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HomeMy WebLinkAbout01-5488KAREN A. WERNER Plaintiff : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA Vo LIFE INVESTORS INSURANCE COMPANY OF AMERICA Defendant CIVIL JURY TRIAL DEMANDED NOTICE YOU HAVE BEEN SUED 1N COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attomey 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 OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PENNSYLVANIA 17013 TELEPHONE: (717)-249-3166 KAREN A. WERNER Plaintiff Vo LIFE INVESTORS INSURANCE COMPANY OF AMERICA Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL JURY TRIAL DEMANDED COMPLAINT was, an adult individual, residing at 511 Cumberland County, Pennsylvania. Plaintiff; Karen A. Werner, now is, and at all times relevant to this action East Winding Hill Road, Mechanicsburg, 2. Defendant, Life Investors Insurance Company of America, now is, and at all times relevant to this action was, authorized by the Pennsylvania Insurance Department to engage in the business of writing and selling life insurance in the Commonwealth of Pennsylvania, with its principal place of business located at 4333 Edgewood Road N.E., Cedar Rapids, Iowa. 3. On February 15, 2001, defendant issued a policy of life insurance on the life of Edward A. Werner of Cumberland County, Pennsylvania (the "insured"), bearing the A true and correct copy of the policy is attached hereto as policy number 012643018. Exhibit "A." 4. The insured died on February 23, 2001, while the policy was in force, and plaintiff was the listed beneficiary. 5. On July 3, 2001, plaintiff gave defendant written notice of the insured's death as required by the terms of the policy and furnished defendant with good, sufficient, due and satisfactory proofs of the fact and cause of the insured's death on forms supplied by defendant, containing complete answers to each question propounded therein. 6. By reason of the above, defendant is obligated to pay plaintiff the sum of ninety-six thousand ($96,000.00) dollars, which is the amount of the death benefit under the policy. 7. Despite repeated requests, defendant has failed and refused and still refuses to pay plaintiff the sum of ninety-six thousand ($96,000.00) dollars or any part thereof. WHEREFORE, plaintiff prays that this Honorable Court will enter judgment in favor of plaintiff and against defendant in the amount of ninety-six thousand ($96,000.00) dollars plus interest and costs and such other relief as the Court deems appropriate. Respectfully submitted, R. Mark Thomas ID# 41301 I01 S. Market Street Mechanicsburg, PA 17055 (717) 796-2100 VERIFICATION I verify that the statements made in the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. §4904, relating to unsworn falsification to authorities. Life Investors Insurance Company of America A Stock Company Home Office located at: 4333 Edgewood Road N.E., Cedar Rapids, Iowa 52499 (Hereafter called the Company, we, our or us) (319) 398-8511 INSURED: EDWARD A WERNER POLICY NUMBER: 012643018 OWNER(S): EDWARD A WERNER FACE AMOUNT: S 96,000 POLICY DATE: FEBRUARY 15, 2001 WE AGREE 10 DAY RIGHT TO CANCEL - To pay the Proceeds of this policy to the beneficiary upon receiving due proof of the Insured's death, and - To provide you with the other rights and benefits of this policy. These agreements are subject to the provisions of this policy. You may cancel this policy by delivering or mailing · written request to us or to the agent from whom It was purchased. You must return the policy to us or the agent before midnight of the tenth day after the day you receive It. Your written request given by mall end return of the pollay by mall ere effective on being postmarked, properly addressed and postage prepaid. We must return all payments made for this policy within thirty days after we receive notice of cancellation and the returned policy, Signed for us at our home office. SECRETARY PRESIDENT This policy is a legal contract between the policyowner and the company. READ YOUR POLICY CAREFULLY Payment of the Single Sum Benefit reduces this Policy's Death Benefit end Specified Amount es those amounts exist on the date the Single Sum Benefit Is paid. Benefits paid under the Terminal Condition Accelerated Death Benefit may be considered taxable Income to you. We urge you to consult your personal tax advisor regarding matters of possible taxation. LEVEL TERM TO AGE 95 LIFE INSURANCE POLICY CONVERSION PERIOD SPECIFIED ON PAGE THREE TERMINAL CONDITION ACCELERATED DEATH BENEFIT FACE AMOUNT PAYABLE AT DEATH PRIOR TO EXPIRY DATE NON -PARTICIPATING EXHIBIT "A" APTL0304 39 400 DEFINITIONS When we use the following words, this is what we mean: AGE BENEFICIARY EXPIRY DATE FACE AMOUNT IMMEDIATE FAMILY The Insured's age at the Insured's last birthday, unless we state otherwise. The person to receive the proceeds in the event of the Insured's death. The date on which coverage under this policy expires. the Insured's age turns 95, as shown on page 3. The amount upon which death proceeds are determined. shown on page 3. A spouse, child, brother, sister, parent, grandparent or grandchild of the Insured or Owner. This is the date when The Face Amount is INDEBTEDNESS IN FORCE INSURED LAPSE OR LAPSED PHYSICIAN PHYSICIAN'S STATEMENT Any due and unpaid premium. The period of time the Insured's life remains insured under the terms of this policy. The person whose life is insured under this policy as shown on page 3. A premium is in default, and the Insured's life is no longer insured under the terms of this policy. An individual licensed to practice medicine and treat injury or illness in the state in which treatment is received and who is acting within the scope of that license. A Physician must be someone other than: (a) (b) (c) (d) the Insured; the Owner; a person who lives with the Insured or Owner; or a person who is part of the Insured's or Owner's Immediate Family. A written statement acceptable to the Company and signed by a Physician which: (a) gives the Physician's diagnosis of the Insured's terminal medical condition; and (b) states with reasonable medical certainty the terminal medical condition will result in the death of the Insured within 12 months from the date of the Physician's Statement APTL0304 39 400 PAGE 2 