HomeMy WebLinkAbout07-30-07
t F:\FILES\12024\petition
Revised: 7130/07 8:50AM
IN RE: ESTATE OF
COLLEEN M. NICHOLSON
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHAN'S COURT DIVISION
NO. 2005 - 729
PETITION PURSUANT TO 20 P A.C.S.A. 66111.2
AND NOW, comes Petitioner JAMES C. NICHOLSON, by and through his attorneys
MARTSON, DEARDORFF, WILLIAMS OTTO GILROY & FALLER, and requests that this Court
enter an order declaring the beneficiary designation made by Colleen M. Nicholson survived her
divorce with Petitioner, and in support thereof, avers as follows:
1. James C. Nicholson (hereinafter "Petitioner"), is an adult individual with an address
of 91 Smith Road, York Springs, Adams County, Pennsylvania 17372.
2. USAA Life Insurance Company (hereinafter "Respondent Insurance Company"), is
a corporation which does business in Pennsylvania and has an address of9800 Fredericksburg Road,
San Antonio, Bexar County, Texas 78288.
3. Colleen M. Nicholson (hereinafter "Decedent"), is an individual who died on August
5, 2005.
4. Amanda 1. Nicholson and Jessica M. Nicholson (hereinafter collectively
J
"Respondents"), are adult individuals, daughters of Decedent, and contingent beneficiaries under the
Policy. The Respondents' address is 154 B. West Penn S1., Carlisle, Cumberland County,
Pennsylvania. .
5. On December 28, 1984, Decedent initiated a Flexible Premium Adjustable Life
Insurance Account, Policy No. 1569690-U1, with Respondent Insurance Company (hereinafter
"Policy"), designating Petitioner as the beneficiary. A true and accurate copy of said policy with
beneficiary designation is attached hereto as Exhibit" A."
6. Decedent fulfilled all condition precedents to the Policy including paying all the
premiums up to the point of her death.
(")
<;;0
<~:o
-~:D(")
.;~~M
. -"-::: :::0
--.::cn::;;;;.::
j(JO
--'O-n
><c
'---':0
:o-i
.1>
!"-..:>
<:::;)
c::::I
--'
c-
c:
r-
w
o
-0
::r.::
'i?
o
co
7. During Decedent's life, Decedent was married to Petitioner until April 8, 1999, at
which point Decedent and Petitioner divorced. A true and accurate copy of the divorce decree is
attached hereto as Exhibit "B."
8. Despite this divorce, Decedent kept Petitioner as beneficiary to her Policy with
Defendant.
9. Applicable law provides that a spouse beneficiary to a life insurance policy shall be
treated as predecessor of decedent spouse.
10. Respondent Insurance Company was aware that Decedent and Petitioner were
divorced prior to Decedent's death.
11. However, the law also provides that the former spouse is entitled to the policy if there
is an indication that the designation of spouse as beneficiary was intended to survive divorce. 20
Pa.C.S.A. ~6111.2.
12. Decedent intended that her designation of Petitioner as beneficiary survive her divorce
with Petitioner.
13. This intention is evidenced from the Last Will and Testament (hereinafter "Will")
decedent executed on March 22, 2002. A true an accurate copy of said Will is attached hereto as
Exhibit "C."
14. The same Will, executed on March 22, 2002, was executed after Decedent and
Plaintiff divorced on April 8, 1999.
15. As is evident from the Will, Petitioner is devised much of Decedent's property,
including horses.
16. This creates the reasonable inference that despite the divorce, Decedent and Petitioner
still had an amicable relationship and Decedent intended Petitioner remain beneficiary of her policy
with Defendant.
17. Petitioner has made a claim for benefits under said Policy.
18. Respondent Insurance Company will not release the funds to Petitioner without a
Court Order directing them to do the same.
19. Respondents have been contacted on multiple occasions regarding Petitioner's right
to the Life Insurance proceeds, but have failed to respond.
WHEREFORE, Petitioner, James C. Nicholson, requests this Court enter an order declaring
that the beneficiary designation made by Colleen M. Nicholson survive her divorce with Petitioner
and that Petitioner be declared the sole beneficiary of the Policy.
Respectfully Submitted,
MARTSON LAW OFFICES
By ce-trv<- 5 r<--
Christopher E. Rice, Esquire
Attorney LD. No. 90916
10 East High Street
Carlisle, P A 17013
(717) 243-3341
Date: 7, 3D /" 0 7
Attorneys for Petitioner
~ .
,.
~
USAA
USAA LIFE INSURANCE COMPANY
USAA BUILDING - San Antonio, Texas 78288
(A Stock Company)
FLEXIBLE PREMIUM ADJUSTABLE LIFE INSURANCE POLICY
THE INSURING AGREEMENT
USAA LIFE INSURANCE 'COMPANY will pay to the Beneficiary the Amount of Insurance as provided for
in this policy as soon as we receive due proof that the death of the Insured occurred while this policy
was in force.
The policy is issued by USAA LIFE INSURANCE COMPANY and signed at our Home Office in San
Antonio; Texas on the Effective Date shown.
FLEXIBLE PREMIUMS PAYABLE DURING LIFETIME OF THE INSURED UNTIL MATURITY DATE
DEATH BENEFIT PAYABLE AT DEATH PRIOR TO THE MATURITY DATE
NON-PARTICIPATING - NO DIVIDENDS
CASH VALUE PAYABLE ON MATURITY DATE
~~H.~
David H. Roe - President
RIGHT TO RETURN POLICY
WITHIN 20 DAYS
~
John L. Swyers - Secret ry
This policy may be returned to the Company or
to the agent through whom it was purchased
within twenty days after its delivery. Upon
return, we will refund any premium paid. The
policy will be deemed void as if no policy had
been issued.
DUPUCATE POLICY
READ YOUR POLICY CAREFULLY
Al594-0054 2-82
DEFRA
07442-1186
LUL201ST
~~!O.Pt~IODIC pq:.I~
INI".~ P~E~I~ RfCElveD
S2~SO
!.," .~o
~A"~'Y
_~5 ..1Il...~~...-ei)_..~___-~:~~
.$E" LA$T &..,tGA., o~ ''''~..o
ON~.ift'!CfIV~ OAft 2"
AN?oIUALLTI
un CLASS~
~'tAL2
~ _eNS! CHA"Gf!S
3.OS O~ "1..-'; PR~IU~ '~~~IV:tO
..rASY .,~.~ ONLY:
...17 P~II '10"1'" ... ADCUT10.. TO TH! A"'''''L C"f""t25.
~ 0.... 'IIU"II!t E ~ S
AL""'-09'!lt
L. ~4'M-O~O
P":)Q14"OJ~ I
cas' Fa..
fE~':4-"t'O~
INS loR!:!>
".re"'. ,~
fIlLEJlI8LP. tIIlA~II(I.:j"':'A,:.ius.T~F. LI~e
LOA" J ~E''':::5' E.~,~~E~~""
CHILI) COV!:Q..Gf .~ 10:::" -~.. -. __ &o.s.o ~ER u~., - fl'E
8~..e- If 'ULL ilE.. 1:If-~OJl':'TA"'T-.F';)A _S LONe. -$ I T IS I... .,o~-::
7! , AA E~OOD!;~" -:..,
2-!~
. O.-Sl.
~93
,... IS
'j.. !U
;>>~ ICY I. , II F I C& 11 OM ...f :lIt14,\ Tt ON
:OlL::E:" .. ..,OttLSO..
15"!>9~"OU'
J:OL I CY ~!te"
COLL(E~ . NIC"ULSON
..
oe AT... lIE..' I , epTUN
12"l8'1~.
,.- PF. t T I"/! l) I. TE
1 ?'28'!()52
"lA 'VA' T., OA Te-
SPE:'I ~I c;o
S2'hOOO
· If IS "'as'U~L;: .,......T ':':)Ytcto\G~ -'u.. ~ .'Jct~ ~IO~ TO TI-tF. ...-TuQIYY j4TIf s...oWN IF
SCJl!llS'!Qu~)f' Pfit'=''' h'--~ &~-! NOT p,.l:.> FOu.,'l_.",:' "" "''4e'"'' n, THE '.....".-L ~lte..,.....
Oct .,- T"iE CA~'" "Al.l.Ii .S 1~"!'"IC1E~' '0 C3"Tl",U: C.01l"::~.r;~ fa SUCH >ATf.
...-. 59"-OO~" l-~~
I,. ;.-, a,.. ~"',' I
p. ~E 2
OUPUCATc POUCY
...;
POI.. I(Y Sc..e "'U
._- _..
'aeLE 0"- GU."IH'I!I!I) ""'HLl' COST" i......utU
--- . ~ ;:.
