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Home My WebLink About14-3335 Supreme Court of Pennsylvania Court of Common Pleas For Prothonotary, Use only: Civil Cover Sheet Docket No: Cumberland County j' -333S- 6441d The information collected on this form is used solely for court administration purposes. This form does not supplement or replace thefiling and service o pleadin s or other papers as required bylaw or rules of court. Commencement of Action: S ❑ Complaint 0 Writ of Summons ❑ Petition ❑ Transfer from Another Jurisdiction ❑ Declaration of Taking E C Lead Plaintiff's Name: Lead Defendant's Name: Cynthia A. Kerekes, executrix Primerica, Inc. T Dollar Amount Requested: ❑within arbitration limits I Are money damages requested? ❑✓ Yes ❑ No (check one) ❑outside arbitration limits O N Is this a Class Action Suit? ❑Yes ❑✓ No Is this an MDJAppeal? ❑ Yes © No A Name of Plaintiff/Appellant's Attorney: William P. Douglas ❑ Check here if you have no attorney(are a Self-Represented [Pro Se] Litigant) Nature of the Case: Place an"X"to the left of the ONE case category that most accurately describes your PRIMARY CASE. If you are making more than one type of claim, check the one that you consider most important. TORT(do not include Mass Tort) CONTRACT(do not include Judgments) CIVIL APPEALS ❑ Intentional ❑ Buyer Plaintiff Administrative Agencies ❑ Malicious Prosecution ❑ Debt Collection:Credit Card ❑ Board of Assessment ❑ Motor Vehicle ❑ Debt Collection:Other ❑ Board of Elections Nuisance Dept.of Transportation Premises Liability Statutory Appeal:Other S Product Liability(does not include mass tort) ❑ Employment Dispute: E Slander/Libel/Defamation Discrimination C 8 Other: ❑ Employment Dispute:Other ❑ Zoning Board T 42 Pa.C.S.§8371 ❑ Other: I ❑ Other: O MASS TORT ❑ Asbestos N Tobacco Toxic Tort-DES Toxic Tort-Implant REAL PROPERTY MISCELLANEOUS ❑ Toxic Waste ❑ Ejectment ❑ Common Law/Statutory Arbitration B ❑ Other: Eminent Domain/Condemnation ❑ Declaratory Judgment HGround Rent Mandamus ❑ Landlord/Tenant Dispute HNon-Domestic Relations ❑ Mortgage Foreclosure:Residential Restraining Order PROFESSIONAL LIABLITY Mortgage Foreclosure:Commercial ❑Quo Warranto ❑ Dental ❑ Partition ❑Replevin ❑ Legal ❑ Quiet Title ❑Other: ❑ Medical ❑ Other: ❑ Other Professional: Updated 1/1/2011 I I ` 2011, JUN W-2 PM 2 William P.Douglas,Esq. Supreme Court LD.#37926 CUMBERLAND COUNITY, Douglas Law Office PENNSYLVANIA 43 West out Street Carlisle,Pennsylvania 17013 Telephone(717)243-1790 i Cynthia A. Kerekes, individually and In the Court of Common Pleas of in her capacity as Executrix of the Cumberland County, Pennsylvania Estate of Paul Jerome Brown,Jr., a/k/a Paul J. Brown,Jr., deceased 1497 English Drive Mechanicsburg, PA 17055 Plaintiffs No. 2014 Civil Term j vs I i Primerica, Inc. t%a/d/b/a Primerica Life Insurance Company Civil action law 3120 Breckenridge Blvd. Jury Trial Demanded Duluth, GA 30099 Defendant Praecipe to Issue a Writ of Summons Dear Mr. Buell: Please issue a Writ of Summons against the defendant, Primerica, Inc., t/a/d/b/a Primerica Life Insurance Company. i William P. DouQgs, Esq. Attorney for aintiffs Date:June 2, 2014 �R /03-75r PP4. Commonwealth of Pennsylvania County of Cumberland Cynthia A. Kerekes, individually and In the Court of Common Pleas of in her capacity as Executrix of the Cumberland County, Pennsylvania Estate of Paul Jerome Brown,Jr., a/k/a Paul J.Brown, Jr., deceased .1497 English Drive Mechanicsburg„PA 17055 Plaintiffs � 3,33-S- CGGi No. 2014 Civil Term vs Primerica, Inc. t/a/d/b/a Primerica Life Insurance Company 3120 Breckenridge Blvd. Civil action law Duluth, GA 30099 Jury Trial Demanded Defendant Writ of Summons To: Primerica, Inc. t/a/d/b/a Primerica Life Insurance Company 3120 Breckinridge Boulevard Duluth, GA 30099-0001 You are hereby notified that- Cynthial�A. Kerekes, individually and in her capacity as Executrix of the Estate of Paul Jerome Brown,Jr. a/k/a Paul J. Brown,Jr., deceased have brought an action a ainst you. June 2, 2014 I �� Q.—axLF-LL Prothonot y William P. Douglas, Esq. Douglas Law Office 43 West South Street Carlisle, Pennsylvania 17013 (717)243- 1790 I William P. Douglas, Esq. Supreme Court LD. #37926 Douglas Law Office 43 West South Street Carlisle, Pennsylvania 17013 Telephone (717) 243-1790 OF THE PROTHONOTARY 2014 AUG -1 Ply 2: 30 CUMBERLAND COUNTY PENNSYLVANIA Cynthia A. Kerekes, individually and in her capacity as Executrix of the Estate of Paul Jerome Brown, Jr., a/k/a Paul J. Brown, Jr., deceased Plaintiffs vs Primerica, Inc. t/ a/ d / b / a Primerica Life Insurance Company Defendant In the Court of Common Pleas of Cumberland County, Pennsylvania NOTICE No. 2014 Civil Term 3335 Civil action law 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 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 PLAINTIFF. 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 S. Bedford Street Carlisle PA 17013 717-249-3166 DATE: August 1, 2014 BY Complaint 1. The plaintiffs, Cynthia Kerekes, individually and in her capacity as Executrix of the Estate of Paul Jerome Brown a / k/ a Paul J. Brown, Jr., deceased, 1497 English Drive, Mechanicsburg, Cumberland County, Pennsylvania. 2. The Defendants, Primerica, Inc., t/ a / d / b / a Primerica Life Insurance Company, is a corporation registered in and doing business in the Commonwealth of Pennsylvania, with their home office located at 3120 Breckenridge Blvd., Duluth, GA, 30099. Said defendant is hereinafter referred to as Primerica. 3. In 1988, Primerica issued a policy of insurance to, Paul J. Brown, Jr., at the time he was married to Francesca Rosaria Brown. Paul J. Brown, Jr. was the sole titled owner of said policy of insurance from the date of inception until his death in 2014. 4. When the policy was originally issued Paul J. Brown, Jr., he named his then wife, Francesca Brown as primary beneficiary and his mother, Antoinette Brown, as the contingent beneficiary. 5. Antoinette Brown died in 2001, as a result the contingent beneficiary would be the estate of Paul J. Brown, Jr. 6. On April 15, 2004, a Decree and Order were issued finalizing the divorce of Paul J. Brown, Jr., from Francesca Rosaria Brown. Pursuant to the Equitable Distribution Agreement Francesca Rosario Brown waived any and all interest in said policy of insurance. This information has been provided to Primerica. A copy of the information provided to them has been attached hereto. As a result of the death of Antoinette Brown in 2001 and the aforesaid divorce (statutory waiver of beneficiary designation), there would be no beneficiary named in the policy of insurance from April 15, 2004 through April 25, 2008 and the default beneficiary would be the Estate of Paul J. Brown, Jr., deceased pursuant to the terms of the policy. 7. In the spring of 2008, Cynthia Kerekes, and her husband Paul J. Brown, Jr., met with Kevin Goodman, a representative of Primerica. The meeting occurred in their home here in Gilbertsville, Pennsylvania. The reason for the meeting was to discuss the reissue a 20 year term life insurance policy with Primerica that was owned by Paul J. Brown, Jr., and insuring his life and to name Paul Brown's current wife Cynthia Kerekes as primary beneficiary of said policy. Correspondence from Primerica addressed to Paul Brown indicates that a Policy Change Application referencing policy number 0412796493 was submitted to Primerica Life Insurance Company underwriting department and a certificate of insurance was issued with a policy date of April 15, 2008 and an issue date of May 17, 2008, bearing certificate number 0412796493. The premium for said coverage was $55.63 per month which was drawn from the joint checking account of Paul J. Brown, Jr. and his wife Cynthia Kerekes. 8. The aforesaid policy of life insurance in effect on April 28, 2014, between the plaintiffs and Primerica which provided for the payment of $183,000.00 in the event of the death of Paul J. Brown, Jr. 9. In 2008, Kevin Goodman, while acting as an agent for and while working within the course and scope of his employment with Primerica met with Paul Brown and his wife Cynthia and was told that Cynthia was to be the beneficiary of the policy of insurance in the event of Paul's death. Documention was executed at that time to make Cynthia Kerekes beneficiary of the aforesaid policy. 10. Paul Brown died on April 28, 2014 while residing in Upper Allen Township, Cumberland County, Pennsylvania. 11. Following his death, the agent, Kevin Goodman was contacted by Cynthia Kerekes to inform him of Paul's death. He then told her repeatedly that people change beneficiary designations all the time and she was no longer the beneficiary. He told her Paul had changed the beneficiary designation to Francesa Brown. 12. Following her conversation with Kevin Goodman she then called Primerica and she was told that there had been no contact of any kind with Paul Brown since 1988 and the beneficiary of the policy was the former wife Francesca Brown. 13. Following that conversation with Primerica Cynthia Kerekes provided the divorce documentation showing that Francesa Brown was divorced from Paul J. Brown, Jr. and had waived any interest in the policy and was statutorily remove as beneficiary. 14. Primerica has frivolously, and with no proper foundation for their actions, fraudulently, knowingly and intentionally misrepresented and refused to pay proceeds under their policy of insurance in accordance with the terms of the policy. 15. The bad faith conduct of Primerica gives rise to a cause of action pursuant to 42 Pa. C.S.A. §8371. 16. The defendant failed to promptly and completely investigate the claim of the plaintiffs arising under the aforementioned contract of insurance. 17. The defendant did not act in good faith to effectuate prompt, fair and equitable resolution of the plaintiffs' claim, knowing that liability to pay benefits is clear and coverage applies, and as a result, the plaintiffs have been forced to incur expense to protect her interests. 18. The defendant failed to promptly provide a factually sound explanation for the basis of denial in the insurance policy in relation to the facts or applicable law for denial of the claim. 19. The defendant has willfully, maliciously and/or recklessly withheld benefits from the plaintiff, due to its failure to investigate the claim thoroughly. Said conduct constitutes a breach of an implied covenant. 20. The defendant, in bad faith, have failed to pay benefits without a sound legal basis for said failure and have failed to fully inquire into the possible basis which might support the insured's claim of coverage. 21. Primerica has deliberately acted in conscious disregard and with reckless indifference to the rights of their insured. 22. The defendant impliedly and/ or expressly warranted that it would, in good faith, provide insurance coverage to Paul J. Brown, Jr. and Cynthia Kerekes, in accordance with the contract and abide by the terms of said contract but have failed to do so. 23. As a result of the aforesaid, the defendant breached its contract and / or warranty, which breach resulted in loss to the plaintiffs, In addition, as a result of Primerica's bad faith conduct, Cynthia Kerekes has suffered aggravation, inconvenience and emotional distress. 24. The plaintiff hereby requests all remedial relief as provided in 42 Pa. C.S.A. §8371 and payment in full of all available insurance benefits due under the contract. Wherefore, it is prayed that judgment be entered in favor of the plaintiffs and against the defendant in an amount in excess of that requiring compulsory referral to arbitration. Respectfull August 1, 2014 William P. Douglas, E AFFIDAVIT I hereby swear or affirm that the foregoing is true and correct to the best of my knowledge and / or information and belief. This is made subject to the penalties of 18 Pa.C.S.§ 4904 relating to unsworn falsification to authorities. Cynthia A. Kerekes PRIMERICA Life Insurance Company A Citi Company Executive Offices: 3120 Breckinridge Boulevard Duluth, Georgia 30099-0001 For Policyowner Service Call 1-800-257-4725 We will pay the Face Amount, in a lump sum, to the Beneficiary upon receiving due proof that the Insured died before the Expiry Date and while this Policy was in force. This agreement is subject to the provisions on the following pages, which constitute the Policy. RIGHT TO RETURN POLICY:. You may return this Policy to Us or Our authorized agent for any reason within 45 days after You receive it. If returned, it will be considered void from the beginning. Any premium paid will be refunded. This Policy is effective at 12:01 A.M. on the Date of Issue. Signed on the Date of Issue at Our Executive Offices. Secretary 7C5": President TERM LIFE INSURANCE POLICY TO AGE 95 WITH INDETERMINATE PREMIUMS INITIAL LEVEL PREMIUM IS GUARANTEED AFTER WHICH IT IS SUBJECT TO CHANGE AS SHOWN ON THE SPECIFICATIONS PAGES EXCHANGEABLE AFTER FIVE YEARS TO ANNUAL INCREASING PREMIUM OR DECREASING TERM INSURANCE TO AGE 100 C5PA 10.07 NONPARTICIPATING Primerica Life Insurance Company (A Stock Company) Home Office: Boston, Massachusetts C5PA ln n7 TABLE OF CONTENTS PART 1: DEFINITIONS Page 4 PART 2: GENERAL PROVISIONS Page 4 PART 3: BENEFICIARY PROVISIONS Page 5 PART 4: PREMIUM PROVISIONS Page 5 PART 5: EXCHANGE PROVISIONS Page 6 Policy Page 2 POLICY SPECIFICATIONS POLICY NUMBER: 0412796493 INSURED: PAUL J BROWN JR ISSUE AGE: 49 DATE OF ISSUE: DUPLICATE FACE AMOUNT: $183,000 POLICY DATE: APRIL 15, 2008 PREMIUM CLASS: PREFERRED EXPIRY DATE: APRIL 15, 2054 FORM NUMBER PLAN NAME FACE PREMIUM AMOUNT YEARS 1-20 C5PA TERM LIFE INSURANCE TO AGE 95 $183,000 $585.57 C5PA(20) 10.07 Policy Page 3 (THIS PAGE INTENTIONALLY LEFT BLANK) PREMIUMS FOR C5PA Premiums for C5PA will be the scheduled premiums. *Any premium after the guaranteed period is subject to change in accordance with the premium change provision. The scheduled premiums will not change more than once per year and will never be greater than the maximum premiums. Any change will apply to all policies of this form with the same issue age, duration, class, date, and state. See Part 4, Premium Changes By Company. SCHEDULED MAXIMUM POLICY ATTAINED MONTHLY MONTHLY FACE YEARS AGE PREMIUMS PREMIUMS AMOUNT 01 49 $55.63 $55.63 $183,000.00 02 50 $55.63 $55.63 $183,000.00 03 51 $55.63 $55.63 $183,000.00 04 52 $55.63 $55.63 $183,000.00 05 53 $55.63 $55.63 $183,000.00 06 54 $55.63 $55.63 $183,000.00 07 55 $55.63 $55.63 $183,000.00 08 56 $55.63 $55.63 $183,000.00 09 57 $55.63 $55.63 $183,000.00 10 58 $55.63 $55.63 $183,000.00 11 59 $55.63 $55.63 $183,000.00 12 60 $55.63 $55.63 $183,000.00 13 61 $55.63 $55.63 $183,000.00 14 62 $55.63 $55.63 $183,000.00 15 63 $55.63 $55.63 $183,000.00 16 64 $55.63 $55.63 $183,000.00 17 65 $55.63 $55.63 $183,000.00 18 66 $55.63 $55.63 $183,000.00 19 67 $55.63 $55.63 $183,000.00 20 68 $55.63 $55.63 $183,000.00 21 69 $242.52* $458.44 $183,000.00 22 70 $266.17* $499.12 $183,000.00 23 71 $298.15* $546.06 $183,000.00 24 72 $333.45* $598.39 $183,000.00 25 73 $372.39* $655.07 $183,000.00 26 74 $415.68* $717.48 $183,000.00 27 75 $464.53* $786.50 $183,000.00 28 76 $519.29* $862.30 $183,000.00 29 77 $580.66* $945.57 $183,000.00 30 78 $648.98* $1,037.71 $183,000.00 31 79 $724.96* $1,137.15 $183,000.00 32 80 $808.23* $1,248.42 $183,000.00 33 81 $899.33* $1,399.32 $183,000.00 34 82 $997.55* $1,569.52 $183,000.00 35 83 $1,104.12* $1,739.20 $183,000.00 36 84 $1,222.69* $1,926.78 $183,000.00 37 85 $1,354.12* $2,138.01 $183,000.00 38 86 $1,498.94* $2,329.59 $183,000.00 39 87 $1,657.66* $2,618.01 $183,000.00 40 88 $1,830.64* $2,919.29 $183,000.00 C5PA(20) 10.07 Policy Page 3 (Cont'd) PREMIUMS FOR C5PA (Cont'd) SCHEDULED MAXIMUM POLICY ATTAINED MONTHLY MONTHLY FACE YEARS AGE PREMIUMS PREMIUMS AMOUNT 41 89 $2,016.14* $3,240.57 $183,000.00 42 90 $2,176.43* $3,536.63 $183,000.00 43 91 $2,341.59* $3,686.32 $183,000.00 44 92 $2,512.13* $3,980.99 $183,000.00 45 93 $2,687.20* $4,418.05 $183,000.00 46 94 $2,867.48* $4,969.68 $183,000.00 C5PA(20) 10.07 Policy Page 3 (Cont'd) TOTAL PREMIUM PAYMENT OPTIONS TOTAL PREMIUM PAYMENT OPTIONS (includes all riders): MODE ANNUAL SEMI-ANNUAL QUARTERLY MONTHLY PRESENT YEAR $585.57 $304.50 $155.18 $55.63 TOTAL YEARLY COST PRESENT YEAR $585.57 $609.00 $620.72 $667.66 If you would like additional information about the costs of our periodic pnyments, please contact us at 1-800-257-4725. CSPA(20) 8OO 257'472S- CSPA(2O) 10.07 Policy Page 3 (Cont'd) PART 1 DEFINITIONS These are some key words used in this Policy. 1. ATTAINED AGE - The Issue Age plus the number of policy years since the Policy Date. 2. BENEFICIARY - The person(s) to whom the Policy proceeds are payable at the death of the Insured. This is the person(s) named in the application as the Beneficiary, unless later changed (see Part 3). 3. DATE OF ISSUE - The date shown on Page 3 on which We issue the Policy to You. This date controls the Incontestability and Suicide Exclusion provisions in Part 2. 4. EXPIRY DATE - The date shown on the Policy Specifications. This Policy is not in force on or after this date. 5. FACE AMOUNT - The amount of insurance for each policy year which is shown on Pages 3 and 3 (Cont'd). 6. INSURED - The person whose life the Policy insures and who is named in the Policy Specifications. 7. ISSUE AGE - The Insured's age on the birthday nearest the Policy Date. 8. NOTICE TO US - Information We have received which is signed by You, and acceptable to Us. 9. POLICY DATE - The date (shown on Page 3) from which premium due dates, policy anniversaries, policy years and policy months are measured. 10. PREMIUM CLASS -The risk classification used in determining what premiums You pay. 11. WE, OUR or US - Primerica Life Insurance Company. 