PQLICY The same day and month as your Policy Date for each succeedrng yea1' your ANNIVERSARY policy remains in force. POLICY DATE The date coverage under this policy becomes effective and the date from which expiry dates and premium due dates are determined. POLICY YEAR The twelve month period directly preceding the policy anniversary. PROCEEDS The amount we are obligated to pay under the terms of this policy when the Insured dies. REINSTATE To restore coverage after the policy has lapsed. TERMINAL CONDITION A condition resulting from injury or illness which, as determined by a Physician, while the policy is in ,force:. has. .reduce..d the Insur'.,ed's life expectancy to not more than 12 months rrom tne ~3ate of the Physicians Statement. TERMINATE The Insured's life is no longer insured under any of the terms of this policy. YOU, YOUR The owner of this policy is as shown in the application, changed as provided for in this policy. The owner is otherwise stated. unless subsequently the Insured unless WRITTEN REQUEST A request in writing signed by you on a form agreeable to us. APTL0304 39 400 PAGE 2A PO. LICY NUMBER: 012643016 FACE AMOUNT: $ 96,000.00 AGE/SEX: 42/MALE PREMIUM CLASS: TOBACCO TYPE 0F COVERAGE BASIC POLICY LEVEL TERM INSURANCE TO AGE 95 Conversion allowed prior to the earlier of: end of 2~th Policy Year or Insured's Age 70 ##ADDITIONAL INSURED RIDER KAREN A WERNER CASH VALUE RIDER POLICY SPECIFICATION PAGE INSURED: EDWARD A WERNER POLICY DATE: FEBRUARY 1§, 2001 EXPIRY DATE: FEBRUARY 15, 2054 OWNER(S): EDWARD A WERNER AMOUNT 96,000.00 POLICY YEARS PREMIUM IS PAYABLE INITIAL GUARANTEED PREMIUM PAYMENTS (ANNUAL) To Age 95 S 856.08 96,000.00 TO AGE 95 355.20 1,706.76 25 YEARS 495.48 #*FOR THE FIRST 25 YEARS OR UNTIL EXPIRY OF RIDER, IF SOONER. Total Annual Premium on Policy Date ................................................................................ $ 1,706.76 The Initial Guaranteed Premium Is guaranteed for 5 years. SCHEDULE OF TOTAL PREMIUMS ~.GJLGy._Y_O~ ~ ' -~-e.13::lJ.~3QIJ~ ~ $ 142.22 Monthly Years 1-5 $ 1,706.76 $ 853,38 $ Modal Factors 1.00 0.50 0.25 0.08333 The cost of the Terminal Condition Accelerated Death Benefit is included in the Basic Policy premium. APTL0304 39 400SP PAGE 3 GUARANTEED PREMIUM SCHEDULE ANNUAL PREMIUMS FOR POLICY BENEFITS POLICY NUMBER: 012643018 INSURED: EDWARD A WERNER ~#GUARANTEED #WGUARANTEED ~GUARANTEED MAXIMUM *GUARANTEED MAXIMUM POLICY TERM LIFE TOTAL POLICY TERM LIFE TOTAL YEAR INSURANCE PREMIUM YEAR INSURANCE PREMIUM 1 856.08 1,706.76 28 19,202.64 27,407.76 2 856.08 1,706.76 29 20,900.88 30,074.64 3 856.08 1,706.76 30 22,788.24 33,143.76 4 856.08 1,706.76 31 24,935.76 36,690.00 5 856.08 1,706.76 32 27,360.72 40,699.92 6 2,567.76 4,330.44 33 30,019.92 45, 105.36 7 2,797.20 4,648.20 34 32,976.72 49,955.28 8 3,058.32 5,005.32 35 36,945.36 55,954.32 9 3,313.68 5,377.80 36 41,136.72 62,376.72 10 3,657.36 5,859.72 37 45,514.32 69,802.32 11 4,012.56 6,360.84 38 50, 157.84 77,996.88 12 4,428.24 6,931.08 39 55,242.96 87,254. 16 13 4,892.88 7,559.88 40 59,993.04 99,849.36 14 5,392.08 8,221.32 41 65,300.88 114,814.60 15 5,934.48 8,918.28 42 76,910.16 138,239.76 16 6,500.88 9,652.68 43 86,490.00 162,046.80 17 7,113.36 10,462.92 44 87,354.00 173,754.00 18 7,746.00 11,325.96 45 88,218.00 175,194.00 19 8,458.32 12,330.12 46 89,082.00 176,634.00 20 9,257.04 13,491.72 47 89,946.00 178,074.00 21 10,162.32 14,830.92 48 90,810.00 179,514.00 22 11,187.60 16,322.76 49 91,674.00 180,954.00 23 12,325.20 17,971.08 50 92,538.00 182,394.00 24 13,568.40 19,731.72 51 93,402.00 183,834.00 25 14,870.16 21,564.36 52 94,266.00 94,266.00 26 16,248.72 23,012.88 53 95,130.00 95,130.00 27 17,674.32 25,093.20 AFTER THE 5TM POLICY YEAR, WE RESERVE THE RIGHT TO CHANGE THE INITIAL GUARANTEED LIFE INSURANCE PREMIUM FOR EACH POLICY YEAR THEREAFTER. THE PREMIUM MAY BE MORE OR LESS THAN SHOWN ON PAGE 3, BUT WILL NEVER EXCEED THE GUARANTEED MAXIMUM TOTAL PREMIUM. #INCLUDES ANNUAL POLICY FEE OF $ 90.00 ##TOTAL ANNUAL PREMIUM COLUMNS INCLUDE PREMIUMS FOR ANY ADDITIONAL BENEFITS WHICH MAY BE ATTACHED TO YOUR POLICY EXCEPT FOR THE MONTHLY DISABILITY INCOME RIDER, IF ELECTED.. APTL0304 39 400SPA PAGE 3A THE CONTRACT GENERAL PROVISIONS Your .policy is issued in consideration of the application and the payment of premiums as provided for in this policy. Your policy, any endorsement(s), and the copy of the application attached to it contain the entire contract between you and us. Any statements made in the application(s) either by you or by the Insureds will, in the absence of fraud, be considered representations and not warranties. Also, any written statement made either by you or by the Insureds w not be used to void your policy nor defend against a claim under your po cy un ess the statement is contained in the application(s). No change or waiver of any of the provisions of this policy w l be valid unless made in writing by us and signed by our president, a vice president, our secretary or an officer of the company, ldo agent or other person has the authority to change or waive any provision of your policy. Any extra benefit rider attached to this policy will become a part of this policy and will be subject to all the terms and conditions of this policy unless we state otherwise in the rider. SUICIDE EXCLUSION If the Insured, whether sane or insane, dies by suicide within two years from the policy date, our liability will be limited to an amount equal to the premiums paid for this policy. If you were a Missouri citizen at the t me of ssue or reinstatement, the following provision will apply: The suicide of the Insured is no defense to payment of regular life insurance benefits, t~or is the suicide of the Insured while insane a defense to payment of accidental death benefits, if any, available under this policy, unless we can show that the Insured intended suicide when he applied for these benefits. INCONTESTABILITY ASSIGNMENT MISSTATEMENT OF AGE OR SEX BENEFICIARY We cannot contest this policy, except for non-payment of Premium, after it has been in force during the lifetime of the Insured for two years after: (a) the Policy Date; or (b) the effective date of reinstatement of this policy. Your policy may be assigned by you. The assignment must be in writing and filed at