- --.
'THE CO.4,.., tt4S 'HIP: AIGH' TO 'CtlMCK! U!" 'ttAlIt ,"1.WM.ftI!D "A'f"
- .....1.
1t,,".r'CHTm lao.. -
- . ~._~~~~'._---" .._______ :\':::.1.:. __
-----. ....,t: . -'-EII o-'O..._-~ ,.. t..
._,___.- '.~..~ ~._:.~.::~,.-,., .- _$- P ...J. 0 - .-, _ .."_'
.._ .. W'2~_.~:=,:=,:,::,:~._......_...
...;..
I
~~
A 'T .'lflIeO-AGI' _AA ~7 - -
41:-"-":"
.'-~- t;o ;;,' .'
~~ ";A' 'fA '''ED "-Ge~~'---"-A'a _':: _ -
o.Jo ~ .-'''-. ~ ..
21)
29
30
3a
32
1.J
3.
35
36
oJT
38
.)~
-0
" I '-.::...;.::
----...4Z...-.. .
. _.-'--~ 4 J
.-.- '.4.
40;
~b
..,
-'-4!t
49
50
~I
52
~~
~"
~.,j
56
~1
~~
5Q
.....0
.16 SUO
.17100
. 1 '7~OO
~j.oOO
.I.~O
.19000
.1970"0
.20500
.2 1$00
'-;'z"i'700 ''::-', ::
---;.....z.io1Q::--.- .___=~~-_ . ,
.!'6 'O'O'-.-==-=:.: '''-
. _.., ... '.2a300~==::" -;:..
_.. .....3.0_~_'O!:::.:~:7--
. :13.0.0 ~_.. _
.n__ :..:..36 .JO.O.:::-:------.,-
"0 .3940'0==-:' '"
.. _........2800--.......
...O~O. .
.50800::::..._
.~~500 '-"
.60 '00
.66400-
. 7Z ?O 0
. 79~O --
.86900'
.9~OOO .~':':
).03ftOO
1.13~O
1.2- '0'
1.357'00
1.4b'SOO
1.62401)
1.7770')
.1
..~
63
~4
65
6.
.7
..,
. 69
_;0. '70
"0 ...!:~. _ 7' I
J 7~
- - ...:..."..=-=,."..:------. '.,:? ., 3
-- :~.: --. 74
.,~
.,-.-- -. 7.
.,.,
7!.' .-
-- 79' --
80
I.
82
--"83 --
a. -
85
8&
'&7
8~:
'-'89
90
9.
9~
93
9-
. n_~ .--:
'I"4-':S~ ~A"~S ."e ~.:)~ f!ot'; "'se ~'''''IC~ .T l~$UE
~~~.~~~_ z-ez "H~"'~J'
PA ("~ ~
.....00
2.11100
2.31100
Z.5aIOO
2. n6O...
~.03fOO
3.33000
3...700
3. ..7.0 _._..__
4. .SO~ .
4.71700
$.10000
'). ...00
!I. 9~>> 0-----
---:6.388"0
. ~-6. 90600-.' --
7.490041'
a.aot )00'-"-- .
8.85700
9.62400
10.4:1700
11.28600
. z. .~IOO
1 3. "600
14.06700
I S. 0900 0
I.. ,.,MO
I 7. 3t 300
."62100
20.0.600
21.~200
Z 3. St"o 0
2~. 70000
l..3:J~OO
DUPLICATE POUCY
AO~"JO~ COYEA.aeS
- . __ O!.JJJ~~'O!'~- !".>r
.. ..r.. ,,"I'S. '~=." . .~. .--'~'--.- __~;::-.
. e;:.~;(Y~ ~,~ ._~ ~E.'E~aE. -28 198 ~,,~ ." . -. f~~ a!!~ I ON .~~~
........... -, -. ~~.:.~
'=" -- - . RATES PEq Uft 11" - '.1' .....
A"~JNeD AGE
21
2~
2-:
30
3l
32
"3
3"
3~
a.. .........~ . 36-
3'
38 -
_'. u_. 39.___---
. - ...
40
... ....... , 1_. :_. ..
4Z
43
4.
..5
SCtEf>ULE
. J HSUitl!O
COLL~!N .. NfCtiOLSON
'DECl!"BI!"-~.~.OI' . ~
lltA1E
.50000
.\0000
.50~O._. .
.50000
.$0000 .
.~OOOO
. ~O 000
.50OCJO _ ____ _ _ . .
.SOooO;':-;
. .~OOOO-
.~OOOO.' .:. :"'.
.$000.0. .-. .
.~OOO~:_-- .,.... ~.:..- -... - - -"-" -'-'--- -- ::-.." ~:;
. ~O 000
.~O.oO O.:~.":'",,":..:._. .
.'\0000:,.- _n -- --.-
. 50 OOO~ -.- .
.SOoOO
.~~O~.~ .
At fA IN!O AC'Ae
..
"7
04'
49
SO
51
Si
$~
. . .;.... 5"."..
-.----. ~..;.-'.."\..~ '.__ 55 "~
56
57
58': :.' ...-.
'''p ._. .59
.0.
61. .
~2'-
a,
64
RATE
. SOoo 0
.50000
.500:>>0
.wooo
. SO GO a
.MOOO
.10000
.50000
.50000
.50000
.~ooo
. ')0000
.50000
. 50~~ 0
. .50.,00
.~oo'o"
.~oooo
.50000
. soooo
TH~S::: ':,A'~S ~1C. ~PLIC.~'-: 4S .IF T"iE t:"~CTIV! ~4''! O!' T...J~ CO"lfE"QAC'.":
~~.-'JO'54 2-42 !)'.~.!I"'~'''ou, ~."e 3-A
-- - _.- .
DUPlICATE POUCV
..... . "-'~~~---'-- .:!~ ....- .
.- .'-- .~~_-~ JC" SC~:;lILE
, AlU..!._~. CMJ U A~'E!O Y lL.UI: S
.~7~~~:_:
. ~ -'
3
--"
5
.Ct
7
8
:::..~
10
... .;"~.-'" - .:.. _.
--'-~:-ll._ .:_. ._.:
.-- ....-.:,1 3~-~-.'" .. .
'j" - '-:'~=::;-;.-
. _._~_:1:5.:.;....;,.;.:~,-"
.. _16_ -:::.-..:~::... ~.-. '
. . -"7-'
.-.-"-'- '8. _.. ._::::::,'
. -:-~~-~~~~-_.' ...::~...-:
AGE . ;ii
A Ge _6~6-'- ..
.~ b'5
~-..-....
-~-_..._- -"
. .-'
....~'.AO...,STA8l.E LI ft!
-l:i-S";"i'URtII!fC)~" V~\l!
....-. -,..r.'~, - . _. .. - .
..___7. .. "="':'.!rJh_.~. .
.' :,.'~'...!~'O.
....... ...":'_' -! :'.7" ... 0
.. 0
.... 0
.. 0
. '---'~'.. 0
:,: .. 0
.: .. 0
~-... 0
.. 0
..... "
. "':f-l.,..e..o
.. ..:\~... 0
. . '~-:L.. 0
".. .~-.. 0
':'",,"':;....0_
'.~'.. 0
._...... ._.... ~_.._...~..... 0
-:-. ". ..._ 0
.~. _.0. 0
.. 0
.. 0
.. 0
.- ....~:.,..
. ~.SE3 ~" ~I~I.UM IN'~~~ST ~~ ..;~ ,~~ GU.qA~T~~O cos~ OF l~'VPANCE RATES
.. I~ 'We UNLI~ELY ~v~~T ~~. ~~ GUAq&~T~~O I~E~~S' ~AT~ o~ ..~~ WAS
PA 10 ""0 T-E l,iU.qAfilCTE'10 ",ST OF' l"SU".a~= IItA'i OfAQ:c.I1. .00 If IO'ICAL io'lite"IUMS
WOA.:> ctE :'H:OUI_~O '0 CO~"I:otU'! c;oVe".'.t::
AL 5~. -')0 -;. 2 -8 Z
o I 'j f) .:;.0 ~'l~J .
e>>.. (;!: )- '"
I
OUPLlCATE POUCy
~CL ICY SCtE:;\JU
T ACI~ 0" GU.... AtfT~!:) Y _L~ S
END 01' .
~LI(Y Y~A"
ADNITAeL! .....!
eASt:' ::~URIleNDrlt VAL~
:.~ .:~
I
t
)
.
5
6
7
8
9
10
II
12
13
I.
IS
16
17
Ie
19
20
4GE ;'5
A GI! 60
. GE b~
..
..
..
..
..
..
..
..
..
..
..
:...~. ..
.;....._~. ..
..
~ :. ~ ..
0..