12. YOU or YOUR - The Owner of the Policy. Unless You tell Us otherwise, the Owner is the Insured. PART 2 GENERAL PROVISIONS OWNER OF POLICY - This Policy belongs to You. During the Insured's life, You have all of the rights described in this Policy. You may change the Owner by Notice to Us. Unless otherwise specified the change in owner designation is effective the date the Notice to Us is signed, subject to any payments made or actions taken by Us prior to receipt of the Notice. If You die, Your rights will pass to the named contingent owner, if any. If there is no named contingent owner, Your rights will pass to the Insured. THE. CONTRACT - This Policy is issued in consideration of the application and payment ofthe first premium. A copy of the application, including any supplemental applications, is attached and is a part of the Policy. Together, they are the entire contract. All statements in the application, except fraudulent ones, are deemed to be representations and not warranties. No statement will void this Policy or be used in defense of a claim unless: (1) it is contained in a written application; and (2) a copy of that application is attached to this Policy. DUPLICATE POLICY - You may request a duplicate copy of Your current Policy, which will not contain a copy of the application(s), unless requested by You. A duplicate Policy request should be sent to Us at Our Executive Offices. We will charge a fee for each duplicate Policy request. WAIVER OR MODIFICATION - Any change to this Policy must be in writing and signed by Our President or Secretary. No agent or any other person can change this Policy or waive any of its provisions on Our behalf. MISSTATEMENT OF AGE - If the age of the Insured has been misstated in the application, We will be liable only for the amount of insurance the premiums paid would have purchased for the correct age. INCONTESTABILITY- We will not contest this Policy after it has been in force for two years during the Insured's life, except for nonpayment of premiums. The two years begin on the Date of Issue. This provision does not apply to any rider for disability benefits or additional insurance specifically for accidental death. SUICIDE EXCLUSION - If the Insured dies by suicide, while sane or insane, within two years of the Date of Issue, We are only liable for the premiums paid. REPLACED COVERAGE - If insurance coverage (excluding group coverage) is to be replaced, as shown in the application, and has terminated: (a) prior to the Insured's death, including death by suicide; and. (b). between 60 days before and 60 days after the Date of Issue of this Policy, We will not contest the amount of the replaced coverage that would not have been contestable had it not been replaced. If it is not possible to terminate any coverage to be replaced because of its provisions within 60 days after the Date of Issue of this Policy, such 60 -day period will be extended to the earliest possible date for the coverage to be terminated under its provisions. For example, You are insured under another company's policy for $100,000 and that policy has been in force two years. If this Policy replaced the other company's policy, We would not contest this Policy for up to $100,000. We would however, be able to contest any amount over $100,000. You will not lose the time accrued for the amount of insurance replaced due to this Policy's Incontestability and Suicide Exclusion provisions. NONPARTICIPATION - This Policy does not participate in Our profits or surplus. ASSIGNMENT - You may assign Your rights under this Policy. You must give Notice to Us of the assignment. Unless otherwise specified, the assignment is effective on the date the Notice to Us is signed, subject to any payments made or actions taken by Us prior to receipt of the Notice. We are not responsible for the validity of any assignment. The interest of any Beneficiary not designated irrevocable will be subject to the rights of any assignee. C5PA in 07 Policy Page 4 PAYMENT OF PROCEEDS - Due proof of the death of the Insured must be sent to Us at Our Executive Offices. We must receive a certified death certificate, completed claim forms and a valid authorization for Us to obtain all medical and other records concerning the insured. Death proceeds equal: (1) the Face Amount of this Poiicy as shown on Page 3; plus (2) any rider benefits; and minus (3) any overdue premium if death occurs during a grace period. Any interest payable on death proceeds will be paid according to applicable state law. CANCELLATION You may cancel Your Policy at any time by sending Notice to Us. Your Policy will be canceled as of the date We receive the Notice, or, if stated in Your Notice, as of a later date. If this Policy is canceled before the Expiry Date and premiums have been paid in advance, We wifl refund any unearned portion of the premiums paid beyond the end of the policy month in which cancellation occurred. PART 3 BENEFICIARY PROVISIONS BENEFICIARY - The Beneficiary's interest wUl end if the Beneficiary dies before the insured. 11 no primary Beneficiary is living at the Insured's death, the death proceeds will be paid to any contingent Beneficiary. The proceeds will be paid to the Owner if the Insured dies and there is no primary or contingent Beneficiary. Proceeds will be paid to the nsured's estate if there is no iving Beneficiary or Owner. We may rely on a sworn statement by any responsible person to discover the identity or nonexistence of any Beneficiary not identified by name. If a Beneficiary is a partnership, We will pay the proceeds to the partnership as it is constituted at the time of the lnsured's death. CHANGE GF BENEFICIARY You can change a Beneficiary by Notice to Us. You can only change a Beneficiary while the lnsured is alive. A Beneficiarydesignated irrevocable on Our records may not be changed except with the written consent of that Beneficiary. A Beneficiary change will take effect on the date You signed the Notice to Us. If the Insured died before We receive this Notice, the change is effective, subject to any prior payment of proceeds. PART 4 PREMIUM PROVISIONS PREMIUM PAYMENTS Premiums are payable to Us in advance. The first premium is due on or before delivery of this Policy and may be paid to Us through one of Our agents. Subsequent premiums must be paid to Us at Our Executive Offices and are due at 12, 6, 3 or 1 Policy month intervals, depending on the premium payment option You �hose in the application. The premiums shown on Pages 3 and 3 nt'd) are for the premium payment option You chose. Premium amounts for all available payment options are on Page 3 (Cont'd). More frequent payments result in a higher total annualized premium. You may change the premium payment option for future premium payments upon Notice to Us. Premiums are not due for any period after the Insured's death or the Expiry Date. If a part of the total premium is no longer payable under the provisions of a Rider, the total premium wili be adjusted accordingly. PREMIUM CHANGES BY COMPANY - Premiums for this Policy will be the scheduled premiums shown on Page 3 (Cont'd), unless changed by Us. We reserve the right to change the scheduled premiums after the guaranteed premium period shown on Page 3 (Crk'd) We will not change them often than once d in no event will apply uniformly to all policies of this form issued to Insureds having the same Issue Age, duration, Premium u|aoo, year, month, and state of issue; and willwillbe based on future anticipated or emerging experience, ino|uding, but not limited to investment earnings, mortality, persistency, taxes and expenses. No change in premiums or Premium Ciass 'vViUouourbacauoecddntehoratiuncf the tnsured's health or change in occupation. We will mail written notice to You at least 60 days prior to the date on which a change in Your scheduled premiums will become effective. We will send You new policy specifications pages to reflect any changes in scheduled -prenniunms. OTHER PREM!UM CHANGES - Changes requested by You and approved by US to the Face Amount Premium Class of this Policy or the Face Amount or Premium Class of any Riders may also change Your scheduled premiums. 9EFUND OF UNEARNED PREMIUM AT DEATH - If the Insured dies while .thio Policy is in foroe, the proceeds payable to the Beneficiary shall include a refund of the unearned portion of the premiums paid beyond the end of the policy month in which death occurred. GRACE PERIOD - This Policy has a 31 day grace period. This means that, except for the first premium, if a premium is not paid on or betore the date it is due, it may be paid during the next 31 days. No interest will be charged for this late payment. During this 31 day period, the Policy will stay in force. If You do not pay the premium by the end of the grace period, this Policy will automatically terminate. REINSTATEMENT - If this Policy terminates due to unpaid premium, it may be reinstated within three years after the date the first unpaid premium was due, if prior to the Expiry Date. To reinstate this Policy, We must have evidence of insurability satisfactory to Us for alt persons to be covered and payment of all unpaid premiums, plus interest at 6% per year compounded annually. The Policy Date of the reinstated policy will remain the original Policy Date. The reinstated date is the date We approve the reinstatement application. Another i for i tu1i this Policy is by providing evidenceof insurability satisfactoto Us for alt persons to be covered and payment of one month's premium. The Policy Date of the reinstated policy will be adjusted based on the length of time Your policy was lapsed. Reinstatement in this manner may result in changes in insurance age(s) and premiums may increase. You will be notified by Us if there is a premium increase. The reinstated date is the date We approve the reinstatement application. C5PA Policy Page s The reinstated Policy shall be incontestable to the same extent as indicated in the above Incontestability Provision, from the reinstated date. This means that the two year contestable period will begin anew with the reinstatement. PART 5 EXCHANGE PROVISIONS EXCHANGE AT ATTAINED AGE - You may exchange this Policy at any time after it has been in force for five years to the Annual Increasing Premium Term Insurance to Age 100 Plan or the Decreasing Term Insurance to Age 100 Plan described below. If the exchange is for the same class of insurance, we will not require evidence of insurability. The new plan will take effect on the exchange date and this Policy will terminate. The exchange date will be the date of application accompanied by the first premium payment. However, the new plan's Incontestability and Suicide Exclusion provisions will be controlled by the Date of Issue of this Policy. We will issue either revised policy specifications pages or a new policy. The following conditions are necessary for exchange: (1) We receive Notice to Us requesting an exchange; (2) the face amount of the new plan is not less than the minimum required by Us nor greater than the Face Amount in effect under this Policy on the exchange date; (3) the Insured is alive; (4) this Policy is in force on the exchange date; (5) premiums for Your current Policy are not being waived under any rider attached to this Policy; and (6) the exchange plan will be issued at Our premium rates for that plan for the Insured's Attained Age on the exchange date based on the same Premium Class shown on Page 3, provided the face amount of the new plan is not less than the minimum required by Us nor greater than the Face Amount in effect under this Policy on the exchange date. ANNUAL INCREASING PREMIUM TERM INSURANCE TO AGE 100 PLAN - For this plan, the face amount remains level while premiums increase each year with Attained Age. Annual premiums per $1,000 face amount for this plan are shown below in Table B. We reserve the right to change the premiums shown in Table B. We will not change the premiums to more than the maximum premiums shown in Table B. TABLE B PREFERRED PLUS/PREFERRED ANNUAL EXCHANGE PREMIUMS PER $1,000 FACE AMOUNT THE ANNUAL POLICY FEE OF $75 MUST BE ADDED. AGE SCHEDULED MAXIMUM AGE SCHEDULED MAXIMUM $149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS $149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS 20 $ 1.13 $ 0.79 $ 0.71 $ 0.63 $ 1.28 60 $ 11.55 $ 6.00 $ 5.57 $ 5.35 $ 12.45 21 1.13 0.79 0.71. 0.63 1.28 61 12.75 6.64 6.15 5.91 13.51. 22 1.13 0.79 0.71 0.63 1.28 62 14.09 7.33 6.79 6.52 14.67. 23 1.13 0.79 0.71 0.63 1.28 63 15.49 8.05 7.47 7.18 15.87 24 1.13 0.79 0.71 0.63 1.28 64 17.01 8.84 8.19 7.88 17.16 25 1.13 0.79 0.71 0.63 1.28 65 18.51 9.71 9.00 8.65 18.59 26 1.13 0.79 0.71 0.63 1.28 66 19.96 10.62 9.84 9.46 20.18 27 1.13 0.79 0.71 0.63 1.28 67 21.53 11.59 10.75 10.33 21.91 28 1.13 0.79 0.71 0.63 1.28 68 23.30 12.69 11.76 11.31 23.84 29 1.13 0.79 0.71 0.63 1.28 69 25.89 13.54 12.55 12.06 25.96 30 1.13 0.79 0.71 0.63 1.28 70 27.97 14.90 13.81 13.27 28.30 31 1.13 0.79 0.71 0.63 1.28 71 30.55 16.74 15.43 14.74 31.00 32 1.13 0.79 0.71 0.63 1.28 72 33.55 18.77 17.20 16.35 34.01 33 1.13 0.79 0.71 0.63 1.28 73 36.13 21.01 19.15 18.16 37.27 34 1.19 0.82 0.74 0.65 1.38 74 38.99 23.50 21.32 20.15 40.86 35 1.26 0.86 0.77 0.69 1.50 75 42.14 26.31 23.74 22.38 44.83 36 1.34 0.90 0.80 0.72 1.60 76 45.53 29.46 26.46 24.88 49.19 37 1.45 0.95 0.86 0.77 1.73 77 49.24 32.99 29.49 27.66 53.98 38 1.51 0.99 0:90 0.80 1.80 78 53.36 36.92 32.86 30.75 59.28 39 1.63 1.06 0.95 0.86 1.90 79 57.73 41.29 36.58 34.16 65.00 40 1.77 1.12 1.01 0.93 2.02 80 62.77 46.08 40.66 37.89 71.40 41 1.91 1.20 1.08 0.99 2.14 81 70.91 51.32 45.10 41.91 80.08 42 2.07 1.26 1.15 1.06 2.27 82 80.38 56.97 49.88 46.25 89.87 43 2.26 1.35 1.23 1.14 2.44 83 89.34 63.10 55.02 50.93 99.63 44 2.45 1.45 1.32 1.22 2.64 84 98.35 69.92 60.75 56.14 110.42 45 2.67 1.56 1.42 1.32 2.88 85 109.18 77.48 67.08 61.33 122.57 46 2.92 1.66 1.52 1.43 3.15 86 121.82 85.81 74.04 67.00 133.59 47 3.18 1.78 1.63 1.54 3.48 87 136.81 94.94 81.64 73.13 150.18 48 3.48 1.89 1.75 1.65 3.85 88 152.77 104.89 89.90 79.72 167.51 49 3.77 2.01 1.86 1.77 4.26 89 168.99 115.56 98.74 86.99 185.99 50 4.10 2.14 1.98 1.90 4.73 90 186.55 124.78 106.62 94.58 203.02 51 4.54 2.36 2.19 2.10 5.25 91 204.78 134.28 114.74 102.13 211.63 52 5.03 2.61 2.42 2.33 5.84 92 224.31 144.09 123.11 109.96 228.58 53 5.56 2.89 2.69 2.58 6.48 93 244.82 154.16 131.72 118.04 253.72 54 6.13 3.19 2.95 2.84 7.15 94 266.42 164.53 140.58 126.40 285.45 55 6.78 3.53 3.26 3.14 7.88 95 291.16 175.19 149.69 134.59 324.63 56 7.56 3.93 3.65 3.51 8.72 96 318.25 189.53 161.95 145.61 361.83 57 8.43 4.38 4.06 3.90 9.59 97 381.82 317.05 270.91 243.58 400.13 58 9.41 4.90 4.53 4.35 10.53 98 404.11 335.57 286.73 257.81 406.69 59 10.45 5.43 5.04 4.84 11.48 99 426.92 354.52 302.91 272.37 428.65 NOTE: AGE IS ATTAINED AGE. C5PA 111 !17 Policy Page 6 TABLE B (CONT'D) NON -TOBACCO USE ANNUAL EXCHANGE PREMIUMS PER $1,000 FACE AMOUNT THE ANNUAL POLICY FEE OF $75 MUST BE ADDED. AGE SCHEDULED MAXIMUM AGE SCHEDULED MAXIMUM $149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS $149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS 20 $ 1.13 $ 1.10 $ 0.99 $ 0.90 $ 1.64 60 $ 11.55 $ 10.43 $ 9.68 $ 9.24 $ 16.01 21 1.13 1.10 0.99 0.90 1.64 61 12.75 11.52 10.69 10.20 17.37 22 1.13 1.10 0.99 0.90 1.64 62 14.09 12.73 11.81 11.27 18.87 23 1.13 1.10 0.99 0.90 1.64 63 15.49 13.99 12.99 12.39 20.40 24 1.13 1.10 0.99 0.90 1.64 64 17.01 15.36 14.27 13.60 22.07 25 1.13 1.10 0.99 0.90 1.64 65 18.67 16.87 15.67 14.94 23.91 26 1.13 1.10 0.99 0.90 1.64 66 20.40 18.43 17.11 16.33 25.94 27 1.13 1.10 0.99 0.90 1.64 67 22.30 20.29 18.71 17.85 28.17 28 1.13 1.10 0.99 0.90 1.64 68 24.41 22.36 20.48 19.53 30.66 29 1.13 1.10 0.99 0.90 1.64 69 26.03 24.02 21.83 20.82 33.38 30 1.13 1.10 0.99 0.90 1.64 70 28.64 26.61 24.03 22.91 36.39 31 1.13 1.10 0.99 0.90 1.64 71 31.46 29.45 26.51 25.24 39.86 32 1.13 1.10 0.99 0.90 1.64 72 34.48 32.49 29.18 27.73 43.73 33 1.13 1.10 0.99 0.90 1.64 73 38.48 35.82 32.10 30.44 47.92 34 1.19 1.16 1.04 0.95 1.77 74 42.92 39.50 35.31 33.42 52.53 35 1.26 1.22 1.09 1.00 1.93 75 47.89 43.57 38.89 36.74 57.64 36 1.34 1.29 1.17 1.07 2.06 76 53.49 48.12 42.86 40.42 63.24 37 1.45 1.39 1.26 1.15 2.23 77 59.73 53.15 47.28 44.51 69.40 38 1.51 1.45 1.31 1.21 2.31 78 66.68 58.71 52.16 49.02 76.22 39 1.63 1.56 1.42 1.30 2.44 79 74.36 64.79 57.52 53.94 83.57 40 1.77 1.69 1.54 1.42 2.60 80 82.78 71.41 63.35 59.32 91.80 41 1.91 1.81 1.65 1.53 2.75 81 91.98 78.57 69.69 65.14 102.96 42 2.07 1.95 1.78 1.66 2.92 82 101.90 86.21 76.33 71.37 115.55 43 2.26 2.11 1.93 1.80 3.14 83 112.60 94.37 83.45 78.04 128.10 44 2.45 2.29 2.09 1.96 3.40 84 124.55 103.42 91.37 85.47. 141.97 45 2.67 2.48 2.28 2.14 3.70 85 137.75 113.36 100.11 93.68 157.59 46 2.92 2.70 2.48 2.34 4.05 86 152.25 124.20 109.67 102.67 171.76 47 3.18 2.92 2.70 2.55 4.48 87 168.13 135.98 120.14 112.53 193.09 48 3.48 3.17 2.93 2.78 4.95 88 185.40 148.70 131.52 123.23 215.37 49 ` 3.77 3.42 3.16 3.01 5.47 89 200.93 162.19 143.68 134.72 239.13 50 4.10. 