our home office. We assume no responsibility for the validity or effect of any assignment of this policy or of any nterest in it. Any proceeds which become payable to an assignee will be payable in a single sum and will be subject to proof of the assignee's interest and the extent of the assignment. If the age or sex of the Insured has been misstated, the benefits will be those which the premiums paid would have purchased for the correct age and sex. When we receive due proof of the Insured's death, we will pay the proceeds of this policy, to the beneficiary or beneficiares who are named in the application for this policy unless you subsequently change the beneficiary. In that event, we will pay the proceeds to the beneficiary named in your last change of beneficiary request as provided for in this policy. P1554 PAGE 4 CHANGE OF OWNER OR BENEFICIARY If a beneficiary dies before the !nsured that benefcary's interest in this policy ends with that beneficiary s death. On y those benefcaries who survive the Insured will be eligible to share in the proceeds. If no beneficiary survives the Insured, we will pay the proceeds of this policy to you, if living, otherwise to your estate. If you have reserved the right to change the owner or Beneficiary, you can file a written request with us on a form satisfactory to the Company to make such a change. If you have not reserved the right to change the Beneficiary, the written consent of the irrevocable Beneficiary will be required. Your written request will not be effective until it is recorded in our home office records. After it has been so recorded, it will take effect as of the date you signed the request. However, if the Insured dies before the request has been so recorded, the request will not be effective as to those proceeds we have paid before your request was recorded in our home office records, PREMIUMS PAYMENT INTERVALS ADJUSTMENT OF PREMIUMS GRACE PERIOD Your first premium is due as of the po cy date, and is payable in advance. All premiums after the first p. remium are payable on or before the date they are due and must be ma~led to us at our home office. If you would like a receipt for a premium payment we will give you one, signed by a company off cer, upon request. The frequency of the premium payments are shown on page 3 of your polic,,v. Interruption of premium payments Will cause your policy to enter the ~race Period. Premiums may be paid annually, semi-annually, quarterly or monthly. The mode of payment may be changed at any policy anniversary by written agreement. Guaranteedpremiums are shown in the TA~hE OF ANNUAL PREMIUMS FOR POLICY BENEFITS, page 3A. After the 5 Policy Year, we reserve the right to change the Initial Guaranteed Life Insurance Premium shown in the table. The premiums may be more or less, but w l never exceed the Guaranteed Maximum Total Premium shown in that table. Any change in premiums, base coverage and or any attached riders, will be made on the same basis for all policies in effect the same length of time, issued to Insureds of the same Premum Class and ssue aide No change in Premium Class or premium will occur due to a change n the Insurec~'s health status or occupation. Each change will be based on our expectations as to future mortality, investment earning, expense, and persistency experience. Your policy has a 31 day grace period. This means that if a premium is not paid on or before the date it is due, you may pay that premium during the 31 day period immediately following the due date. The Insured's life will continue to'be insured during this 31 day period. If the Insured dies during this period, we will deduct a premium for the 31 day grace period from the proceeds of this policy. This 31 day grace period does not apply to the first premium payment. PB1554 PAGE 5 REINSTATEMENT BASIS USED FOR CALCULATIONS NONPARTICIPATING CONVERSION PRIVILEGE If a premium is not received before the end of the 31 day grace period, your policy will terminate and no further premium payments may be made. However, even if your policy terminates, during the lifetime of the Insured, this policy can be reinstated if it was terminated because a grace eriod ended without sufficient premium payments. Any reinstatement must bePdone within 5 years from the end of the grace perio~J. We will require: 1. Your written request to reinstate this policy, 2. The Insured's written consent to reinstatement, 3. Evidence of insurability satisfactory to us, 4. Payment of all overdue premiums with interest from the due date of each premium. The interest rate is six percent (6%) per annum, compounded annually, and 5. Payment or reinstatement of any indebtedness. The date of reinstatement will be the Monthly Anniversary Date on or following the date the application for reinstatement is approved by us, so long as the Insured is still living. If all the conditions for reinstatement are satisfied, coverage under this Policy will be effective as though it had continued in force from the lapse date to the date of reinstatement. We use the 1980 Commissioner's Male or Female Standard Ordinary Mortality Table, (S or NS), Age Last Birthday. Reserves are not less than the required minimum reserves. If required, we have filed a detailed statement about this with your State Insurance Department. This policy will not share in our surplus dis?ibut ons. While this policy is in force, you may convert it to a new policy. The conversion may be made during the convers onperiod described on page 3, if no premium is in default. The following conditions apply: 1. The face amount of the new policy does not exceed the amount of insurance under this policy on the date of conversion. 2. The face amount of the new policy s not less than the minimum amount we ssue. There will always be a plan available in an amount to which you may convert. 3. You must send us a written request for the conversion. 4. The new policy is on any Life plan written by us other than Term Insurance. §. Premiums for the new ~oolicy will be for the same class of risk as for this policy and for the msured's sex and age as of the date of the new policy. 6. The new policy is dated as of the date of conversion. Coverage under this policy terminates when coverage under the new po cy begins. 