..
',::1'
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
(>>
()
o
o
o
o
.. 0
: ..
;'..
..
..
..
· !\4SE~ :>tf "'1~1"i.M IN'~R':ST ::J'- . .3' ..~m GUAqA""TI!!:O cost OP' l"*St.)~A"'CE Q4T~S
.. I'" 'We ~LI"'ELY I!Yf.~T u........ .....~ c.u4q....Tt'~O I""'!~I!ST JdIT! 01' ..,'C WAS
PAlO AIIlfO ToE ':iUA~A""T€I!O (.tIST o~ I"SU"A'<~ WA"i OMCI'''iEI). AOOIT IO~t.. PAE"lutltS
"OA-:) ~ :'~Q\lI~D "0 CQ"'''~,! C.OVc~Ac.E
"L. 5~. -~o 0;6 Z -Sll
Oi 'i~~~'J\.I1
---.------------- ------ - --- - -..
p. C;~ ;)-~
I
O(JPlJCATE POl!CY
DEFINITIONS
IN THIS POLICY -
YOU or YOUR means the Owner of the Policy, as shown on the initial application, unless changed.
WE, OUR or US means the USAA LIFE INSURANCE CaMP ANY.
INSURED means the Insured named on the Schedule. The Insured mayor may not be the Owner.
SCHEDULE means the Policy Schedule most recently sent to you by us.
PLANNED PERIODIC PREMIUM PAYMENTS means that payment which you feel you can pay periodically
as specified on the Policy Schedule. You may increase your Planned Periodic Premium Payment.
UNSCHEDULED PREMIUM PAYMENTS means any payment that you wish to make.
ANNUAL DATE means the same date each year as the policy effective date.
MATURITY DATE means the policy anniversary. following the Insured's 95th birthday.
MONTHLY ANNIVERSARY DA ~E. means the same day of each month as the policy effective date. .
NET PREMIUM is the gross premium less the percentage of premium expense charges shown in the
Policy Schedule.
NOTICE TO US means information we have received at our Home Office which is written, signed by
you, and is acceptable to us.
PROOF means evidence satisfactory to us for insurability or for other matters which require proof.
SPECIFIED AMOUNT means the amount indicated on the policy schedule page.
DEATH BENEFIT OPTIONS:
,. OPTION A - A death benefit that is the greater of the Specified Amount shown on the policy
schedule page or the minimum amount required to qualify the policy as life insurance under
Section 7702 of the Internal Revenue Code.
2. OPTION 8 - A death benefit that is the greater of the Specified Amount shown on the policy
schedule page plus the policy's cash value or the minimum amount required to qualify the policy
as life insurance under Section 7702 of the Internal Revenue Code.
AL594-0054 2-82
Page 4
LUL201S1
lJUPUCATF. POUCY
.
INCONTEST ABILITY
The Company will not contest this policy or any increases to it for any reason, except for
non-payment of premiums, after they have been in force during the Insured's lifetime for two years.
The two-year period for the policy begins on the Effective Date of the policy and the two-year
period for any increase begins on the Effective Date of the increase.
This provision does not apply:
1) To benefits in case of disability if a part of the policy, or
2) To additional insurance for death by accident if a part of the policy.
MISSTATEMENT OF AGE OR SEX
Age in this policy means age last birthday. If the Insured's age or sex has been misstated, we will
adjust the policy values to those based on correct monthly deductions since the policy Effective Date.
SUICIDE EXCLUSION
For the first two full years from the Effective Date of the policy, if the Insured commits suicide, while
sane or insane, we will terminate the policy and refund the premiums paid less any loan and any partial
surrender amount This exclusion applies to any increases in benefits from the Effective Date for each
increase.
CONFORMITY WITH LAWS
This policy is subject to the laws of the state where the application was signed. If part of it does not
follow that law, it will be treated as if it does.
NON-PARTICIPATING
This is a non-participating policy. This policy will not share in any of the Company's profits or surplus
earnings. The Company will not pay dividends on this policy.
PREMIUM PROVISIONS
SCHEDULED PREMIUMS
The first premium is due on the Effective Date of the policy. Other Planned Periodic Premium
Payments may be made at the interval indicated on the Policy Schedule page.
We will send premium notices if requested. They can be sent each 3, 6, or 12 months. All premiums
must be paid at our Home Office or to our authorized agent who will give a receipt signed by our
President or Secretary. You may increase the amount or change the frequency of other planned
periodic payments.
UNSCHEDULED PREMIUMS
Additional premium payments may be made at any time prior to the Maturity Date, provided there is no
existing indebtedness.
AL594- 0054 2- 82
Page 6
LUl201S1
DUPLICATE POLICY
Death Benefit Options:
Option A:
A death benefit that is the greater of the Specified Amount shown on the policy schedule page or the
minimum amount required to qualify the policy as life insurance under Section 7702 of the Internal
Revenue Code.
Option B:
A death benefit that is the greater of the Specified Amount shown on the policy schedule page plus
the policy's cash value or the minimum amount required to qualify the policy as life insurance under
Section 7702 of the Internal Revenue Code.
The "minimum amount required to qualify the policy as life insurance under Section 7702 of the
Internal Revenue Code" is determined by multiplying the policy's cash value by a specified percentage
which is based on the Insureds attained age. The "specified percentages" required by t~e Internal
Revenue Code are:
ATTAINED ATTAINED
AGE PERCENTAGE AGE PERCENTAGE
0-40 250% 61 128%
41 243 62 126
42 236 63 124
43 229 64 122
44 222 65 120
45 215 66 119
46 209 67 1"18
47 203 68 117
48 197 69 116
49 191 70 115
50 185 71 113
51 178 72 1 11
52 171 73 109
53 164 74 107
54 157 75-90 105
55 150 91 104
56 146 92 103
57 142 93 102
58 138 94 101
59 134 95 and older 100
60 130
DEA TH BENEFIT CHANGES
The Owner may change the death benefit after it has been in effect for one year, by written notice to
us. Any change is subject to the following conditions:
1) Any reduction will be against the most recent increase in insurance.
2) Any increase will require proof of insurability. The application for any increase will be attached
to and made a part of this policy.
3) You may change from Option B to Option A by written notice to us. The new specified amount
will be the death benefit as of the effective date of change.
4) You may change from Option A to Option B by written notice to us. The new specified amount
will be the death benefit less the cash value as of the effective date of change.
AL594-0054 2-82
Page 8
DUPLICATE POLICY
LUL201S1
NON-FORFEITURE PROVISIONS
CASH VALUE
On each Monthly Anniversary Date the cash value shall be calculated as (a) minus (b) plus (c) plus (d) plus
te} minus (f) minus (g) where:
(a) The cash value on the prior Monthly Anniversary Date;
(b) The monthly deductions for the month following the Monthly Anniversary Date;
tc) One month's interest on (a) minus (b):
td) The net premium received for the policy in the prior month;
(e) Interest on each net premium from the day it is credited to this policy to the Monthly
Anniversary Date;
(f) Reductions in cash value for all partial surrenders since the beginning of the preceding Monthly
Anniversary Date;
(g) Interest on each partial surrender from the day it is granted to this policy to the Monthly
. Anniversary Oate.
On any day between Monthly Anniversary Dates, the cash value will reflect interest, payments, and
withdrawals to that date.
The cash value on the Effective Date of this policy is the net premium for the policy less the monthly
deduction for the month following the Effective Date.
MONTHLY DEDUCTION
The monthly deduction for each policy mon~h is (a) plus (bl plus (c) where:
(a) The cost of insurance and the cost for any policy riders.
(b) A nominal charge per S 1 ,000 initial specified amount on the Insured plus a flat monthly charge.
These charges are shown in the Policy Schedule. This applies only to the first 12 policy
months.
(c) A nominal charge (shown in Policy Schedule) per month per $1,000 of any increase in the
specified amount on the Insured. This applies only for the first "2 months after the increase
becomes ef fective.
Monthly deductions are made in advance of the period for which they apply.
INTEREST RATE
The guaranteed interest rate applied in the calculation of the cash value is .36748 percent per month,
compounded monthly. This is equal to 4 1/2 percent per year compounded yearly. Interest in excess
of the guaranteed rate may be applied in the calculation of cash values at such increased rates and in
such manner as determined by us. However, interest in excess of .36748 percent per month
compounded monthly will not be applied to the portion of the cash value which equals any
indebtedness due the Company.
COST OF INSURANCE
The cost of insurance is determined monthly for each specified amount, by using the attained age on
the prior annual date.
If the specified amount includes the cash value (Option Al and the specified amount has been
increased, the cash value will be considered part of the initial specified amount. If the cash value is
greater than the initial amount, it will be part of any additional specified amounts in the order of the
increases.