3.71 3.44 3.29 6.08 90 216.96 176.25 156.48 146.80 . .261.03 51 4.54 4.09 3.80 3.63 6.75 91 233.48 189.73 169.95 159.55 272.10 52 5.03 4.54 4.22 4.02 7.51 92 250.52 203.64 184.12 172.99 293.89 53 5.56 5.03 4.67 4.45 8.33 93 268.04 217.95 199.06 187.16 326.21 54 ' 6.13 5.54 5.13 4.90 9.19 94 286.05 232.67 214.78 202.11 367.01' 55 6.78 6.12 5.69 5.42 10.13 95 304.58 247.74 228.70 215.21 417.38 56 7.56 6.83 6.35 6.05 11.21 96 324.95 264.31 243.98 229.59 465.21 57 8.43 7.61 7.07 6.74 12.33 97 389.85 317.11 292.73 275.46 514.45 58 9.41 8.50 7.90 7.52 13.54 98 412.62 335.61 309.81 291.53 522.89 59 10.45 9.43 8.76 8.35 14.75 99 435.91 354.57 327.30 307.99 551.12 NOTE: AGE IS ATTAINED AGE. TOBACCO USE ANNUAL EXCHANGE PREMIUMS PER $1,000 FACE AMOUNT THE ANNUAL POLICY FEE OF $75 MUST BE ADDED. AGE SCHEDULED MAXIMUM AGE SCHEDULED MAXIMUM $149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS $149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS. 20 $ 1.83 $ 1.80 $ 1.56 $ 1.50 $ 2.53 40 $ 2.87 $ 2.76 $ 2.47 $ 2.39 $ 4.35 21 1.83 1.80 1.56 1.50 2.53 41 3.10 2.99 2.69 2.59 4.67 22 1.83 1:80 1.56 1.50 2.53 42 3.38 3.25 2.92 2.82 5.04 23 1.83 1.80 1.56 1.50 2.53 43 3.69 3.54 3.20 3.10 5.49 24 1.83 ' 1.80 1.56 1.50 2.53 44 4.01 3.84 3.49 3.38 6.00 25 1.83 1.80 1.56 1.50 2.53 45 4.37 4.16 3.79 3.69 6.60 26 1.83 1.80 1.56 1.50 2.53 46 4.71 4.48 4.11 3.99 7.27 27 1.83 1.80 1.56 1.50 2.53 47 5.13 4.87 4.47 4.35 8.12 28 1.83 1.80 1.56 1.50 2.53 48 5.63 5.32 4.92 4.80 9.17 29 1.83 1.80 1.56 1.50 2.53 49 6.18 5.83 5.41 5.28 10.35 30 1.83 1.80 1.56 1.50 2.53 50 6.79 6.37 5.95 5.81 11.66 31 1.83 1.80 1.56 1.50 2.53 51 7.53 7.07 6.61 6.45 13.09 32 1.83 1.80 1.56 1.50 2.53 52 8.35 7.84 7.33 7.16 14.66 33 1.83 1.80 1.56 1.50 2.53 53 9.26 8.69 8.12 7.93 16.34 34 1.90 1.86 1.63 1.56 2.76 54 10.30 9.67 9.04 8.82 18.19 35 2.03 1.99 1.74 1.68 3.06 55 11.44 10.73 10.04 9.80 20.14 36 2.16 2.11 1.85 1.77 3.32 56 12.74 11.96 11.18 10.92 22.25 37 2.34 2.28 2.01 1.94 3.62 57 14.22 13.35 12.47 12.19 24.51 38 2.48 2.41 2.12 2.05 3.82 58 15.75 14.78 13.82 13.50 26.72 39 2.66 2.59 2.29 2.22 4.09 59 17.50 16.42 15.36 15.00 29.18 NOTE: AGE IS ATTAINED AGE. C5PA 10.07 Policy Page 7 TABLE B (CONT'D) TOBACCO USE (CONT'D) ANNUAL EXCHANGE PREMIUMS PER $1,000 FACE AMOUNT THE ANNUAL POLICY FEE OF $75 MUST BE ADDED. AGE SCHEDULED MAXIMUM AGE SCHEDULED MAXIMUM $149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS $149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS 60 $19.39 $18.21 $17.02 $16.61 $31.75 80 147.18 140.53 119.26 114.39 166.89 61 21.42 20.11 18.80 18.36 34.44 81 162.73 154.91 131.94 126.35 185.34 62 23.72 22.27 20.81 20.34 37.47 82 180.55 169.89 145.54 139.16 205.47 63 26.12 24.53 22.93 22.39 40.53 83 200.07 184.74 160.15 152.90 225.27 64 28.71 26.96 25.20 24.61 43.78 84 222.99 201.10 176.39 168.15 246.65 65 31.57 29.64 27.71 27.06 47.34 85 245.89 218.97 194.30 184.97 268.36 66 34.31 32.21 30.12 29.41 51.14 86 271.91 238.36 213.95 203.38 286.80 67 37.39 35.10 32.81 32.05 55.42 87 296.98 259.26 235.36 223.42 315.55 68 40.77 38.28 35.78 34.95 60.14 88 325.31 281.68 258.60 245.15 344.48 69 43.30 40.65 38.00 37.12 65.28 89 352.24 305.26 283.39 268.28 373.81 70 47.64 44.73 41.81 40.84 71.03 90 383.25 329.61 309.36 292.49 398.01 71 55.84 51.06 46.58 45.40 77.60 91 416.32 354.71 336.56 317.79 416.42 72 62.06 58.05 51.73 50.33 84.88 92 452.40 380.59 365.00 344.21 452.50 73 69.59 65.86 57.40 55.74 92.75 93 493.27 407.21 394.71 371.77 493.37 74 78.39 74.62 63.68 61.72 101.42 94 543.40 434.59 425.69 400.47 543.50 75 88.17 84.54 70.71 68.40 110.21 95 566.60 462.73 453.26 426.40 568.43 76 98.65 95.31 78.54 75.84 119.83 96 594.61 492.93 482.84 454.23 626.44 77 109.60 105.60 87.28 84.14 130.23 97 655.20 566.74 555.14 522.24 684.72 78 121.09 116.33 96.95 93.30 141.47 98 738.53 599.81 587.52 552.72 739.53 79 133.44 127.80 107.61 103.38 153.68 99 780.25 633.69 620.72 583.94 781.25 NOTE: AGE IS ATTAINED AGE. DECREASING TERM INSURANCE TO AGE 100 PLAN - For this plan, the face amount decreases while premiums remain level. The face amount decreases each year with Attained Age, as shown in Table C below. We reserve the right to change the scheduled face amount, but not lower than the minimum face amount as determined from Table C. TABLE C PREFERRED PLUS/PREFERRED FACE AMOUNT PER $100.00 BASIC ANNUAL PREMIUMS THE BASIC ANNUAL PREMIUM IS THE ANNUAL PREMIUM FOR THIS PLAN MINUS THE ANNUAL POLICY FEE OF $75 AGE SCHEDULED MINIMUM AGE SCHEDULED MINIMUM $149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS $149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS 20 $88,495 $126,582 $140,845 $158,730 $78,125 40 $56,497 $89,285 $ 99,009 $107,526 $49,504 21 88,495 126,582 140,845 158,730. 78,125. 41 52,356 83,333 92,592 101,010 46,728 22 88,495 126,582 140,845 158,730 78,125 42 48,309 79,365 86,956 94,339 44,052 23 88,495 126,582 140,845 158,730 78,125 43 44,247 74,074 81,300 87,719 40,983 24 88,495 126,582 140,845 158,730 78,125 44 40,816 68,965 75,757 81,967 37,878 25 88,495 126,582 140,845 158,730 78,125 45 37,453 64,102 70,422 75,757 34,722 26 88,495 126,582 140,845 158,730 78,125. 46 34,246 60,240 65,789 69,930 31,746 27 88,495 126,582 140,845 158,730 78,125 47 31,446 56,179 61,349 64,935 28,735 28 88,495 126,582 140,845 158,730 78,125 48 28,735 52,910 57,142 60,606 25,974 29 88,495 126,582 140,845 158,730 78,125 49 26,525 49,751 53,763 56,497 23,474 30 88,495 126,582 140,845 158,730 78,125 50 24,390 46,728 50,505 52,631 21,141 31 88,495 126,582 140,845 158,730 78,125 51 22,026 42,372 45,662 47,619 19,047 32 88,495 126,582 140,845 158,730 78,125 52 19,880 38,314 41,322 42,918 17,123 33 88,495 126,582 140,845 158,730 78,125 53 17,985 34,602 37,174 38,759 15,432 34 84,033 121,951 135,135 153,846 72,463 54 16,313 31,347 33,898 35,211 13,986 35 79,365 116,279 129,870 144,927 ' 66,666 55 14,749 28,328 30,674 31,847 12,690 36 74,626 111,111 125,000 138,888 62,500 56 13,227 25,445 27,397 28,490 11,467 37 68,965 105,263 116,279 129,870 57,803 57 11,862 22,831 24,630 25,641 10,427 38 66,225 101,010 111,111 125,000 55,555 58 10,626 20,408 22,075 22,988 9,496 39 61,349 94,339 105,263 116,279 52,631 59 9,569 18,416 19,841 20,661 8,710 NOTE: AGE IS ATTAINED AGE. C5PA 111!1? Policy Page 8 TERM LIFE INSURANCE POLICY TO AGE 95 WITH INDETERMINATE PREMIUMS INITIAL LEVEL PREMIUM IS GUARANTEED AFTER WHICH IT IS SUBJECT TO CHANGE AS SHOWN ON THE SPECIFICATIONS PAGES EXCHANGEABLE AFTER FIVE YEARS TO ANNUAL INCREASING PREMIUM OR DECREASING TERM INSURANCE TO AGE 100 NONPARTICIPATING C5PA 1n nr7 TABLE C (CONT'D) TOBACCO USE FACE AMOUNT PER $100.00 BASIC ANNUAL PREMIUMS THE BASIC ANNUAL PREMIUM IS THE ANNUAL PREMIUM FOR THIS PLAN MINUS THE ANNUAL POLICY FEE OF S75 AGE SCHEDULED MINIMUM AGE SCHEDULED MINIMUM $149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS $149,999 and below $150,000 $249.999 $250,000 S499,999 $500,000 and over ALL FACE AMOUNTS 20 $54,644 $55,555 $64,102 566,666 $39,525 60 55,157 $5,491 55,875 $6,020 53,149 21 54,644 55,555 64,102 66,666 39,525 61 4,668 4,972 5,319 5,446 2,903 22 54,644 55,555 64,102 66,666 39,525 62 4,215 4,490 4,805 4,916 2,668 23 54,644 55,555 64,102 66,666 39,525 63 3,828 4,076 4,361 4,466 2,467 24 54,644 55,555 64,102 66,666 39,525 64 3,483 3,709 3,968 4,063 2,284 25 54,644 55,555 64,102 66,666 39,525 65 3,167 3,373 3,608 3,695 2,112 26 54,644 55,555 64,102 66,666 39,525 66 2,914 3,104 3,320 3,400 1,955 27 54,644 55,555 64,102 66,666 39,525 67 2,674 2,849 3,047 3,120 1,804 28 54,644 55,555 64,102 66,666 39,525 68 2,452 2,612 2,794 2,861 1,662 29 54,644 55,555 64,102 66,666 39,525 69 2,309 2,460 2,631 2,693 1,531 30 54,644 55,555 64,102 66,666 39,525 70 2,099 2,235 2,391 2,448 1,407 31 54,644 55,555 64,102 66,666 39,525 71 1,790 1,958 2,146 2,202 1,288 32 54,644 55,555 64,102 66,666 39,525 72 1,611 1,722 1,933 1,986 1,178 33 54,644 55,555 64,102 66,666 39,525 73 1,436 1,518 1,742 1,794 1,078 34 52 631 53,763 61,349 64,102 36,231 74 1,275 1,340 1,570 1,620 985 35 49,261 50,251 57,471 59,523 32,679 75 1,134 1,182 1,414 1,461 907 36 46,296 47,393 54,054 56,497 30,120 76 1,013 1,049 1,273 1,318 834 37 42,735 43,859 49,751 51,546 27,624 77 912 946 1,145 1,188 767 38 40,322 41,493 47,169 48,780 26,178 78 825 859 1,031 1,071 706 39 37,593 38,610 43,668 45,045 24,449 79 749 782 929 967 650 40 34,843 36,231 40,485 41,841 22,988 80 679 711 838 874 599 41 32,258 33,444 37,174 38,610 21,413 81 614 645 757 791 539 42 29,585 30,769 34,246 35,460 19,841 82 553 588 687 718 486 43 27,100 28,248 31,250 32,258 18,214 83 499 541 624 654 443 44 24,937 26,041 28,653 29,585 16,666 84 448 497 566 594 405 45 22,883 24,038 26,385 27,100 15,151 85 406 456 514 540 372 46 21,231 22,321 24,330 25,062 13,755 86 367 419 467 491 348 47 19,493 20,533 22,371 22,988 12,315 87 336 385 424 447 316 48 17,761 18,796 20,325 20,833 10,905 88 307 355 386 407 290 49 16,181 17,152 18,484 18,939 9,661 89. 283 327 352 372 267 50 14,727 15,698 16,806 17,211 8,576 90 260 303 323 341 251 51 13,280 14,144 15,128 15,503 7,639 91 240 281 297 314 240 52 11,976 12,755 13,642 13,966 6,821 92 221 262 273 290 220 53 10,799 11,507 12,315 12,610 6,119 93 202 245 253 268 202 54 9,708 10,341 11,061 11,337 5,497 94 184 230 234 249 183 55 8,741 9,319 9,960 10,204 4,965 95 176 216 220 234 175 56 7,849 8,361 8,944 9,157 4,494 96 168 202 207 220 159 57 7,032 7,490 8,019 8,203 4,079 97 152 176 180 191 146 58 6,349 6,765 7,235 7,407 3,742 98 135 166 170 180 135 59 5,714 6,090 6,510 6,666 3,427 99 128 157 161 171 128 NOTE: AGE IS ATTAINED AGE. RIDERS - The continuation in the new plan of any benefits provided by Rider(s) attached to this Policy which are not exchanged will be subject to the provision for continuation, if any, in each Rider. The premium for any Rider continued after exchange will be added to the premium for the new plan. This Policy may not be exchanged more often than once every five years, subject to the terms and conditions listed above and the age and risk classifications available at that time: RIDER EXCHANGE AT DEATH OF INSURED - If any Insured Spouse Riders attached to this Policy are in force upon the Insured's death, they may be exchanged for a new policy in accordance with the Exchange provision in each rider except that: (a) the exchange must be made within 30 days after the Insured's death; and (b) the effective date of the new policy will be the day We receive Notice to Us for the exchange. If the Insured Spouse dies before exchange takes effect and within 30 days after the Insured's death, We will pay to the Beneficiary of the Rider the insurance in force under the Rider at the Insured's death, less any overdue premium for the Rider. C5PA Policy Page 10 10.07 TABLE C (CONT'D) PREFERRED PLUS/PREFERRED (CONT'D) FACE AMOUNT PER $100.00 BASIC ANNUAL PREMIUMS THE BASIC ANNUAL PREMIUM IS THE ANNUAL PREMIUM FOR THIS PLAN MINUS THE ANNUAL POLICY FEE OF $75 AGE SCHEDULED MINIMUM AGE SCHEDULED MINIMUM $149,999 and below $150,000 $249,999 $250,000 5499,999 $500,000 and over ALL FACE AMOUNTS $149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS 60 $8,658 $16,666 $17,953 $18,691 $8,032 80 $1,593 $2,170 $2,459 $2,639 $ 1,400 61 7,843 15,060 16,260 16,920 7,401 81 1,410 1,948 2,217 2,386 1,248 62 7,097 13,642 14,727 15,337 6,816 82 1,244 1,755 2,004 2,162 1,112 63 6,455 12,422 13,386 13,927 6,301 83 1,119 1,584 1,817 1,963 1,003 64 5,878 11,312 12.210 12,690 5,827 84 1,016 1,430 1,646 1,781 905 65 5,402 10,298 11,111 11,560 5,379 85 915 1,290 1,490 1,630 815 66 5,010 9,416 10,162 10,570 4,955 86 820 1,165 1,350 1,492 748 67 4,644 8,628 9,302 9,680 4,564 87 730 1,053 1,224 1,367 665 68 4,291 7,880 8,503 8,841 4,194 88 654 953 1,112 1,254 596 69 3,862 7,385 7,968 8,291 3,852 89 591 865 1,012 1,149 537 70 3,575 6,711 7,241 7,535 3,533 90 536 801 937 1,057 492 71 3,273 5,973 6,480 6,784 3,225 91 488 744 871 979 472 72 2,980 5,327 5,813 6,116 2,940 92 445 694 812 909 437 73 2,767 4,759 5,221 5,506 2,683 93 408 648 759 847 394 74 2,564 4,255 4,690 4,962 2,447 94 375 607 711 791 350 75 2,373 3,800 4,212 4,468 2,230 95 343 570 668 742 308 76 2,196 3,394 3,779 4,019 2,032 96 314 527 617 686 276 77 2,030 3,031 3,390 3,615 1,852 97 261 315 369 410 249 78 1,874 2,708 3,043 3,252 1,686 98 247 298 348 387 245 79 1,732 2,421 2,733 2,927 1,538 99 234 282 330 367 233 NOTE: AGE IS ATTAINED AGE. NON -TOBACCO USE FACE AMOUNT PER $100.00 BASIC ANNUAL PREMIUMS THE BASIC ANNUAL PREMIUM IS THE ANNUAL PREMIUM FOR THIS PLAN MINUS THE ANNUAL POLICY FEE OF $75 AGE SCHEDULED MINIMUM . AGE SCHEDULED MINIMUM $149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS 8149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE, AMOUNTS 20 $88,495 $90,909 $101,010 $111,111 $60,975 60 $8,658 $9,587 $10,330 $10,822 $6,246 21 88,495 90,909 101,010 111,111 60,975 61 7,843 8,680 9,354 9,803 5,757 22 88,495 90,909 101,010 111,111 60,975 62 7,097 7,855 8,467 8,873 5,299. 23 88,495 90,909 101,010 111,111 60,975 63 6,455 7,147 7,698 8,071 4,901 24 88,495 90,909 101,010 111,111 60,975 64 5,878 6,510 7,007 7,352 4,531- 25 88,495 90,909 101,010 111,111 60,975 65 5,356 5,927 6,381 6,693 4,182 26 88,495 90,909 101,010 111,111 60,975 66 4,901 5,425 5,844 6,123 3,855 27 88,495 90,909 101,010 111,111 60,975 67 4,484 4,928 5,344 5,602 3,549- 28 88,495 90,909 101,010 111,111 60,975 68 4,096 4,472 4,882 5,120 3,261 29 88,495 90,909 101,010 111,111 60,975 69 3,841 4,163 4,580 4,803 2,995 30 88,495 90,909 101,010 111,111 60,975 70 3,491 3,757 4,161 4,364 2,748. 31 88,495 90,909 101,010 111,111 60,975 71 3,178 3,395 3,772 3,961 2,508 32 88,495 90,909 101,010 111,111 60,975 72 2,900 3,077 3,427 3,606 2,286 33 88,495 90,909 101,010 111,111 60,975 73 2,598 2,791 3,115 3,285 2,086 34 84,033 86,206 96,153 105,263 56,497 74 2,329 2,531 2,832 2,992 1,903 35 79,365 81,967 91,743 100,000 51,813 75 2,088 2,295 2,571 2,721 1,734 36 74,626 77,519 85,470 93,457 48,543 76 1,869 2,078 2,333 2,474 1,581 37 68,965 71,942 79,365 86,956 44,843 77 1,674 1,881 2,115 2,246 1,440 38 66,225 68,965 76,335 82,644 43,290 78 1,499 1,703 1,917 2,039 1,311- 39 61,349 64,102 70,422 76,923 40,983 79 - 1,344 1,543 1,738 1,853 1,196 40 56,497 59,171 64,935 70,422 38,461 80 1,208 1,400 1,578 1,685 1,089. 41 52,356 55,248 60,606 65,359 36,363 81 1,087 1,272 1,434 1,535 971 42 48,309 51,282 56,179 60,240 3,4,246 82 ' 981 1,159 1,310 1,401 865 43 44,247 47,393 51,813 55,555 31,847 83 888 1,059 1,198 1,281 780 44 40,816 43,668 47,846 51,020 29,411 84 802 966 1,094 1,170 704 45 37,453 40,322 43,859 46,728 27,027 85 725 882 998 1,067 634 46 34,246 37,037 40,322 42,735 24,691 86 656 805 911 973 582 47 31,446 34,246 37,037 39,215 22,321 87 594 735 832 888 517 48 28,735 31,545 34,129 35,971 20,202 88 539 672 760 811 464. 49 26,525 29,239 31,645 33,222 18,281 89 497 616 695 742 418 50 24,390 26,954 29,069 30,395 16,447 90 460 567 639 681 383 51 22,026 24,449 26,315 27,548 14,814 91 428 527 588 626 367 52 19,880 22,026 23,696 24,875 13,315 92 399 491 543 578 34(1 53 17,985 19,880 21,413 22,471 12,004 93 373 458 502 534 306 54 16,313 18,050 19,493 20,408 10,881 94 349 429 465 494 272 55 14,749 16,339 17,574 18,450 9,871 L() (0 rs 00 07 1 0) 0) 0) 0) CI) 328 403 437 464 239 56 13,227 14,641 15,748 16,528 8,920 307 378 409 435 214 57 11,862 13,140 14,144 14,836 8,110 256 315 341 363 194 58 10,626 11,764 12,658 13,297 7,385 242 297 322 343 191 59 9,569 10,604 11,415 11,976 6,779 229 282 305 324 181' NOTE: AGE IS ATTAINED AGE. C5PA tv., Policy Page 9 PRIMERICA LIFE INSURANCE COMPANY Home Office: Boston, Massachusetts Executive Offices: 3120 Breckinridge BouJevard, Duluth, Georgia 30099-0001 TERMINAL CONDITION ACCELERATED BENEFITS ENDORSEMENT PAYMENT OF THIS BENEFIT WILL REDUCE THE AMOUNT OF DEATH BENEFIT PROCEEDS THE BENEFICIARY WILL RECEIVE We have issued this Endorsement as a part of the Policy to which it is attached. BENEFITS Description of Benefits - We will advance the Accelerated Benefit if you develop a Terminal Condition, subject to all of the provisions of this Benefit and the PoIicy. We will pay to the Owner or to his designee, upon his written direction and upon forms acceptable to us, 40% of the Face Amount of the Policy and/or Riders, if any, not to exceed a maximum of $250.000. This Benefit will be paid in a lump sum. A benefit payment notice will be provided. The Effective Date of this Endorsement is the same as the Date of Issue of the Policy. An administrative fee of $200, plus interest will be charged for this Accelerated Benefit. Interest will be calculated at the current yield on 90 day Treasury Bill. The interest is computed on the total of the amount advanced and the administrative fee. The Accelerated Benefit advance, administrative fee, and, interest will be deducted from the death benefit proceeds when those benefits become payable. Howevmr, if these amounts equal the remaining death benefit, the Policy terminates. (See the Termination provision.) In order to exercise this Banafit, we must receive at our Executive Offices a written Physician Statement which diagnoses your medical condition as being a Terminal Condition, as defined herein. We have the right to require, at our expense, that you be exarnined by a Physician desin tedbyuuinovdertomarify the diagnosis. We must also receive a written, notarized consent on a form provided by us of any irrevocable Beneficiary or assignee before this option may be exercised. This Benefit mabe taxable upon receipt of the Accelerated Benetit advance. As with all tax matters, you may want to consult your personal tax advisor prior to exercising acceptance of this Benefit. DEFINITIONS "We" or "Us" refers to the Company. "You" or "Your refers to the Insured and/or the Insured Spouse and/or the Other Insured Person. The Owner refers to the Owner of the Policy. Physician - Physician means an individual who is licensed to practice medicine and treat condition or injury in the state in which treatment is received and who is acting within the scope of that Iicense. Physician does not include: 1) you; 2) the Owner; 3) a person who lives with you or the Owner; or 4) a person who is your or the Owner's parent, spouse or child. Physician Statement - A Physician Statement means a statement acceptable to us, signed by a Physician, which: 1) gives the Physician's diagnosis of your noncorrectable medical condition; 2) is given while the Policy is in force; and 3) states that, with reasonable