy Schedule) of the
policy. Each unit of Death Benefit under this Agreement is $1,000 for an Insured
Child after the age of 14 days and before the age of 180 days. On and after the
age of 180 days, each unit of Death Benefit is $5,000 for each Insured Child.
Payment is subject to the provisions of this policy and this Agreement.
3. SUICIDE: If any Insured Child commits suicide, while sane or insane, within
2 years from the effective date of this Agreement, the total liability shall be
the cost of insurance for such child.
4. BENEFICIARY: Any amount payable under this Agreement, upon the death of the
Insured Child, will be paid:
a) To the Beneficiary then designated for this benefit on our
records as named in the application or subsequently changed as
provided in the policy, if living;
b) Otherwise to the Insured under this policy, if living;
c) But if neither of the above are living, to the estate of the
Insured Child.
5. CONVERSION: Upon termination of this Agreement, insurance on each Insured
Child may be converted. In addition, while this Agreement is in force, insurance
on any child may be converted when such child attains age 23. Prior to age 23 of
the Insured Child, the amount of the new policy may not exceed $5,000 per unit
of Death Benefit. For conversion as of the Monthly Deduction Day immediately
following the Insured Child's 23rd birthday, the amount of the new policy may
not exceed $25,000 per unit of Death Benefit. Conversion may be to any plan of
insurance except term insurance, issued by us at the time of conversion.
Evidence of insurability shall not be required upon conversion. All plans of
insurance available on conversion are subject to plan requirements. Supplemental
Agreements providing benefits in event of total disability or accidental death
will be included in the new policy only with our consent. The new policy will be
issued on the basis of the rates in effect at the time of the conversion.
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When insurance on a child terminates, the right to convert shall be available
for the next 31 days. If the death of a Child occurs in this 31 day period, we
will pay the Insured Child's Benefit.
6. ASSIGNMENT: This benefit provided under this Agreement may not be assigned.
7. VALUES: This Agreement has no cash or loan values.
8. RESPRESENTATIONS AND CONTESTABILITY: All statements made in the application
for this Agreement by or on behalf of the Insured Child, will, in the
absence of fraud, be deemed representations and not warranties. The validity
of this Agreement shall not be contestable after it has been in force for 2
years during the lifetime of the Insured Child.
9. TERMINATION OF AGREEMENT: This Agreement terminates:
a) On the Monthly Deduction Day on or next following the date we receive
written request of the Owner and presentation of the policy at the
Home Office of the Company for endorsement;
b) Upon termination of this policy; or
c) When the policy matures.
When coverage is scheduled to terminate on a given date, it will terminate at
12:00 midnight on that date
This Agreement is effective on the Policy Date of Issue of this policy unless
another effective date is stated below.
Effective Date: _______________ COUNTRY INVESTORS LIFE ASSURANCE COMPANY
(if other than Policy Date of Issue) BLOOMINGTON, ILLINOIS
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