The Schedule shows whether the cash value is included in the specified amount.
AL594-0054 2-82
Page 10
LUlZ01S1
DUPLICATE POLICY
~DDITIONAL REPORTS
Upon request. we' will furnish the Owner with a projection which shows the expected results of the
future. This projection will be made for at least 20 years from the date of the report. Any cash value
pro jections must use the existing cash value at the time of the projection request, the guaranteed
interest rate, and the maximum mortality cost. Additional cash value pro jections may be made based on
the existing cash value and current interest and mortality assumptions. We will use reasonable
assumptions and the basis of the assumptions will be provided. We may charge a reasonable fee for
this service.
BASIS OF COMPUTATION
Minimum cash values, options when the policy terminates, and reserves for this policy are based on
the Commissioners 1958 Standard Ordinary Mortality Table, age last birthday. with interest at 4 1/2%
compounded annually.
All of the values are the same or more than' the minimums set by the laws of the state where the
application was signed. We 'have filed a detailed statement about this with your State Insurance
Department.
Reserves are calculated on a modified preliminary term method but will not be less than the reserves
produced by the Commissioners Reserve Valuation Method.
AL594-00S4 2-82
Page 12
DUPLICATE POUCy
lULZQ1S1
~..,..
'.~>l.
~~:1
I
\.,;;:1
USM LIFE INSURANCE COMPANY
ENDORSEMENT MODIFYING LOAN INTEREST PROVISION
Attached to and forming a part of
Policy No.
The section of this policy entitled "Loan Interest" is hereby deleted and the following substituted therefor:
LOAN INTEREST: Loan interest is payable in advance on the loan. The rate of interest you will be
charged is an annual rate of 7.40/0. We will add interest to the loan on each Annual Date.
w~1J\~~
Secretary
1I594-0090 10-82
DUPLICATE POUCY
UL
USAA LIFE INSURANCE COMPANY
San Antonio. Texas
(,
CHILDREN'S TERM INSURANCE RIDER
RIDER AGREEMENT
USAA LIFE INSURANCE COMPANY, for consideration received, will provide level term life insurance on anj
Insured Children and shall pay the applicable death benefits, subject to the conditions and limitations below
RIDER PROVISIONS
DEFINITIONS
This Rider is issued in consideration of the application for the Rider and thE
future deduction of cost therefor. The application is attached to and madE
part of this Rider. The cost for this Rider vvill be deducted from the cash valuE
of the Policy on the same dates as the monthly deduction for the Policy.
This Rider is attached to and is part of the Policy. The ternlS and conditions oi
the Policy apply to this Rider. Where such terms and conditions are
inconsistent, the Rider prevails with respect to Rider benefits.
For the purposes of this Rider, the following definitions apply:
1) The Insured is the person insured under the Policy to which this Rider is
attached.
2) An I nsured Child is:
a) Any child, stepchild or legally adopted child of the Insured
provided such child is listed in the application forthis Rider and also
provided that the child is under 18 years of age at the tirne of
application.
b) Any child subsequently born of the marriage of the Insured
provided the child survives to the 14th day of life.
c) Any child subsequently adopted by the Insured provided the child
is under 18. years of age at the time of adoption.
RIDER BENEFITS
USAA LIFE INSURANCE COMPANY will provide the following benefits upon receipt of due proof that death
occurred while this Rider is in force:
CONSIDERATION
GENERAL PROVISION
(
Benefit A. on Death of Insured Child
Upon the death of an Insured Child, the Company will pay S 1000 for each unit of the Rider in force at the time
of such Child's death. We will pay the benefit to:
1) The Insured, if living; otherwise
2) The estate of the Insured Child; or
3) As otherwise stated in the application.
Insurance on an Insured Child TERMIN/-\ TES on the earliest of:
'--
1) The 1-1 ider anniverSAry following the child's 25th- birthday; or
7) The Expiration Date of the. Rider; or
3} The end of the Grace Period defined in the Policy if the cost of the Rider is not paid.
Benefit B. on Death of Insured
Upon the death of the Insured, coverage will continue as paid-up level term life insurance. in the appropria t:)
f a/nount set forth in Benefit A. above, or any Insured Child then living until:
L'
'j) The Rider annivers3ry following the Child's 25th birthday; or
2) The Expiration Date of the Ridf~r, 'vvhichever is earlier.
DUPLICATE POucr
PA594-019t 9-63
PA...UL
(, COST FOR RIDER
REINST ATEMENT
WAIVER OF rv10NTHL Y
DEDUCTION
INCONTEST ABILITY
MISSTATEMENT OF
AGE OR SEX
SUICIDE EXCLUSION
(~
CONVERSION
l:
PA594-0191 9-83
The cost for the Rider is in addition to the cost for the Policy and these cost;:
will be deducted until the Expiration Date of the Rider unless the death of thE
Insured occurs prior to that time. In such event no further costs for this Rider
will be deducted.
This Rider may be reinstated under the same terms and conditions as the
Policy to 'Nhich it is attached. All persons to whom the reinstated coverage
applies must be living on the date the Rider is reinstated.
If the Policy provides for the Waiver of Monthly Deduction benefit. such
benefit will also apply to this Rider. Otherwise. no such benefit exists under
this Rider.
The Company will not contest this Rider for any reason, other than non-
payment of the cost therefor or fraud, after it has been in force for two years
during the lifetime of any person narned in the original application who i'~;
insured by this Rider.
If the age or sex of an Insured Child was not correctly stated when this Rider
was issued, the Company will adjust the benefits to the correct amount 8t the
time of death 01 the Insured Child. This means that each benefit of this Rider
will be changed to that which the cost for this Rider would have purchased at
the correct age or sex.
If the Insured or an Insured Child, while sane or insane (in Missouri. while sane),
comrnits suicide during the first two years this Rider is in force, the only benefit
payable will be an amount equal to the total of all deductions for the cost of
this Rider attributable to such Insured or Insured Child made prior to the date
of death. The two-year period begins on the Effective Date of the Rider.
Insured survivors may immediately ,apply for conversion if the Policy to which
this Rider is attached terminates due to suicide by the Insured.
The terrn insurance on the life of any Insured Child may be converted to any
plan of whole life or term insurance that we write. We will not require proof of
insurability to convert. The amount of the new policy may not be more than 10
times the amount on each Insured Child under the Rider nor less than the
minimum amount we write for the plan chosen.
Application to convert must be made within 60 days before the date the
insurance being converted is due to terminate. Premiums on the insurance
being converted must be paid as of the termination date of this Rider. The new
policy will be issued in the same mortality class as the insurance being
converted. The effective date of the new policy will be the date the conversion
is made. The premiurn charged will be the appropriate published rate for the
person to be insured as of the date of conversion. Supplemental contracts
attached to the new policy nlust be applied for and have our approval.
-----. -
The requirements to convert are:
1} Written application fronl the person to be insured; and
2) Payrnent of the first prenliurn for the new policy.
For conversion to be effective, 'vve must receive these requirernents during tho
lifetime of the person to be insured and before:
1) The Expiration Date of the Rider; and
2) The Rider anniversQry follo'vving an Insured Child's attaining age 25.
lbuPUCATE POLlCV
. t
( TERMINATION
EXPIRATION DATE
NON-PARTICIPATING
VALUES
EFFECTIVE DATE
(
c
PA594-0191 9-83
Except as provided in Benefit B., this Rider will terminate on the earliest 01
1) The Expiration Date of the Rider;
2) The expiration of the Grace Period for unpaid cost for this Rider or thE
Policy; or
3) The date the Policy is surrendered, converted, or continued under c
nonforfeiture option or otherwise terminated.
NOTE: Except as provided in Benefit B.. any Insurance continued under thE
nonforfeiture provisions of the Policy shall not include any benefit~
under this Rider.
This Rider expires on the Rider anniversary following the Insured's 65th
birthday.
This Rider will not share in any of the Company's profits or surplus earnings.
This Rider has:
1) No cash value; or
2) No cash surrender value; or
3) No loan value
The Effective Date of this Rider is the Effective Date of the Policy, unless a later
date is shown below.
Effective Date, if later than the Effective Date of this Policy:
Y~s:e;#W;~
~--..
DUPl~Afc POLley
PA-UL
II
~.....
Q-r I
IS t ;,; :?</ I~
.
I k. AESIDEJ'tCE
I I. 8USP'ESS
~ iO.JCY TO
I ~Bidlnce 0 BuIine>>
I rt. ~Go'L tOE ~T~lE
I (,..C1f.l: *"lUTNI'f
, Qr;LY) crrv C()(J'olTV S~"TE
Ii -~ - CIIfIR2IR CIfU' . OMU 01' M fIOlJCY. to . onu 1"HM ~ .....-: ..J
la.~ .. ._____fb~~~.I;...~______~
. c. I\OOAESS
o 0Ctler. :,.,:
.