medical certainty, the noncorrectable medical condition will result in your death in 6 months or less from the date of the Physician Statement. Terminal Condition - Terminal Condition is a noncorrectable medical condition that with reasonable medical certainty, will result in your death in 6 months or Iess from the date of the Physician Statement. Accelerated Benefit - An Accelerated Benefit is the advance prior to the date of your death of 40% of the Face Amount of the Policy and/or Riders, if any, not to exceed a maximum of $250,000. The Accelerated Benefit advance, administrative fee, and interest result in the establishment of a lien against the Face Amount of the Policy and/or Riders, if any. PL -E80 PA GENERAL PROVISIONS Future Premiums - The advance of an Accelerated Benefit will have no effect on the amount of future premiums, if any, required under the Policy and/or Riders, if any. Waiver of Premium - If a Disability Waiver of Premium Benefit Rider is attached to this Policy and the Insured otherwise qualifies for that Benefit and for the Accelerated Benefit, then for purposes of the Disability Waiver of Premium Benefit Rider, the Insured will be deemed to be Totally Disabled until the final death benefit proceeds are paid. Assignment - This Benefit must not be legally or equitably assigned except to us as security for the lien. We must receive an assignment form making us assignee of this Policy for the amount of the Accelerated Benefit. We must receive a notarized consent form from all irrevocable Beneficiaries, if any. We also reserve the right to require a consent form from a spouse, other Beneficiaries, or any other person if, in our discretion, such person's consent is necessary to protect our interests. Other Conditions - The Accelerated Benefit must be requested voluntarily by the Owner. This Benefit provides for the advance of the proceeds of the Policy normally payable at your death. This Benefit is not meant to cause the Owner to involuntarily obtain proceeds which ultimately would be payable to the Beneficiary. Therefore, the Owner is not permitted to exercise this Benefit: 1) if the Owner is required by law to use this Benefit to meet the claims of creditors, whether in bankruptcy or otherwise; or 2) if the Owner is required by a government agency to use this Benefit in order to apply for, obtain, or otherwise keep a government benefit or entitlement; or 3) if the Benefit would adversely affect the recipient's eligibility for Medicaid. How to Apply For This Benefit - You and the Owner must apply for this option in writing, on forms provided by us, and provide proof satisfactory to us, including a Physician Statement which states that you have a Terminal Condition. We have the right to have you examined at our expense by a physician we choose. Exclusion - This Benefit does not apply to any Children's Term Insurance Rider that may be attached to your Policy. Conformity With State Statutes - If any provision of the Benefit is in conflict with the laws of the state in which you reside, the provision is automatically amended to meet the minimum requirements of such laws. Termination This Benefit will terminate on the earliest of the following dates: 1) the date on which your Policy terminates; or 2) the date on which the Owner's written request to cancel this Benefit is received at our Executive Offices, provided the Owner's written request is received prior to an Accelerated Benefit advance. This Benefit will terminate when the lien plus interest equals the death benefit. Signed at Duluth, Georgia. PL -E80 PA Stanton J. Shapiro, Secretary Primerica Life Insurance Company �� J�� PRIMERICA ��KJ��l��l��N� ��l��[��l�� Home Office: Boston, Massachusetts Executive Offices: 3120 Breckinridge Boulevard, Duluth, Georgia 30099-0001 For Poflcyowner Service caII 1-800-257-4725 ENDORSEMENT This Endorsement is made a part of the Policy to which it is attached. The following provision will be added to the Policy: ARBITRATION PROVISION UNDER THIS PROVISION, ARBITRATORS, NOT COURTS OR JURIES, WILL RESOLVE CERTAIN DISPUTES. DEFINITIONS FOR ARBITRATION PROVISION As used in this Arbitration Provision ( foflowing definitions will apply: ~You^nr^Your" means any and all persons who sign this application. "You' or 'Your' also means anyonewho has a Dispute, as defined below, with Us. "We" or "Us" means Primerica Life Insurance Company, Primerica Financial Services, Inc., or their respective corporate pavanta, uubaidiahoo, aMi|iakeo, pnede000aom, assignees, successors, employees, rtu. independent contractors, directors, and officers (whether acting in their corporate or individual capacity). "We" or "Us" also includes any person or entity who may be jointly or severaily liable with either You or any of Us regarding any Dispute. "Dispute" means any case, controversy, tort (including any intentional tort), disagreement, |awouit, or claim now or hereafter existing between You and any of Us, and arising from or related to this app|ioation, the sale of the policy applied for, any issued Policy resulting from this application, or any aspect of the relationship between You and Us that arises from this application or such policy, including, without |imkahon, anything related to: this Provision, its execution and enlorceability, and the arbitrability of anyDispute pursuant to this Provision, including bunot Iimited to the scope of this Provision and any defenses to enforcement of this Provision; any one or more past, poenen\, or future sales presentations relating to insurance or related benefits; applications for insurance; amendments to such applications; insurance policies or riders or amendments to them; any act or omission by You or Us; fraud or misrepresentation, including Disputes for failing to disclose material facts; any matter arising out of common law or contract; any federal or state statute or regu|ahon, or any alleged violation thereof, including without limitation insurance and consumer protection laws. AGREEMENT TO ARBITRATE DISPUTES You or We mire that any Dispute, except those specifically excluded below in this Provision, shall be resolved by binding arbitration in accordance with the Federal Arbitration Afiling a demand for arbitration with JAMS or its successor organization. The demand shall be fi|ed, and the arbitration shall be oonducted, in accordance with the JAMS Financial Services Rules in effect on the date the demand for arbitration is filed unless any terms in those rules are inconsistent with this Pnovioion, in which case the terms of this Provision will prevail. You and We may, by mutual aOneement, select an arbitration administrator other than JAyWS, in which case the arbitration shall be filed and conducted under that administrator's rules, to the extent they are not inconsistent with this Provision. You may obtain a copy of the JAMS arbitration Rules at no charge at www.jamsadr.com, or by contacting the Office of the General Counsel for Primerica Life Insurance Company. DISPUTES EXCLUDED FROM ARBITRATION We cannot require You to arbitrate any Dispute arising solely from the alleged failrefusal to pay a claim for PLA -04 PA 10.03 ADDITIONAL TERMS Administration of Arbitration. The arbitrator shall decide the Dispute in accordance with the applicable law, and shall be empowered to award any damages or other relief provided for under the applicable law. The award shall be final and binding. The arbitrator shall make any award in writing and shall include written findings of fact and conclusions of law. Number of Arbitrators. The arbitration shall be conducted by a single arbitrator, unless any party to the arbitration requests a panel of three arbitrators. If such a request is made, the arbitration shall be conducted by a panel of three arbitrators. Place of Arbitration. If a hearing is required, the arbitration shall be conducted in the county of Your residence, unless all parties agree to another location. Costs. The cost of any arbitration proceeding shall be divided as follows: The party making demand upon the administrator for arbitration shall pay to the administrator when the demand is made a sum equal to the cost of filing a complaint in a court of general jurisdiction in Your county. We will pay to the administrator all other costs for the arbitration proceeding (including a single arbitrator's fees and room rental fees). If a party makes a request for a panel of three arbitrators, the party making such request shall pay the fees of those additional arbitrators. Each party will bear the expense of its own attorney, expert, and witness fees and expenses, regardless of which party prevails, except that the arbitrator shall apply any applicable law in determining whether a party should recover any or all attorneys fees and expenses from another party. No Consolidation or Joinder of Parties. All parties to the arbitration must be individually named. Arbitrations conducted pursuant to this Provision shall not determine the rights and obligations of persons other than parties individually named in the arbitration, and shall not have any bearing on the resolution of any other Dispute or controversy. Unless mutually agreed to by the parties, and notwithstanding anything else that may be in this Provision, no class action, private attorney general action or other representative action may be pursued in arbitration, and individual Disputes may not be consolidated into one action. Severability and Survival. If the arbitrator or any court determines that one or more terms of this Provision or the arbitration Rules is unenforceable, or would make this Provision unenforceable, only such term(s) shall be deemed unenforceableand shall be deemed stricken from this Provision, but such determination shall not impair or affect the enforceability of the other terms of this Provision or the arbitration Rules. This Provision shall survive rescission, termination or changes to the policy, the application and the relationship between You and Us. This Endorsement shall not waive, alter or extend in any respect, except as herein stated, any of the conditions, provisions or agreements of the Policy to which it is attached. j14-44 Secretary 7(75: President PLA -04 PA 10.03 WHITE AND WILLIAMS LLP BY: Sean P. Mahoney, Esquire Atty. I.D. No. 90313 1650 Market Street One Liberty Place 1 Suite 18000 Philadelphia, PA 19103-7395 (215) 864-6342 Attorneys for Defendant Primerica Life Insurance Company (incorrectly designated in the caption as "Primerica, Inc.") CYNTHIA A. KEREKES, individually and in her capacity as Executrix of the Estate of Paul Jerome Brown, Jr., a/k/a Paul J. Brown, Jr., deceased, Plaintiff, v. PRIMERICA, INC., t/a/d/b/a Primerica Life Insurance Company, Defendant. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 2014 CIVIL TERM NO. 14-3335 NOTICE OF REMOVED CASE _~ -< s..0 Pursuant to 28 U.S.C. § 1446(d), Defendant, Primerica Life Insurance Company (incorrectly designated in the caption as "Primerica, Inc. "), by its attorneys, White and Williams LLP, hereby provides written notice to all adverse parties and to the Court that the above - captioned matter has been removed to the United States District Court for the Middle District of Pennsylvania, where it has been docketed as Cynthia A. Kerekes v. Primerica, Inc., No. 1:14-CV- 01665-JEJ. A true and correct copy of the Notice of Removal filed with the District Court is attached hereto as Exhibit "A". Respectfully submitted, WHITE AND WILLIAMS DATE: August 29, 2014 BY: 14200787v.1 CERTIFICATE OF SERVICE Sean P. Mahoney, Esquire, attorney for Defendant Primerica Life Insurance Company (incorrectly designated in the caption as "Primerica, Inc."), hereby certifies that on this 29th day of August, 2014, he caused a true and correct copy of the foregoing Notice of Removed Case and the exhibits attached thereto to be served upon the following via FedEx, postage prepaid: William P. Douglas, Esquire DOUGLAS LAW OFFICE 43 West South Street Carlisle, PA 17013 Attorney for Plaintiff Cynthia A. Kerekes -2- 14200787v.1 Sean . Mahoney, Esquire JS 44 (Rev. 12/12) Case 1:14-cv-01665-JEJ Document 1-1 Filed 08/26/14 Page 1 of 1 CIVIL COVER SHEET The JS 44 civil cover sheet and the information contained herein neither replace nor supplement the filing and service of pleadings or other papers as required by law, except as provided by local rules of court. This fort, approved by the Judicial Conference of the United States in September 1974, is required for the use of the Clerk of Court for the purpose of initiating the civil docket sheet.(SEE INSTRUCTIONS ONNEAT PAGE OFTHIS FORM) I. (a) PLAINTIFFS CYNTHIA A. KEREKES, individually and in her capacity as Executrix of the Estate of Paul Jerome Brown, Jr., a/k/a Paul J. Brown, Jr., deceased, (b) County of Residence of First Listed Plaintiff Cumberland (EXCEPT IN U.S. PLAINTIFF CASTES) (C) Attorneys (Firm Name, Address, and Telephone Number) William P. Douglas, Esquire DOUGLAS LAW OFFICE 43 West South Street, Carlisle, PA 17013 DEFENDANTS PRIMERICA LIFE INSURANCE COMPANY County of Residence of First Listed Defendant Duluth, G orgia (IN U.S. PLAINTIFF CASES ONLY) NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF THE TRACT OF LAND INVOLVED. Attorneys (if Known) Sean P. Mahoney, Esquire WHITE AND WILLIAMS LLP,1650 Market Street, One Liberty Place, Suite 1800, Philadelphia, PA 19103-7395 II. BASIS OF JURISDICTION (Place an "X" in One Box Only) O I U.S. Government Plaintiff 0 3 Federal Question (U.S Government Nat a Party) O 2 U.S. Government $1 4 Diversity (bndl(Iie Citizenship of Parties in hem 111) Defendant . CITIZEN SHIP OF PRINCIPAL PARTIES (Place on 'X" in One Box for Plaintiff For Diversity Cases Only) and One Box)* Defendant) PTF DEF PTF DEF Citizen of This Slate DI I 0 I Incorporated nr Principal Place 0 4 0 4 of Business In This State Citizen of Another State 0 2 0 2 Incorporated and Principal Place 0 5 5 of Business In Another State Citizen or Subject of a 0 3 0 3 Foreign Nation Foreign Country 0 6 0 6 IV. NATURE OF SUIT (Place an 'X" in One Box Onl h >:CONTRACr,1,11 ;. Y <:;:.,. , 1.. TORTS''' . " . • . "'a •,:1::FORFEITURE/PENALTY` , ; , : BANKRUPTCY 'z' OTHER STATUTES. ?::.) NI 110 Insurance O 120 Marine 0 130 Miller Act 0 140 Negotiable Instrument 0 150 Recovery of Overpayment PERSONAL INJURY PERSONAL INJURY 0 310 Airplane 0 365 Personal Injury - 0 315 Airplane Product Product Liability Liability 0 367 Health Care/ 0 320 Assault, Libel & Pharmaceutical 0 625 Drug Related Seizure of Property 21 USC 881 0 690 Other 0 422 Appeal 28 USC 158 0 423 Withdrawal 28 USC 157 0 375 False Claims Act 0 400 State Reapportionment 0 410 Antitrust 0 430 Banks and Banking 0 450 Commerce =PROPERTY RtGHTS:rnf':S & Enforcement ofJudgment 0 151 Medicare Act 0 152 Recovery of Defaulted Student Loans (Excludes Veterans) O 153 Recovery of Overpayment of Veteran's Benefits O 160 Stockholders' Suits 0 190 Other Contract 0 195 Contract Product Liability 0 196 Franchise Slander Personal Injury 0 330 Federal Employers' Product Liability Liability 0 368 Asbestos Personal 0 340 Marine Injury Product 0 345 Marine Product Liability Liability PERSONAL PROPERTY 0 350 Molar Vehicle 0 370 Other Fraud 0 355 Motor Vehicle 0 371 Truth in Lending Product Liability 0 380 Other Personal 0 360 Other Personal Property Damage Injury 0 385 Property Damage 0 362 Personal Injury - Product Liability Medical Malpractice 0 820 Copyrights 0 830 Patent 0 840 Trademark 0 460 Deportation 0 470 Racketeer Influenced and Corrupt Organizations 0 480 Consumer Credit 0 490 Cable/Sat TV 0 850 Securities/Commodities/ Exchange 0 890 Other Statutory Actions 0 891 Agdeultural Acts 0 893 Environmental Matters 0 895 Freedom of Information Act 0 896 Arbitration 0 899 Administrative Procedure Act/Review or Appeal of Agency Decision 0 950 Constitutionality of State Statutes g i ::.. ' •LA'BOR:' i, SOCIAL 'SECURITY a z R. 0 710 Fair Labor Standards Act 0 720 Labor/Management Relations 0 740 Railway Labor Act 0 751 Family and Medical Leave Act 0 790 Other Labor Litigation 0 791 Employee Retirement Income Security Act 0 861 HIA (13956) 0 862 Black Lung (923) 0 863 DI WC/DI W W (405(g)) 0 864 SSID Title XVI 0 865 RSI (405(g)) ..•::REAI1 PROPERTY : : CIVIL`RIGHTS 11': - PRISONER`PETOTIONS''= FEDERAI:',TAX.SUITS >/ 0 210 Land Condemnation 0 220 Foreclosure O 230 Rent Lease & Ejectment 0 240 Torts to Land O 245 Tort Product Liability 0 290 All Other Real Property 0 440 Other Civil Rights 0 441 Voting 0 442 Employment 0 443 Housing/ Accommodations 0 445 Amer, w/Disabilitics - Employment 0 446 Amer. w/Disabitities - Other 0 448 Education ilabeas Corpus: 0 463 Alien Detainee 0 510 Motions to Vacate Sentence 0 530 General 0 535 Death Penalty Other: 0 540 Mandamus & Other 0 550 Civil Rights 0 555 Prison Condition 0 560 Civil Detainee - Conditions of Confinement 0 870 Taxes (115. Plaintiff or Defendant) 0 871 IRS—Third Party 26 USC 7609 : „_•'";;i';IMMIGRATION''rr7 l'i 0 462 Naturalization Application 0 465 Other Immigration Actions V. ORIGIN (Place an "X" in One Box Only) 0 1 Original X2 Removed from 0 3 Remanded from Proceeding State Court Appellate Court 0 4 Reinstated or 0 5 Transferred from 0 6 Multidistrict Reopened Another District Litigation (.specify) VI. CAUSE OF ACTION Cite the U.S. Civil Statute under which you are filing (Da not cite Jurisdictional statutes unless diversity): 28 U.S.C. 1441, 1446, 1332 Brief description of cause: Breach of contract and bad faith pursuant to 42 Pa.C.S. 8371 VII. REQUESTED IN O CHECK IF THIS ISA CLASS ACTION COMPLAINT; UNDER RULE 23, F,R,Cv.P. VIII. RELATED CASE(S) IF ANY (See instruclinnr)r JUDGE DEMAND CHECK YES only if demanded in complaint: JURY DEMAND: 0 Yes IS( No DOCKET NUMBER DATE 08/26/2014 SIGNA 0I FOR OFFICE USE ONLY RECEIPT tt AMOUNT APPLYING IFP JUDGE MAG. JUDGE Case 1:14-cv-01665-JEJ Document 1 Filed 08/26/14 Page 1 of 6 IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA CYNTHIA A. KEREKES, individually and in her capacity as Executrix of the Estate of Paul Jerome Brown, Jr., a/k/a Paul J. Brown, Jr., deceased, CIVIL ACTION Plaintiff, v. NO. PRIMERICA, INC., t/a/d/b/a Primerica Life Insurance Company, Defendant. NOTICE OF REMOVAL TO THE HONORABLE JUDGES OF THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA: Defendant, Primerica Life Insurance Company (incorrectly designated in the caption as "Primerica, Inc.") (hereafter "Primerica"), by its attorneys, White and Williams LLP, hereby removes the matter captioned as Cynthia A. Kerekes v. Primerica, Inc., No. 2014 Civil Term 3335 from the Court of Common Pleas of Cumberland County, 14096584v.1 Case 1:14-cv-01665-JEJ Document 1 Filed 08/26/14 Page 2 of 6 Pennsylvania to the United States District Court for the Middle District of Pennsylvania, in support thereof averring as follows: 1. On June 2, 2014, Plaintiff Cynthia Kerekes ("Kerekes") commenced an action captioned as above solely by Writ of Summons in the Court of Common Pleas of Cumberland County, Pennsylvania, which action was docketed at No. 2014 Civil Term 3335. A true and correct copy of Plaintiff's Writ of Summons is attached hereto as Exhibit "A". 