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Home My WebLink About10-0304IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION Plaintiff(s) & Address(es) JANICE TOWNSEND BARISKI, Individually, and as Executrix of The ESTATE OF JAMES LEE BARISKI, 57 Longwood Drive Case No. Civil Term Mechanicsburg, PA 17050, Vs. Civil Action Defendant(s) & Address(es) REASSURE AMERICA LIFE INSURANCE N COMPANY, MACCABEES LIFE INSURANCE COMPANY, -« c-- c/o C T Corporation System ry'r ` z 350 North Saint Paul Street v', -- -nM Dallas, TX 75201-4284. PRAECIPE FOR WRIT OF SUMMONS i-; C_ ji i TO THE PROTHONOTARY OF SAID COURT: -Z-4 Issue summons in the above case Writ of Summons shall be issued and forwarded Date : January 11, 2010 Harrisbura. PA 17108-1166 Telephone #: 717-237-5397 Supreme Court ID Number: 80680 !f" qz #°g M NI god ?- ?? X36 ?? s WRIT OF SUMMONS TO: ? SS,I 1L z i w L r4- /A35,veA-vcs- MA CGA-9b'2esT G_t' 3 (N5 viv'ldvUd- w?, ' YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFF(S) HAS/HAVE COMMENCED AN ACTION AGAINST YOU. A 9? Prothonotary/Clerk, Civil Division Date: by ZA:??AA Deput Address: P.O. Box 1166. 100 Pine St. FI! ;I 2it10 J -1111i, 203 Fj,,j -/: { Charles T. Young, Jr. I.D. No. 80690 McNees Wallace & Nurick LLC P. 0. Box 1166 100 Pine Street Harrisburg, PA 17108-1166 717.237.5397 717.237.5300 (fax) cvoung ..mwn.com i . P Y k`t a tal ?,.: -kF,,' +f Attorneys for Plaintiffs JANICE TOWNSEND BARISKI, : IN THE COURT OF COMMON PLEAS OF The ESTATE OF JAMES LEE BARISKI, : CUMBERLAND COUNTY, PENNSYLVANIA Plaintiffs V. REASSURE AMERICA LIFE INSURANCE COMPANY, MACCABEES LIFE INSURANCE COMPANY, Defendants Case No. 10-304-Civil Civil Action PRAECIPE TO FILE AFFIDAVIT OF SERVICE TO THE PROTHONOTARY OF SAID COURT: Please file the attached Affidavit of Service regarding service of the Writ of Summons on Defendant Reassure America Life Insurafi6e Comoanv. McNEES W/AVLAGE 4 NO" RICK LLC By Charles T. Young Jr I.D. No. 80690 P. O. Box 1166 100 Pine Street Harrisburg, PA 17108-1166 717.237.5397 717.237.5300 (fax) cvoung Dmwn.com Dated: January 25, 2010 Attorneys for Plaintiffs It 1/14/2010 8:37 AM FROM: Civil Action Group TO: +1 (214) 6517114 PAGE: 002 OF 005 Janice Townsend Barisal, et. al., Plaintiff(s) vs. Reassure America Life Insurance, et. al., Defendant(s) Service of Process by APS International, Ltd. 1-800-328-7171 APS International Plaza 7800 Cknroy Road Mlnneapolis, PIN S5439-3122 APS File #: 1015744001 AFFIDAVIT OF SERVICE -- Corporate NIcNEES, WALLACE & NURICK Nis. Josephine N1. Brinley 100 Pine St. P.O. Box 1166 liarrisburg, PA 17108-1166 Service of Process on: -Reassure America Life Insurance Company, do CT Corporation System Court Case No. 10-304-Civil State of. 'I--os ) ss. County of Dallas ) Name of Server: Pkamdaz Sadise , undersigned, being duly sworn, deposes and says that at the time of service,X/he was of legal age and was not a party to this action; Date/Tlmc of Service: that on the 13th day of JarunY , 20 10 , at 3:30 o'clock P M Place of Servile: at 350 N. St. Paul Street , in Dallas, TX..75201 Documents Served: the undersigned served the documents described as: Writ of Summons; Service of Process on: A true and correct copy of the aforesaid document(s) was served on: Reassure America Life Insurance Company, c/o CT Corporation System Person Served, and Method of Service: By delivering them into the hands of an officer or managing agent whose name and title is: by cblive"M b'br'ie (33tc'ar aa'tbCriaed to aooept Description of The person receiving documents is described as follows: Person Receiving Sex F ; Skin Color HL'Panic ; Hair Color b adt Facial Hair na Documents: Approx. Age 35 ; Approx. Height 5'7" ; Approx. Weight 200 l s X To the best of my knowledge and belief, said person was not engaged in the US Military at the time of service. Signature of Server: Undersigned declares under penalty of perjury Subscribed and sworn to before me this that the foregoing is true and correct. 1 ay of Jars. , 20 10 1 Signature of Scrver Not Public f..issiot? res) APS International, Ltd. MLOAPEREZ MY COMMISSION X12 E9 T }? ,-App 2010 Jill,, '26 F11 L: 11 Charles T. Young, Jr. I.D. No. 80690 McNees Wallace & Nurick LLC P. 0. Box 1166 100 Pine Street Harrisburg, PA 17108-1166 717.237.5397 717.237.5300 (fax) cVounq(cD- wn.com Attorneys for Plaintiffs JANICE TOWNSEND BARISKI, : IN THE COURT OF COMMON PLEAS OF The ESTATE OF JAMES LEE BARISKI, : CUMBERLAND COUNTY, PENNSYLVANIA Plaintiffs V. REASSURE AMERICA LIFE INSURANCE COMPANY, MACCABEES LIFE INSURANCE COMPANY, Defendants Case No. 10-304-Civil Civil Action PRAECIPE TO FILE AFFIDAVIT OF SERVICE TO THE PROTHONOTARY OF SAID COURT: Please file the attached Affidavit of Service regarding service of the Writ of Summons on Defendant Maccabees Life Insurance q?or pang. McNEES WAXLACE & r4UIXICK LLC By Dated: January 25, 2010 717.237.5397 717.237.5300 (fax) cyounq(a)-mwn.com Harrisburg, PA 17108-1166 Charles T. Young r. I.D. No. 80690 P. O. Box 1166 100 Pine Street Attorneys for Plaintiffs 1/14/2010 8:37 AM FROM: Civil Action Group TO: +1 (214) 6517114 PAGE: 004 OF 005 Janice Townsend Bartski, et. al.. Plaintiff(s) Reassure America Life Insurance, et. al., Defendant(s) Service of Process by APS International, Ltd. 1-800-328-7171 APS International Plaza 7800 Glenroy Road Minneapolis, MN 554351-3122 APS File fl: 101574-0001 McNEES, WALLACE & NURICK Ms. Josephine M. Brinley 100 Pine St. P.O. Box 1166 Harrisburg, PA 17108-1166 AFFIDAVIT OF SERVICE -- Corporate Service of Process on: --Maccabees Life Insurance Company, c% CT Corporation System Court Case No. 10-304-Civil State of: "Oos ) ss. County of: D las ) Name of Server: Brandon Sacbse , undersigned, being duly sworn, deposes and says that at the time of service, if/he was of legal age and was not a party to this action; DatelTime of Service: that on the 13th day of X17 , 20 10 , at 3.30 o'clock P M Place of Service: at 350 N. St. Paul Street , in Dallas, TX 75201 Documents Served: the undersigned served the documents described as: Writ of Summons; Service of Process on: A true and correct copy of the aforesaid document(s) was served on: Maccabees Life Insurance Company, c/o CT Corporation System Person Served, and Method of Service: By delivering them into the hands of an officer or managing agent whose name and title is. by cb1,w'ing to N? Gui::ia, autl=ized to accept Description of The person receiving documents is described as follows: Person Receiving Sex F • Skin Color HisPmic • Hair Color blar-k Documents: ? ;Facial Hair ra Approx. Age 35 ; Approx. Height 5'7" ; Approx. Weight R lbs x To the best of my knowledge and belief, said person was not engaged in the US Military at the time of service. Signature of Server: Undersigned declares under penalty of perjury Subscribed and sworn to before me this that the foregoing is true and correct. Motary y of Jan. , 20 10 Signature of Sarver (Commission pines) APS International, Ltd. MELI89ASIZ t MY COMMISSION EXPIRES December 4, 21112 .( . POST & SCHELL, P.C. BY: RICHARD L. MCMONIGLE, JR., ESQ E-MAIL: rmcmonigle@postschell.com I.D. # 33565 FOUR PENN CENTER 1600 JOHN F KENNEDY BLVD. PHILADELPHIA, PA 19103 215-587-1000 JANICE TOWNSEND BARISKI, Individually, and as Executrix of THE ESTATE OF JAMES LEE BARISKI, Plaintiffs, vs. REASSURE AMERICA LIFE INSURANCE COMPANY, MACCABEES LIFE INSURANCE COMPANY, Defendants. ATTORNEYS FOR DEFENDANTS REASSURE AMERICA LIFE INSURANCE COMPANY, MACCABEES LIFE INSURANCE COMPANY IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY NO. 10-304-CIVIL ENTRY OF APPEARANCE Kindly enter my appearance on behalf of the Defendants, REASSURE AMERICA LIFE INSURANCE COMPANY and MACCABEES LIFE INSURANCE COMPANY, in the above- captioned matter. Dated: February 24, 2010 POST & SCH C. By ichard L. McMonigle, Jr., Esquire Four Penn Center 1600 John F Kennedy Blvd. Philadelphia, PA 19103 215-587-1000 Attorneys for Defendants Reassure America Life Insurance Company, Maccabees Life Insurance Company CERTIFICATE OF SERVICE I hereby certify that the attached Entry of Appearance in the foregoing matter has been sent via first class mail to the following person(s): Charles T. Young, Jr., Esquire McNEES WALLACE & NURICK, LLC 100 Pine Street P.O. Box 1166 Harrisburg, PA 17108-1166 POST & SCREW. P.C BY: RICHARD L. McMONIGLE, ESQUIRE Attorney for Defendants DATED: February 24, 2010 r POST & SCHELL, P.C. BY: RICHARD L. MCMONIGLE, JR., ESQUIRE E-MAIL: rmcmonigle@postschell.com I.D. # 33565 FOUR PENN CENTER 1600 JOHN F KENNEDY BLVD. PHILADELPHIA, PA 19103 215-587-1000 JANICE TOWNSEND BARISKI, Individually, and as Executrix of THE ESTATE OF JAMES LEE BARISKI, Plaintiffs, VS. REASSURE AMERICA LIFE INSURANCE COMPANY, MACCABEES LIFE INSURANCE COMPANY, Defendants. ATTORNEYS FOR DEFENDANTS REASSURE AMERICA LIFE INSURANCE COMPANY, MACCABEES LIFE INSURANCE COMPANY IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY NO. 10-304-CIVIL PRAECIPE TO FILE COMPLAINT TO THE PROTHONOTARY: n - s ? r y }}4i c-n .o -c Please enter a Rule upon the plaintiffs to file a Complaint within twenty (20) days hereof or suffer the entry of a judgment of non pros. Dated: February 24, 2010 POST & S By RICHARD L. MCMONIGLE, JR., ESQ. Four Penn Center 1600 John F Kennedy Blvd. Philadelphia, PA 19103 215-587-1000 Attorneys for Defendants Reassure America Life Insurance Company, Maccabees Life Insurance Company -10 01 RULE TO FILE COMPLAINT AND NOW, this e day of MA.t1Dh , 2010, a Rule is hereby granted upon the to file a Complaint herein within twenty (20) days after service hereof or suffer the entry of a judgment of non pros. ) - -C) "Ll - P H _ OT 2 i CERTIFICATE OF SERVICE I hereby certify that the attached Praecipe to File Complaint/Rule to File Complaint in the foregoing matter has been sent via first class mail to the following person(s): Charles T. Young, Jr., Esquire McNEES WALLACE & NURICK, LLC 100 Pine Street P.O. Box 1166 Harrisburg, PA 17108-1166 POST & SC L C. BY: RICHARD L. McMONIGLE, ESQUIRE Attorney for Defendants DATED: February 24, 2010 POST & SCHELL, P.C. BY: RICHARD L. MCMONIGLE, JR., ESQUIRE E-MAIL: rmcmonigle@postschell.com I.D. # 33565 FOUR PENN CENTER 1600 JOHN F KENNEDY BLVD. PHILADELPHIA, PA 19103 215-587-1000 JANICE TOWNSEND BARISKI, Individually, and as Executrix of THE ESTATE OF JAMES LEE BARISKI, Plaintiffs, vs. REASSURE AMERICA LIFE INSURANCE COMPANY, MACCABEES LIFE INSURANCE COMPANY, Defendants. ATTORNEYS FOR DEFENDANTS REASSURE AMERICA LIFE INSURANCE COMPANY, MACCABEES LIFE INSURANCE COMPANY IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY NO. 10-304-CIVIL PRAECIPE TO FILE COMPLAINT TO THE PROTHONOTARY: n a F ' _: ? cam, Please enter a Rule upon the plaintiffs to file a Complaint within twenty (20) days hereof or suffer the entry of a judgment of non pros. Dated: March 10, 2010 POST & By L. MCMONIGLE, JR., ESQ. Four Penn Center 1600 John F Kennedy Blvd. Philadelphia, PA 19103 215-587-1000 Attorneys for Defendants Reassure America Life Insurance Company, Maccabees Life Insurance Company RULE TO FILE COMPLAINT AND NOW, this IL(? day of MUCK , 2010, a Rule is hereby granted upon the to file a Complaint herein within twenty (20) days after service hereof or suffer the entry of a judgment of non pros. a??D - P HONG ARY 2 CERTIFICATE OF SERVICE I hereby certify that the attached Praecipe to File Complaint/Rule to File Complaint in the foregoing matter has been sent via first class mail to the following person(s): Charles T. Young, Jr., Esquire McNEES WALLACE & NURICK, LLC 100 Pine Street P.O. Box 1166 Harrisburg, PA 17108-1166 POST & SCRELL, P.C. BY: R HARD L. McMONIGLE, ESQUIRE Attorney for Defendants DATED: March 10, 2010 McNEES WALLACE & NURICK LLC Michael R. Kelley Attorney I.D. No. 58854 Charles T. Young, Jr. Attorney I.D. No. 80680 P.O. Box 1166, 100 Pine Street Harrisburg, PA 17108-1166 (717) 237-5397 (phone) (717) 260-1760 (fax) Attorneys for Plaintiffs op T?!c r ARY 2B1U N3R 19 Pay 1: 08 Cv`°,R L r 7 in J N; JANICE TOWNSEND BARISKI, : IN THE COURT OF COMMON PLEAS OF Individually and as the Executrix : CUMBERLAND COUNTY, Of the ESTATE OF JAMES LEE : PENNSYLVANIA BARISKI, Plaintiffs V. REASSURE AMERICA LIFE INSURANCE COMPANY, MACCABEES LIFE INSURANCE COMPANY, Defendants. : CASE NO. 10-304-CIVIL : CIVIL ACTION -LAW : JURY TRIAL DEMANDED NOTICE You have been sued in Court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiffs. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 AVISO USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de los proximos veinte (20) dias despues de la notificacion de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objecciones a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted puede perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. CUMBERLAND COUNTY BAR ASSOCIATION 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 2 McNEES WALLACE & NURICK LLC Michael R. Kelley Attorney I.D. No. 58854 Charles T. Young, Jr. Attorney I.D. No. 80680 P.O. Box 1166, 100 Pine Street Harrisburg, PA 17108-1166 (717) 237-5397 (phone) (717) 260-1760 (fax) Attorneys for Plaintiffs JANICE TOWNSEND BARISKI, : IN THE COURT OF COMMON PLEAS OF Individually and as the Executrix : CUMBERLAND COUNTY, Of the ESTATE OF JAMES LEE : PENNSYLVANIA BARISKI, Plaintiffs V. REASSURE AMERICA LIFE INSURANCE COMPANY, MACCABEES LIFE INSURANCE COMPANY, Defendants. CASE NO. 10-304-CIVIL CIVIL ACTION -LAW JURY TRIAL DEMANDED COMPLAINT Plaintiffs Janice Townsend Bariski and the Estate of James Lee Bariski, by and through their attorneys McNEES WALL-ACE & NURICK LLC, hereby file this Complaint against Defendants. In support thereof, Plaintiffs state the following: PARTIES 1. Plaintiff Janice Townsend Bariski is an adult individual residing in Mechanicsburg, Cumberland County, Pennsylvania. Ms. Bariski was the wife of the late James Lee Bariski (the "Plaintiffs' Decedent,") and she is presently serving as the Executrix of the Estate of James Lee Bariski. 2. Defendants are or were insurance companies. Upon information and belief, Maccabees Life Insurance Company became Royal Maccabees Life Insurance Company, and still later Reassure America Life Insurance Company. 3 THE FACTS 3. On or about June 8, 1990, James Lee Bariski purchased a life insurance policy from Maccabees Life Insurance Company, being Policy No. 3166593 in the face amount of $250,000 (the "Policy"), and named as primary beneficiary of the death benefit, Janice Bariski. (Exhibit "A.'? 4. James Bariski paid the premiums on the Policy for many years. 5. James Bariski changed the beneficiary on the Policy to provide a creditor with security for the payment of a debt. However, the debt was later paid, and any right or title under the Policy was subsequently assigned to Janice Bariski. (Exhibit "B.'? 6. In 2002, James Bariski was diagnosed with cancer and ultimately, passed away on or about December 20, 2007. 7. After James Bariski became ill and prior to his death, Defendants informed Mr. Bariski that they had not received the premium due in November 2005, and he had a grace period in which to make the premium payment. 8. James Bariski mailed the premium payment prior to the expiration of the grace period. 9. Defendants wrongly informed James Bariski that the Policy had lapsed because they had not received the premium payment prior to the expiration of the grace period. 10. Defendants informed James Bariski that they would reinstate the Policy without evidence of insurability if all past due premium payments were received in their office no later than January 8, 2006. 4 11. Upon information and belief, Defendants received the payment from James Bariski prior to January 8, 2006. 12. On or about January 9, 2006, Defendants wrongly informed James Bariski that the Policy had terminated due to non-payment of premiums and reinstatement of terminated coverage would require evidence of insurability. 13. On or about January 16, 2006, Defendants purported to have received payment from James Bariski on January 10, 2006, insisted that the Policy had lapsed, and forwarded a reinstatement application and authorization form. 14. James Bariski informed Defendants of his payment of the premium and requested the reinstatement of the Policy. 15. Defendants wrongfully refused to recognize the continued existence of coverage under the Policy. 16. Upon the death of Mr. Bariski, Defendants did not make payment of the Policy proceeds. 17. James Bariski handled his own financial and insurance matters, and for the most part, did not discuss these issues with others. Plaintiffs only discovered the purported lapsing of the Policy upon review of Mr. Bariski's records several months after his death. 18. Upon discovery of the purported lapsing of the Policy, Plaintiffs enlisted the assistance of others in communicating with Defendants. During the course of these communications, Defendants continued to defend their improper conduct. COUNT I BREACH OF CONTRACT 19. Paragraphs 1 to 18 above are incorporated herein as if set forth in full below. 5 20, Plaintiffs' Decedent paid the premiums due under the Policy in a timely manner and otherwise honored all of his contractual obligations. 21. Defendants breached their obligations under the Policy through the following conduct: a. Defendants misrepresented the requirements of Pennsylvania law and the Policy regarding the payment of premiums. b. Defendants wrongly informed Plaintiffs' Decedent that the Policy had lapsed because Defendants had not received premium payments. c. Defendants wrongly informed Plaintiffs' Decedent that the Policy had terminated due to non-payment of premiums and reinstatement of terminated coverage would require evidence of insurability. d. Defendants wrongly refused to recognize the continued existence of coverage under the Policy. e. Defendants wrongly refused to pay the benefits due under the Policy upon the passing of Plaintiffs' Decedent. 22. Plaintiffs were improperly deprived the benefits of the Policy and suffered damages due to Defendants' breach of the Policy requirements. WHEREFORE Plaintiffs request judgment against Defendants in the amount of the policy proceeds plus consequential damages, incidental damages, interest, and costs. Count II BAD FAITH UNDER 42 PA.C.S. & 8371 23. Paragraphs 1 to 18 above are incorporated herein as if set forth in full below. 6 24. Plaintiffs' Decedent paid the premiums due under the Policy in a timely manner for many years and otherwise honored all of his obligations as an insured. 25. Plaintiffs' Decedent communicated with Defendants in a timely manner, advising them of the relevant facts. 26. Upon information and belief, Defendants knowingly misrepresented the terms and conditions of the Policy and the requirements of Pennsylvania law, and they refused to honor their obligations despite the lack of a reasonable basis for their conduct. Defendants' misconduct included the following: a. Defendants misrepresented the terms and conditions of the Policy to Plaintiffs' Decedent, including but not limited to, the requirements concerning payment of premiums. b. Defendants recklessly chose not to conduct an investigation of their lockbox or the manner in which premiums were handled. c. Defendants misrepresented that the Policy had lapsed because they had not received premium payments. d. Defendants misrepresented that the Policy had terminated due to non- payment of premiums and reinstatement of terminated coverage would require evidence of insurability. e. Defendants wrongfully refused to recognize the continued existence of coverage under the Policy and recklessly claimed that coverage had lapsed due to non- payment of premiums. f. Defendants wrongfully refused to pay the benefits due under the Policy. 7 g. Defendants wrongfully continued to defend their improper conduct, ignoring the terminal condition of their insured, and the fragile and vulnerable condition of his wife. h. Defendants wrongfully compelled Plaintiffs to file suit in order to recover under the Policy. 27. Plaintiffs were deprived of the benefits of the Policy and denied financial security due to Defendants' misconduct. WHEREFORE Plaintiffs request judgment against Defendants for punitive damages, attorneys' fees, interest at the prime rate of interest plus 3%, and costs. Count III VIOLATIONS OF THE CONSUMER PROTECTION LAW 28. Paragraphs 1 to 18 above are incorporated herein as if set forth in full below. 29. Plaintiffs' Decedent paid the premiums due under the Policy in a timely manner and otherwise honored all of his obligations as an insured. 30. Plaintiffs' Decedent communicated with Defendants in a timely manner, advising them of the relevant facts. 31. Upon information and belief, Defendants knowingly misrepresented the terms and conditions of the Policy and the requirements of Pennsylvania law, and refused to honor their obligations as follows: a. Defendants misrepresented the terms and conditions of the Policy to Plaintiffs' Decedent, including but not limited to, the requirements concerning payment of premiums. b. Defendants recklessly chose not to conduct an investigation of their lockbox or the manner in which premiums were handled. 8 c. Defendants misrepresented that the Policy had lapsed because they had not received premium payments. d. Defendants misrepresented that the Policy had terminated due to non- payment of premiums and reinstatement of terminated coverage would require evidence of insurability. e. Defendants wrongfully refused to recognize the continued existence of coverage under the Policy and recklessly claimed that coverage had lapsed due to non- payment of premiums. f. Defendants wrongfully refused to pay the benefits due under the Policy. g. Defendants wrongfully continued to defend their improper conduct, ignoring the terminal condition of their insured, and the fragile and vulnerable condition of his wife. h. Defendants wrongfully compelled Plaintiffs to file suit in order to recover under the Policy while knowing that their conduct lacked a reasonable basis in law or fact. 32. Plaintiffs were deprived the benefits of the Policy and denied financial security due to Defendants' misconduct. 