SUCCESSOR ~ - TO ~ 'OA.NJl-.Nf.:\:r.;~ OF DEATH Or~N----"-- - - - -- -.-
:I. ~ , r fl . ~ I ..---- -- -_.--------r;:-~SfcTRF!';rIl~ ~._..-------:
~~'"id_ ~~UV:, J c~~ (', ._ _ . .__.___- __ ..L._2:-'~ <f___j:~~, =-~3..t:: _~
JJ.~ '. ...... I
. Q, i' ,~~. ,_" ~ L~? t. 'J f' -u~i--i 'C'-. I)~ 72, I
11.~nas~ ~c= _ \Ju=~~ J
B. POLICY ft'fFORJ"WlOI't
I ... Jl\Nt AI'IU:D reM . OEK oru OPE .I. .,. rmw. tEATH IEM!JIff
i FLEXlaaz rafAlCIJII' , ~ t I
i :::aLEU'E ~. Dovru:<8 ____u~-::~......-_--j
I .-.,-..:~::'-r - ~. -----.-- .-..- ... ,~ -. ..-..--..--.---.-'---.--..--:
r-. -- - . . .~,_..--~
;. ._._ _ ._ __~ ~.c~~~~~ ________ _.__. = ... ---,~]~.-~=._ -~~-~.. .~.._-.~.~___._ ____0.:
! :: Di~bil~.,. W.i'~r QI "\onlht\. ~uclicon I
,'--- --' ~ ~. to" ..,. .-.-.;;:._~. --- - -'-5 - .- -...----1
r;: _ Of''-: - ......~=~~r.-.. ro.-~ - roa- :I .~. ~~~
I ~SfJLCJl:i) _ \\mtNPLs.~~
! :: ~onlhl~. Prt.A"dll..:;led CIlrck = ~i.Annually !:>irflC1 I ~ :)' . .4.~-- I ~ --C.' -~. C r") I
~ntlllv Go~~'NMnI Altotmen~ :: .o\nnu.n,. Oire<:t ! . ~ " , C . C~J ":J ~
.. ~~rlv D!l'ec:t do. I
*~~__.________._L . :'2f~~~..I~~~_~ ~
C. SMOf(JI"fG
t 1. ~ YOU ~ ON=. <;1' IlUE ~ .. ntr: LASr VENn
o 'ft dr-to
//::j
[JSM UfE IrtSURNtC% CCJiIIfIA/'fY Us.a.A Bu.Id.r'lg . San 'VIlQf1lO T"*-, 7lj7.ba
f'.SM4011 JU
.~ I
---~..--- .
.,/'
.-'
./'
v" 4018
DUPLICATE POLICY
.
to
D. UfE INSURNtCE NOW I" fORCE Ort UR OF PROPOSED INSURED
.. .'. niI'~ iiai.....wa am.raD YO Ia..G "" lR ~ ~ NIIII'I!I NOW It PDMD'~' . t.
I ," -- "*-. ~ ~..,.' -~ . .,. . I "~.:r' .:. .
'.. "o\~"'.!'-'''''' _.' ...~..rJ4'1-.~" '-.. .'. ,..' ,.., .. . ..,.:;.....- '. ...;:,.U.'''', ,.,I~
O,Ys- . p" . Va ctwdc ~ * ~. ~ 10 poky III!ir1!J ~ · .:- ~ :-".- 0'
I. ~ Of CJ:I'PN<< .........,.... _=Of ~..-~
I
ACCEe'ITH.
rEAnt NOJtn'
I
r---
I
f. AVOCA110rt
19. HM THE PIUOl!fD....!\D ~ If OR DOd HE COImJlIU'MPMOOM1~'~JIlU'IaIIIOIU 1W:Ir<<1H)~~' '
~ ~AT RM:J'tG. ~ ~ OII'~ I:IMN3. tw<<) ~ IIOQ( OR ~Aft ~ . _ '
I 11"~ d""No . Yft. cifo!,(ribc .... - --
l .... !
I -
I .
F, AVIATION
'110... ~~1IWI~FlDIIt~oR ~H! PINt TO R.Y!If THE FUIURf ~~~. aiEW~ STOD!1'ffORN!.
U Y'''!o ~ If yH. ___ .. ttlfough , below ., ~ II'lo. go 10 SectIVf\ '3. - I
I KI1\'::- .m;---.-.- --- --- d___ ~~ -. ~~~,.,. ""'" ~ 12 MOS- ~ l'EXT 12..0& j'
13:~ CiWiO--: .~_.- -----t.=---=--=t-=-~~ = .
l d.CJVI.Wf - C~ =t ' =t= t= . 3
I 0 SCHEIXllED AM..I'tE -E -- - -- -1.
I 0 OlliER Onc-,,~ pIIIJlIOW
. (, nll:1I<< bfIcNo __ ___ I _~.__
~l " -i
e. ~~ _ NON C~ TVf'E{SI Of ~-;-- HOuRS n0Vm j
AIflCR/IF'T _ ~ 'J.2~ MQS.I'G:J l-^5T 121#07 EST. NEXT 12 MOS,
r [j AS PLOT . I
o . S ~TUCE1"tT
-1
I. . .-on ~ ~ ~ pmnUn. ~1\ do )OU ptdef?
o ~ IddiIlor\Il ~ Q HIIloc ~ conItIitI .... ofIIiItion Cllcllnion a~ W: 1 11'-""9 . . ~
r<<Jn: The __ clptiDM ... .... IIppIy to h ~ DeIttI ... The ~ ~ c~ ... U'IIC kltm cannaI be .-.ed.
G. BBtEFICIARY 0ESIGrtA110tt
II.IEJIIEJIICWIJ IIE8IGI'MIIDft c-.. "... .. ... __ fIA -.... ....
L A FRST ')f\CrD-.( "\,rlu.I~C;"\
\
b, CClffilr'l<Z."ff . _& "\ G.. ~rc.. . "\ (\, j~ ~,._()':i ;,"
11E.1A1D'f TO
I'CSQRfJ)
\ ~\~Lj 1'~-s~
-----=E:qD;J~ 1 ~-)-~
I I
1w)
''''''''7' J....
OUP'JCATE P()liC'~
H. SPEOAL REQDf.S1S
~
. >,' ,f> . "'~:t""~"''''''''';.~ ".
tOll omc:E"ADCllllti "Ih~,oe ~DD ... .. .... ..... . ..: '~'1;.:l~.? J'/"i ~' ,
........,U'.........~.af~~...~.I.. F - ...........~~.......~.~..J*...~.. .
. ..........~f.................~ . '. .. I .. ,_'- :. ',' . ......~.. ~L" ... -~_.
. ,." ,.' ". ,I' ..~ '..... " . -'. .' . . :.... I" ... r.('~.jf ~ f;.~ ",,~. ~' ...
PART II
I. DfClARAT'IOrf OF IftSURABI1..ITW U't UEO OF MEDICAL f.XN\
f . ~ -.MI. ..1IIioI. is ~ b1cauw at . or amourt ti inwrir1c~. OInk '* tedlcft ~ ~ 10 Sedicln J for ,igrwtu~ d ltIe ~"oUI
and ~ Lf'4II '. .. _. . ..
1~ .. WMI' . ftIOfOIED ...... tIBGHf Me WEICIft?
lit. Nff IBIIIf awm DC-.a MSI' WIlIP
11 HAS nc HOIICIID .... ~ ." 1'I&QI!D FOR OR
HAD ....:A~ OF RfI ~ ~ ~~. ~'en.o;r.,?
':'E..~
.. High bDod ..... ~ pIin or chofdef II the
neIIl or ciladllaly ~~. ,'"
o
-
b. Tuberculolis.~. or di5cJrdef d'h ~ ..
'Y*m~ 0
c. ^"" chclrdcr ~ 1M ~ ~~? .
r~M'IoIt:'" itIIHina. g. tMctdcf~1Mr. I*'C,",J -
~I
~
rf
-""0 .
d. ~ ~ merMl Of br.., diIordtr 01
CUMIlIiOnI. .-1fysiI. .~:>
11:. hfy di~ d !he geniuI org.ns. ~. Off oolhe9
gI'ftilo-vlMrY ~?
f. ~. ~ Of di50rdn 01 maca boJne
Of joirU? '
o
o
o
g. c.nm, 1J.mOr, ~ ~ ~ Of
PMcInson', 0iIMIlt. nUllpIe ~ Ot ~?
o
h. f'.-niIy Reawd: (... r.m~ histDty d ~
cI*Ies. eInCW. hip blood prestul't, nr3rl or IUdney ~,
ml!I'ltIt .... or Sliclde..