7. If premiums are being waived under a rider attached to this policy at the time of conversion the premums under the new policy will not be waived. If the policy is converted in accordance with the conversion conditions listed above, the Incontestability and Suicide provisions in the new policy shall b® void. PC1554 PAGE 6 SETTLEM;=NT OPTIONS OPTION 1 OPTION 2 PAYMENT OF PROCEEDS You may, during the Insured's lifetime, request that we pay the Proceeds under one of the following settlement options, We will also use any other method of payment that is agreeable to you and us, including a lump sum payment, In the event a death claim arises under this policy, settlement shall be made as outlined in the Interest From Date of Death provision on page 8, -Interest Payments- (Payment of interest on the Proceeds at such times and for a period that is agreeable to you and us.) Withdrawal of Proceeds may be made in amounts of at least S l00. At the end of the period, any remaining Proceeds will be paid in either a single sum or under any other method we approve. -Payments for a Specified Period- (Monthly payments for a specified number of years.) The amount of each monthly payment for each $1 000 of Proceeds applied under this option is shown in Option 2 Table. The monthly payments for any period not shown will be furnished upon request. Option 2 Table PAYMENTS ~OR A SPECIFIED PERIOD Number of Amount of Years Payable Monthly Payments 5 817.91 10 9.61 15 6.87 20 5.51 25 4.71 30 4.18 OPTION 3 -Life Income- (Monthly payments for the life of the person who s to receive the income.) ,We will require satisfactory proof of the person's a_cie and sex Pavments can De guaranteed for either L~fe, 10 or 20 years, or as the Guaranteec~ Return of Policy Proceeds." The amount of each month y payment for each S 1,000 of. Proceeds applied under this option is shown in Option 3 Table. The monthly payments for any ages not shown will be furnished upon request. Option 3 Table LIFE INCOME MONTHLY INCOME PAYMENTS Guaranteed For Guaranteed For Life 10 Years M AGE F M AGE F $3.84 50 S3.53 S3.82 50 S3.52 4.20 55 3.81 4. 1 § 5,5 3.79 4.67 60 4.17 4.59 60 4.14 5.33 65 4.68 5. 17 65 4.61 6.26 70 5.39 5.89 70 5.24 Guaranteed Return of Guaranteed For Policy Proceeds 20 Years M AGE F M AGE F $3.71 50 $3.47 $3.74 50 $3.49 4.00 55 3.71 4.02 §5 3.73 4.37 60 4.02 4.34 60 4.03 4.84 65 4.42 4.69 65 4.38 5.45 70 4.94 5.02 70 4.77 S510 PAGE 7 OPTION 4 OPTION OTHER SETTLEMENT OPTIONS INTEREST FROM DATE OF DEATH CONDITIONS -Payments of Specified Amount- (Monthly payments of a specified amount until the Proceeds and interest are fully paid.) -Joint and Survivor Life Income- (Monthly payments during the jo nt lifetime of two persons and continued during the lifetime of the survivor.) We will pay the amount retained with nterest, n equal monthly payments, as shown in the Option 5 Table. The monthly payment for other age or sex combinations will be furnished upon request. )tlon 5 Table JOINT ANI~r~-I~/~/I~I~'~'FE INCOME MONTHLY PAYMENTS FOR EACH $1,000 OF AMOUNT RETAINED AGE OF OTHER PAYEE* AGE (FEMALE) OF ONE 15 Years 10 Years 5 Years PAYEE Less than Less than Less than Same as (MALE)* Male Male Male Male Payee's Payee's Payee's Payee's 50 $2.98 $3.08 83. 19 $3.30 55 3. 10 3.23 3.36 3.51 60 3.26 3.42 3.60 3.80 65 345 3.67 3.91 4.18 70 3.72 4.00 4.34 4.72 A{~e nearest birthday. The Proceeds will be paid in any other manner agreed to by us. If the proceeds under this po cy are not paid within thirty days after we receive due proof of the death of the insured, we will pay interest on the proceeds from the date of death to the date of payment. The interest rate will be determined by us, but never be less than 3%. In the event of the death of the nsured, the proceeds payable under this policy shall include the refund of all premiums, f any, paid beyond the month in which the death occurs, f the refund of premiums is not paid within thirty days after we receive due proof of the death of the Insured, we will pay interest on such refund from the date of death to the date of payment. The interest rate will be determined by us, but never be less than 3%. Proceeds of less than $1,000 may not be applied under any settement option. We may change the payment frequency if payments under an option become less than $20. A corporation may receive payments under a life income option only if the payments are based On the life of the Insured, or a surviving spouse or dependent of the insured. If a settlement option is requested, we will prepare an agreement to be signed which will state the terms and conditions under whch the payments will be made. This agreement will include a statement regarding the w~thdrawal value, if any, and to whom any remaining Proceeds will be paid following the death of the person receiving the payments. A beneficiary may select a settlement option only after the Insured's death. However, you may provide that the Beneficiary will not be permitted to change the settlement option you have selected. SB§10 PAGE 8 PROCEEDS EXEMPT FROM CLAIM OF CREDITORS To the extent permitted by law, no payment of Proceeds or }nterest we make will be subject to the claims of any creditor. Also, if you provide that the option selected cannot be changed after the Insured's death, the payments will not be subject to the debts or contracts of the person receiving the payments. If garnishment or any other attachment of the ~ayments is attempted, we will make those payments to a trustee we name. he trustee will apply those payments for the maintenance and support of the person you named to receive the payments. RATE OF INTEREST Options 1 through 5 are based on a guaranteed interest rate of 3.0% using the "1983 Table a" Mortality Table with projection. SC510 PAGE 9 TERMINAL CONDITION ACCELERATED DEATH BENEFIT Limited Life Expectan0y You may elect to receive a portion of the Policy's Face Amount in a Single Sum Benefit, when the Insured, specified on page 3, has incurred a Terminal Condition while the policy is in force. There is no administrative fee for this benefit. When we receive your request and proof satisfactory to us that the Insured has incurred a Terminal Condition we will pay the Single Sum Benefit to the Owner We will make payment when all of the