9 WHEREFORE Plaintiffs request judgment against Defendants for treble damages, attorneys' fees, interest, and costs. Mc By P.O. Box 1166, 100 Pine Street Harrisburg, PA 17108-1166 Phone: (717) 237-5397 Fax: (717) 260-1760 E-mail: cyounga-mwn.com Dated: March 1", 2010 Attorneys for Plaintiffs 10 VERIFICATION Subject to the penalties of 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities), I, Janice Townsend Bariski, hereby verify that I have reviewed the foregoing Complaint, and the allegations contained therein are true and correct to the best of my knowledge, information, and belief. J nice Townsend Bari i ,vX Dated: March 2, 2010 MACCABEES LIFE INSURANCE COMPANY A Stock Company 25800.Northwestem Highway, P.O. Box 2165, Southfield, Michigan 48037-2165 Maccabees Life Insurance Company will pay the Insurance Proceeds to the Beneficiaryif the Insured dies, while this.Policy is in force. The Surrender Value of this Policy will be paid to the Policy Owner if the Insured isliving on the.Maturity Date.`AII of the rights and benefits of this Policy may be exercised by the Owner. This Policy?4s a- legal contract between the Policy Owner and=the Company ... READ YOUR POLICY CAREFULLY, This Policy;is issued in consideration of the attached Signed for the Company at its I Secretary application and the advance payment of premiums shown on the Schedule `Page. TWENTY DAY RIGHT TO EXAMINE POLICY If, for any reason, this Policy is not satisfactory, it may be returned within twenty days after receipt by delivering it to any agent of the Company or mailing it to the Home Office of the Company. Immediately upon such delivery or mailing, this Policy will be deemed void from the beginning. All premiums paid will be refunded to the Owner within ten days of the policy return. come Office in Southfield, Michigan /President FLEXIBLE PREMIUM ADJUSTABLE LIFE INSURANCE POLICY V Adjustable Benefit Amount Flexible Premium Payments Insurance Proceeds Payable At Death Before The Maturity Date Surrender Value Payable On The Maturity Date Non-Participating Schedule Of Benefits And Premiums Appears On Page 3 MM-FPAL-5 (R1) (20) IMPORTANT NOTICE Please read the copy of the application attached to this policy. Carefully check the application and write to Maccabees Life Insurance Company, 25800 Northwestern Highway, P.O. Box 2165, Southfield, Michigan 4803 7-2 1 65, within 10 days, if any information shown on it is not correct and complete, or if any past medical history has been left out of the application. This application is, part of the policy, and the policy was issued on the basis that the answers to all questions and the information shown are correct and complete. 41-4512 R1 TABLE OF CONTENTS ANNUAL REPORT ................................................ L-2 (FPAL-5) ASSIGNMENT ................................................... L-3 (FPAL-5) BENEFICIARY ................................................... L-3 (FPAL-5) DEFINITIONS ............................................... MM-DEF (FPAL-5) NON-PARTICIPATION .......................................... L-3 (FPAL-5) R1 GENERAL PROVISIONS ........................................... L-2 (FPAL-5) GRACE PERIOD ................................................. L-4 (FPAL-5) INSURANCE PROCEEDS .......................................... L-1 (FPAL-5) LOAN PROVISIONS ............................................... L-7 (FPAL-5) NONFORFEITURE PROVISIONS .................................... L-5 (FPAL-5) OWNERSHIP .................................................... L-3 (FPAL-5) PREMIUMS ...................................................... L-4 (FPAL-5) REINSTATEMENT ................................................. L-4 (FPAL-5) SETTLEMENT OPTIONS ........................................... L-9 (FPAL-5) MM-FPAL-5-TC (R1) SCHEDULE OF BENEFITS AND INITIAL MONTHLY EXPENSE CHARGES BENEFIT INITIAL DATE TO WHICH INITIAL TYPE SPECIFIED COVERAGE IS MONTHLY BENEFIT PROVIDED EXPENSE AMOUNT CHARGE FLEXIBLE PREMIUM -$50,000* JUNE 8, 2042 $12.29 ADJUSTABLE LIFE V-250 *THIS AMOUNT DOES INCLUDE THE ACCUMULATION VALUE MAXIMUM ADMINISTRATIVE CHARGE: 55.00 MAXIMUM SURRENDER CHARGE: $823.00 COVERAGE CONTINUATION COMPONENT: $19.04 NOTE: THE TERMINATION DATE IS THAT ELECTED BY THE OWNER. IT IS POSSIBLE THAT COVERAGE WILL CEASE PRIOR TO THE MATURITY SHOWN IF SUBSEQUENT PREMIUMS AND INTEREST CREDITED ARE INSUFFICIENT TO CONTINUE COVERAGE TO SUCH A DATE. UPON MATURITY, THERE MAY BE LITTLE OR NO SURRENDER VALUE. POLICY NUMBER: 4104-287 INSURED: JAMES ,L BARISKI SEX: -MALE PREMIUM CLASS: STANDARD-NONSMOKER INITIAL PREMIUM: 5431.80 DO NOT SURRENDER YOUR POLICY OR ALLOW IT COWSULTINiG THE COMPANY. IN CASE OF ANY 'iObO LOCAL MACCABEES AGENCY OP WRITE THE DATE OF ISSUE: MATURITY DATE: ISSUE AGE: 43 JUNE 8, 1990 JUNE 8, 2042 MONTHLY DEDUCTION DAY IS: THE 8-TH DAY OF EACH. MONTH PLANNED PERIODIC PREMIUMi $431.80 (ANNUAL) TO LAPSE FOR ANY REASON WITHOUT 4UESTION ABOUT THIS POLICY, CONTACT COMPANY AT ITS HOME OFFICE. MM-.SPEC-83 PAGE 3 DEFINITIONS Whenever used in the Policy, the following words MATURITY DATE mean: The date specified as such on the Schedule Page, ACCUMULATION VALUE upon which the Surrender Value will become payable if the Insured is living. The amount of money that is credited with interest to the Policy on a monthly basis. BENEFICIARY The person named in writing by the Owner to receive the Insurance Proceeds in the event of the Insured's death. CASH VALUE The amount of Accumulation Value of this Policy less any Surrender Charges. COMPANY The Maccabees Life Insurance Company. DATE OF ISSUE The date shown on the Schedule Page from which policy years, months and anniversaries shall be determined. HOME OFFICE OF THE COMPANY 25800 Northwestern Highway, P.O. Box 2165, Southfield, Michigan 48037-2165 INDEBTEDNESS The sum of any unpaid policy loans and any unpaid policy loan interest. INITIAL PREMIUM The amount due at the Date of Issue shown on the Schedule Page and payable in advance. INSURANCE PROCEEDS The total amount the Company will pay upon the death of the Insured. INSURED The person named on the Schedule Page whose life this Policy insures. LOAN VALUE The amount that can be borrowed under the Policy. MONTHLY DEDUCTION DAY The day of each month shown on the Schedule Page when the Accumulation Value of the Policy is calculated and the Monthly Expense Charge is deducted. The first Monthly Deduction Day shall be the Date of Issue. MONTHLY EXPENSE CHARGE The total amount deducted each month for the coverage provided under the Policy and any additional benefits provided by rider. OWNER The person to whom this Policy belongs. PARTIAL SURRENDER An amount available in cash at any time upon request equal to 50% or more of the Surrender value. PLANNED PERIODIC PREMIUM PAYMENT The amount of regular premium payment elected by the Insured. This amount and the frequency of payment are shown on the Schedule Page. The Owner may change the amount and frequency of the Planned Periodic Premium Payment at any time subject to the policy provisions. Any change in frequency and amount will be reflected in the Annual Report provided by the Company. SPECIFIED BENEFIT AMOUNT The initial amount of coverage shown on the Schedule Page. This Amount maybe changed by the Owner at any time subject to the policy provisions. Any change in the Specified Benefit Amount will be reflected in a Specification Endorsement. SURRENDER CHARGE The amount deducted by the Company from the Accumulation Value if the Policy is surrendered. SURRENDER VALUE The amount of Cash Value, less any indebtedness, available in cash or an Optional Method of Settlement upon the termination or maturity of this Policy. WITHDRAWAL An amount available in cash at any time upon request which is less than 50% of the Surrender Value. MM-DEF (FPAL-5) R1 INSURANCE PROCEEDS PROCEEDS PAYABLE This Policy shall terminate upon the death of the Insured. The Company will pay the Insurance Proceeds subject to the provisions of this Policy to the Beneficiary upon receipt of due proof of the Insured's death. The Company will require surrender of this Policy as a condition of payment. The Insurance Proceeds payable depend on the Specified Benefit Amount Option in effect at the date of death. Two Specified Benefit Amount Options are available under this Policy: LEVEL OPTION-The Specified Benefit Amount as shown on the Schedule Page includes the Accumulation Value. Under this option, the Insurance Proceeds at the Insured's date of death shall equal the greater of: 1) the Specified Benefit Amount on the date of death; or 2) the Accumulation Value on the date of death multiplied by the percentage shown in the Table of Minimum Death Benefit Percentages for the Insured's attained age. INCREASING OPTION-The Specified Benefit Amount as shown on the Schedule Page is in addition to the Accumulation Value. Under this option, the Insurance Proceeds at the Insured's date of death shall equal the greater of: 1) The Specified Benefit Amount on the date of death, plus the Accumulation Value on the date of death; or 2) the Accumulation Value on the date of death multiplied by the percentage shown in the Table of Minimum Death Benefit Percentages for the Insured's attained age. Any increases or decreases made to the Specified Benefit Amount may change the Insurance Proceeds payable. Any loan, Withdrawal, or Partial Surrender of this Policy will be subtracted from the Insurance Proceeds. If the Insured is living on the Maturity Date and this Policy is in force, this Policy shall terminate and the Company shall pay the Surrender Value to the Owner. The Maturity Date is shown on the Schedule Page. It is possible that coverage will terminate prior to the Maturity Date if premiums paid following payment of the Initial Premium are insufficient to continue coverage to such date. It is also possible that coverage will terminate prior to the Maturity Date shown if the Company changes the interest rate or the Monthly Cost of Insurance Rates. CHANGES IN SPECIFIED BENEFIT AMOUNT OPTION The Schedule Page shows the option elected in the original application. The option may be changed by the Owner as allowed by the Company. If the Increasing Option is in effect and the Owner changes to the Level Option, the Specified Benefit Amount subsequent to this change will equal the total of the Specified Benefit Amount prior to the change plus the Accumulation Value. Thereafter, the Specified Benefit Amount will include the Accumulation Value. If the Level Option is in effect and the Owner changes to the Increasing Option, the Specified Benefit Amount subsequent to this change will equal the Specified Benefit Amount prior to the change less the Accumulation Value. Thereafter, the Specified Benefit Amount will not include the Accumulation Value. CHANGES IN SPECIFIED BENEFIT AMOUNT The Specified Benefit Amount of this Policy may be increased or decreased upon written request by the Owner subject to the following conditions: 1) Any decrease will become effective on the Monthly Deduction Day that falls on or next follows the date the request is received by the Company. Such decrease will reduce the Specified Benefit Amount in the following order: a) it will decrease the insurance provided by the most recent increases successively; b) It will decrease the Initial Specified Benefit Amount. 2) The Specified Benefit Amount may not be decreased to an amount less than $25,000. 3) The Specified Benefit Amount may not be changed by an amount less than $10,000. 4) Any request for an increase must be applied for on a supplemental application. Such increase will be subject to evidence of insurability satisfactory to the Company. Any increase will be subject to the sufficiency of the Accumulation Value, less any indebtedness, to cover the next Monthly Expense Charge. Any increase will become effective on the effective date shown on the Specification Endorsement. 