1 Exhibit 1.A.5. DOCID=Form VL101 PROVIDENT MUTUAL LIFE INSURANCE COMPANY 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 Provident Mutual Life...Life Insurance Policy • February 4th, 1999 • Provident Mutual Variable Growth Separate Account