terms and conditions of proof have been met and subject to the conditions and limitations within this benefit. We will provide a Benefit Payment Notice to the Owner when we receive proof satisfactory to us that the Insured is diagnosed as having a Terminal Condition. The Single Sum Benefit may only be elected once. Payment of the Single Sum Benefit will result in reductions of the Policy's values and benefits, as described below. The Single Sum Benefit is equal to: The Policy Face Amount in effect on the date the Single Sum Benefit is paid. MULTIPLIED BY The Election Percentage. A percentage equal to no less than 25% but no more than 50% of the Policy's Face Amount, subject to a maximum benefit of S250,000. If the maximum benefit of $250,000 is paid, the election percentage w ll equal $2§0000 divided by the Policy's Face Amount. This coud result in an elect on percentage of less than 25%. DIVIDED BY {1+ i), where i equals the greater of (A) or (B) on the date the Single Sum Benefit is paid. {A) equals the current yield on 90 day treasury bills; and (B) equals the current maximum statutory adjustable Policy Loan Interest Rate. MINUS Indebtedness, Percentage. Benefit Reduction REQUEST FOR ACCELERATION Request Forms Proof of Termlnsl Condition if any, at the time the Single Sum Benefit is paid, multiplied by the Election The Policy's Face Amount and indebtedness, if any, as those amounts exist on the date the Single Sum Benefit is paid, will be reduced by the Election Percentage. At the time of payment we will provide you with revised policy spec f cat on pages which reflect the reduction of all values applicable to the Policy and all benefits it provides. The Request for Acceleration may be given to us any time after the date the Insured incurs a Terminal Condition as defined on page 2A. This request must identify the Insured and be sent to us at our Home Office. We will send request forms to the Owner when the request for acceleration is received. If we do not send the request form within 15 days, the Owner will be considered to have complied with the Proof of Terminal Condition requirements by giving us a Physician Statement acceptable to us and a written statement of the nature and extent of the Terminal Condition. Written proof of the Insured's Terminal Condition must be received by us at our Home Office before we will make a Snge Sum Benefit payment. This Proof will include a properly completed request form, unless as described above, and a Physician Statement acceptable to us We may request additional medical information from the Physician submttng the statement, or any other Physician providing care to the Insured. We will not unreasonably withhold our acceptance of Proof of Terminal Condition. All benefits described in the provision will be available as soon as we receive satisfactory Proof of Terminal Condition. AD255 PAGE 10 Physical Examination Payment of Acoelersted Benefits We reserve the right to have a Physician of our choosing examine the Insured, at our expense, prior to making a Single Sum Benefit payment, in the event that the Physician we choose provides a different diagnosis of the Insured's medical condition, we reserve the right to rely on the statement from the Physician of our choosing for acceleration request purposes. All terminal condition accelerated benefits will be paid to the Owner. Upon the death of the Owner, if other than the Insured, we will pay the benefits to the estate of the Owner. BENEFIT CONDITIONS Consent for Benefit Payment Payment of the Single Sum Benefit is subject to the following rules: (a) You must complete a form provided by us, signed by the Owner; (b) The Policy or an eligible term rider must not be within one year of expiration or endowment at the time the benefit is requested; (c) If there is an irrevocable beneficiary or assignee, they must consent in writing to payment of this benefit; (d) Your Policy is not eligible for this benefit if: (1)the Terminal Condition is the result of intentionally self-inflicted injuries; (2) the Owner is required by law to use this benefit to meet the claims of creditors, whether in bankruptcy or otherwise; or (3),~ou are required by a government agency to use this benefit to apply rot, obtain, or keep a government benefit or entitlement; and (e) You must provide Proof that the Insured has met conditions under the Benefits provision, including an attending Physician's Statement and any other proof we may require. We reserve the right to seek a second medical opinion or have the Insured examined at our expense by a Physician we choose. We must obtain written consent from any irrevocable beneficiary and any assignee on record before the Single Sum Benefit is paid. An assignee's consent is required only to the extent that benefits paid would reduce this Policy's values and benefits below the amounts assigned. ADB25§ PAGE 11 lUl® LIFE INVESTORS INSURANCE COMPANY OF AMERICA Home Office located at: 4333 Edgewood Road N.E., Cedar Rapids, Iowa A Stock Company (Hereafter called, we, our or us) 52499 ADDITIONAL INSURED LEVEL TERM TO AGE 95 LIFE INSURANCE RIDER This extra benefit Rider, attached to and made a part of the Policy, provides as described below, term to age 95 life insurance on the Additional Insured. We agree to pay the death benefits to your beneficiary when we receive due proof at our administrative office of the following: 1. The death of the Additional Insured under this Rider. 2. The Additional Insured's death occurred while this Rider was in force. 3. The Additional Insured's death occurred before the expiry date of this Rider. ADDITIONAL INSURED The Additional Insured is the person shown as the Additional Insured on page 3 of the Policy. ADDITIONAL INSURED'S AGE The Additional Insured's age at the Additional Insured's last birthday, unless we state otherwise. EXPIRY DATE The expiry date means the Rider anniversary following the Additional Insured's 95th birthday. AMOUNT OF DEATH BENEFIT The amount of death benefit payable for this Rider is shown on page 3 of the Policy. is payable in addition to the proceeds payable under the Policy. This amount TERMINATION This Rider will terminate on the earliest of the following dates: 1. The expiry date of this Rider. 