5) The Specified Benefit Amount may not be increased if there has been a prior decrease. APPLICATION FOR ADDITIONAL INSURANCE Additional insurance on the life of the Insured's spouse or child may be applied forby supplemental application. Approval of the additional insurance shall be subject to evidence of insurability satisfactory to the Company. Additional insurance shall also be subject to the sufficiency of the Accumulation Value, less any indebtedness, to cover the next Monthly Expense Charge. Such new insurance will be provided by rider and will become effective on the effective date shown on the Specification Endorsement. L-1 (FPAL-5) GENERAL PROVISIONS THE CONTRACT This Policy, the attached application for this Policy, any attached riders, any supplemental applications for increases in the Specified Benefit Amount, and any Specification Endorsements make up the entire contract between the parties. This Policy shall take effect upon delivery, provided the Initial Premium has been paid, the Insured is living, and there has been no material change in the health of the Insured as shown in the application. After this Policy has been in force during the Insured's lifetime for two years from the date on which the Specified Benefit Amount is increased, the Company loses the right to contest a claim which involves the increase in Specified Benefit Amount. This provision does not apply to any Disability Benefit or Accidental Benefit attached to this Policy. MISSTATEMENT OF AGE OR SEX All statements made in the application are, in the absence of fraud, deemed representations and not warranties. No statement made by the Insured or on his behalf will be used in defense of a claim under this Policy unless it is made in a written application and a copy of the application containing that statement is attached to the Policy when issued. Policy years, policy months, and policy anniversaries are measured from the Date of Issue of the Policy. Attained age means age last birthday on the prior policy anniversary. Any change or waiver of any provision of this Policy must be in writing and signed by an officer of the Company. SUICIDE If the Insured dies by suicide while sane or insane, within two years from the Date of Issue, the Insurance Proceeds will not be paid. The amount payable will be the total of premiums paid less any indebtedness on this Policy, and less any Withdrawal and Partial Surrender amounts paid. A new two-year period will apply to any increase in the Specified Benefit Amount beginning on the date of each increase. The amount payable under this provision attributable to a policy increase will be the Costs of Insurance for that increase if death by suicide, while sane or insane, occurs during the first two years following the increase. If the Insured's age or sex has been misstated, the proceeds payable upon death will be: 1) the Accumulation Value on the date of death; plus 2) that amount of insurance which would have been purchased by the most recent Cost of Insurance deduction had the correct Cost of Insurance Rate been used. ANNUAL REPORT At least once each year the Company will send the Owner an Annual Report which shows: 1) The current Accumulation Value; 2) The current Surrender Value; 3) The amount of any outstanding policy loan; 4) Premiums paid since the last Report; 5) Expense Charges since the last Report. 6) The Specified Benefit Amount; 7) Interest credited since the last Report; and 8) Any Partial Surrenders or Withdrawals since the last report. The amount payable under this provision will be paid to the Beneficiary. INCONTESTABILITY After this Policy has been in force during the Insured's lifetime for two years from the Date of Issue, the Company loses the right to contest a claim based on statements made in the application. ILLUSTRATIVE REPORT The Company will provide an illustrative report of projected future Insurance Proceeds and Cash Values which will be sent to the Owner upon request. The Company may charge a reasonable fee for providing such a Report. L-2 (FPAL-5) CONTROL OF POLICY BENEFICIARY The Insurance Proceeds will be paid to the Beneficiary last named in writing by the Owner. Two or more Beneficiaries will receive equal shares of the proceeds unless a different allocation is specified. A Beneficiary must survive the Insured. Otherwise, his share will be paid to the surviving Beneficiary or Beneficiaries in equal shares. If no Beneficiary has been named or there are no surviving Beneficiaries, the Insurance Proceeds will be paid to the Owner, if living; otherwise to the Owner's estate. CHANGE OF BENEFICIARY CHANGE OF OWNERSHIP The Owner may name a new Owner by written notice mailed to the Company. The change will take effect on the day it was signed, subject to any action taken by the Company prior to the recording of the change at the Home Office. ASSIGNMENT This Policy may be assigned by the Owner as collateral. Any assignment must be in writing and a signed copy sent to the Company at its Home Office. The Owner may change any Beneficiary at any time while the Insured is living. A written notice of change must be sent to the Company at its Home Office. The change will take effect on the day it was signed, subject to any action taken by the Company prior to the recording of the change at the Home Office. OWNERSHIP This Policy belongs to the Owner. If the Owner dies, this Policy belongs to the Owner's designee, or the Owner's estate if no Owner's designee has been named. The rights of the Owner and the interest of any Beneficiary will be subject to the rights of any assignee of record as specified in the assignment. The Company is not subject to the rights of any assignee of record. The Company is not responsible for the validity or effect of any assignment. NON-PARTICIPATION Maccabees Life Insurance Company is a stock company. This Policy shall not participate in the divisible surplus of the Company. L-3 (FPAL-5) R1 PREMIUMS PAYMENT The Initial Premium is due on the Date of Issue and is payable in advance. Subsequent premiums are payable in advance of the period to which they apply. No benefit will be provided on the basis of any premium until that premium has been paid. The amounts and frequency of Planned Periodic Premium Payments are shown on the Schedule Page. Premiums must be paid to the Company at its Home Office. Upon request, a receipt signed by the President or Secretary of the Company will be furnished for any premium payment. Changes in frequency and increases or decreases in the amount of Planned Periodic Premium Payments may be made by the Owner. The Planned Periodic Premium cannot be changed to an amount less than $50.00. Premium payment notices will be sent to the Owner upon written request. The notices may be sent annually, semi-annually, or quarterly. Under the special payment facility, Planned Periodic Premium Payments of $25.00 or more may be made on a monthly basis. Additional premium payments may be made at any time during the continuance of this Policy. The Company reserves the right to refuse to accept any premiums which would disqualify this Policy from favorable tax treatment as life insurance under federal law. If premiums paid during any policy year exceed the federal life insurance premium guidelines, the Company will return the excess premiums with interest of at least 4% within sixty days after the end of the policy year. GRACE PERIOD Except as provided below, this Policy will enter the Grace Period if the Surrender Value on the Monthly Deduction Day is insufficient to cover the Monthly Expense Charge. (The Accumulation Value, Surrender Value, and Monthly Expense Charge are described in the Nonforfeiture Provisions.) The above notwithstanding, prior to the ninth policy anniversary, this Policy will enter the Grace Period if: The Accumulation Value less indebtedness on the Monthly Deduction Day is less than the Monthly Expense Charge; or if The Surrender Value on the Monthly Deduction Day is less than the Monthly Expense Charge; and The sum of the premiums paid since the Date of Issue, less any loans, Withdrawals or Partial Surrenders, is less than the Coverage Continuation Requirement as of the Monthly Deduction Day. As of each Monthly Deduction Day during the first nine policy years, the Coverage Continuation Requirement shall be the sum of the Coverage Continuation Components applicable to each policy month from the Date of Issue. The Coverage Continuation Component in effect on the Date of Issue is shown on the Schedule page. The Coverage Continuation Component will change as of the effective date of any increase in the Specified Benefit Amount, modification of rating classification, or any addition of, increase in, or maturity of, any rider. The Coverage Continuation Component in effect as of any Monthly Deduction Day will apply to the policy month next following. The Company will notify the Owner of any change in the Coverage Continuation Component. A Grace Period of sixty-one days will be allowed for the payment of premiums sufficient to cover any past due Monthly Expense Charges and applicable loan interest. Written notice of such premium will be mailed to the last known address of the Owner and any assignee of record at least thirty days before the Grace Period ends. If such premium is not paid within the Grace Period, all coverage will terminate without value at the end of the Grace Period. If a claim by death during the Grace Period becomes payable under the Policy, any overdue Monthly Expense Charge will be deducted from the Insurance Proceeds. REINSTATEMENT If this Policy terminates as provided in the Grace Period provision, the Owner may apply for reinstatement. The application must be received by the Company at its Home Office within five years of the date of termination, but before the Maturity Date, and must include: 1) evidence of insurability of the Insured satisfactory to the Company; 2) payment of a premium sufficient to prevent this Policy from entering a Grace Period for at least three months after the date of reinstatement; 3) payment or reinstatement of any policy loan; and 4) payment of interest on the reinstated loan from the date of reinstatement to the end of the policy year. Reinstatement will not be effective until the date the application is approved by the Company. The Incontestability provision with respect to the reinstatement application and the Suicide provision will apply from the effective date of reinstatement. 