RElAl1Cf'&tP
f'AllER
o
ACE
, Fl..I\IING
STA.n:: OF HE."Lnt-- lIf:A..~ F I'O()R
/lCTlfER
BROnER/SISTER
I
'ES NO I
a/' a I
I ~ IWITHE HOfiC:lIe If18CIIED;
.. 0Ihet thin ~ ..., in IJ e-. ~ .
~ gr ohr ~ 01 ItW!IU ...,., ~
'IIIifIin pIIIlIl 5 ~;l II l'CaJbne pI1ysica so "*.
b. Ewr UMd ~ ~, LSD. ClIClIInC
augs. hlfutinogl!ftl. ~ \.1\" an b
adwice d .~?
o
~
c. loW " ~ b II. ... ......, ~~
~ ~ <Waled. r-.t or rsricV1cP.
;J
::J.-
7 in, n I~-S
prl'J~OSS
aM! .....AILI tw ALL YEa MIIlIJII (1M'" we
........ .... af ............... __ ..,. ......
tI ,.,.... ~ ..... ....,.,.
~I
pc,,," l.
r "
I
I
lUw. IlidltioNl !I.ftt I! Tf'qUiledl
If" DECEASED ;
""- " ""'j ~-L<\' ( :. I
l....~... '-4~ . .'\ ~ . 'L11~
J :
1
I
!
~ DOAL& OF YES ~
1)\- -6:t ~"J~''-<'''(,.f
~. e(,l~h.L p~....rt('~.~..
I
PlE.ASE SIGN ON REVFRSE SIDE
'''....0071 l..~
I
-t
DUPLICATE POUCY
J. cOrtOOtONS RB.An~ TO ntlS APPUCAtJOI'f AND MOntES
The PrapD.s ..... and the AppIcn. . cdw ... tile
PIIapOIed ...... ..... thIt .. 1 11151...............
""'~.. ~ ,.. One Ind Two d OW "I'J'k1lM n
campIeIle .............., Ibebatd"~Md
belli end _ c6red _ co.~.4.'I for Ihe NuRInce
appW for. It ,. e.pNIIIy egreed thIt .
I. The COllll8lJIlIUIhoItIed liD emend ...~ ~ M
~"I"" naIIIIan rn the tpeee ~ -Home 0fIIat
McIIians ... Co.ledIoI.- In Older tD caned Iny 'PPM'1I
errors 01 ""I....... 'The _,,~1ClI d." PclIc:.y iIIued .. .
reut. d tHI ~, ~ . shell aIf1ItUI-a tIIUficIIIIon. d such
.,..lCfrr.,aa .. WIll _ the .4iRu6".. d the bI:ne8dary
~ OMk.A.fp. and mechod d ~ fA h
proceeds d IUCh P'oky.
2. 1be CanIpwIr ..... ana. no ...., under IhII ~n
pItar 10 cw., 01... Paley ..... ... .... at candIb"
e:llpI'aMId ....... .. md. to wi: (a) 1ft IIIICMIt ...... to
IIIe fht ruI premUn .. ......... .... (1)>) III ~
..v.6'118Inc:Wnt.", medk:II ~........,
fM~'" "4:Iw..~ IIhe A--" . ........ ~
.. ~~.... lor ~....,. ......~....~:
mo. AIfI " _.,....... lID. ,. --- ..., ..
CA....~ ... ~. prKIkB.. ..... r.-.......... ,
PoIcr ...... lor .......... .... .. .... .... __ .... % .
.. 0I--.r". "l~"'~" of~o"."""',,:._ .
~8_"" 01...." .. ~ .... Nell 1'" till
--.r";T~ "~n r InJ d ttw 1bL.. CGI.... II not met. the
...., 01 .. c.c.q.a, .. be .... to Ibc reIunI 01l1li
IIIICIUIIt fJI ........ .1bmI&.ed.
PRIOR TO DE1.Nf1'V.Ofo' THE POUCY. llE CtJIII'NffS
~ ~8lm':.::c.JNtBt THIS APFLICAnort 5IW.L
NOT EXCEED $200.00CrlNCJ.lD'<<i ACCI)EM'AL DEAnt
BENEfTT.
f hiM .- 'h.1 UIl'~ the IbcM! nr:Ake - IN ......
tIons and cxn.t:~. ~nc:I!IftinI IJI/fi n.nnce becornuo
effec.1h,le Ware ~c'_~ is lsstJed.'
I
I
II OiII'd..~L"~':)f(\'-' \")C_ r~.i "-r,.\)t'(~.:t'-r.;'i;..__3_,(~of_.J~{'~~ ____.19]"./ -.
lIN ~T"'Tf. C~l~ "~'. ~
-;- ~-+
. ~dir.:'/f,\')>'''i \\.Ar1--.f.'f.j{':J:=:-__ .>> I ~.t~~~'~~
i Sl(jNATORf.. OF PN0P051:]) r;SURED ~tiN/,'Wd:: OF APFlI('ANT I" l'lIher Ihan p~ h~,wtl
I l(" .. ,/1 'l1 .(;' ,t;~/~';JP'-
I ._~~~~~:. ~~~---
L_~~NATURt:.-?'"" ~'Jfl"l~_______.,____.___ ___________
PL.EASE SIGN PERMISSION l.ETTER .
. I heteby authorize III'f/ licensed ~~ meckaI practlioner, ho!9ilaJ, riinic If' ocher medical Of medically nMIed r.:tIiIy.
in:u'aRO! cornpIIn1. the ~at lnIr:nndon au,.., or rJChet OI!;ant&alkn inailuticn or penon. that tn ln1 records 01
IcncMIedge ~. me Of my heIti\. or Ihe child d ~ under1:gnrd, CO gve to the: ~ LIFE IrfS(JR.A.NCE COl'tPNff or Its
reinsurers eny sdI irlonnation. .
I ^ ph,_~~'hk ee;:.'Y d 1hl$ ~'!t'~ at-=: ~ ti .....J cb Uw ariginai. ~
L-. ----- '--'.'-' ----- ---.----.
I SIG."I."T!II~ Of' \\.1ll"lESS.' i -:>o"',j,.....rf_'nt:. O~ WOPoStl.; ~I:.D, .
w---~.J~~L.I-/- ~ 4/ ~:;..O~__ _ __ _ ...: ~ _0._(..19:(::::.:.ji\._J1.~!~:A{(Jf/"--' --
! D~!E' '.' ,_, .' i 51,......a.;~f. UF _a,pruc:",-"~ IF Ort1(~R H1A."4 ~D 'NSl~H)
!..... _._l.:--~.:...3. -=...::~.:f.. --- .--- - ---.., - .~. --..---- -.---... ~ -- --- -~
I
I In mIIIcing this~"" for in5uranr.e It is undetsiood dVIt an
! ~ ~ report may b@ ~ -MJer~
~io.nlltion is (jbClined ct;rough penonaI ~;8S 1MtI1 )-"JUr
neigNuS. friend5. 0( dJlers with whom )IOU ~ <<:~:aIrUd.
This inq.Ary"&..Ides WofmaIian as to 'PII r.hardC1~. genet'81
fnformation g;~'t' In this 4!ppIicMion fNy ~ ~ ~ to
oCher in5lnnce "=~~ to....hich yr:..~ mclke ~;JPIiclllion for
I~ or heIIIIh inS&nnC.~ ~ CCft8'age at !o 1IIttidt a daim is
subrriaed.
'epu~on. per!CN1 characteristics ar'l(4 mode d living. You
hiM! the ~ 10 make . Mitten reque.A wlhin . IM5QMbte
period cJ time to ~ ~1. detailed inlOfTTNltion about
!he I'1I!IILft .-xl -.:ope of this ~.
Upon re:eipt of a requr5t from you, the MI8 wit ..-ange
cfjsdosu~ 01 any .nfOl'1'T\8tion " I'niIY have In 'PI file. (Medical
infonnation will be di5c105ed only to your attencIng ptrpic:ian.)
f yJU question 1he atC\IT'ik.y cI jnform8ticJn in the Buftlau's
fill!. 'fOIl may c:ont.Jct the Bureau and seek I! (()"I~~ in
ao_~;)tdance whh !he procedu~ set fOlth in the Federal Fair
':redit Reporting Act. The addrfts d Ihe Bueau's ..~..~
~ is P03l OffICe Box 105. Essa SIatitrI. Boston.