2. The date on which we receive your written request to terminate this Rider. 3. The date the Policy is terminated, exchanged, converted or surrendered 4. The date the Rider or Policy lapses for {allure to pay a premium. 5, The death of the Additional Insured. 6. The date the conversion privilege on this Rider is exercised. Our acceptance of a premium, for any period after the date of termination of this Rider, shall create no liability to us, nor will it constitute a waiver of the termination. Any. premium for this Rider which has been accepted by us after the date of termination of the Rider, w~ll be refunded. THE CONTRACT In this Rider "Policy" means the Policy in which you have requested that this Rider be included. "Page 3 and Page 3A" mean page 3 and page 3A of the Policy. The Insured is the person shown as the Insured on page 3 for this Rider. This Rider is issued in consideration of the application and the payment Of premiums as provided. ARAIR502 39 400 Page 1 of 3 The amount of insurance under this Rider and the premium-paying period are shown on page 3 of the Po]icy. If premiums are being waived on the Policy, then the waiver also applies to this Rider. This rider is part of the policy. Except as stated in this rider, all other policy provisions apply. RIDER DATE Rider months, years and anniversaries are measured from the Rider Date. The Rider date is the Policy date unless a different Rider date is shown in the Policy, or an endorsement attached to the Policy. When used in the Rider, "date of issue" means the Rider Date. INCONTESTABILITY This Rider is subject to the Incontestability provisions of the Policy. However, the contestable period shall as far as this Rider is concerned, be measured from the date of issue of this Rider. MISSTATEMENT OF AGE OR SEX If the age or sex of the Additional Insured has been misstated, the benefits will be those which the premiums paid for the Rider would have purchased for the correct age and sex. SUICIDE EXCLUSION If the Additional Insured, whether sane or insane, dies by suicide within two years from the Rider date, our liability will be limited to an amount equal to the premiums paid for this Rider. if you were a Missouri citizen at the time of issue of the Rider, the following provision will apply The suicide of the Additional Insured is no defense to payment of regu ar life insurance benefits, nor is the suicide of the Additional Insured while insane a defense to payment of accidental death benefits, if any, available under this Rider, unless we can show that the Additional Insured intended suicide when they applied for this Rider. If the Rider or Policy is reinstated, this Section will be reinstated. A new two year period shall apply beginning on the date of reinstatement. If the Additional Insured, whether sane or insane, dies by suicide within two years from the reinstatement date, our liability for this Rider will be limited to an amount equal to the premiums paid for this Rider from the date of reinstatement. REINSTATEMENT If a Rider premium is not received before the end of the 31 day grace period, this Rider will terminate and no further Rider premium payments may be made. However, even if the Rider terminates, during the lifetime of the Additional Insured, the Rider can be reinstated if it was terminated because a grace period ended without sufficient payment. Any reinstatement must be done within 5 years from the end of the grace period. We will require: 1. Your written request to reinstate this Rider. 2. The Additional Insured's written consent to reinstatement. 3. Evidence of insurability satisfactory to us. 4. Payment of all overdue Rider premiums with nterest from the due date of each premium. The interest rate is s x percent (6%)per annum, compounded annually. NON -PARTICIPATION This Rider will not share in our surplus earnings. BASIS OF COMPUTATION The Male and Female 1980 CSO, (S or NS), Age Last Birthday tables were used as the basis for computation. Reserves are not less than the required minimum reserves. PREMIUMS FOR THIS RIDER The premiums for this Rider will be included in the total premium as shown on page 3 of the Policy. If this Rider is terminated, the total premium for the Policy will be reduced by the amount of premium for this Rider, excluding the annual Rider fee. ARAIRS02 39 400 Page 2 of 3 After the. 5th Policy Year, we reserve the right to change the Rider premium for ~ach I:Jolicy year thereafter. The current total premium will never be more than the guaranteed maximum total premium shown on page 3A. Any change in premium will be made on the same basis for all policies in effect the sams length of time, issued to Insureds of the same premium class end issue age. No change in premium class or ~remium will occur due to a change in the Insured's health status or occupation. Each change will be ased on our expectations as to future mortality, investment earning, expense, and persistency experience. CONVERSION PRIVILEGE While this Rider is. in force, you may convert it to a new Policy. The conversigp may be made prior to the esrlier of the Additional Insured's Age 70 or the end of the 25TM Policy Year, if no premium is in default. The following conditions apply: 1. The face amount of the new Policy doss not exceed the amount of insurance under this Rider on the date of conversion. 2. The face amount of the new Policy may not be less than the minimum amount we issue. There will always be e plan available in an amount to which you may convert. 3. You must send us a written request for the conversion, 4. The new Policy is on any Life plan written by us other than Term Insurance. ,5. Premiums for the new Policy will be for the Additional Insured's sex and age as of the date of the new Policy and the premium class as stated on the application for the new Policy. 6. The new Policy is dated as of the date of conversion. Coverage under this Rider terminates when coverage under the new Policy begins. 