1 A /OnAI C% NONFORFEITURE PROVISIONS ACCUMULATION VALUE The Accumulation Value on the Date of Issue shall be at least 931/2 percent of premiums paid on or before the Date of Issue, less the Monthly Expense Charge for the first month. On each Monthly Deduction Day the Accumulation Value shall be calculated as (a), plus (b) plus (c), minus the sum of (d) plus (e) where: COST OF INSURANCE The Cost of Insurance is determined on a monthly basis. The Cost of Insurance is determined separately for the Initial Specified Benefit Amount and for each increase in Specified Benefit Amount. The Cost of Insurance is calculated as (a), multiplied by the result of (b) minus (c), where: (a) is the Accumulation Value on the preceding Monthly Deduction Day; (b) is one month's interest on (a); (c) is 931/2 percent or more of all premiums received since the preceding Monthly Deduction Day; (d) is the amount of any Partial Surrender, Partial Surrender Charge, Withdrawal and Withdrawal fee since the preceding Monthly Deduction Day; (e) is the Monthly Expense Charge for the month following the Monthly Deduction Day. On any day other than a Monthly Deduction Day, the Accumulation Value shall be calculated as (f) plus (g) minus (h), where: (f) is the Accumulation Value as of the preceding Monthly Deduction Day; (g) is 931/2 percent or more of all premiums received since the preceding Monthly Deduction Day; (h) is the amount of any Partial Surrender, Partial Surrender Charge, Withdrawal or Withdrawal fee since the preceding Monthly Deduction Day. MONTHLY EXPENSE CHARGE The Monthly Expense Charge shall be calculated as (i) plus Q), where: (i) is the Cost of Insurance (as described below) plus the cost of additional benefits provided by rider. (j) is the Administrative Charge. The Administrative Charge shall not exceed, but may be less than, the Maximum Administrative Charge shown on the Schedule Page. INTEREST RATE The interest rate used in the calculation of the Accumulation Value is guaranteed to be a minimum of .32737 percent per month, compounded monthly, which is equal to 4 percent per year compounded annually. Interest in excess of the guaranteed minimum rate may be credited as determined by the Company's Board of Directors. Interest credited on the portion of the Accumulation Value that is loaned will at no time be less than the guaranteed minimum interest rate. (a) is the Cost of Insurance Rate as described in the Cost of Insurance Rates section. (b) is the Insurance Proceeds at the beginning of the policy month divided by 1.0032737. (c) is the Accumulation Value at the beginning of the policy month. If the Accumulation Value is included in the Specified Benefit Amount and there have been increases in the Insurance Proceeds, then the Accumulation Value shall be first considered a part of the Initial Specified Benefit Amount. If the Accumulation Value exceeds the Initial Specified Benefit Amount, it shall then be considered a part of additional Specified Benefit Amounts resulting from increases in the order of the increases. Any deduction for the Cost of Insurance during the Grace Period shall not be considered a waiver by the Company of the terms of the Grace Period provision. Any such charge shall be deducted from the Accumulation Value as of the date of the charge. COST OF INSURANCE RATES The monthly Cost of Insurance Rate is based on the sex, attained age, and rating class of the person insured. Monthly Cost of Insurance Rates will be determined by the Company from time to time based on its expectations as to future mortality experience. However, the Cost of Insurance Rates will not be greater than those shown in the Table of Guaranteed Maximum Insurance Rates or as the same are amended by the rating factor, if any, shown on the Schedule Page. Any change in the Cost of Insurance Rates will be on a uniform basis for insureds of the same age, sex and classification whose policies have been in force for the same length of time. The interest rate used to calculate the guaranteed Cost of Insurance Rates is 4% per year. The Table of Guaranteed Maximum Insurance Rates is also applicable to increase amounts of insurance subject to any applicable rating factor shown on the Schedule Page. The guaranteed Cost of Insurance Rates are based on the 1980 Smoker or Nonsmoker Commissioner's Standard Ordinary Mortality Table (CSO), Age Last Birthday. L-5 (FPAL-5) NONFORFEITURE PROVISIONS (Continued) CASH VALUE The Cash Value shall be calculated as the Accumulation Value less the Surrender Charge. SURRENDER CHARGE The Surrender Charge is the lesser of (a) or (b), where: (a) is the Accumulation Value; (b) is the Maximum Surrender Charge shown on the Schedule Page multiplied by the factor from the Table of Surrender Charge Factors that corresponds to the policy year of surrender. SURRENDER CHARGE FOR INCREASES IN SPECIFIED BENEFIT AMOUNT If the Specified Benefit Amount is increased, a separate Surrender Charge will be applied at the time of the increase. The Specification Endorsement providing for the increase will include the Maximum Additional Surrender Charge resulting from the increase. The Additional Surrender Charge will equal the Maximum Additional Surrender Charge shown on the Specification Endorsement multiplied by the factor from the Table of Surrender Charge Factors that corresponds to the number of years since the increase. The Additional Surrender Charge resulting from an increase shall be added to the amount specified in (b) above to determine the total Surrender Charge. BASIS OF COMPUTATIONS Accumulation Values are based on the 1980 Smoker or Nonsmoker CSO Mortality Table, Age Last Birthday, with interest at 4 percent per year compounded annually. Accumulation Values are at least equal to those required on the Date of Issue by the state in which this Policy was purchased. Reserves are based on the 1980 Smoker or Nonsmoker CSO Mortality Table, Age Last Birthday, with interest at the Calendar Year Statutory Valuation Interest Rate. Reserves are calculated using a Modified Preliminary Term method, but are not less than the reserves calculated using the Commissioner's Reserve Valuation method. Where required, a detailed statement of the method of computation of Accumulation Values and reserves under this Policy has been filed with the insurance department of the state in which this Policy was purchased. CONTINUATION OF INSURANCE In the event Planned Periodic Premium payments are not continued, insurance coverage under this Policy and any benefits provided by rider will be continued in force. Such coverage shall be continued until termination as provided in the Grace Period provision. This provision shall not continue the Policy beyond the Maturity Date nor continue any rider beyond the date for its termination, as provided in the rider. If the Insured is living on the Maturity Date and the Policy is still in force, the Company will pay the Surrender Value to the Owner. WITHDRAWAL A Withdrawal from this Policy may be made at any time prior to termination upon written request by the Owner to the Company at its Home Office. The sum of all Withdrawals cannot equal or exceed 50% of the Surrender Value. When a Withdrawal is made, the amount of the Withdrawal will be deducted from the Accumulation Value. The Insurance Proceeds shall be reduced by the amount of the Withdrawal. An additional fee of $25.00 will be deducted from the Accumulation Value for each Withdrawal. Not more than three Withdrawals will be allowed in any policy year. The Company reserves the right to defer a Withdrawal for a period permitted by law, but not for more than six months from the date of receipt of the request by the Company at its Home Office, unless such payment would be used to pay premiums on policies in force with the Company. PARTIAL SURRENDER A Partial Surrender of this Policy may be made at any time prior to termination by written request of the Owner to the Company at its Home Office. A Partial Surrender is an amount which when added to all previous Partial Surrenders and Withdrawals equals or exceeds 50% of the Surrender Value. If a Partial Surrender is made, an additional fee will be deducted from the Accumulation Value as follows. The additional fee will equal the Surrender Charge multiplied by the ratio that the Partial Surrender bears to the Surrender Value. After a Partial Surrender, the Surrender Charge for the Policy will be reduced by the additional fee. The Insurance Proceeds, the Accumulation Value, and the Cash Value will be reduced by the amount of the Partial Surrender. Not more than three Partial Surrenders will be allowed in any policy year. The Company reserves the right to defer a Partial Surrender for a period permitted by law, but not for more than six months from the date of receipt of the request by the Company at its Home Office, unless such payment would be used to pay premiums on policies in force with the Company. L-6 (FPAL-5) The NONFORFEITURE PROVISIONS (Continued) SURRENDER AND SURRENDER VALUE This Policy may be surrendered at any time prior to termination upon written request by the Owner to the Company at its Home Office. The amount payable on surrender of this Policy shall be the Surrender Value, which is the Cash Value less any indebtedness, on the date of surrender. The Surrender Value will be paid in cash or under an elected Settlement Option. If surrender is requested under this section within 30 days after a policy anniversary, the Surrender Value shall not be less than the Surrender Value on that anniversary, less any Partial Surrenders, Withdrawals, or loans made on or after such anniversary. If this Policy is surrendered, coverage shall terminate as of the next Monthly Deduction Day. The Company reserves the right to defer the payment of the Surrender Value for the period permitted by law, but not for more than six months from the date of receipt of the request by the Company at its Home Office, unless such payment would be used to pay premiums on policies in force with the Company. POLICY LOAN PROVISIONS POLICY LOANS The Owner can borrow against this Policy as sole security for any amount up to the Loan Value at any time prior to the termination of this Policy. The loan must be requested by the Owner in writing. On a policy anniversary, premium due date, or during a Grace Period the Loan Value is the Cash Value less any loan and accrued interest. Otherwise, the Loan Value is the amount with interest which equals the Loan Value on the next policy anniversary. Before advancing the loan amount, the Company may withhold an amount sufficient to pay interest on total indebtedness to the end of the policy year and any Monthly Expense Charges due during the next three months, or to the end of the policy year, whichever occurs first. Loans under this policy will bear interest at a rate that is subject to adjustment on each policy anniversary. The initial interest rate charged on any loan will be the Company's Adjustable Loan Interest Rate in effect on the previous policy anniversary. As of each subsequent policy anniversary, the interest rate charged for the policy year following will be the Adjustable Loan Interest Rate in effect on that policy anniversary. The Owner will be notified of the initial interest rate at the time the loan request is made. The Company will also notify the Owner of any change in the interest rate applicable to an outstanding policy loan. No Policy will terminate in a policy year as the sole result of a change in the interest rate during that policy year. Insurance will remain in force until the time it would have otherwise terminated had the interest rate not been changed. The Owner may be required to sign a loan agreement assigning this Policy to the Company as security. The Company may delay the payment of the loan. Payment may be delayed up to six months from the date the request was received unless such payment would be used to pay premiums on policies in force