1 Exhibit 1.A.5 PROVIDENTMUTUAL LIFE AND ANNUITY COMPANY OF AMERICA INSURED JOHN DOE POLICY NUMBER 9,000,000 ISSUE DATE 01/01/1999 FACE AMOUNT $50,000 ISSUE AGE AND SEX 35, MALE DEATH BENEFIT OPTION A POLICY DATE 01/01/1999 Providentmutual Life and...Life Insurance Policy • November 23rd, 1998 • Providentmutual Variable Life Separate Account