7. If premiums are being waived under a Rider attached to this Policy at the time of conversion, the premiums under the new Policy will not be waived. If the Rider is converted in accordance with the conversion conditions listed above, the Incontestability and Suicide provisions in the new Policy shall be void. Signed for us at our home office. SECRETARY PRESIDENT ARAIR§02 39 400 Page 3 of 3 LIFE INVESTORS INSURANCE COMPANY OF AMERICA Home Office located at: 4333 Edgewood Road N.E., Cedar Rapids, Iowa 52499 A Stock Company (Hereafter called, we, our or us) CASH VALUE RIDER This extra benefit rider, attached to and made part of the policy, provides a Return of Premium Benefit as described below. We will pay to the Policyowner a portion of the total premiums paid for the policy and any riders when the policy terminates. BENEFIT The amount we will pay equals the benefit as defined in the Return of Premium Benefit Calculat on provision on page 3 of th~s Rider. The benefit will be reduced by any amount paid by us to the Policyowner under a disability rider other than Waiver of Prem um Benefit. Such reduction wll not exceed the accumulation of the premium paid for the D sab ty Rider. TERMINATION This rider will terminate: 1. On surrender, termination, lapse, or conversion of the policy; 2. When any Nonforfeiture Option goes into effect; 3. When the Insured dies; or 4. When the Rider premium is not paid before the end of the Grace Period. Our acceptance of a premium, for any period after the date of termination of this rider, shall create no liability to us, nor will it constitute a waiver of the term nation. Any premium, which has been accepted by us, will be refunded. You may terminate this rider by written request. If you elect to terminate the rider prior to policy termination, no benefits will be paid. If this rider has terminated, you can not reinstate it. THE CONTRACT In this rider "policy" means the policy in which you have requested that this rider be included. "Page 3" means page 3 of the policy. This Rider is issued in consideration of the application and the payment of premiums as provided. The Insured is the person shown as the Insured on page 3 of this rider If premiums are being waived on the policy, then the waiver also applies to this rider. This rider is part of the policy. Except as stated in this rider, all other policy provisions apply. RIDER DATE Rider months, years and anniversaries are measured from the rider date. The rider date is the policy date unless a different rider date is shown in an endorsement attached to the policy. PREMIUMS FOR THIS RIDER The premiums for this rider w l be ncuded in the total premium as shown on page 3 of the policy and must be paid with the Policy Premum Premiums for this rider are payable to the age shown for this rider on page 3. If this rider is terminated, the total premium for the policy will be reduced by the amount of premium for this rider. ARRP0501 39 400 Page 1 of 3 NONFORFEITURE OPTIONS If the policy lapses as provided in the policy's Grace Period provision, the policy will have a cash value equal to the Return of Premium b~nefi[ We will require your written request and the return of the policy if you select one of the two available options below: 1. Cash Surrender The policy may be surrendered for its cash value. The cash value is equal to the Return of Premium benefit. 2. Extended Level Term Insurance If no option is selected, this option will be automatic. Under th s opt on, you may continue the policy as extended level term insurance. The term period wil start on the due date of the unpaid premium. That period will be determined by applying the cash vaue as a net single premium for such insurance. At the end of that period, the insurance will terminate and there will be no cash value remaining. Any insurance provided under the Extended Level Term Option may be surrendered for its cash value. The cash value will equal the net single premium for the insurance remaining. If such surrender occurs within 30 days after a policy anniversary, the value will not be less than the cash value on that anniversary. Deferral of Cash Value Payment We reserve the right to defer payment of the cash value for up to 6 months after we receive your written request. We will pay interest at a rate not less than the minimum rate required by state law, if the deferral period is 30 days or more. Basle Used for Caloulatlona Cash value amounts equal or exceed the values based on: - 1980 CSO Nonsmoker and Smoker Tables; - Age Last Birthday; - Maximum Interest Rate permissible by the Standard Nonforfeiture Law; Death occurring at the end of the policy year. Extended Level Term Insurance Option is based on: 1980 CET Nonsmoker and Smoker Tables; Age Last Birthday; Maximum Interest Rate permissible by the Standard Nonforfeiture Law; Death occurring at the end of the policy year. Policy values equal or exceed those required by the state n which this policy is delivered. A detailed statement of the method used to compute those values has been filed with the insurance department of that state. ARRP0501 39 400 Page 2 of 3 RETURN .OF PREMIUM BENEFIT CALCULATION 1) Multiply the amount for this Rider as shown on the Policy Specificaton Page TIMES 2) Factor for the appropriate Policy Year as shown in the below table TIMES 3) Lesser of current Policy Year or years payable for this Rider as shown on the Policy Specification Page, (Amount shown for this Rider on Policy Specification Page X la) X lb) below for the appropriate Policy Year). The maximum benefit will never exceed the total premiums paid to date. End of Number of End of Number of Policy y~er #Factor {al Years lb) Policy Year aFactor la) Years lb) 1 0% 1 41 135% 25 2 0% 2 42 138% 25 3 0% 3 43 141% 25 4 0% 4 44 144% 25 5 0% 5 45 147% 25 6 2% 6 46 150% 25 7 4% 7 47 153% 25 8 6% 8 48 156% 25 9 8% 9 49 159% 25 10 10% 10 50 162% 25 11 13% 11 51 165% 25 12 16% 12 52 168% 25 13 19% 13 53 171% 25 14 22% 14 54 174% 25 15 25% 15 55 177% 25 16 30% 16 56 ' 181% 25 17 35% 17 57 185% 25 18 40% 18 58 189% 25 19 45% 19 59 193% 25 20 50% 20 60 197% 25 21 80% 21 61 201% 25 22 70% 22 62 205% 25 23 80% 23 63 209% 25 24 90% 24 64 213% 25 25 100% 25 65 217% 25 26 102% 25 66 221% 25 27 104% 25 67 225% 25 28 106% 25 68 230% 25 29 108% 25 69 235% 25 30 110% 25 70 240% 25 31 112% 25 71 245% 25 32 114% 25 72 250% 25 53 116% 25 73 255% 25 34 118% 25 74 260% 25 35 120% 25 75 265% 25 36 122% 25 37 124% 25 38 126% 25 39 129% 25 40 182% 25 ~The factor will increase proportionately from with this benefit amount upon your request. the end of a Policy Year to the next. We will