Massachusetts 02! 12. IeIephonl!! number <617l 426-~,
\
I
I
I
I
I
i
I
I
I
\
I compeny 10 v.f1id'l )UU t-.a'.Ie o1Pf' -loed f<< 1ft or heo!IIh lnsuf'BOCt! information in its file tc oCher life insurance compllnies to
I CO\~. or to M..;m a d~ is s-obnitt.ed.1he MI8 will ~. Vllhom you may iIppIy for life Of health In!Wf'anc.e. or to whom a
5U':h c~ wiIh the irI~1Otl it may hiwe in its f~. c~im for benefits may br. 5UbmiUed,
1__.__ ______ --_. '-- - ..- - - ---. .. -- - -.-'-- - -.. ....- ----
f \".~';~71 }IJ
1rtforTNmr. )IOU proMde 1lIiII be treaIed a "'UI~!tiII ~
thai USAA LFE ~ COMPNff !:# its rft15un!n may
~ a btW rt!pOft lheR.'oon r.o che ~ WonNIOQn Bureau.
is nonopniJt rT'op..t>....');p ~ d lie in!Iurana!
c~ies 1IIhich cperIIte an irlom..uon achange in behalf
d It$ mem~ Upon request by ~ ~ in5Unlnce
USM. UFE ll'iSUIW"<lCE COMPNftI may also rdea:Ie
DUPLICATE. POUC~
~
~
~~..."".,
I. Chlk IWIr ...... ca. Ut .....
z. QIct .... II ..... .....
U..' 1.,..."...... rw .....
JIIUOiI.".
A,pIitation 171 TM Addllion. ID USAA lIE INSJfWIl OOMP~,
SIn Amunio, T IUS
Far41111l1r lasurRl ,.. Dr OeIIIIdtnl Cildren 81111:1 Rider
0"'" 1_'"
OC!M OT_
1'I1f 16
fIlM. _
.. '.~'..
...... __.._.............;..... iIII.....~~. ..".,. ...!'~..._...~~.~!W., ..............
.. .." ....... .. ...... .... Mr. ... .... .. _ . . '.
~ -C5IR I W9III1 . , .. ... , AIIOlIa lORIIII'
.. . fT. 1M PIl/IIDS ~~ ..,-- flalMftIMt
_...-~....
A ("\....{\tvM. -;' ~J 1'1.U'J"1:
~I.
IUSI"'-"~
ram Dt1IJIWSllDIiUlHI Of .ENlfIQM\'Wll. '"ll_O UIIIIIItlf. MSIt PIll'Y.IOJIiar lIB IS lnADID.
. . ...._.........tllal DY. .~ ft,-..'"
--.-------.
.., .... .__.. ...: n.s 'lJ . ftS WI]
a. ..,. ...... ".... ..,.. .i... II.. ,-,,, ~1IDrY ftI1IIlI? 0 rr I c-'tlll uIlts"," ., ,;~ .""" ~ ... "'" "'" I., JIll.... .~ I
~ 11M ft....... ... llf .._ II dllI ""-r 1'fSl1D? 0 B" III",.. ~"'., .... ......... ,...' 0 ~
L ~~ lIIIf d._ rf......... ....11AiG. ...... fill MId'..Ir.., 0 r:1" j IISd -"amm. .......lSD. ......... ~ ~ unless I
.. 11M.........,.........,........ or ~ ........ ..' roD L~.. 011 " . tdft. '" · ~.'..'''' , .~ II ~. I
.. lid"" -.. III ,. ..... .... ~ III __ 9ril1lrI,..., syPtIIl' Ll -
I. IIW ,lleu......, ... ., .... lIl1 .-.. ..... ., pili' 0 0 I . . I
. 11M Clnnr. ..... IJIIIIIiL ....... ~..... II Pl,i1..', o...s.. .....
sd.m fJI .....' 0 r;!
t.. ......... ,.. . .... ... lI1E .......' ~ ~ -.l
'.'1 ,... .. ... -.. ..,W- i. IlMItIeI S. ... hi ,........ .... (II ........ .... ....... ... .......... . __I
_ -~--. ~ft -, .1 _.._~.- .
"~~_qdol~"'~sIld~""-::~
I
eni"i aIIf ~ odW ItlIn PmIf19I'? 0 Yes EI ra . yes. gift dellIts,
l/lllflla.
. lCllioft II
. 1111 .11 " . It
) utII.. .... .. . ... flr .. Pt... _iii ft. dII P*Y .. IIIlich fit IW. is arIIdlId.
I have tad Ih, .an ~I .., SIIt!merI$ Ind ...1..... III be .... die llIS1 III ..;~.. ....iiiir-
Cr. .
~~~J.~~' ,,[.)t?c.
r
--_-.1
(1' ~-~~
liIliMflll 01' nGllf IINi .......a f(Jl ..~-
IUASI SI&II ~_1DTEII
11 ""1lIIaire IIlf ~ ",1IIdicIl pr...... .....1ilK . adw _iallIlIltdicIIr r.....IdIy. .,1llU alIIIPIr. lhe MllliaI hftr__ II. .
1.......... ............. 1M" ..,,..lh. .... ~!he ner!lipd .. dle 1MIr. ~ 1M........... co givt '0 Iht lJSM LIft IMSUJWG CDI8I'f..
ts ,....In .., MIl ......
A ... aIIIY '" .. ..,ilJIiaft .. III . nit . die or.....
.'
I Slli1llAlUlllIJ tl2IIID ~ MSIt I'WC" --
I 1"-': .: -... t.... '\ 1.1. f:" 1" - .
, '_' _.'_ ~. t..: ., t v_< ~ V ~ V ,---
i~~ ~ f 1I:111i I'1U'U:ll>> 'DR IIISIJIlAIIIa . . .
:_- -7~
,.: /.' ' (. "
,/ ~/''''..'' ~-,.,..
:.~~ j
Ull.....
I ,. 'J. -' ~-
'''s..~" II to
r..~ U
..)
DUPLICATE POliCY
UIM UN IIIIIURMCI COWMY
I
APPENDIX 8
Surrender ~ tndex..DiScto....~..
Per $ UJOO 01 FKe Amount of Basic tnsUrince. . - .-. -. .
~ '-.' -~.- '..
__ _ ._._ USAAUFE INSU~C!rCOMPANY - --
Name of fns\l'ed C OII~'AJ ft1 JJ Jc.J, ni s .MJ .'A;e _-.c;17 Sex FemAk.
Initial Specified Amooot of Policy: .~ ~ 00 C _..
-
Descriptive rtUe of PoliC'j. FlnIbI.""""m Ad'uSU.....I;I,. '. ...~..
Policy Number. I ~, - 9/, - "0 .... u I
1 OYar Su"ender_~: ,~ ."_ _~reflec:ts ass~~ftiterest rates and costof.insurance).
. :--20Y.earSul!.~lndex: -o,-,-,.q . ,. '{ieflects:a$Sum~eresfrateS;ndcoSiofin;;r.nci).
_:.:za~~ -...."':'-.-... . .' ~ .
The Su~.!ncter Comparison Index was destgned to measure the:mi8iIVe'cG~oUite Insuran'~ protection-aridmay~ ~
--~':--._ ._be.~~Jg,~ ~rison of similar policies offered by other.compan~soi~rcJtemal beri~fjt societies. T echnicany.
- - the Index ~ft".e relationship.between the amounts paid by,ttle.insumd.(the averag~a"nual premiu~!)JM .
.thea'mounts paid by~tIle insurer (the cash value of the policvin.tha evenfof surrendet.Oviiperioas 6f J Oind .~o- 4
-'-,,:;:_years) all adjusted for compound'interest'at the rate of fIVe percent per ann~tcHefleCnhe timing of payments.
.-- '.. ...
'Nhen comparing similar poticies. if alP things are equal. the policy with the lower Index Isg~ally the tower cost
._ ~cy and the bener buy in the event tha: Ihe policy was surrP.nderd at t~ end of the designated period. If death
would occur during the designated peOOd. the poljcy with the'lower Index would'not necessar~ be the lower
..--'COS1 poJicy. The Index does not take into account. among other:things:{'l)'thevalue of the services 01 an agent or
..-.- company; (2) the retative strength and reputation of the compaey: and (3) small differences in polity provisioM.
The rndex (toes assume that annual premiums are paid and. that no addit;onal benefit provisions are included.
3 -I 't - P-s-
Date Prepared
PA594-02SO .~
P~fPAL
P.., IN..........
DUPLlCATE POUCy
THIS PAGE LEfT II'lTEI'lTIOI'lALL Y BLAI'lI(.
nup\,.\Ci\,t: pOUC'!
~
.. . '.'