2. The Writ of Summons does not set forth any specific claims for relief or damages. 3. Defendant Primerica was served with the Writ of Summons by certified mail on June 6, 2014. A true and correct copy of Plaintiff's counsel's letter to Primerica enclosing the Writ of Summons is included in Exhibit "A" attached hereto. 4. Plaintiff filed a Complaint in this action on August 1, 2014. A true and correct copy of Plaintiff's Complaint is attached hereto as Exhibit -2- 14096584v.1 Case 1:14-cv-01665-JEJ Document 1 Filed 08/26/14 Page 3 of 6 5. Primerica received a copy of the Complaint via email from Plaintiff's counsel, William Douglas, to the undersigned on August 1, 2014. A true and correct copy of Mr. Douglas' email is attached hereto as Exhibit 6. Pursuant to 28 U.S.C. §§ 1441, any civil action brought in a state court of which this court has original jurisdiction may be removed to this Court by the defendant or defendants in that action. 28 U.S.C. § 1441 (2014). 7. Pursuant to 28 U.S.C. § 1446, a notice of removal of a civil action must be filed within 30 days after the receipt by the defendant, through service or otherwise, of a copy of the initial pleading setting forth the claim for relief upon which the action is based. 28 U.S.C. § 1446 (2014). 8. Plaintiff's Complaint is the initial pleading in this matter setting forth the claims for relief upon which Plaintiff's action is based. 9. This Notice of Removal is timely because it has been filed within 30 days of Primerica's receipt of the Complaint on August 1, 2014. -3- 14096584v.1 Case 1:14-cv-01665-JEJ Document 1 Filed 08/26/14 Page 4 of 6 10. This Court has original jurisdiction over this action because the amount in controversy exceeds $75,000.00, exclusive of interests and costs, and complete diversity of the citizenship of the parties exists within the meaning of 28 U.S.C. § 1332. 11. Plaintiff, Cynthia Kerekes, resides in Mechanicsburg, Pennsylvania. 12. The decedent, Paul J. Brown, Jr., resided in Mechanicsburg, Pennsylvania at the time of his death. 13. Plaintiff, in her individual capacity and in her capacity as the legal representative of the Estate of Paul J. Brown, Jr., is therefore a citizen of the Commonwealth of Pennsylvania for purposes of diversity of citizenship within the meaning of 28 U.S.C. § 1332. 14. Defendant, Primerica Life Insurance Company, is a Massachusetts corporation with its principal place of business in Duluth, Georgia. -4- 14096584v.1 Case 1:14-cv-01665-JEJ Document 1 Filed 08/26/14 Page 5 of 6 15. Primerica is therefore a citizen of the Commonwealth of Massachusetts and the State of Georgia for purposes of diversity of citizenship within the meaning of 28 U.S.C. § 1332. 16. The amount in controversy in this matter exceeds $75,000.00, exclusive of interests and costs, because Plaintiff's Complaint seeks $183,000.00 in life insurance benefits as well as punitive damages pursuant to Pennsylvania's "bad faith" statute, 42 Pa.C.S,A. § 8371. 17. Pursuant to 28 U.S.C. § 1446(d), Primerica will provide prompt notice to the Plaintiff and to the state court of the filing of this Notice of Removal. DATE: August 26, 2014 14096584v.1 WHITE AND WILLIAMS LLP BY: /s/ Sean P. Mahoney Sean P. Mahoney, Esquire 1650 Market Street One Liberty Place 1 Suite 1800 Philadelphia, PA 19103-7395 (215) 864-6342 (215) 789-7577 (FAX) mahoneys@whiteandwilliams.com -5- Attorneys for Defendant Primerica Life Insurance Company Case 1:14-cv-01665-JEJ Document 1 Filed 08/26/14 Page 6 of 6 CERTIFICATE OF SERVICE Sean P. Mahoney, Esquire, attorney for Defendant Primerica Life Insurance Company, hereby certifies that on this 26th day of August, 2014, he caused a true and correct copy of the foregoing Notice of Removal to be served upon the following via FedEx overnight delivery, postage prepaid: William P. Douglas, Esquire DOUGLAS LAW OFFICE 43 West South Street Carlisle, PA 17013 Attorney for Plaintiff Cynthia A. Kerekes -6- 14096584v.1 /s/ Sean. P. Mahoney Sean P. Mahoney, Esquire Case 1:14-cv-01665-JEJ Document 1-2 Filed 08/26/14 Page 1 of 4 EXHIBIT A Case 1:14-cv-01665-JEJ Document 1-2 Filed 08/26/14 Page 2 of 4 Commonwealth of Pennsylvania County of Cumberland Cynthia A. Kerekes, individually and in her capacity as Executrix of the Estate of Paul Jerome Brown, Jr., a/k/a Paul J. Brown, 'Jr., deceased 1497 English Drive Mechanicsburg, PA 17055 VS In the Court of Common Pleas of Cumberland County, Pennsylvania P1iii•nfJ /9- 3375CJ - No. 2014 Civil Term Primerica, Inc. t/ a / d/b/ a Primerica Life insurance Company 3120 Breckenridge Blvd. Duluth, GA 30099 Defendant Civil action law Jury Trial Demanded Writ of Summons To: Primerica, Inc. t/ a/ d / b/ a Primerica Life Insurance Company 3120 Breckinridge Boulevard Duluth, GA 30099-0001 You are hereby notified that - Cynthia A. Kerekes, individually and in her capacity as Executrix of the Estate of Paul Jerome Brown, Jr. a/ k/ a Paul J. Brown, Jr., deceased have brought an action against you. June 2, 2014 .---4LLELL Prothonc a William P. Douglas, Esq. Douglas Law Office 43 West South Street Carlisle, Pennsylvania 17013 (717) 243 -- 1790 TRUE COPY FROM RECORD in Testimony whereof, 1 here unto set my hand and the seal of said rt at Carlisle, Pa. This day of , 20 ProthOnotary Case 1.14-rv-01665-.1F.1 flnrsiment 1-2 Fila° nR/26J14 Pane R of T>toug1as Imiaw Office June 2, 2014 Primerica, .Inc. t/ a/ d/ b / a Primerica Life Insurance Co. 3120 Breckenridge Blvd. Duluth, GA 30099 CERTIFIED, RETURN_ RECEIPT J ..Ci : ... rE_D, DELIVER TO ADDRESSEE ONLY Gentlemen: WPD:brc 4.3 I4/est ,South ,Shred Cr/i1, Pennsylvania .17013 Tel:: (717)243-1790 Fax: (717) 24.3-8955 dottglrrslrr:.ntt+'etotlrli zk.net RECEgY 0 JUN LEGAL Re: Cynthia A. Kerekes, individually and in her capacity as Executrix of the Estate of Paul J. Brown, Jr., deceased v. Primerica, Inc., t/a/d/b/a Primerica Life Insurance Company Enclosure Pursuant to 42 Pa. C.S.A. 5323 enclosed for service upon you is a writ of summons in a civil action. Sincerely, • William P. Douglas. Esquire linurd Certified Civil trial Attorney DOUGLAS LAW OFFICE 43 West South Street Carlisle, Pennsylvania 17013 lf� i aaia;idljir :1/kglgBal i I I i 71314 0150 0001 3752 3577 110 PosTE& SEAMS111 1000 II 30099 u.s-POSTAGE o CAHLI .PA 013 JUNA OST 14 $519 005,908-07 Primerica, Inc. t/a/d/b/a Primerica Life Insurance Co. 3120 Breckenridge Blvd. RECEIVED Duluth, GA 30099-0001 JUN p 6 Zil 14 LEGAL s9$4 C•C Cvv 3 I��f1i�'11i�'!��'JJj'Jrr�lll'I1J1lIffJflll'1'IJit�'1llll!)!!It' • Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 1 of 25 EXHIBIT B Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 2 of 25 lAtillia») P. Douglas, Esq. Supretne colis.11.0. #37926 Douglms- Law Office 43 IYesl. South Slreet C rl PetinsvIvro! la .17013, Tetepliatto (777)213-7790 Cynthia A. Kere.kes,. individually and in her capacity as Executrixof the Estate of Paul Jerome Brown, jr., a/k/a Pan] J. Brown, Jr., deceased Plaintiffs vs Primerica, Inc. t/a/d/b/ a Primerica Life Insurance Company OF THE PROTHONO:FARY 1.01.11AUG -I PM 3Q CUMBEInANO COUNTY PENNSYLVANIA In the Court of Common Pleas of Cumberland County, Pennsylvania No. 2014 Civil Terrri 3335 Defelithint Civil action law NOTICE YOU HAVE BEEN SUED IN COURT. IF YOU WASH TO DEFEND AGAINST THE CLAIMS SET FORTH. IN THE FOLLOWING PAGES, YOU MUST TAKE ACTION WITHIN TWENTY 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 DEFE.NSESOR OBJECTIONS TO THE CLABVIS.S1-3T 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 PLAINTIFF. YOU MAY LOSE MONEY OR PROPERTY OR OTHER RIGHTSIMPO1M\ NT 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 SE 1 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 ABour AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO 'FEE. Cumberland County Bar Association 32 S. Bedford Street Carlisle PA 170.13 717-249-3106 DATE: August 1, 2014 BY L) Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 3 of 25 Complaint 1. The plaintiffs, Cynthia Kerekes, individually and in her capacity as Executrix of the Estate of Paul Jerome Brown a/k/a Paul J. Brown, Jr., deceased, 1497 English Drive, Mechanicsburg, Cumberland County, Pennsylvania. 2. The Defendants, Primerica, Inc., t/a/d/b/ a Primerica Life Insurance Company, is a corporation registered in and doing business in the Commonwealth of Pennsylvania, with their home office located at 3120 Breckenridge Blvd., Duluth, GA, 30099. Said defendant is hereinafter referred to as Primerica. 3. In 1988, Primerica issued a policy of insurance to, Paul J. Brown, Jr., at the time he was married to Francesca Rosaria Brown. Paul J. Brown, Jr. was the sole titled owner of said policy of insurance from the date of inception until his death in 2014. 4. When the policy was originally issued Paul J. Brown, Jr., he named his then wife, Francesca Brown as primary beneficiary and his mother, Antoinette Brown, as the contingent beneficiary. 5. Antoinette Brown died in 2001, as a result the contingent beneficiary would be the estate of Paul J. Brown, Jr. 6. On April 15, 2004, a Decree and Order were issued finalizing the divorce of Paul J. Brown, Jr., from Francesca Rosaria Brown. Pursuant to the Equitable Distribution Agreement Francesca Rosario Brown waived any and all interest in said policy of insurance. This information has been provided to Primerica. A copy of the information provided to them has been attached hereto. As a result of the death of Antoinette Brown in 2001 and the aforesaid divorce (statutory waiver of beneficiary designation), there would be no beneficiary named in the policy of insurance from April 15, 2004 through April 25, 2008 and the default beneficiary would be the Estate of Paul J. Brown, Jr., deceased pursuant to the terms of the policy. 7. In the spring of 2008, Cynthia Kerekes, and her husband Paul J. Brown, Jr., met with Kevin Goodman, a representative of Primerica. The meeting occurred in their home here in Gilbertsville, Pennsylvania. The reason for the meeting was to discuss the reissue a 20 year term life insurance policy with Primerica that was owned by Paul J. Brown, Jr., and insuring his life and to name Paul Brown's current wife Cynthia Kerekes as primary beneficiary of said policy. Correspondence from Primerica addressed to Paul Brown indicates that a Policy Change Application referencing policy number 0412796493 was submitted to Primerica Life Insurance Company underwriting department and a certificate of insurance was issued with a policy date of April 15, 2008 and an issue date of May 17, 2008, bearing certificate number 0412796493. The premium for said coverage was $55.63 Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 4 of 25 per month which was drawn from the joint checking account of Paul J. Brown, Jr. and his wife Cynthia Kerekes. 8. The aforesaid policy of life insurance in effect on April 28, 2014, between the plaintiffs and Primerica which provided for the payment of $183,000.00 in the event of the death of Paul J. Brown, Jr. 9. In 2008, Kevin Goodman, while acting as an agent for and while working within the course and scope of his employment with Primerica met with Paul Brown and his wife Cynthia and was told that Cynthia was to be the beneficiary of the policy of insurance in the event of Paul's death. Documention was executed at that time to make Cynthia Kerekes beneficiary of the aforesaid policy. 10. Paul Brown died on April 28, 2014 while residing in Upper Allen Township, Cumberland County, Pennsylvania. 11. Following his death, the agent, Kevin Goodman was contacted by Cynthia Kerekes to inform him of Paul's death. He then told her repeatedly that people change beneficiary designations all the time and she was no longer the beneficiary. He told her Paul had changed the beneficiary designation to Francesa Brown. 12. Following her conversation with Kevin Goodman she then called Primerica and she was told that there had been no contact of any kind with Paul Brown since 1988 and the beneficiary of the policy was the former wife Francesca Brown, 13. Following that conversation with Primerica Cynthia Kerekes provided the divorce documentation showing that Francesa Brown was divorced from Paul J. Brown, Jr. and had waived any interest in the policy and was statutorily remove as beneficiary. 14. Primerica has frivolously, and with no proper foundation for their actions, fraudulently, knowingly and intentionally misrepresented and refused to pay proceeds under their policy of insurance in accordance with the terms of the policy. 15. The bad faith conduct of Primerica gives rise to a cause of action pursuant to 42 Pa. C.S.A. §8371. 16. The defendant failed to promptly and completely investigate the claim of the plaintiffs arising under the aforementioned contract of insurance. 17. The defendant did not act in good faith to effectuate prompt, fair and equitable resolution of the plaintiffs' claim, knowing that liability to pay benefits is clear and coverage applies, and as a result, the plaintiffs have been forced to incur expense to protect her interests. Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 5 of 25 18. The defendant failed to promptly provide a factually sound explanation for the basis of denial in the insurance policy in relation to the facts or applicable law for denial of the claim. 19. The defendant has willfully, maliciously and/or recklessly withheld benefits from the plaintiff, due to its failure to investigate the claim thoroughly. Said conduct constitutes a breach of an implied covenant. 20. The defendant, in bad faith, have failed to pay benefits without a sound legal basis for said failure and have failed to fully inquire into the possible basis which might support the insured's claim of coverage. 21. Primerica has deliberately acted in conscious disregard and with reckless indifference to the rights of their insured. 22. The defendant impliedly and/or expressly warranted that it would, in good faith, provide insurance coverage to Paul J. Brown, Jr. and Cynthia Kerekes, in accordance with the contract and abide by the terms of said contract but have failed to do so. 23. As a result of the aforesaid, the defendant breached its contract and/or warranty, which breach resulted in loss to the plaintiffs, In addition, as a result of Primerica's bad faith conduct, Cynthia Kerekes has suffered aggravation, inconvenience and emotional distress. 24. The plaintiff hereby requests all remedial relief as provided in 42 Pa. C.S.A. §8371 and payment in full of all available insurance benefits due under the contract. Wherefore, it is prayed that judgment be entered in favor of the plaintiffs and against the defendant in an amount in excess of that requiring compulsory referral to arbitration. Respectfull August 1, 2014 William P. Douglas, E Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 6 of 25 AFFIDAVIT I hereby swear or affirm that the foregoing is true and correct to the best of my knowledge and/or information and belief. This is made subject to the penalties of 18 Pa.C.S.§ 4904 relating to unsworn falsification to authorities. i4461e-dev Cynthia A. Kerekes Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 7 of 25 PRIMERICA Life Insurance Company A Citi Company E,eculive Offices: 3?70 Breckinridge Boulevard Duluth, Georgia 30099-0001 For Policyowner Service Call 1-800-257-4725 We will pay the Face Amount, in a lump sum, to the Beneficiary upon receiving due proof that the Insured died before the Expiry Date and while this Policy was in force. This agreement is subject to the provisions on the following pages, which constitute the Policy, RIGHT TO RETURN POLICY: You may return this Policy to Us or Our authorized agent for any reason within 45 days atter You receive it. It returned, it will be considered void from the beginning. Any premium paid will be refunded. This Policy is effective at 12:01 A.M. on the Date of Issue, Signed on the Date of Issue at Our Executive Offices. 