with the Company. LOAN INTEREST RATE Interest is payable in advance on the first interest payment due date and on each policy anniversary that follows. The first interest payment due date is the date of the loan. Interest not paid when due is added to the loan and bears interest at the same rate as the loan. The Adjustable Loan Interest Rate will be determined as of the first day of each January, April, July, and October, and will be determined by comparing the Adjustable Loan Interest Rate in effect for the preceding three months with a maximum interest rate defined by law and described below. Any change in the Adjustable Loan Interest Rate will be subject to the following: L-7'(FPAL-5) (RI) POLICY LOAN PROVISIONS (Continued) a. The Adjustable Loan Interest Rate will be lowered to be equal to or less than the legal maximum interest rate if such legal maximum rate is .5% or more lower than the Adjusted Loan Interest Rate for the preceding three months. b. The Adjustable Loan Interest Rate may be increased by at least .5% but not higher than the legal maximum interest rate, if the legal maximum interest rate is .5% or more higher than the Adjustable Loan Interest Rate for the preceding three months. The Adjustable Loan Interest Rate will not exceed the greater of: (1) The Published Monthly Average for the calendar month ending two months before the date on which the rate is determined; or (2) The interest rate used to compute the Accumulation Value under the Policy during the applicable period plus 1% per year. The Published Monthly Average is Moody's Corporate Bond Yield Average-Monthly Average Corporate as published by Moody's Investors Service, Inc., or any successor to it. In the event that Moody's Corporate Bond Yield Average-Monthly Average Corporate is no longer published, the Published Monthly Average will be a substantially similar average established by regulations issued by the Insurance Commissioner of the state in which this Policy was purchased. REPAYMENT AND TERMINATION Policy loans,. including accrued interest, may be repaid in whole or part at any time prior to termination of this Policy. A loan outstanding at the end of the Grace Period may not be repaid until this Policy is reinstated. All funds received by the Company under this Policy will be credited as premium payment unless clearly marked for loan repayment. Whenever the policy loan plus accrued interest equals or exceeds the Cash Value of this Policy, written notification will be sent to the last known address of the Owner and assignee, if any. This Policy will terminate sixty-one days after the date of mailing the notification. 1 0 ienwi C% of SETTLEMENT OPTIONS AVAILABILITY The Insurance Proceeds of this Policy will be paid in one sum unless a payment option is chosen. All or part of the Insurance Proceeds may be applied under one of the following options. However, the amount to be applied must be at least $3,500.00. The amount must also provide a periodic payment of at least $20.00 to each payee. If the payee is not a natural person, the proceeds may not be placed under a Settlement Option without the consent of the Company. ELECTION 5. ANNUITY OPTION. Annuity payments will be made during the lifetime of a payee; or jointly to two payees, one of whom must be the Insured, during their lifetimes; and continuing to the survivor during his remaining lifetime. 6. Payments will be made under any single premium immediate life or joint and survivor annuity contract as may be issued by the Company on the date proceeds become payable. The amount of each annuity payment will be 102% of the payment which the amount retained by the Company would otherwise purchase. The Company's rates in use on such date will be used as the basis for payment. The Owner may elect a Settlement Option or change a prior election at any time while the Insured is living. The election must be recorded by the Company at its Home Office before it is effective. The Company shall not be liable for any payments it may have made before receiving that notice. If no option is in effect at the Insured's death, any Beneficiary may choose a Settlement Option. Unless this election is made irrevocable before the proceeds are placed under a Settlement Option, the payee may change the election at any time. OPTIONS 1. INTEREST OPTION. Left on deposit with the Company with the interest payable at not less than 3% per year. The deposit period and withdrawal rights will be as agreed at the time of the election. 2. INSTALLMENT OPTION, FIXED PERIOD. Payable in equal installments for the number of years elected (not more than 20). The amount of each payment is shown in the Settlement Option Tables. Rights of commutation of unpaid installments will be as approved by the Company at the time of election. 3. LIFE INCOME OPTIONS. 10 or 20 YEARS CERTAIN. Payable in installments for certain period elected, and continuing thereafter for the remaining lifetime of the person on whose life the income depends. The amount of each installment is shown in the Settlement Option Tables. 4. INSTALLMENT OPTION, FIXED AMOUNT. Payable in installments until the proceeds applied, together with interest on the unpaid balance at the effective rate of 3% per year, are exhausted. Amounts of installments and withdrawal rights will be as approved by the Company at the time of election. The amount payable under any option shall be the actuarial equivalent of the amount of Insurance Proceeds applied under that option. Under Options 3 and 5, proof satisfactory to the Company a) of the date of birth and sex of the payees and b) that the payee is alive may be required before payment is made. In the event of the death of a Payee under a Settlement Option containing a period certain, any remaining proceeds shall be paid to the Beneficiary or Beneficiaries designated by the Owner. If no Beneficiary has been named or there are no surviving Beneficiaries, the proceeds will be paid to the Payee's designated Beneficiary or the Payee's estate. PAYMENT The first payment under Options 2, 3 and 4 will be due the date the proceeds are applied under the Settlement Option. If the proceeds are payable due to the Insured's death, the first payment will be due on the date of death. The first payment under Options 1 and 5 will be due one, three, six, or twelve months thereafter, depending on the mode of payment selected. EXCESSINTEREST The interest payments under Option 1 and the guaranteed payments under Options 2, 3, or 4 are based on a guaranteed interest rate of 3% per year. The interest payments under Option 1 or the guaranteed payments under Options 2 and 3 may be increased by excess interest as declared by the Company. Excess interest will be used to extend the period under Option 4. PROTECTION OF PROCEEDS The proceeds of payments due or to become due under any option may not be assigned by the Beneficiary. To the extent permitted by law, the proceeds will not be subject to the claims of creditors of the Beneficiary or the Insured. L-9 (FPAL-5) ? R SETTLEMENT OPTION TABLES MONTHLY PAYMENTS FOR EACH $1,000 OF PROCEEDS OPTION 2 OPTION 3 OPTION 5 FIXED PERIOD LIFE INCOME LIFE INCOME 000 APPLIED PER $1 PER $1,000 APPLIED PER $1,000 APPLIED , NO GUARANTEED Age Guaranteed PERIOD Period No. of Annual Monthly 10 20 Age Monthly Years Payment Payment Male Female Years Years Male Female Payment 1 $1 000.00 $84.47 45 $3.99 $3.87 45 $4.02 2 , 507 39 42.86 46 4.05 3.92 46 4.09 3 . 343.23 28.99 47 4.11 3.97 47 4.15 4 261 19 22.06 48 4.17 4.02 48 4.22 5 . 211.99 17.91 49 4.24 4.07 49 4.29 6 179.22 15.14 45 50 4.31 4.12 45 50 4.37 7 155.83 13.16 46 51 4.38 4.17 46 51 4.45 8 138.31 11.68 47 52 4.45 4.22 47 52 4.53 9 124 69 10 53 48 53 4.53 4.28 48 53 4.62 10 . 113.82 . 9.61 49 54 4.61 4.34 49 54 4.71 11 104.93 8.86 50 55 4.70 4.39 50 55 4.81 12 97 54 8.24 51 56 4.79 4.45 51 56 4.91 13 . 91.29 7.71 52 57 4.88 4.50 52 57 5.01 14 85 95 7.26 53 58 4.97 4.56 53 58 5.12 15 . 81.33 6.87 54 59 5.07 4.62 54 59 5.24 16 77.29 6.53 55 60 5.18 4.68 55 60 5.37 17 73.74 6.23 56 61 5.28 4.73 56 61 5.50 18 70.59 5.96 57 62 5.39 4.79 57 62 5.63 19 67.78 5.73 58 63 5.51 4.84 58 63 5.78 20 65.26 5.51 59 64 5.63 4.90 59 64 5.93 60 65 5.75 4.95 60 65 6.09 61 66 5.88 5.00 61 66 6.26 62 67 6.01 5.05 62 67 6.44 63 68 6.14 5.10 63 68 6.63 64 69 6.28 5.14 64 69 6.83 65 70 6.42 5.19 65 70 7.05 66 71 6.57 5.23 66 71 7.27 67 72 6.71 5.26 67 72 7.51 68 73 6.86 5.30 68 73 7..76 69 74 7.02 5.33 69 74 8.03 70 75 7.17 5.36 70 75 8.32 71 76 7.32 5.38 71 76 8.62 72 77 7.47 5.40 72 77 8.94 73 78 7.63 5.42 73 78 9.28 74 79 7.78 5.44 74 79 9.64 75 80 7.93 5.45 75 80 10.03 76 81 8.08 5.47 76 81 10.44 77 82 8.22 5.48 77 82 10.88 78 83 8.36 5.49 78 83 11.34 79 84 8.49 5.49 79 84 11.84 80 85 8.62 5.50 80 85 12.37 81 8.74 81 12.93 82 8.85 82 13.54 83 8.96 83 14.18 84 9.06 84 14.87 85 9.14 85 15.60 SETT TABLE OF MINIMUM DEATH BENEFIT PERCENTAGES Attained Age Percentage Attained Age Percentage Through 40 250% 60 130 41 243 61 128 42 236 62 126 43 229 63 124 44 222 64 122 45 215 65 120 46 209 66 119 47 203 67 118 48 197 68 117 49 191 69 116 50 185 70 115 51 178 71 113 52 171 72 111 53 164 73 109 54 157 74 107 55 150 75-90 105 56 146 91 104 57 142 92 103 58 138 93 102 59 134 94 101 TABLE OF SURRENDER CHARGE FACTORS Policy Year Of Surrender Or Years Since Increase Factor 1 1.00 2 1.00 3 1.00 4 1.00 5 1.00 6 .80 7 .60 8 .40 9 .20 10 And After 0 III TBL1 (FPAL-5) TABLE OF GUARANTEED MAXIMUM MALE INSURANCE RATES P ER $1,000 NON-SMOKER SMOKER MONTHLY MONTHLY MONTHLY MONTHLY AGE RATE AGE RATE AGE RATE AGE RATE 1 .08584 48 .36347 1 .08584 48 .70383 2 .08251 49 .39349 2 .08251 49 .76559 3 .08084 50 .42768 3 .08084 50 .83403 4 .07751 51 .46688 4 .07751 51 .91166 5 .07334 52 .51193 5 .07334 52 .99933 6 .06917 53 .56365 6 .06917 53 1.09871 7 .06500 54 .62122 7 .06500 54 1.20729 8 .06250 55 .68547 8 .06250 55 1.32342 9 .06167 56 .75557 9 .06167 56 1.44626 10 .06250 57 .82985 10 .06250 57 1.57581 11 .06750 58 .91250 11 .06750 58 1.71209 12 .07667 59 1.00518 12 .07667 59 1.85343 13 .08917 60 1.10873 13 .08917 60 2.02158 14 .10334 61 1.22400 14 .10334 61 2.20569 15 .11335 62 1.35684 15 .14669 62 2.41331 16 .12335 63 1.50727 16 .16336 63 2.64531 17 .13085 64 1.67447 17 .17503 64 2.89921 18 .13585 65 1.85761 18 .18420 65 3.16834 19 .13919 66 2.05588 19 .19004 66 3.45020 20 .14002 67 2.26344 20 .19337 67 3.74229 21 .13835 68 2.49957 21 .19337 68 4.04883 22 .13585 69 2.75591 22 .19004 69 4.38161 23 .13252 70 3.04592 23 .18670 70 4.74911 24 .12918 71 3.37720 24 .18170 71 5.16235 25 .12502 72 3.75992 25 .17586 72 5.62985 26 .12252 73 4.19334 26 .17253 73 6.14841 27 .12085 74 4.67004 27 .17086 74 6.71732 28 .12001 75 5.18003 28 .17086 75 7.32578 29 .12001 76 5.71919 29 .17336 76 7.94851 30 .12085 77 6.28340 30 .17753 77 8.57456 31 .12335 78 6.87612 31 .18337 78 9.20818 32 .12668 79 7.51607 32 .19087 79 9.87149 33 .13168 80 8.22375 33 .20087 80 10.58674 34 .13752 81 9.01810 34 .21255 81 11.37459 35 .14419 82 9.91569 35 .22672 82 12.24906 36 .15169 83 10.91280 36 .24339 83 13.18833 37 .16169 84 11.99040 37 .26424 84 14.18421 38 .17253 85 13.12418 38 .28758 85 15.18033 39 .18420 86 14.29994 39 .31427 86 16.16034 40 .19837 87 15.49991 40 .34512 87 17.16810 41 .21338 88 16.71910 41 .37848 88 18.22020 42 .22922 89 17.97489 42 .41517 89 