~ ~
~ y
~ ~
~ ~
~ ~
I ~ ~
~ -~
;.:( )'..'" '::,>>:;'.:: ":.>>;.".:'~3:..., .~:~.:~::: ..~<.:~;.. )>>:.:~: .:.~:.::~::: .::.:.:;,.:~ '::.:+;( .....:.~~;.: ):€~": >;:.>.,: ):.:~~: :'.~:.:~..: :,",.:+:." "'.:+:...: ...~:.:.._ .".:.:.,. ,~~:.:~::: ):.:.::: :: ~::.:.'.: :.:.~.:.':: )~.;~.:: :::-:+;.:. ..,.::.:...: ::'.~~~.:: ::'.=.;~..: :-:.::.:~;:
~
~
~~~
~
i
~.~
~
i:1
~
t.~
~
(.;
~
[~
~)
;>
~~~
!
,
Io~ ~'.
~
~
~.~
~
~
~
~
~.~
~
~.~
~
~
~.~
~
~.~
'-
~~)
W
~.~
COLLEEN NICHOLSON
No. ...??~~.~.~.?... .................. 19
Versus
__ __..... JAMES... c..__ .NI CHOLSON.... ._....,._ --. -....... --.. -.--
AND NOW, ...
DECREE IN...
· ~ V 0 R C E M e~ 30 ~~ ·
. (t. . . . . . .. . .!? . . .. " 19.99..., it is ordered and
decreed that .....~. .I;.~~;e:.~ . r,;l:r~IiOLSQ~ . . . . .. . . . . . .. . .. . .. . . . ., pia i ntiff,
and. . . . . JAMES. C.. .blICHOLSON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., defendant,
are divorced from the bonds of matrimony.
The court retains iurisdiction of the following claims which have
been raised of record in this action for which a final order has not yet
been entered;
~
None
. . . . . . . . . . . . I . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . . . . . . . . . I . . . I . . . . . . . . . . ,
~
~
....,..
~
~.~
~
~.~
~
.
I, COLLEEN NICHOLSON of South Middleton Township, Cumberland County,
Pennsylvania, being of sound and disposing mind, memory, and understanding, hereby declare
this instrument to be my Last Will and Testament, revoking any and all Wills by me heretofore
made.
ITEM ONE: I direct my hereinafter named Executors to pay all my just debts, funeral
expenses and administration expenses, including inheritance taxes, as soon as may be conveient
after my decease.
ITEM TWO: I give my truck and horse trailer to JAMES C. NICHOLSON, of South
Middleton Township, Cumberland County, Pennsylvania.
ITEM THREE: I give my Ford Tempo or other car to AMANDA J. NICHOLSON, of
South Middleton Township, Cumberland County, Pennsylvania. I give my Mercury Tracer to
JESSICA M. NICHOLSON of Cumberland County Pennsylvania.
ITEM FOUR: I hereby give my House, to my Executors upon the following trust:
a. JAMES C. NICHOLSON shall have personal use and occupation of my house
as a place of residence, and the use thereof during his lifetime. My daughters may
also live in the house, however, they must contribute to the household bills.
b. The monthly rent payable by JAMES C. NICHOLSON during his lifetime
shall not exceed the prorated cost of taxes and insurance on the house. JAMES C.
NICHOLSON shall be responsible for the costs of utilities.
c. JAMES C. NICHOLSON shall be responsible for necessary and reasonable
upkeep and maintenance of the house as well as care and upkeep of the horses and
dogs.
d. My Executor shall be responsible to ensure that the grounds of the property are
maintained as nearly as possible as they were at my death.
e. I authorize my Executor, during the lifetime and with the consent of, JAMES
C. NICHOLSON to lease the premises on such reasonable terms as my Executor
may determine such that the rents received are paid to JAMES C. NICHOLSON.
f. Upon the death of JAMES C. NICHOLSON, the house shall pass to these two
of my children, AMANDA J. NICHOLSON of South Middleton Township,
Pennsylvania, and JESSICA M. NICHOLSON, of South Middleton Township, or
their issue per stirpes, for their use absolutely.
ITEM FNE: Should JESSICA M. NICHOLSON be a minor at the time of my death,
desire that AMANDA J. NICHOLSON shall act as her legal guardian.
ITEM SIX: I give all the rest, residue and remainder of my Estate, real, personal, or
mixed, of whatsoever nature and wheresoever situate, iQ three equal shares, unto JAl\1p~ C.
NICHOLSON, and my daughters, AMANDA J. NICHOLSON, and JESSICA M. NICHOLSON,
or my daughters issue per stirpes.
ITEM SEVEN: I hereby nominate, constitute and appoint JAMES C. NICHOLSON and
AMANDA J. NICHOLSON as Co-Executors of this, my Last Will and Testament.
ITEM EIGHT: I direct that my Executor or Co-Executrices, shall not be required to give
bond for the faithful performance of their duties in this or any other jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this this, my Last Will and
Testatmen~ consisting of ~ typewritten page(s), bearing my signature,
this ;}d1J"(jay of ~ A.D. 2002.
.
ACKNOWLEDGEMENT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
BOROUGH OF CARLISLE
I, COLLEEN NICHOLSON, the Testator, whose name is signed to the attached or
foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I
signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and
that I signed it as my free and voluntary act for the purposes therein expressed.
C~DAr ~
COLLEEN NICHOLSON. Testator
On this, thed d tJoiy of IU~ . 2002, before me, a Notary Public, the
undersigned officer, personally appeared COLLEEN NICHOLSON, Testator, known orproven
to me to be the person whose name is subscribed to the within Last Will and Testament, and
acknowledged that he executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set m hand and official seal.
T ~Yl';PV8LID"'''''''''c''c''"7':"i.r;,:;~~
t JPJ.:E t{:}?:~~~!o< ~~g;:;~ ~'~h!;c
; C~rif!S!9 ~r.j, [~i:;~i;Snd c;...nw
(SE fy C~'7tmi3a!c.r. E:q;bos ~pt 6. 2'004
~,
AFFIDA VIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
BOROUGH OF CARLISLE
The foregoing will, consisting of ~ typewritten page(s), was,
on thQ ~ Ab/ day of h v-eJ- , 20~signed, sealed, published and declared by the
said testator as and for his/her L~ Will and Testament, and it is hereby acknowledged that said
testatrix appeared to be of lawful age and sound mind and memory and there was no evidence of
undue influence. We, at her request and in her presence, have hereunto subscribed ournames as
attesting witnesses:
~t')~.
Witness
of
~ jfJA--/7o;3
Address /
On this, the day of , 20~efore me, a Notary Public, the undersigned
officer, personally appeared f'-oreA c:e e. 11 Ctru II"-t- , known or proven to me to be the
person whose name is subscribed to the within Last Will and Testament, and acknowledged that
she executed the same for the purposes therein contained.
IN 'NITNESS WHEREOF, I hereunto set
I/~
- #fflA.j- j4/Ci.-WA... of /r--C~wLL. y.c! Ctr //Jk,.
Witnes? Address ------
On this, the ')JjJJJ day of fvttx,J;.. , 200~before me, a Notary Public, the undersigned
officer, personally appeared ~ rA4- ' known or proven to me to be the
person whose name is subscribed to the Withm Last Will and Testament, and acknowledged that
she executed the same for the purposes therein contained.
IN WIlNESS WHEREOF, I hereunto s
.... :JI~. _~'T_
I r:;:~):~,,~~(~~:I~l ~2lU.
AV~ E. ADMffS, NGtiUY FubHc
I 'J. Soro, Cumtelland CoL:nty
My Commission Exptres Sept 6, 2004
~
.
VERIFICATION
Christopher E. Rice, Esquire, of the firm of MARTS ON DEARDORFF WILLIAMS OTTO
GILROY & FALLER, attorneys for James Nicholson in the above Petition, certifies that the
statements made in the foregoing Petition Pursuant to 20 Pa.C.S.A. ~6111.2 are true and correct to
the best of his knowledge, information and belief. He understands that false statements herein are
made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to
authorities.
CdlJ,A 5 Y(
Christopher E. Rice
.
.
CERTIFICATE OF SERVICE
I, Mary M. Price, an authorized agent for Martson Deardorff Williams Otto Gilroy & Faller,
hereby certify that a copy of the foregoing Petition was served this date by depositing same in the
Post Office at Carlisle, P A, first class mail, postage prepaid, addressed as follows:
Amanda J. Nicholson
154 B West Penn Street
Carlisle, P A 17013
Jessica M. Nicholson
154B West Penn Street
Carlisle, P A 17013
USAA Life Insurance
Attn: Karen Brosch, FLMI
USAA Policy Number 1569690-U1
9800 Fredericksburg Road
San Antonio, TX 78288
MARTS ON LAW OFFICES
By
M
Ten st High Street
Carlisle, P A 17013
(717) 243-3341
Dated: 1/30 ) 0 I