14‘/.4. C5PA 10.07 Secretary 7C7V- President TERM LIFE INSURANCE POLICY TO AGE 95 WITH INDETERMINATE PREMIUMS INITIAL LEVEL PREMIUM IS GUARANTEED AFTER WHICH IT IS SUBJECT TO CHANGE AS SHOWN ON THE SPECIFICATIONS PAGES EXCHANGEABLE AFTER FIVE YEARS TO ANNUAL INCREASING PREMIUM OR DECREASING TERM INSURANCE TO AGE 100 NONPARTICIPATING Primerica Life Insurance Company (A Stock Company) Home Office: Boston, Massachusetts CSPA 1 n 117 Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 8 of 25 TABLE OF CONTENTS PART 1: DEFINITIONS Page 4 PART 2: GENERAL PROVISIONS Page 4 PART 3; BENEFICIARY PROVISIONS Page 5 PART 4: PREMIUM PROVISIONS Page 5 PART 5: EXCHANGE PROVISIONS Page 6 Policy Page 2 Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 9 of 25 FC.LICY `.PECIFICI+TI0IlS POLICY NUMBER: 0412796493 INSURED: PAUL J BROWN JR ISSUE AGE: 49 DATE OF ISSUE: DUPLICATE FACE AMOUNT: $183,000 POLICY DATE: APRIL 15, 2008 PREMIUM CLASS: PREFERRED EXPIRY DATE: APRIL 15, 2054 FORM NUMBER PLAN NAME CPA TERM LIFE INSURANCE TO AGE 95 CSPA(20) 10.07 Policy Page 3 FACE PREMIUM AMOUNT YEARS 1.20 $183,000 $585.57 Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 10 of 25 . •.. (THIS PAGE INTENTIONALLY LEFT BLANK) Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 11 of 25 Premiums for CEPt. l.. ' ;re the SCheiiu'ed premiums. ,Any premium aft.e: the guaranteed period is subject to change in accordance with the premium change provision. The scheduled premiums will not change more than once per year and will never be greater than the maximum premiums. Any change will apply to all policies of this form witch the same issue age, duration, class, date, and state. See Part 4, Premium Changes By Company. . SCHEDULED MAXIMUM POLICY ATTAINED MONTHLY MONTHLY FACE YEARS AGE PREMIUMS PREMIUMS AMOUNT 01 49 $55.63 $55.63 $183,000.00 02 50 $55.63 $55.63 $183,000.00 03 51 $55.63 $55.63 $183,000.00 04 52 $55.63 $55.63 $183,000.00 05 53 $55.63 $55.63 $183,000.00 06 54 $55.63 $55.63 $183,000.00 07 55 $55.63 $55.63 $183,000.00 08 56 $55.63 $55.63 $183,000.00 09 57 $55.63 $55.63 $183,000.00 10 58 $55.63 $55.63 $183,000.00 11 59 $55.63 $55.63 $183,000.00 12 60 $55.63 $55.63 $183,000.00 13 61 $55.63 $55.63 $183,000.00 14 62 $55.63 $55.63 $183,000.00 15 63 $55.63 $55.63 $183,000.00 16 64 $55.63 $55.63 $183,000.00 17 65 $55.63 $55.63 $183,000.00 18 66 $55.63 $55.63 $183,000.00 19 67 $55.63 $55.63 $183,000.00 20 68 $55.63 $55.63 $183,000.00 21 69 $242.52* $458.44 $183,000.00 22 70 $266.17* $499.12 $183,000.00 23 71 $298.15* $546.06 $183,000.00 24 72 $333.45* $598.39 $183,000.00 25 73 $372.39* $655.07 $183,000.00 26 74 $415.68* $717.48 $183,000.00 27 75 $464.53* $786.50 $183,000.00 28 76 $519.29* $862.30 $183,000.00 29 77 $580.66* $945.57 $183,000.00 30 78 $648.98* $1,037.71 $183,000.00 31 79 $724.96* $1,137.15 $183,000.00 32 80 $808.23* $1,248.42 $183,000.00 33 81 $899.33* $1,399.32 $183,000.00 34 82 $997,55* $1,569.52 $183,000.00 35 83 $1,104.12* $1,739.20 $183,000.00 36 84 $1,222.69* $1,926.78 $183,000.00 37 85 $1,354.12* $2,138.01 $183,000.00 38 86 $1,498.94* $2,329.59 $183,000.00 39 87 $1,657.66* $2,618.01 $183,000.00 40 88 $1,830.64* $2,919.29 $183,000.00 CSPA(20) 10.07 Policy Page 3 (Cont'd) Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 12 of 25 M:7;r21!Wi AGE 1:REMlow.i 42 50 2,176.43' (13 9) ?,14i .5q 44 4t 93 17,f1.87,20' 46 94 1.1?,867.48, • (1 HAXIm&..1 MONIKY ORMitiM.,„ i13,211D.311 $3,536.63 $3,686.3? 13,980.99 1-4,418,05 i4,969.C18 Policl YzAc.)e 3 (Cont'd) r1. MICAiri • 1183,000.00 $183,000,00 T183,000.00 $183,000.00 :3,183,000.00 Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 13 of 25 iOTAI. PREMIUM PAYMENT OPTIONS TOTAL PREMIUM PAYMENT OPTIONS (includes all riders): MODE ANNUAL SEMI-ANNUAL QUARTERLY MONTHLY PRESENT YEAR $585.57 $304.50 $155.18 $55.63 TOTAL YEARLY COST PRESENT YEAR $585.57 $609.00 $620.72 $667.56 If you would like additional information about the costs of our periodic payments, please contact us at 1-800-257-4725. CSPA(20) 10.07 Policy Page 3 (Cont'd) Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 14 of 25 PART 1 DEFINITIONS These are some key words used in this Policy. 1. ATTAINED AGE • The Issue Age plus the number of policy years since the Policy Dale. 2. BENEFICIARY - The person(s) to whom the Policy proceeds are payable at the death of the Insured. This is the person(s) named in the application as the Beneficiary, unless later changed (see Part 3). 3. DATE OF ISSUE - The dale shown on Page 3 on which We issue the Policy to You. This dale controls the Incontestability and Suicide Exclusion provisions in Part 2. 4. EXPIRY DATE -The dale shown on the Policy Specifications, This Policy is not in force on or after this dale. 5. FACE AMOUNT - The amount of insurance for each policy year which is shown on Pages 3 and 3 (Cont'd). 6. INSURED -The person whose life the Policy insures and who is named in the Policy Specifications. 7. ISSUE AGE - The Insured's age on the birthday nearest the Policy Date. 8. NOTICE TO US - Information We have received which is signed by You, and acceptable to Us. 9. POLICY DATE - The dale (shown on Page 3) from which premium due dates, policy anniversaries, policy years and policy months are measured. 10. PREMIUM CLASS - The risk classification used in determining what premiums You pay. 11. WE, OUR or US - Primerica Life Insurance Company. 12. YOU or YOUR - The Owner of the Policy. Unless You tell Us otherwise, the Owner is the Insured, PART 2 GENERAL PROVISIONS OWNER OF POLICY - This Policy belongs to You. During the Insured's life, You have all of the rights described in this Policy, You may change the Owner by Notice to Us. Unless otherwise specified the change in owner designation is effective the date the Notice to Us is signed, subject to any payments made or actions taken by Us prior to receipt of the Notice. If You die, Your rights will pass to the named contingent owner, if any. If there is no named contingent owner, Your rights will pass to the Insured. THE, CONTRACT.- This Policy is issued in consideration of the application and payment of, the first premium. A copy of the application, including any supplemental applications, is attached and is a part of the Policy. Together, they are the entire contract. All statements in the application, except fraudulent ones, are deemed to be representations and not warranties. No statement will void this Policy or be used in defense of a claim unless: (1) it is contained in a written application; and (2) a copy of that application is attached to this Policy. DUPLICATE POLICY - You may request a duplicate copy of Your current Policy, which will not contain a copy of the application(s), unless requested by You. A duplicate Policy request should be sent to Us at Our Executive Offices. We will charge a fee for each duplicate Policy request. WAIVER OR MODIFICATION - Any change to this Policy must be in writing and signed by Our President or Secretary. No agent or any other person can change this Policy or waive any of its provisions on Our behalf. MISSTATEMENT OF AGE - If the age of the Insured has been misstated in the application, We will be liable only for the amount of insurance the premiums paid would have purchased for the correct age. INCONTESTABILITY - We will not contest this Policy alter it has been in force for two years during the Insured's life, except for nonpayment of premiums. The Iwo years begin on the Date of Issue. This provision does not apply to any rider for disability benefits or additional insurance specifically for accidental death. SUICIDE EXCLUSION - If the Insured dies by suicide, while sane or insane, within two years of the Date of Issue, We are only liable for the premiums paid. REPLACED COVERAGE - If insurance coverage (excluding group coverage) is to be replaced, as shown in the application, and has terminated: (a) prior to the Insured's death, including death by suicide; and (b) between 60 days before and 60 days after the Date of Issue of this Policy, We will not contest the amount of the replaced coverage that would not have been contestable had it not been replaced. It it is not possible to terminate any coverage to be replaced because of its provisions within 60 days after the Date of Issue of this Policy, such 60 -day period will be extended to the earliest possible date for the coverage to be terminated under its provisions. For example, You are insured under another company's policy for $100,000 and that policy has been in force two years. If this Policy replaced the other company's policy, We would not contest this Policy for up to $100,000. We would however, be able to contest any amount over $100,000. You will not lose the time accrued for the amount of insurance replaced due to this Policy's Incontestability and Suicide Exclusion provisions. NONPARTICIPATION - This Policy does not participate in Our profits or surplus. ASSIGNMENT - You may assign Your rights under this Policy. You must give Notice to Us of the assignment. Unless otherwise specified, the assignment is effective on the date the Notice to Us is signed, subject to any payments made or actions taken by Us prior to receipt of the Notice. We are not responsible for the validity of any assignment. The interest of any Beneficiary not designated irrevocable will be subject to the rights of any assignee. C5PA 1 fl n7 Policy Page 1 Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 15 of 25 PAYMENT OF PROCEEDS • Due proof of the death 01 the Insured must be seal to Us al Our Executive Offices. We must receive a certified death certificate, completed claim forms and a valid authorization for Us to obtain all medical and other records concerning the Insured. Death proceeds equal: (1) the Face Amount of this Policy as shown on Page 3; plus (2) any rider benefits; and minus (3) any overdue premium if death occurs during a grace period. Any interest payable on death proceeds will be paid according to applicable state law. CANCELLATION - You may cancel Your Policy at any lime by sending Notice to Us. Your Policy will be canceled as of the date We receive the Notice, or, if slated in Your Notice, as of a later date. If this Policy is canceled before the Expiry Date and premiums have been paid in advance, We will refund any unearned portion of the premiums paid beyond the end of the policy month in which cancellation occurred. PART 3 BENEFICIARY PROVISIONS BENEFICIARY - The Beneficiary's interest will end it the Beneficiary dies before the Insured. If no primary Beneficiary is living at the Insured's death, the death proceeds will be paid to any contingent Beneficiary. The proceeds will be paid to the Owner if the Insured dies and there is no primary or contingent Beneficiary. Proceeds will be paid to the Insured's estate if there is no living Beneficiary or Owner. We may rely on a sworn statement by any responsible person to discover the identity or nonexistence of any Beneficiary not identified by name. If a Beneficiary is a partnership, We will pay the proceeds to the partnership as it is constituted at the time of the Insured's death. CHANGE OF BENEFICIARY - You .can change a Beneficiary by Notice to Us. You can only change a Beneficiary while the Insured is alive. A Beneficiary designated irrevocable on Our records may not be changed except with the written consent of that Beneficiary. A Beneficiary change will take effect on the dale You signed the Notice to Us. If the Insured died before We receive this Notice, the change is effective, subject to any prior payment of proceeds. PART 4 PREMIUM PROVISIONS PREMIUM PAYMENTS - Premiums are payable to Us in advance. The first premium is due on or before delivery of this Policy and may be paid to Us through one of Our agents. Subsequent premiums must be paid to Us at Our Executive Offices and are due at 12, 6, 3 or 1 Policy month intervals, depending on the premium payment option You chose in the application. The premiums shown on Pages 3 and 3 (Cont'd) are for the premium payment option You chose. Premium amounts for all available payment options are on Page 3 (Cont'd). More frequent payments result in higher total annualized premium. You may change the premium payment option for future premium payments upon Notice to Us. Premiums are not due for any period after the Insured's death or the Expiry Date. If a part of the total premium is no longer payable under the provisions of a Rider, the total premium will be adjusted accordingly. PREMIUM CHANGES BY COMPANY - Premiums for this Policy will be the scheduled premiums shown on Page 3 (Cont'd), unless changed by Us. We reserve the right to change the scheduled premiums atter the guaranteed premium period shown on Page 3 (Cont'd). We will not change Them more often than once a year, and in no event will the scheduled premiums be greater than the maximum premiums shown on Page 3 (Cont'd). Any such change will apply uniformly to all policies of this form issued to Insureds having the same Issue Age, duration, Premium Class, year, month, and state of issue; and will be based on future anticipated. or emerging experience, including, but not limited to investment earnings, mortality, persistency, taxes and expenses. No change in premiums or Premium Class will occur because of deterioration of the Insured's health or change in occupation. We will mail written notice to You at least 60 days prior to the date on which a change in Your scheduled premiums will become effective. We will send You new policy specifications pages to reflect any changes in scheduled premiums. OTHER PREMIUM CHANGES - Changes requested by You and approved by US to the Face Amount or Premium Class of this Policy or the Face Amount or Premium Class of any Riders may also change Your scheduled premiums. REFUND OF UNEARNED PREMIUM AT DEATH • If the Insured dies while this Policy is in force, the proceeds payable to the Beneficiary shall include a refund of the unearned portion of the premiums paid beyond the end of the policy month in which death occurred. GRACE PERIOD • This Policy has a 31 day grace period. This means that, except for the first premium, if a premium is not paid on or before the date it is due, it may be paid during the next 31 days. No interest will be charged for this late payment. During this 31 day period, the Policy will stay in force. If You do not pay the premium by the end of the grace period, this Policy will automatically terminate. REINSTATEMENT- If this Policy terminates due to unpaid premium, it may be reinstated within three years after the date the first unpaid premium was due, if prior to the Expiry Date, To reinstate this Policy, We must have evidence of insurability satisfactory to Us for all persons to be covered and payment of all unpaid premiums, plus interest at 6% per year compounded annually. The Policy Date of the reinstated policy will remain the original Policy Date. The reinstated date is the date We approve the reinstatement application. Another option for reinstating this Policy is by providing evidence of insurability satisfactory to Us for all persons to be covered and payment of one month's premium, The Policy Date of the reinstated policy will be adjusted based on the length of time Your policy was lapsed. Reinstatement in this manner may result in changes in Insurance age(s) and premiums may increase. You will be notified by Us if there is a premium increase. The reinstated date is the date We approve the reinstatement application. CSPA Policy Page 5 10.07 Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 16 of 25 The reinstated Policy shall be inconleslable to the same extent as indicated in the above Incontestability Provision, from the reinstated dale. This means that the Iwo year contestable period will begin anew with the reinstatement, PART 5 EXCHANGE PROVISIONS EXCHANGE AT ATTAINED AGE - You may exchange this Policy at any lime after it has been in force for five years to the Annual Increasing Premium Term Insurance to Age 100 Plan or the Decreasing Term Insurance to Age 100 Plan described below. If the exchange is for the same class of insurance, we will not require evidence of insurability. The new plan will lake effect on the exchange date and this Policy will terminate. The exchange dale will be the dale of application accompanied by the first premium payment. However, the new plan's Inconteslability and Suicide Exclusion provisions will be controlled by the Dale of Issue of this Policy. We will Issue either revised policy specifications pages or a new policy. The following conditions are necessary for exchange: (1) We receive Notice to Us requesting an exchange; (2) the face amount of the new plan is not less than the minimum required by Us nor greater than the Face Amount in effect under this Policy on the exchange date; (3) the Insured is alive; (4) this Policy is in force on the exchange date; (5) premiums for Your current Policy are not being waived under any rider attached to this Policy; and (6) the exchange plan will he issued at Our premium rates for that plan for the Insured's Attained Age on the exchange dale based on the same Premium Class shown on Page 3, provided the face amount of the new plan is not less than the minimum required by Us nor greater than the Face Amount in effect under this Policy on the exchange dale. ANNUAL INCREASING PREMIUM TERM INSURANCE TO AGE 100 PLAN - For this plan, the face amount remains level while premiums increase each year with Attained Age. Annual premiums per $1,000 face amount for this plan are shown below in Table B. We reserve the right to change the premiums shown In Table B. We will not change the premiums to more than the maximum premiums shown in Table B. TABLE B PREFERRED PLUS/PREFERRED ANNUAL EXCHANGE PREMIUMS PER $1,000 FACE AMOUNT THE ANNUAL POLICY FEE OF $75 MUST BE ADDED. Policy Page 6 CSPA to to SCHEDULED MAXIMUM AGE SCHEDULED MAXIMUM AGE $149,999 and below 5150,000 $249,999 5250,000 $499,999 $500,000 and over ALL FACE AMOUNTS 3149,999 and below $150,000 $249,999 $250,000 5499,999 5500,000 and over ALL FACE AMOUNTS 20 21 22 23 24 $ 1.13 1.13 1.13 1.13 1.13 $ 0.79 0.79 0.79 0.79 0.79 50.71 .0.71. 