18.74923 43 .24673 90 19.28574 43 .45521 90 20.32834 44 .26590 91 20.68243 44 .49942 91 21.43307 45 .28758 92 22.21791 45 .54613 92 22.71710 46 .31093 93 24.04369 46 .59452 93 24.36888 47 .33595 94 26.50346 47 .64709 94 26.62992 GMR-5M TABLE OF GUARANTEED MAXIMUM FE MALE INSURANCE RATES P ER $1,000 NON-SM OKER SMOKER MONTHLY MONTHLY MONTHLY MONTHLY AGE RATE AGE RATE AGE RATE AGE RATE 1 .07000 48 .31427 1 .07000 48 .49024 2 .06667 49 .33678 2 .06667 49 .52611 3 .06500 50 .36180 3 .06500 50 .56449 4 .06417 51 .38932 4 .06417 51 .60537 5 .06250 52 .42101 5 .06250 52 .65209 6 .06000 53 .45604 6 .06000 53 .70383 7 .05917 54 .49191 7 .05917 54 .75641 8 .05834 55 .53028 8 .05834 55 .81066 9 .05750 56 .56866 9 .05750 56 .86408 10 .05750 57 .60620 10 .05750 57 .91417 11 .05834 58 .64375 11 .05834 58 .96343 12 .06167 59 .68630 12 .06167 59 1.01603 13 .06500 60 .73638 13 .06500 60 1.07866 14 .06834 61 .79814 14 .06834 61 1.15717 15 .06667 62 .87493 15 .08001 62 1.25825 16 .07501 63 .96927 16 .08417 63 1.38107 17 .08167 64 1.07532 17 .08834 64 1.51813 18 .08001 65 1.18975 18 .09251 65 1.66276 19 .08251 66 1.30838 19 .09501 66 1.80994 20 .08417 67 1.42954 20 .09751 67 1.95214 21 .08584 68 1.55491 21 .09918 68 2.09605 22 .08667 69 1.69453 22 .10168 69 2.25256 23 .08834 70 1.85845 23 .10418 70 2.43759 24 .09001 71 2.05839 24 .10668 71 2.67212 25 .09168 72 2.30363 25 .10918 72 2.95957 26 .09418 73 2.59756 26 .11335 73 3.30170 27 .09584 74 2.93610 27 .11668 74 3.69191 28 .09834 75 3.31428 28 .12085 75 4.11856 29 .10168 76 3.72382 29 .12585 76 4.57248 30 .10418 77 4.16309 30 .13168 77 5.04701 31 .10751 78 4.63892 31 .13669 78 5.54895 32 .11085 79 5.16656 32 .14252 79 6.09610 33 .11501 80 5.76724 33 .15002 80 6.70972 34 .12001 81 6.45895 34 .15836 81 7.40696 35 .12585 82 7.25729 35 .16753 82 8.20087 36 .13418 83 8.15937 36 .18170 83 9.11907 37 .14419 84 9.15556 37 .19837 84 10.11631 38 .15502 85 10.23537 38 .21755 85 11.17773 39 .16669 86 11.39164 39 .23839 86 12.29517 40 .18087 87 12.62319 40 .26340 87 13.45788 41 .19587 88 13.93142 41 .29008 88 14.67216 42 .21088 89 15.32721 42 .31677 89 15.93752 43 .22588 90 16.82248 43 .34345 90 17.34402 44 .24089 91 18.45266 44 .37014 91 18.86254 45 .25757 92 20.28063 45 .39849 92 20.55222 46 .27508 93 22.43826 46 .42768 93 22.54368 47 .29425 94 25.22305 47 .45771 94 25.22305 GMR-5F TABLE OF GUARANTEED VALUES POLICY NUMBER 4104-287 FACE AMOUNT 550,000 INSURING JAMES L BARISKI END OF ATTAINED CASH CONTINUATION OF POLICY AGE OF OR LOAN INSURANCE PERIOD YEAR INSURED VALUE YEARS MONTHS 1 44 0.00 0 10 2 45 0.00 1 9 3 46 0.00 2 6 4 47 0.00 3 1 5 48 181.37 3 7 6 49 528.47 3 11 7 50 865.89 4 2 8 51 1,190.83 4 3 9 52 1,499.90 4 4 10 53 1,789.10 4 3 11 54 1,889.05 4 2 12 55 1,959.99 4 0 13 56 1,996.62 3 9 14 57 1,993.96 3 5 15 58 1,947.59 3 - 1 16 59 1,850.34 2 9 17 60 1,693.45 2 3 18 61 1,467.03 1 10 19 62 1,159.73 1 4 20 63 755.68 0 9 THIS POLICY WILL LAPSE AT AGE 65 UNLESS A HIGHER PREMIUM IS PAID. FLEXIBLE PREMIUM ADJUSTABLE LIFE V-250 THE GUARANTEED CASH VALUES ASSUME THAT THE GUARANTEED MAXIMUM INSURANCE RATES ARE CHARGED, THAT NO EXCESS INTEREST IS PAID, AND THAT NO CHANGE IN THE SPECIFIED BENEFIT AMOUNT OR OPTION, NO CHANGE IN THE PLANNED PERIODIC PREMIUM SHOWN ON THE SCHEDULE PAGE, AND NO PARTIAL SURRENDERS OR LOANS ARE MADE. FORM MM-CVCI MACCABEES LIFE INSURANCE COMPANY A Stock Company 25800 Northwestern Highway, P.O. Box 2165, Southfield, Michigan 48037-2165 RIDER Attached to and forming part of the Policy as of its Date of Issue. The Section of the Policy entitled "GENERAL PROVISIONS" is hereby amended by adding the following paragraph: The Owner may require upon written request to the Company at any time to have a report provided to him demonstrating the expected results of the future. The Company reserves the right to charge a nominal fee for this service. Signed for the Company at its Home Office in Southfield, Michigan Secretary /President 42-5651 Rl MACCABEES LIFE INSURANCE COMPANY A Stock Company 25800 Northwestern Highway, P.O. Box 2165, Southfield, Michigan 48037-2165 RIDER Attached to and forming part of the Policy as of its Date of Issue. The Section of the Policy entitled "NONFORFEITURE PROVISIONS" is hereby amended by adding the following language: EXTENDED TERM INSURANCE OPTION This extended term insurance option may be requested. If the insured dies while this Policy is on extended term insurance, the insurance Proceeds will be the Specified Benefit of the Policy on the due date of the first unpaid premium; The Insurance Proceeds will be reduced by the balance of any outstanding policy loan. The length of the extended term insurance will be determined by applying the surrender value at the net single premium rate based on the Insured's attained age. While the Policy is on extended term insurance, the Policy may be surrendered for the net single premium of the remaining benefits. This Policy, while on extended term insurance, may be reinstated subject to requirements specified in the Reinstatement provision of the contract. The net single premiums referred to in this section are based on: (1) mortality according to the 1980 Commissioner's SmokerNon- smoker Mortality Table; (2) interest of 4% compounded annually. Signed for the Company at its Home Office in Southfield, Michigan Secretary /President 42-6181 (R1) MACCABEES LIFE INSURANCE COMPANY A Stock Company 25800 Northwestern Highway, P.O. Box 2165, Southfield, Michigan 48037-2165 RIDER Attached to and forming part of the Policy as of its Date of Issue. The Section of the Policy entitled "GENERAL PROVISIONS" under "Misstatement Of Age Or Sex" is hereby amended by deleting the second sentence of the f irst paragraph and substituting the following language in its place: 1) the accumulation value on the date of such death,- and Signed for the Company at its Home Office in Southfield, Michigan Secretary President 42-6187 R1 MACCABEES LIFE INSURANCE COMPANY A Stock Company 25800 Northwestern Highway, P.O. Box 2165, Southfield, Michigan 48037-2165 AMENDMENT Attached to and forming part of the Policy as of its effective Date of Issue. The Section of the policy entitled "NONFORFEITURE PROVISIONS" under "INTEREST RATE" is hereby amended by adding as the second paragraph the following language: As of every fifth Policy Anniversary of the Date of Issue through the Twentieth Anniversary, an additional sum will be credited to the Accumulation Value. That additional sum shall be calculated by multiplying the percentage specified for the anniversary in the table below by the total amount of excess interest, including previous fifth-anniversary-credited sums, credited to the Accumulation Value from the Date of Issue, and then reducing that product by the total amount of all previous fifth-anniversary-credited sums. Policy Anniversary Percentages 5th 7.5% 10th 25.0% 15th 45.0% 20th 60.0% Beginning with the Monthly Deduction Day first following the Twentieth Anniversary, and on every Monthly Deduction Day thereafter, each interest rate used in the calculation of the Accumulation Value shall equal the declared interest rate as determined by the Company's Board of Directors plus half of the excess of that declared rate over the guaranteed minimum rate. Signed for the Company at its Home Office in Southfield, Michigan Secretary President 42-7307 (R1) MACCABEES LIFE INSURANCE COMPANY A Stock Company 25800 Northwestern Highway. P.O. Box 2165. Southfield, Michigan 48037 Surrender comparison index Disclosure Per $1,000 or Face Amount of Basic Insurance Name of Insured JAMES L. BARISKI Age 43 Sex MALE Specified Amount of Policy $ $50,000 Death Benefit Option: Specified Amount DOES INCLUDE the Cash Value. Planned Periodic Premium $ $431.80, payable ANNUAL . Descriptive Title of Policy FLEXIBLE PREMIUM ADJUSTABLE LIFE V- 250 Policy Number 4104-287 Index numbers based on cash values and death benefits produced with the Planned Periodic Premium shown and using GUARANTEED cost of insurance rates and the GUARANTEED interest rate of 4%: 10 Year Surrender Index 5.93 20 Year Surrender Index 8.20 Index numbers based on cash values and death benefits produced with the Planned Periodic Premium shown and using CURRENT, NON-GUARANTEED cost of insurance rates and a NON-GUARANTEED interest rate of 7.75 %: 10 Year Surrender Index 3.02 20 Year Surrender Index 1.85 The non-guaranteed interest rate shown is credited to that part of the cash value exceeding $1,000. The guaranteed rate applies to the first $1,000 of cash value. If a policy loan exists, the guaranteed rate only, and not the non-guaranteed rate, applies to that portion of the cash value borrowed. If the interest rate used is higher than that shown, or if the costs of insurance rates are lowered, within the 10 and 20 year period, the Index will be lower. If not, the index will be the same or higher. The Surrender Comparison index was designed to measure the relative cost of life insurance protection and may be useful for comparison of similar policies offered by other companies. Technically, the index shows the relationship between the amounts paid by the insured (the average annual premiums) and the amounts paid by the insurer (the cash value of the policy in the event of surrender over periods of 10 and 20 years all adjusted for compound interest at the rate of five percent per annum to reflect the timing of the payments). When comparing similar policies, if all things are equal, the policy with the lower Index is generally the lower cost policy and the better buy in the event that the policy was surrendered at the end of the designated period. If death would occur during the designated period, the policy with the lower Index would not necessarily be the lower cost policy. The index does not take into account, among other things (1) the value of the services of an agent or company; (2) the relative strength and reputation of the company; and (3) small differences in policy provisions. The Index does assume that annual premiums are paid, and that no additional benefit provisions are included. 16-6706 (R2) W i i A rn 01 Klti? ?sSoc?" c 1 - crz) Agency Agent ?, I! 1p m rn A?. h Code _..,Ln Credit ? 96 Code Agent Code Credit 96 APPLICATION FOR INSURANCE TO PART 1 PA 746591 MACCABEES LIFE INSURANCE COMPANY 1 a Proposed Insured (Print first name, initial, last name) Z. l "C15*1 Soc. Sec. No. a 1b. Second Proposed Insured ? Spouse ? Payor Benefit Soc. Sec. No. 2. Children (if Childrens Term applied for) Complete Part II Jull Name Birthdate Height Weight 3. Residence Address (Street and Number, City, State, Zip) h 7_f ?a u E L ?o,l -?f 5??.•ti1 s?' 17007 4a. Send Premium notices to: Residence Address X Other ? b. Premium Payor: Proposed Insured Beneficiary ? ? Applicant ?Other (Give name/relationship in Q. 25) LIFE ONLY 5a. Kid of Policy 5b Amount /A'4,cWow/'J ClJ DAD -0 oo 6) Birth Date State of Height Mo Day Yr. Age Birth Sex Ft. In. 03 1// 7 y3 A<J_ kl I S F Weight ow 1 yr. ago o U I o? os' 10. Owner-Proposed Insured(s) shall be owner, unless otherwise shown below. (Life and Disability Income) Print 'Name Age Relationship Address Soc. Sec. or Tax No. Owner's Designee Relationship 11. Beneficiary Primary / Relationship ?EGA?c/ Tid?JEN!' 1'D? s 40 u6 4P/0 -f Contingent Relatio ship 12 Life Insurance in Force on Proposed Insured. pa Yr. of Issue Plan Amount Acc. Death n/J q L. D Od0 /?S 6. ClOU k.C/r'Jfv / F / 1<A 6. Flex. Prem, Adjust. Life K, Basic ? Basic + Cash Val Planned Periodic Premium $-5-F 9. 