0.71 0,71 0,71Y0.63 $ 0.63 • 0.63 0.63 0.63 $ 1.28 1.28 1.28 1.28 1.28 60 61 62 63 64 $ 11.55 12.75 14.09 15.49 17.01 $ 6.00 6.64 7.33 8.05 8.84 $ 5.57 6.15 6.79 7.47 8.19 $ 5.35 5.91 6.52 7.18 7.88 5 12.45 13.51 14.67 15.87 17,16 25 26 27 28 29 1.13 1.13 1.13 1.13 1,13 0.79 0.79 0.79 0.79 0.79 0.71 0.71 0.71 0.71 0.71 0.63 0.63 0.63 0.63 0.63 1.28 1.28 1.28 1.28 1.2B 65 66 67 68 69 18.51 19.96 21.53 23.30 25.69 9.71 10.62 11.59 12.69 13.54 9,00 9.84 10,75 11,76 12.55 8,65 9.46 10.33 11.31 12.06 18.59 20.18 21.91 23.84 25.96 30 31 32 33 34 1.13 1.13 1.13 1.13 1.19 0.79 0.79 0.79 0.79 0.82 0.71 0.71 0.71 0.71 0.74 0.63 0.63 0.63 0.63 0.65 1,28 1.28 1.28 1.28 1.38 70 71 72 73 74 27.97 30.55 33.55 36.13 38.99 14.90 16.74 18.77 21.01 23.50 13.81 15.43 17.20 19.15 21.32 13.27 14.74 16.35 19.16 20.15 28.30 31.00 34.01 37.27 40.86 35 36 37 38 39 1.26 1.34 1.45 1.51 1.63 0.86 0.90 0.95 0.99 1.06 , 0.77 0.80 0.86 0.90 0.95 0.69 0.72 0.77 0.80 0.86 1.50 1.60 1.73 1.80 ' 1.90 75 76 77 78 79 42.14 45.53 49.24 53.36 57.73 26.31 29.46 32.99 36.92 41.29 23.74 26.46 29.49 32.86 36.58 22.38 24.88 27.66 30.75 34.16 44.83 49.19 53.98 59.28 65.00 , 40 41 42 43 44 1.77 1.91 2.07 2.26 2.45 1.12 1.20 1.26 1.35 1.451.32 1.01 1.08 1.15 1.23 0.93 0.99 1.06 1.14 1.22 2.02 2.14 2.27 2.44 2.64 80 81 82 83 84 62.77 70.91 80.38 89,34 98.35 46.08 51.32 56.97 63.10 69.92 40.66 45.10 49.88 55.02 60.75 37.89 41.91 46.25 50.93 56.14 71.40 80.08 89.87 99.63 110.42 45 46 47 48 49 2.07 2.92 3.18 ' 3.48 3.77 1.56 1.66 1.70 1.89 2.01 r 1.42 1.52 1.63 1.75 1.86 1.32 1.43 1.54 1.65 1.77 2.88 3.15 3.48 3.85 4.26 85 86 87 88 89 109.18 121.82 136.81 152.77 168.99 77.48 85.81 94.94 104.89 115.56 67.08 74.04 81.64 89.90 98,74 61.33 67.00 73.13 79.72 86.99 122.57 133.59 150.18 167.51 185.99 50 51 52 53 54 4,10 4.54 5.03 5.56 6.13 2.14 2.36 2.61 2.89 3.19 1.98 2.19 2.42 2.69 2.95 1.90 2.10 2.33 2.58 2.84 4.73 5.25 5.84 . 6.48 7.15 9D 91 92 93 94 186.55 204.78 224.31 244.82 266.42 124.78 134.28 144.09 154.16 164.53 106.62 114.74 123.11 131.72 140.58 94.58 102.13 109.96 118.04 126.40 203.02 211.63 228.58 253.72 285.45 55 56 57 5B 59 6.78 7.56 8.43 9.41 10.45 3.53 3.93 4.38 4.90 5.43 3.26 3.65 4,06 4.53 5.04 3.14 3.51 3.00 4.35 4.84 7.88 6.72 9.59 10.53 11.48 95 96 97 98 99 291.16 318.25 381.82 404.11 426.92 175.19 189.53 317.05 335.57 354.52 149.69 161.95 270,91 286,73 302.91 134.59 145.61 243.58 257.81 272.37 324.63 361,83 400.13 406.69 428.55 NOTE: AGE IS ATTAINED AGE. Policy Page 6 CSPA to to Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 17 of 25 TABLE B (CONT'D) NON -TOBACCO USE ANNUAL EXCHANGE PREMIUMS PER S1,000 FACE AMOUNT THE ANNUAL F OLICY FEE DF 575 MUST BE ADDED, _ • AGE SCHEDULED MAXIMUM AGE SCHEDULED MAXIMUM 5149,990 and below 5150,000 5249,999 $250,000 S499,099 $500,000 and over , ALL FACE AMOUNTS 5149,999 and below 5150,000 $249,999 5250,000 5409.099 5500,000 and over ALL FACE AMOUNTS 20 21 22 23 24 $ 1.13. $ 1,10 S 0,99 $ 0.1)0 S 1.64 60 .5 1.1..55 $ 10.43 $ 9.68 S E:1,211 $ 16;0.1 2.5 26 27 28 29 (.13 1,1E) 0.09 0.90 1.64 61 12,75 11.52 10.69 10.20 17.37 0) 1.13 1.10 0.99 0.90 1.04 62 1.4.09 '12.7,3 1181 11.27 18.07 2.5 36 37 30 39 1,13 1.10 0,99 0.00 1.64 33 .15.49 13.99 12.99 12.39 20.14- 22.25 24,51 26.72 29.18 1..13 1.10 0.99 0.610 1.611 64 17.01 15:30 14,27 13.00 .20.40 22.07 7:. 1.13 1.10 0.99 0.90 1.64 65 '18.67 16.87 15.67 14.94 '23.01 " 113 1.10 0')9 0.90 1.1 .1 66 70.40 '18.43 17.11 16.33 25.04 'I 1.13 1.10 9.09 (191) 1.64 67 22.30 20.20 19.71 17.135 28.17. 1.0: 1.13 1.10 0.99 0.910 1,64 58 24.41 22.36 20.48 10.93 .30:66 2 ' 1.13 (.10 0.09 0,90 1.64 69 20.03 24.02 2193 .20 02 33.38 31" 113 1.10 0.90 0.90 1.54 70 28114 2.6.61 24.63 22.91 36.39 3: 1.13 1,10 0.59 (1.00 1.04 71 31.46 29.45 26.11 25.24 .39.86 3:' 1.13 1.10 0110 (1.91.1 1.64 72 34.48 32:49 29.18 27.73 43.73 3: 1.13 1.10 0,99 0.90 1.64 73 38.48 35.82 37.10 30.41 .47.92. 34 1.19 1.16 (.1)4 0.95 1,77 74 1 '42;02 30,50 35.31 33.42 52.53 3!, 1.26 1.22 1.09 1.001.93 75 47.89 43.57 38.89 26.74 57.64 30 1.34 1.29 1.17 1.07 2,06 76 5349 48,12 42136 4042 :63:24 37 1.45 1.39 1.26 1.15 2.23 77 50.73 53.15 47.2.8 44,51 69.40 3(i 1.51 1.45 1,31 1.21 2.31 78 60.60 513.71 52.16 49.02 70.22 39 1.6:3 1.55 1.42 1:30 2.44 79 74.36 64.712 57,52 53.94 83.57 40 1.77 1.69 1.54 1.42 2.60 80 82,79 71,41 6335 59.32 91.80 41 1,91 1.81 1.65 1,53 2.75 81 91.98 78.57 09.69 66.14 102.96 42 2.07 1.95 1.78 186 2.92 82 101.90 86.21 76,33 71.37 115:55 43 2.26 2.11 1.93 1:80 3.14 83 112.60 94.37 ' 03.45 78.04 128.10 44 2.45 2.29 2:09: 1.96 3.40 84 124.55 .103.42 91.37 85.47 1.41.97 45 2.6'7 2.40 2.20 2.14 3.70 85 137.75 113.36 100.11 93:60 157.59 46 2.92 2.70 2.45 2.34 4.05 86 152.25 124.20 109.67 102.67 ' 171.76 47 3:10 2.02 2.70 2.55 4,48 87 168.13 135.90 12.0.14 112.53 193.09 48 3.48 3.17 2.93 2.78 4.95 68 185.40 148.70 131.52 123.23 215.37 49 3.77 3.42 3.16 3.01 5,47 89 200.93 162.19 143.68. 134.72 .239.13 50 4:10.• •, 3,71 3.44. 3.20 6,08 00 216.96 176.25 156.48 146.80 _ 261,03 51 4.54 4.09 3.00 3:63 6:75 91 233.48 189.73 160.05 159.55 .272,10 52 5.03 4.54 4.22 4,02 7.51 92 250.52 203.04 184.12 172.99 293.89 53 0.56 5,93 4.67 4.45 .8.33 93 268.04 217.05 199.06, 187.16 326:21 54 0.13 5.54 5.13 4.90 0.19 94 286.05 232.67 214.78 .202.11 367.01 55 6.78 6.12 . 5.60 5.42. 10,13 95 304.513 247.74 228.70 215.21 417.38 56 7.56 6.93 6.35 6.05 11.21 96 324.95 264.31 243.01 229.59 465.21 57 8,43 7,61 7.07 6,74 12.33 9'? 389.65 317.11 292.73 275:46 514.45 58 9.41 8.50 7.90 7.52 13.54 98 412.62 335.61 309.81 2.91.53 522.89 59 10.45 9.43 8.76 8.35 14.75 99 435.91 354.07 327.30 307.99 551.12 NOTE: AGE IS ATTAINED AGE. TOBACCO USE ANNUAL EXCHANGE PREMIUMS PER $1,000 FACE AMOUNT THE ANNUAL POLICY FEE OF $75 MUST BE ADDED. AGE SCHEDULED MAXIMUM AGE SCHEDULED MAXIMUM $149,999 and below $150,000 S249.996 $250,000 5499.999 S500,000 and over ALL FACE AMOUNTS 5149,999 and below $150,000 S249;999 $250,000 5499,999 5500,000 and over ALL. FACE AMOUNTS 20 21 22 23 24 5 1.83 1,63 1,83 1113 1.133 .5.1.80 1.80 1.8(1 1.80 1.80 S 1.56 1.56 1,50 1.50 1.56 $ 1.50 1.50 1.50 1.60 1.50 $ 2.53 2.53 2.53 2.53 2.53 40 41 42 43 44 5 2.87 3.10 3.38 3.09 4.01 $ 2..76 2.09 3:25 3.54 3,84 $ 2,47 2.69 2.92 3.20 3.49 $ 2.39 2.59 2.82" 3.10 .338 S-4.35 4.67 5.04 5.49 6.00 2.5 26 27 28 29 1.83. 1.83 1.83 1.83 I.83 1.80 1.80 1.80 1.80 1.80 1.56 1.56 1.56 1.56 1136 1,50 1.50 1.50 1.50 1.50 2.53 2,53 2.53. 2.53 2.53 45 46 47 48 49 4.37 4,71 5.13 6133 6:18 4.16 4.48 4.87 5112 5.83 3.79 4.11 4.47 482 5.41 3.69 3.99 4.35 .4.80 5.28 6,60 7.27 8.12 9.17 10.35 30 31 32 33 34 1.93 1.83 1.83 1.83 1.90 1.80 .1.80 1.80 1.80 1116 1.56 1.56 1.56 1.56 1.63 1.50 1.50 1:50 1:50 1.56 2.53 2.53 .2.53 2.53 2.70 5D 51 52 53 54 6,70 7.53 8.35 9.26 10.80 6.37 7.07 7.84 8.69 9.67 .. 5.95 6.01 7.33 8.12 9.04 5.81 6.45 7:16' 7.93 8.82. 11.66 13.09 14.66 16.34 18.19 2.5 36 37 30 39 2.03 2,16 3.34 3.48 2.66 1.99 2.11 2.213 2.41 2.59 1.74 1.85 2.01 2.12 2.20 1.66 1.77 1.04 2.05 2.22 3,06 3.32 3.62 3.02 4.09 55 56 57 58 , 59 '11.44 12.74 14.22 15.75 1'7.50 10.73 11.96 ' 13.35 14.78 16.42 10.04 11.18 12.47 13.82 15.36 0.80. 10.92. 12.19 13.50 15.00 20.14- 22.25 24,51 26.72 29.18 NOTE:.AGE IS ATTAINED AGE. Policy Vogel Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 18 of 25 TABLE B (CONT'D) TOBACCO USE (CONT'D) ANNUAL EXCHANGE PREMIUMS PER $1,000 FACE AMOUNT THE ANNUAL POLICY FEE OF S75 MUST BE ADDED. AGE SCHEDULED MAXIMUM AGE SCHEDULED MAXIMUM $145,999 and below $150,000 5249.999 5250,000 5499.999 5500.000 and over ALL FACE AMOUNTS S149,999 and below 5150.000 S249,999 5250.000 5499,999 S500,000 and over ALL FACE AMOUNTS 50 $I939 $18.21 817.02 $16.61 $31.75 80 147,15 140.53 119.26 114.39 165.89 61 21.42 20.11 15.80 18.36 34.44 81 162.73 154.91 131.94 126.35 185.34 62 23.72 22.27 20.81 20.34 37.47 82 180.55 169.89 145.54 139.16 205.47 63 26.12 24.53 22.93 22,39 40.53 83 200.07 184.74 160.15 152.90 225.27 64 28.71 26.96 25.20 24 01 43.78 84 222.99 201.10 176.39 168 15 246.55 65 31.57 29.64 27 71 27 06 47.34 85 245.89 218.97 194.30 184.97 268.36 66 34.31 32.21 30.12 29.41 51.14 86 271.91 238.36 213.95 203.38 286.80 67 37.39 35.10 32.81 32.05 55.42 87 296.98 259.26 235.36 223.42 315.55 68 40.77 38.28 35,78 34.96 60.14 88 325.31 281,68 259.60 245.15 344.48 69 43.30 40.65 38.00 37.12 65.28 89 352.24 305.25 283.39 268.28 373.81 70 47.64 44.73 41.81 40.84 71.03 90 383.25 329.61 309.36 292.49 398.01 71 55.84 51.06 46 58 45.40 77.60 91 41832 354.71 336.56 317.79 416.42 72 62.06 • 58.05 51 73 50 33 84.88 92 452 40 380.59 365.00 344.21 452.50 73 69.59 65.86 57.40 55.74 92.75 93 493.27 407.21 394.71 371.77 493.37 74 78.39 /4.62 63.68 61 72 101.42 94 543.40 434.59 425.69 400.47 543.50 75 88,17 81.54 70.71 68.40 110.21 95 566.50 462.73 453.26 426.40 568.43 76 98.65 95.31 78.54 75.84 119.83 96 594.61 492.93 482.84 454.23 626.44 77 109.60 105.60 87.28 84.14 130 23 97 65520 566.74 555.14 522.24 684.72 78 121.09 . 116 33 96 95 93 30 141.47 98 738 53 599.81 68752 552.72 739.53 79 133.44 127 80 107.61 103.38 153.68 99 780 25 633.69 620.72 583.94 7E11.25 NOTE: AGE IS ATTAINED AGE. DECREASING TERM INSURANCE TO AGE 100 PLAN - For this plan, the face amount decreases while premiums remain level. The face amount decreases each year with Attained Age, as shown in Table C below. We reserve the right to change the scheduled lace amount, but not lower than the minimum face amount as determined from Table C. TABLE C PREFERRED PLUS/PREFERRED FACE AMOUNT PER $100.00 BASIC ANNUAL PREMIUMS THE BASIC ANNUAL PREMIUM IS THE ANNUAL PREMIUM FOR THIS PLAN MINUS THE ANNUAL POLICY FEE OF $75 AGE SCHEDULED MINIMUM AGE SCHEDULED MINIMUM 6149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS $149,999 and below $150,000 $249,999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS 20 566,495 $126,582 $140,1345 $158,730 $78,125 40 $56,497 $89,285 $ 99,009 $107,526 $49,504 21 88,495 126,582 140,845 158,730 78,125 41 52,356 83,333 92,592 101,010 46,728 22 88,495 126,582 140,845 158,730 78,125 42 48,300 79,365 86,956 94,339 44,052 23 88,495 126.582 140,845 158,730 78,125 43 44,247 74,074 81,300 87,719 40,983 24 88,495 126,582 140,845 158,730 78,125 44 40,816 68.965 75,757 81,967 37,878 25 86,495 126,582 140,845 158,730 78,125 45 37,453 64,102 70.422 75,757 34,722 26 88,495 126.582 140,845 158,730 76,125 46 34,246 60,240 65,789 69,930 31,746 27 88,495 126,582 140,845 158,730 78,125 47 31,446 56,179 51,349 64,935 28,735 28 88,495 126,582 140,845 158,730 78,125 48 28,735 52,910 57,142 60,606 25,974 29 88,495 126,582 140,845 158,730 78,125 49 26,525 49,751 53,763 56,497 23,474 30 88,495 126,582 140,845 158,730 78,125 50 24,390 46,728 50,505 52,631 21,141 31 88,495 126,582 140,845 158,730 78,125 51 22,026 42.372 45,662 47,619 19,047 32 88,495 126,582 140,845 156,730 78,125 52 19,080 38,314 41,322 42,918 17,123 33 88,495 126.582 140,845 158,730 78,125 53 17,985 34,602 37,174 38,759 15,432 34 54,033 121,951 135,135 153,846 72,463 54 16,313 31,347 33,898 35,211 13,986 35 79,365 116,279 129,870 144,927 66,666 55 14,749 28,328 30,674 31,847 12,690 36 74,626 111,111 125.000 138,888 62,500 56 13,227 25,445 27,397 28,490 11,467 37 68,965 105,263 116,279 129,870 57,803 57 11,862 22,831 24,630 25,641 10,427 38 66,225 101.010 111,111 125,000 55,555 58 10,626 20,408 22,075 22,988 9,496 39 61,349 94,339 105.263 116,279 52,631 59 9,569 18,416 19,841 20,661 8,710 NOTE; AGE IS ATTAINED AGE. C5P A In a, Policy Page 8 Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 19 of 25 TERM LIFE INSURANCE POLICY TO AGE 95 WITH INDETERMINATE PREMIUMS INITIAL LEVEL PREMIUM IS GUARANTEED AFTER WHICH IT IS SUBJECT TO CHANGE AS SHOWN ON THE SPECIFICATIONS PAGES EXCHANGEABLE AFTER FIVE YEARS TO ANNUAL INCREASING PREMIUM OR DECREASING TERM INSURANCE TO AGE 100 NONPARTICIPATING C5PA in n7 Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 20 of 25 TABLE C (CONT'0) TOBACCO USE FACE AMOUNT PER S100.00 BASIC ANNUAL PREMIUMS THE BASIC ANNUAL PREMIUM IS THE ANNUAL PREMIUM FOR THIS PLAN MINUS THE ANNUAL POLICY FEE OF $75 AGE SCHEDULED MINIMUM AGE SCHEDULED MINIMUM $149,999 and below 5150,000 5249.999 5250,000 5499,999 5500,000 and over ALL FACE AMOUNTS 5149,999 and below 6150,000 5249.999 $250,000 S499.999 $500,000 and over ALL FACE AMOUNTS 20 $54,644 $55,555 564,102 566,666 $39,525 60 $5,157 $5,491 $5.875 56,020 $3,149 21 54,644 55,555 64,102 66,666 39,525 61 4,668 4.972 5,319 5,446 2,903 22 54,644 55,555 64,102 66,666 39,525 52 4.215 4,490 4,805 4.916 2,668 23 54,644 55,555 64,102 66,666 39.525 63 3,828 4,076 4,361 4,466 2,467 24 54,644 55.555 64.102 66.666 39.525 64 3483 3.709 3.968 4.063 2284 25 54,644 55,555 64.102 66.666 39,525 65 3.167 3,373 3,608 3.695 2.112 26 54,644 55,555 64.102 66.666 39.525 66 2,914 3,104 3,320 3.400 1,955 27 54,644 55,555 64,102 66.666 39,525 67 2.674 2,849 3,047 3.120 1.604 28 54,644 55.555 64,102 66,666 39,525 68 2,452 2,612 2,794 2,861 1,662 29 54,644 55,555 64,102 66.666 39.525 69 2.309 2.460 2.631 2.693 1.531 30 54,644 55,555 54,102 66.666 39,525 70 2.099 2,235 2.391 2.448 1,407 31 54,644 55,555 64,102 66.666 39,525 71 1,790 1.958 2,146 2.202 1,288 32 54,644 55,555 64,102 66,666 39,525 72 1.611 1,722 1.933 1.986 1.178 33 54,644 55,555 64.102 66.666 39,525 73 1,436 1.518 1.742 1.794 1,078 34 52.631 53.763 61.349 64.102 36 231 74 1.275 1.340 1,570 1.620 985 , 35 49,261 50,251 57,471 59,523 32,679 75 1,134 1,182 1,414 1,461 907 36 46,296 47.393 54,054 56.497 30,120 76 1.013 1,049 1,273 1,318 834 37 42,735 43,859 49.751 51.546 27.624 77 912 946 1.145 1,188 767 38 40,322 11,493 17,169 18,780 26,178 78 825 859 1,031 1,071 706 39 37.593 38.610 13.668 45.045 24.449 79 749 782 929 957 650 40 34,843 36,231 „ 40,485 41,841 22,988 80 679 711 838 874 599 41 32,258 33,444 37,174 38,610 21,413 81 614 645 757 791 539 42 29,585 30,769 34.246 35,460 19.841 82 553 588 687 718 486 43 27,100 28,248 31,250 32,258 18,214 83 499 541 624 654 443 44 24,937 26,041 28,653 29,585 16,666 84 448 497 566 594 405 45 22,883 24,038 26,385 27,100 15,151 85 406 456 514 540 372 46 21,231 22,321 24.330 25,062 13,755 86 367 419 457 491 348 47 19,493 20,533 22,371 22,988 12,315 87 336 385 424 447 316 48 17,761 18,796 20,325 20,833 10,905 88 307 355 386 407 290 49 IS 181 17152 18,484 18,.939 9,661 89 283 327 352 372 267 50 14,727 15,698 16,806 17.211 8,576 90 260 303 323 341 251 51 13,280 14,144 15,128 15,503 7,639 91 240 281 297 314 240 52 11,976 12,755 13,642 13,966 6,821 92 221 262 273 290 220 53 10,799 11,507 12,315 12,610 6,119 93 202 245 253 268 202 54 9,708 10,341 11,061 11,337 5,497 94 184 230 234 249 183 55 6,741 9,319 9,960 10,204 4,965 95 176 216 220 234 175 56 7,849 8,361 8,944 9,157 4,494 96 168 202 207 220 159 57 7,032 7,490 8,019 8,203 4,079 97 152 176 180 191 146 58 6,349 6,765 7,235 7,407 3,742 98 135 166 170 180 135 59 5.714 6,090 6,510 _ 6,666 3,427 99 128 157 161 171 128 NOTE: AGE IS ATTAINED AGE. RIDERS - The continuation in the new plan of any benefits provided by Rlder(s) attached to this Policy which are not exchanged will be subject to the provision for continuation, if any, in each Rider. The premium for any Rider continued alter exchange will be added to the premium for the new plan. This Policy may not be exchanged more often than once every five years, subject to the terms and conditions listed above and the age and risk classifications available at that lime. RIDER EXCHANGE AT DEATH OF INSURED - If any Insured Spouse Riders attached to this Policy are in force upon the Insured's death, they may be exchanged for a new policy in accordance with the Exchange provision in each rider except that: (a) the exchange must be made within 30 days alter the Insured's death; and (b) the effective date of the new policy will be the day We receive Notice to Us for the exchange. If the Insured Spouse dies before exchange takes effect and within 30 days after the Insured's death, We will pay to the Beneficiary of the Rider the insurance 1n force under the Rider at the Insured's death, less any overdue premium for the Rider. CSPA Policy Page 10 10,07 Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 21 of 25 TABLE C (CONT'D) PREFERRED PLUS/PREFERRED (CONT'D) FACE AMOUNT PER S100.00 BASIC ANNUAL PREMIUMS THE BASIC ANNUAL PREMIUM IS THE ANNUAL PREMIUM FOR THIS PLAN MINUS THE ANNUAL POLICY FEE OF S75 AGE SCHEDULED MINIMUM AGE SCHEDULED MINIMUM 5149,999 and below 5150,000 S249,999 5250,000 S499,999 6500,000 and over ALL FACE AMOUNTS $149,999 and below $150,000 S249,999 $250,000 S499,999 $500,000 and over ALL FACE AMOUNTS 60 $8,658 $16,666 $17,953 $18,691 $6,032 80 $1,593 $2,170 $2,459 $2,639 $ 1,400 61 7,843 15,060 16,260 16,920 7,401 81 1,410 1,948 2,217 2,386 1,248 62 7.097 13,642 14,727 15,337 6,816 82 1,244 1,755 2,004 2,162 1,112 63 6,455 12,422 13,386 13,927 6,301 83 1,119 1,584 1,817 1,963 1,003 64 5.878 11,312 12.210 12.690 5.827 84 1,016 1.430 1.646 1,781 905 65 5,402 10,298 11,111 11,560 5,379 85 915 1,290 1,490 1,630 815 66 5,010 9,416 10,162 10,570 4,955 86 820 1,165 1,350 1,492 748 67 4,644 8,628 9,302 9.600 4,564 87 730 1,053 1,224 1,367 665 68 4,291 7,880 8,503 8,841 4,194 88 654 953 1,112 1,254 596 69 3 862 7,385 7968 8,291 3.852 89 591 865 1.012 1,149 537 70 3,575 6,711 7,241 7,535 3,533 90 536 801 937 1.057 492 71 3,273 5,973 6,480 6,784 3.225 91 488 744 871 979 472 72 2,980 5,327 5.813 6.116 2,940 92 445 694 812 909 437 73 2,767 4,759 5,221 5,506 2,683 93 408 648 759 847 394 74 2.564 4.255 4.690 4,962 2,447 94 375 607 711 791 350 75 2,373 3,800 4,212 4,468 2,230 95 343 570 668 742 308 76 2,196 3,394 3,779 4,019 2,032 96 314 527 617 686 276 77 2,030 3,031 3,390 3,615 1,852 97 261 315 369 410 249 78 1,874 2,708 3,043 3.252 1,686 98 247 298 348 387 245 79 1,732 2,421 2.733 2.927 1,536 99 234 282 330 367 233 NOTE: AGE IS ATTAINED AGE. NON -TOBACCO USE FACE AMOUNT PER $100.00 BASIC ANNUAL PREMIUMS THE BASIC ANNUAL PREMIUM IS THE ANNUAL PREMIUM FOR THIS PLAN MINUS THE ANNUAL POLICY FEE OF $75 C5PA n re, Policy Page 9 SCHEDULED MINIMUM SCHEDULED MINIMUM AGE $149,999 and below $150,000 $249.999 $250,000 $499,999 $500,000 and over ALL FACE AMOUNTS AGE $149,999 and below $150,000 $249,999 $250,000 S499,999 $500,000 and over ALL FACE. AMOUNTS 20 $88,495 $90,909 $101,010 $111,111 $60,975 60 $8,658 $9,587 $10,330 $10,822 $6,246 21 88,495 90,909 101,010 111,111 60,975 61 7,843 8,680 9,354 9,803 5,757 22 88,495 90,909 101,010 111,111 60,975 62 7,097 7,855 8,467 8,873 5,299 23 88,495 90,909 101,010 111,111 60,975 63 6,455 7,147 7,698 8,071 4,901 24 88,495 90,909 101,010 111.111 60,975 64 5,878 6,510 7,007 7,352 4,531 25 86,495 90,909 101.010 111,111 60,975 65 5,356 5,927 6,381 6,693 4,182 26 88,495 90,909 101,010 111,111 60,975 66 4,901 5,425 5,844 6,123 3,855 27 88,495 90,909 101,010 111,111 60,975 67 4,484 4,928 5,344 5,602 3,549- 28 86,495 90,909 101,010 111,111 60,975 68 4,096 4,472 4,882 5,120 3,261 29 88,495 90,909 101,010 111,111 60,975 69 3,841 4,163 4,580 4,803 2,995 30 88,495 90,909 101,010 111,111 60,975 70 3,491 3,757 4,161 4,364 2,748 31 88,495 90,909 101,010 111,111 60,975 71 3,178 3,395 3,772 3,961 2,508 32 88,495 90,909 101,010 111,111 60,975 72 2,900 3,077 3,427 3,605 2,286 33 81495 90,909 101,010 111,111 60,975 73 2,598 2,791 3,115 3,285 2,086 34 84.033 86,206 96,153 105,263 56,497 74 2,329 2,531 2,832 2,992 1,903 35 79,365 81,967 91,743 100,000 51,813 75 2,088 2,295 2,571 2,721 1,734 36 74,626 77,519 85,470 93,457 48,543 76 1,869 2,078 2,333 2,474 1,581 37 68,965 71,942 79,365 66,956 44,843 77 1,674 1,881 2,115 2,246 1,440 38 66,225 68,965 76,335 82,644 43,290 78 1,499 1,703 1,917 2,039 1,311' 39 61,349 64102 70,422 76,923 40,983 79 1,344 1,543 1,738 1,853 1,196 40 56,497 59,171 64,935 70,422 38,461 80 1,208 1,400 1,578 1,685 1,089 41 52,356 55,248 60,606 65,359 36,363 81 1,087 1,272 1,434 1,535 971 42 48,309 51,282 56,179 60,240 34,246 82 981 1,159 1,310 1,401 865 43 44,247 47,393 51,813 55,555 31,847 83 888 1,059 1,198 1,281 78D 44 40,816 43,668 47,846 51,020 29,411 84 802 966 1,094 1,170 704 45 37,453 40,322 43,859 46,728 27,027 85 725 882 998 1,067 634 46 34,246 37,037 40,322 42,735 24,691 86 656 805 911 973 582 47 31,446 34,246 37,037 39,215 22,321 87 594 735 832 888 517 48 28,735 31,545 34,129 35,971 20,202 88 539 672 760 811 464 49 26,525 29,239 31,645 33,222 18,281 ' 89 497 616 695 742 418 50 24,390 26,954 29,069 30,395 16,447 90 460 567 639 681 383 51 52 22,026 19,880 24,449 22,026 26,315 23,696 27,548 24,875 14,814 13,315 81 82 428 399 527 491 588 543 626 578 367 340 53 17,985 19,880 21,413 22,471 12,004 93 373 458 502 534 306 54 16.313 18,050 19,493 20,408 10,881 94 349 429 465 494 272 55 14,749 16,339 17,574 18,450 9,871 95 328 403 437 464 239 56 13,227 14,641 15,748 16,528 8,920 96 307 378 409 435 214 57 58 11,862 10,626 13,140 11,764 14,144 12,658 14,836 13,297 8,110 7,385 97 98 256 242 315 297 341 322 363 343 194 191 59 9,569 10,604 11,415 11,976 6,779 99 229 282 305 324 181 NOTE: AGE IS ATTAINED AGE. C5PA n re, Policy Page 9 Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 22 of 25 PRIIVIERICA LII<E INSURANCE COMPANY Home Office: Boston, Massachusetts Executive Offices: 3120 Breckinridge Boulevard, Duluth, Georgia 30099.0001 TERMINAL CONDITION ACCELERATED BENEFITS ENDORSEMENT PAYMENT OF THIS BENEFIT WILL REDUCE THE AMOUNT OF DEATH BENEFIT PROCEEDS THE BENEFICIARY WILL RECEIVE We have issued this Endorsement as a part of the Policy to which it is attached, BENEFITS Description of Benefits - We will advance the Accelerated Benefit it you develop a Terminal Condition, subject to all of the provisions of this Benefit and the Policy. We will pay to the Owner or to his designee, upon his written direction and upon terms acceptable to us. 40% of the Face Amount of the Policy and/or Riders, i1 any, not 10 exceed a maximum of $250,000. This Benefit will be paid in a lump sum. A benefit payment notice will be provided. The Effective Date of this Endorsement is the same as the Date of Issue of the Policy. An administrative fee of $200, plus interest will be charged for this Accelerated Benefit. Interest will be calculated at the current yield on 90 day Treasury Bill. The interest is computed on the total of the amount advanced and the administrative fee. The Accelerated Benefit advance, administrative fee, and interest will be deducted from the death benefit proceeds when those benefits become payable, However, if these amounts equal the remaining death benefit, the Policy terminates. (See the Termination provision.) In order to exercise this Benefit, we must receive al our Executive Offices a written Physician Statement which diagnoses your medical condition as being a Terminal Condition, as defined herein. We have the right to require, at our expense, that you be exarriiried.by a Physician designated by us in order to verify the diagnosis. We must also receive a written, notarized consent on a form provided by us of any irrevocable Beneficiary or assignee before this option may be exercised. This Benefit may be taxable upon receipt of the Accelerated Benefit advance, As with all tax matters, you may want to consult your personal tax advisor prior to exercising acceptance of this Benefit. DEFINITIONS "We" or "Us' refers to the Company, 'You" or 'Your" refers to the Insured and/or the Insured Spouse and/or the Other Insured Person. The Owner refers to the Owner of the Policy. Physician - Physician means an individual who is licensed to practice medicine and treat condition or injury in the state in which treatment is received and who is acting within the scope of that license. Physician does not include; 1) you; 2) the Owner; 3) a person who lives with you or the Owner; or 4) a person who is your or the Owner's parent, spouse or child. Physician Statement - A Physician Statement means a statement acceptable to us, signed by a Physician, which: 1) gives the Physician's diagnosis of your noncorrectable medical condition; 2) is given while the Policy is in force; and 3) states that, with reasonable medical certainty, the noncorrectable medical condition will result in your death in 6 months or less from the date of the Physician Statement. Terminal Condition - Terminal Condition is a noncorrectable medical condition that with reasonable medical certainty, will result in your death in 6 months or less from the date of the Physician Statement. Accelerated Benefit - An Accelerated Benefit is the advance prior to the date of your death of 40% of the Face Amount of the Policy and/or Riders, if any, not to exceed a maximum of $250,000. The Accelerated Benefit advance, administrative fee, and interest result In the establishment of a lien against the Face Amount of the Policy and/or Riders, if any. PL -E80 PA 12.97 Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 23 of 25 GENERAL. PROVISIONS Future Premiums - The advance of an Accelerated Benefit will have no effect on the amount of future premiums, if any, required under the Policy and/or Riders, if any. Waiver of Premium - If a Disability Waiver of Premium Benefit Rider is attached to this Policy and the Insured otherwise qualifies for that Benefit and for the Accelerated Benefit, then for purposes of the Disability Waiver of Premium Benefit Rider, the Insured will be deemed to be Totally Disabled until the final death benefit proceeds are paid. Assignment - This Benefit must not be legally or equitably assigned except to us as security for the lien. We must receive an assignment form making us assignee of this Policy for the amount of the Accelerated Benefit. We must receive a notarized consent form from all irrevocable Beneficiaries, it any. We also reserve the right to require a consent form from a spouse, other Beneficiaries, or any other person it, in our discretion, such person's consent is necessary to protect our interests. Other Conditions - The Accelerated Benefit must be requested voluntarily by the Owner. This Benefit provides for the advance of the proceeds of the Policy normally payable at your death. This Benefit is not meant to cause the Owner to involuntarily obtain proceeds which ultimately would be payable to the Beneficiary. Therefore, the Owner is not permitted to exercise this Benefit: 1) if the Owner is required by law to use this Benefit to meet the claims of creditors, whether in bankruptcy or otherwise; or 2) if the Owner is required by a government agency to use this Benefit in order to apply for, obtain, or otherwise keep a government benefit or entitlement; or 3) if the Benefit would adversely affect the recipient's eligibility for Medicaid. How to Apply For Thls Benefit - You and the Owner must apply for this option in writing, on lorms provided by us, and provide proof satisfactory to us, including a Physician Statement which states that you have a Terminal Condition. We have the right to have you examined at our expense by a physician we choose. Exclusion - This Benefit does not apply to arty Children's Term Insurance Rider that may be attached to your Policy. Conformity With State Statutes - If any provision of the Benefit Is in conflict with the laws of the state in which you reside, the provision is automatically amended to meet the minimum requirements of such laws. Termination - This Benefit will terminate on the earliest of the following dates: 1) the date on which your Policy terminates;, or 2) the date on which the Owner's written request to cancel this Benefit is received at our Executive Offices, provided the Owner's written request is received prior to an Accelerated Benefit advance, This Benefit will terminate when the lien plus interest equals the death benefit. Signed at Duluth, Georgia. Stanton J, Shapiro, Secretary Primerica Life Insurance Company Pt. -E80 PA Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 24 of 25 PRIMERICA LIFE INSURANCE COMPANY Home Office: Boston, Massachusetts Executive Offices3120 Breckinridge Boulevard, Duluth, Georgia 30099-0001 For Pollcyowner Service call 1-800-257-4725 ENDORSEMENT This Endorsement is made a part of the Policy mw|ich it is attached. The following provision will be added to the Policy: ARBITRATION PROVISION UNDER THIS PROVISION, ARBITRATORS, NOT COURTS OR JURIES, WILL RESOLVE CERTAIN DISPUTES. DEFINITIONS FOR ARBITRATION PROVISION As used in this Arbitration Provision ("Provision"), the (o|lowingdo(in|Uuno will apply: "You" or "Your" means any and all persons who sign this application. "Yo or 'Your' also means anyone who has a Dispute, as defined below, with Us. "We" or "Us" means Primerica Life Insurance Company, Primerica Financial Services, Inc., or their respective corporate parents, subsidiaries, liateassignees, contractors, directors, and officers (whether acting in their corporate or individual capacity). "We" or "Us" also includes any person or entity who may be jointly or severally liable with either You or any of Us regarding any Dispute. "Dispute" means any case, controversy, tort (including any intentional tort), disagreement, lawsuit, or claim now or hereafter existing between You and any of Us, and arising from or related to this application, the sale of the policy applied for, any issued Policy resulting from this application, or any aspect of the relationship between You and Us that arises from this application or such policy, including, without limitation, anything related to; this Provision, its execution and enforceability, and the arbitrability of any Dispute pursuant to this Provision, Including but not limited to the scope of this Provision and any defenses to enforcement of this Provision; any one or more past, present, or future sales presentations relating to insurance or related benefits; applications for insurance; amendments to such applications; insurance policies or riders or amendments to them; any act or omission by You or Us; f raud or misrepresentation, including Disputes tor failing to disclose material facts; any matter arising out of common law or contract; any federal or state statute or regulation, or any alleged violation thereof, including without limitation insurance and consumer protection laws. AGREEMENT TO ARBITRATE DISPUTES You or We may require that any Dispute, hua specifically in N Provision shall lvag by binding arbitration in accordance with the Federal Arbitration Act, by tiling a demand Icr arbitration with JAMS or its successor organization. The demand shall be filed, and |headbitm8un shall be cpndvuteU, in accordance with the JAMS Financial Services Rules in effect on the date the demand for arbitration is filed unless any terms in those rules are inconsistent with this Provision, in which case the terms of this Provison will prevail. You and We may, by mutual ugraoment, select an arbitration administrator other than JAMS, in which case the arbitration shall be filed and conducted under Thal administrator's rules, to the extent they are not inconsistent with this Provision. You may obtain a copy of the JAMS arbitration Rules at no charge at www.jamsadr.com, or by contacting the Office of the General Counsel for Primerica Life Insurance Company. DISPUTES EXCLUDED FROM ARBITRATION We cannot require You to arbitrate any Dispute hsisolely from the alleged failure or refusal to pay a claim for death befit/ a life i|i insured's death. (Ah Dispute may be litigated in the hue Pl.A-04 PA 10.03 Case 1:14-cv-01665-JEJ Document 1-3 Filed 08/26/14 Page 25 of 25 ADDITIONAL TERMS Administration of Arbitration. The arbitrator shall decide the Dispute in accordance with the applicable law, and shall he empowered to award any damages or other relief provided for under the applicable law. The award shall be final and binding. The arbitrator shall make any award in writing and shall include written findings of fact and conclusions of law. Number of Arbitrators. The arbitration shall be conducted by a single arbitrator, unless any party to the arbitration requests a panel of three arbitrators. II such a request is made, the arbitration shall be conducted by a panel of three arbitrators. Place of Arbitration. If a hearing is required, the arbitration shall be conducted in the county of Your residence, unless all parties agree to another location. Costs. The cost of any arbitration proceeding shall be divided as follows: The party making demand upon the administrator for arbitration shall pay to the administrator when the demand is made a sum equal to the cost of filing a complaint in a court of general jurisdiction in Your county. We will pay to the administrator all other costs for the arbitration proceeding (including a single arbitrator's lees and room rental lees). If a party makes a request for a panel of three arbitrators, the party making such request shall pay the fees of those additional arbitrators. Each party will bear the expense of its own attorney, expert, and witness tees and expenses, regardless of which party prevails, except that the arbitrator shall apply any applicable law in determining whether a party should recover any or all attorneys fees and expenses from another party. No Consolidation or Joinder of Parties. All parties to the arbitration must be individually named. Arbitrations conducted pursuant to this Provision shall not determine the rights and obligations of persons other than parties individually named in the arbitration, and shall not have any bearing on the resolution of any other Dispute or controversy. Unless mutually agreed to by the parties, and notwithstanding anything else that may be in this Provision, no class action, private attorney general action or other representative action may be pursued in arbitration, and individual Disputes may not be consolidated into one action. Severability and Survival. If the arbitrator or any court determines that one or more terms of this Provision or the arbitration Rules is ,unenforceable, or would make this Provision unenforceable, only such term(s) shall be deemed unenforceable •and shall be deemed stricken from this Provision, but such determination shall ndt impair Cr affect the enforceability of the other terms of this Provision or the arbitration Rules. This Provision shall survive rescission, termination or changes to the policy, the application and the relationship between You and Us. This Endorsement shall not waive, alter or extend in any respect, except as herein stated, any of the conditions, provisions or agreements of the Policy to which it is attached. .14e/.4. Secretary PLA -04 PA C President 10.03 Case 1:14-cv-01665-JEJ Document 1-4 Filed 08/26/14 Page 1 of 2 EXHIBIT C Case 1:14-cv-01665-JEJ Document 1-4 Filed 08/26/14 Page 2 of 2 Mahoney, Sean From: William Douglas [douglaslaw@earthlink,net] Sent: Friday, August 01, 2014 4:00 PM To: Mahoney, Sean Subject: brown v primerica complaint Attachments: brown kerekes complaint 08.01.2014.pdf; brown docs to Primerica Shields office.pdf In re: Brown v Primerica Dear Sean: Attached is the complaint filed in this matter, do you want a hard copy sent as well? My client is Cindy Kerekes individually and in her capacity as Executrix of the Estate of Paul j. Brown, Jr., deceased. Pursuant to his will she is also the sole heiress of his estate. Also attached are the communications sent to your client about the divorce and its effect. I referenced them in the complaint but forgot to attach them. I will file a praecipe to effectuate the same. Sincerely, Bill William P. Douglas, Esq. Douglas Law Office 43 West South Street Carlisle, Pennsylvania 17013 Tele: (717) 243-1790 FAX: (717) 243-8955 douglaslawna earthlink.net or douglaslaw(c�mac.com 1