30 Mode N•v 7. Include Additional Benefits Checked Below: a. ? W.P. b. ? A.D.B. $ c. ? Automatic Premium Loan d. ? Payor Benefit e. ? Child Term No. of units f. ? Insurability Benefit $ g. ? Spouses Term No. of units h. ? Monthly Disability Rider $ 8. Use of Dividends? ? Red. Prem. - Left at Interest ? Cash ? One-Year Term, balance to ? Paid up additions 9. Premium Frequency Life ,u& Health :- PAC Master/List Bill No. 13 Will the Life Insurance applied for, if issued, replace any existing insurance or annuities in this or a ny - other com pany? Please circle policies to be replaced. Yes ? No 14. Answer for both Life and Disability Income a. Has the Proposed Insured(s) in Question 1 smoked cigarettes at any time within the past 12 months ? Yes ? No b. Does the Proposed Insured use tobacco in other forms? (If "Yes," describe) ? Yes No 115. Is the Proposed Insured a U.S. citizen? *Yes ? No If "No," give details including visa status. 42-6858-(PA)-1 (1/89) DISABILITY INCOME ONLY 16. B[NEFIIS APPLIED FOR Plan P _? Benefit Benefit Pc_ riod;: t=- L Lifetime Accident Elimination Peri6d_C-?.Q_ (for add'I policY(s) describe fully in 425) ADDI1 ZONAL BENEF ITS 0 Initial Add'I Benefit ? COLA V, Future'lncrease Option $&R:XY- ? Cash Value ? Hospital, Indemnity $ XReturn of Premium O SOS $ ',,, ? ROR ? Requested, Effective Date: ? 17. LOSS PAYEE: ThtZ Owner(s) shall be the loss payee unless another loss paye? is shown. 18a. What were your n t earnings from your occupation or profession last year? Gross income less business expenses) $ (* n b. What did you contribute to IRA, HR10, qualified pension or profit sharing plans? Is this included in 18a? ? Yes X No $ c. What was "other income' last year from dividends, in- terest, rents, royalties, estates and trusts, etc? (Circle items) $ d. What is your approximate, net worth? (Assets less liabilities) 19a. Insurance in force, applied fot, or applying to reinstate. Insurer (If none,sostate) Issue Date Mo. Ben. Elim Perio Ben. Period Payor Type I , b. Will the disability policy applied for eplace any existing coverage. (If Yes, give details in Que tion 25.) X Yes D No c. Does any of the above coverage coor inatc with Social Se( urity? If Yes, which Policy(s) & $DYeSKI No 22a. Name & Address of F m toyer '4> -?,,J b length of Service L "'1 c. Are you actively at work? ave you worked at least air hours per week during the past 6 onths) )'esNo LIFE AND DISABILITY INCOME 23. Has the Proposed Insured(s) in Question 1: (Give details of "Yes" answers in Question 25). Yes No a. a reinstatement or an application for life or health insurance pending or contemplated in any company? DC O b any intention to travel or reside outside the United States or Canada? )F g c in the past two years flown as a pilot, student pilot or crew member, or intend to do so? (If yes, complete attached Aviation Questionnaire) C V d engaged in underwater diving, hang gliding, parachuting, auto, motorcycle or vehicle rac- ing or is such activity contemplated? (if "Yes," describe in #25) .e. had a drivers license suspended or revoked or been convicted in the last 3 years of a moving violation, or of driving while impaired or intoxicated? Give drivers license number C 56 f. ever been convicted of a felony? C g. ever been told he/she had AIDS (Acquired Immune Deficiency Syndrome) or ever been treated for AIDS? ? h. ever used Heroin, Morphine, Cocaine, LSD, Marijuana or other narcotics except as prescribed by a physician? C 24. Amount paid with Application X,1,4 Life $ Annuity $ Health $ 20. Are you covered under a state disability t rogram? - ) Yes ; No 21 Occupational Duties-Fully Describe List all important duties and percentage of time s Ou.`rsec_ o? Cc?:?,p?'1?I r?;h?cy, 5:>?Is e' -Tc, ??cvcn;m<{?t ir?SiHllr; 1;crj? ??r1d?l I on each .FMr -0f argF 25. Remarks /????GO'f/r>+ L?/7N ?4JJ, LFil?a((y/ SF.e a Q a co CID co N v it is understood and agreed that: (1) the answers recorded in Part I above and Part II, bearing the same number, and any Part III required are, to the best of my knowledge and belief, true and complete and correctly recorded and will become part of this application and any contract for insurance issued upon it; (2) Except as provided for in the attached Receipt(s), no insurance shall take effect until the policy is accepted by the Owner and the first premium is paid to the Company and the health, habits and occupation of all proposed insureds remain as stated in the application; (3) Acceptance of any policy issued shall constitute a ratification of any change, correction or addition made by the Company, except in states where required, any change in amount, plan of insurance, classification, age at issue or benefits shall require the signature of the Owner; (4) That no Agent has the authority to waive the answer to any question, to pass on insurability, to v,,aive any of the Company's rights or requirements or to make or alter any contract. /I Application made at ./s ? -? State/• Date ?.Lv , 19) ? I acknowledge receipt of Outline of Coverage. I certify that this application accurately records the informa- tion supplied by the Applicant. Proposed Insured Spouse (If to be Insured) Witness ; ? ,/ / , ?? Q * Proposed Insured Licensed Resident Agent Over Age 18 Applicant/Owner k ?/?,?-/z By (If other than props Insured) (Signature & Title of Officer signing for Firm or Corporation) (If Applicant is a Fir r Corporation, insert name of Company) PART 111 CONTINUATION OF APPLICATION TO MACCABEES LIFE AND ANNUITY COMPANY 1. PROPOSED INSURED L. DETAILS OF "YES" ANSWERS (Identify 2. When did Proposed Ins ed last consult a physician? ate _ O question number and circle all applicable items. Include diagnosis, dates, duration Doctor/Address and names and addresses of all physicians What reatment was given or r com ended? and medical facilities). 1 q vt 4 0 - 0.3 ? & ? -- P O "a , 3. Has any parent, brother, or sister ever had tuberculosis, diabetes, cancer, res o high blood pressure, heart disease, kidney disease, or mental illness? ? Ak 4. Have you within the past five years. B 1 aa? - een examined by or consulted i physician or other practitioner? f O l?R. T.4, Mv?a. x""` b. Been under observation or treatment in a hospital, sanitarium or institution? ? c. Had an x-ray electrocardiogram oo rineor . her laboratory tests? ? S. Have you ever: a. Received benefits or compensation for sickness or injury or had life or P disability insurance rated up, modified, rejected, cancelled or not A" ( renewed? b. Sought advice or treatment for or been arrested for or been addicted to ? the use of alcohol or drugs? Jk/ p c. Had any disease of the reproductive or ans, genital or ans r asts, or any amputation or bodily deformit erni rru ture emorrhoi or 6 y p varicose veins? t j ? b r. 7 ?7v 6. Have you ever had or been treated for- A di di d f h ny a. sease or sor er o t e eyes, ears, nose, throat, or thyroid gland? b. Any deformity or disorder of the back, spine, muscles, bones or joints? ? ? SL, Cry" 'r'"``aJ c. Chest pain, heart murmur, high blood pressure, or any other diseaseor disorder of the heart, circulatory system, blood, or blood vessels? ? d. Peptic ulcer, indigestion, or any disease of the stomach, intestines, gall r bladder, liver, pancreas or spleen? ? e. Tuberculosis, asthma, pleurisy, or any other disease of the chest or lungs?, ? f. Albumin, pus, blood or sugar in urine, urinary stone, or other diseaseof the kidneys, bladder or prostate? ? 1>0 g. Severe headaches, fainting spells, epilepsy, paralysis, nervousness, mental disorder, or any other disease or disorder of the brain or nervous system? ? _ h. Rheumatic or other fever, syphilis, gout, arthritis, goiter, diabetes, cancer, tumor or disorder of the lymph nodes? ? P. i. Any surgical operation, treatment, or any illness, ailment, abnormality, or injury not mentioned above within the past five years? O 7. Are you now under treatment or taking any prescription drugs? ? a. To the best of your knowledge are you now in good health? 41, 9. COMPLETE FOR FEMALES ONLY a. Have you everhada menstrual disorder or anydisorder or diseaseof the breasts or female organs? ? ? b. Have you ever had a miscarriage, difficult labor, stillbirth, or caesarian operation? ? ? c. Are you pregnant? (if "Yes", give date child is expected.) O O 10. Do you have any known indication of any physical disorder, deformity, defect, abnormality, or disease not disclosed in the answers to questions 2 through 9 above? ? I hereby declare that all the statements and answers to the above questions are complete and true to the best of my knowledge and belief, and I agree that the foregoing together with this declaration shall form a part, designated as Part 111 of the application for insurance. I authorize the examining physician to give the Maccabees Lif d A nu' Com any medical information he may have in his files. Witness QL.c? 0'6) ?. ' Examining,,b"ftim (Silhature of person examined or applicant if child under age 16 MA 42-5451 Ps o, sox 2551 bur9, P/1 17100.111!1 , ? - . 19-_L.0 +• FLEXIBLE PREMIUM ADJUSTABLE LIFE INSURANCE POLICY V Adjustable Benefit Amount Flexible Premium Payments Insurance Proceeds Payable At Death Before The Maturity Date Surrender Value Payable On The Maturity Date Non-Participating Schedule Of Benefits And Premiums Appears On Page 3 MM-FPAL-5 (R1) (20) ? Y ASSIGNMENT OF LIFE INSURANCE POLICY AND DEATH BENEFIT PROCEEDS WHEREAS on or about June 8, 1990, James L. Bariski purchased a life insurance policy from Maccabees Life Insurance Company, being Policy No. 3166593 in the face amount of $250,000 (the "Policy"), and named as primary beneficiary of the death benefit, Janice Bariski (his wife); WHEREAS Maccabees Life Insurance Company subsequently became Royal Maccabees Life Insurance Company, and still later Reassure America Life Insurance Company, through a series of transactions not fully understood; WHEREAS on or about September 21, 2004, James L. Bariski changed the primary beneficiary on the Policy to Mark L. Butler (the "Assignor") to provide the Assignor with assurance that a certain debt would be repaid; WHEREAS the debt to the Assignor was fully repaid and James L. Bariski passed away on or about December 26,'2007; NOW THEREFORE, for good and valuable consideration and effective November 1, 2009, Assignor hereby assigns to Janice Bariski (the "Assignee") all of his rights, title, and interest in the Policy and the related death benefit. Assignor further agrees to execute any additional documents; which might reasonably be required to effectuate this assignment. IN WITNESS WHEREOF AND INTENDING TO BE LEGALLY BOUND, the Assignor has executed this Agreement on this NT??' day of January, 2010. WITNE S) Mark L. Butler CERTIFICATE OF SERVICE I, Charles T. Young, Jr., hereby certify that on this _ day of March, 2010, a true and correct copy of the foregoing Complaint was served by U.S. first-class mail, postage prepaid, upon the following: (Counsel for Defendants) Richard L. McMonigle, Jr., Esq. POST & SCHELL, P.C. Four Penn Center 1600 John F. Kennedy Boulevard Philadelphia, PPT)9103 Counsel for Pla