provide you Signed for us at our home office, SECRETARY RPTB0501 00 400 (25) Page 3 of 3 PRESIDENT AMENDMENT OF APPLICATION . I, Edward A Werner, hereby amend my application to Life Investors Insurance Company of America dated, January 16, 2001 as follows: If Insured is a Juvenile enter name here~ Have you or any Proposed Insured EVER been diagnosed as having or been treated for AIDS, or AIDS Related Complex (ARC) or tested positive for the AIDS virus? NO I hereby agree that these changes shall be an amendment to and form a part of the original applicat%on.and of the policy issued thereunder, if any, and that they shall be binding on any person who shall have or claim any interest under such policy. I declare that there has been no change in my occupation, residence, or family history, that I have suffered no illness or injury, and that no company or association has taken adverse action with reference to my insurability since the date of my application to Life Investors .Insurance Company of America. "'I declare that I have ~igned a copy of th%s amendment a part of, the policy issued on this application. DateO at ~j~ this I& day of attached to, and made , f AP~ANT TO BE ATTACHED AND MADE PART OF POLICY NO. #110-012643018 R208-280 PLEASE ~ETURN ONE COPY TO THE HOME OFFICE ~ BUSINESS DEP;uRTMENT Home Office, 4333 [dgewood Road NE, Cedar Rapids, IA 52499 PROPO~D INSURED INFORMATION , Name (Rrst, M.I., Last)~j ~ _ I Home Telephon~ No._ ] Work Telephone No. ]Bir~Dat¢~.BidhPlace(Stat~Country) l S,o~i~l Security No. or ~ ~D. No. H~ght (r] Weight ] Marital Status ] Sex U.S. Citizen If no, give immigration status/type of visa: ~'o~I ~o I ~ I /~ ~Y~s ~ ~o Occupation, Dut!e~, and ANnual Income from Emplpyme0t Monthly Mo_¢gage Payment Haveyou used any tobacco within the last 12 months? ~Yes D No Ifyes, list type and when used last ('ur~/~ BENEFICIARY ANB RELATIONSHIP TO PROPOSEB INSURED (Unless otherwise noted, the beneficia~ of ~the~ p~o~s pm~gsed for Coverage will be the proposed insured.)~/~ ~ ~ OWNER(S) Name Address (Unless otherwise noted, the Owner will be the Insured, For Florida applicants, you may name a secondary addressee to receive notice of possible lapse in coverage- complete the Additional information section.) //~/~ Relationship to Proposed Insured Social Security Number Birth Date Phone ) POLICY INFORMATION · ~.-Ultima Home Protector (5 year guaranteed premium) ] [] Ultima Home Protector Plus ~;~'Level Amount of Insurance Planned Premium 'Term Plan: Number of years (term period) [] 15 [] 20 .(:~,25 [] 30 Mode of Payment (for bank draft, complete Check-O-Matic authorization, and initial payment required.) ~ Monthly Bank Draft O Quaderly O Semi-Annual O Annual Total Amount Paid in Exchange for Receipt $ 'No coverage will be effective in accordance with the terms of the ADDITIONAL SENEFITS (Availability varies) ..',',',',',',',','~L Additional Insured Rider (fill out table below) O Child Rider (fill out table below) © Disability Income Rider Monthly Payout $ Receipt and unless full initial modal premium payment is submitted.) ,~Relurn of Premium Rider Unemployment Benefit Rider Waiver of Premium Rider (term only) Other: Name of Other Proposed Insured(s) Birth Date, Sex Height Weight Social Security Relationship to Amount of Used Tobacco in Number Insured Insurance last 12 months? Yes I~J~N o Yes ~1 No Yes [~ No Yes I~ No INSURANCE IN FORCE :(Ihdlcat~ AmoufTts) '' :,,i, , ~:~.~.!, : . , ~. ., Insured's Name Company / Life Insurance PERSONAL PHYSICAN(S) Name of Proposed Insured fi40fl RRO0 Personal Physcian(s) Name, A~dress. Phone Number / Date Last Visited. Reason. Result COMPLETE THE FOLLOWING For YES an~ ~, give full details in the space provided on the n, age. 1. Will the insurance applied for replace or change any existing insurance or annuities? Have you or any proposed insured, 2. Had any health, disability or life insurance pending with another company? 3. Been declined, postponed, offered a rated or modified life, health or disability policy or been denied reinstatement? 4. Within the past 5 years, been cited or convicted of a moving violation, including DUI, or had a driver's license suspended or revoked? (If yes, provide state and drivers license number.) 5. Within the past t0 years, been treated for or diagnosed by a health care prolessional as having: (Ifyes, circle applicable condition.) a. Any disease or disorder of the blood or circulatory system (such as: beart disease, palpitations, heart murmur, or chest pain, high blood pressure, stroke, anemia), respiratory system (such as: emphysema, asthma, shortness of breath or sleep apnea), brain or nervous system (such as: seizures, epilepsy, multiple sclerosis, mental illness or Alzhe'mer s d sease), urinary tract (such as: kidney or bladder), reproductive system, stomach, intestine, liver (such as: ulcer, colitis, Crohn's disease or hepatitis), endocrine system (such as: diabetes, thyroid), or muscles or bone (such as: arthritis, back prob ems, lupus)? [] Yes []Yes' ~No [] Yes [~ Yes No b. Cancer, cyst, or tumor? [] Yes No c. Currently on any medication or being treated for any cond t on, not listed above? [] Yes ~) No d. Used drugs (such as: hallucinogens, barbiturates, excitants or narcotics) except as medication presciibed by a physician, or been treated or counseled for drug or alcohol use? 6. Within the past 5 years, [~ Yes ¢ No a. Had or been advised to have a check-up, consultation, lab test, EKG, X-ray or other diagnostic test. [] Yes ~ No b. Been or is now fully or partially disabled? · [] Yes No c. Been charged with or convicted of any lelony or been on probation? [2 Yes ' No Please complete the AIDS question for Ihe state the application is signed Jn as indicated in Ihe Authorization section. If Ibis state is not lisled, answer lhe first question. .1) Have you or any Proposed Insured EVER been diagnosed as having or been treated for AIDS, or AIDS Related Complex (ARC) or tested positive for he AIDS virus? For applicanls in: 'l'~ 1 Have you or any Proposed Insured EVER, been diagnosed as having or been treated for AIDS, or AIDS Related Complex (ARC)? I CALIFORNIA ~ Have you or any Proposed Insured EVER, had or been told you/they have AIDS, or AIDS Related Complex (ARC), or been tested for HIV antibodies for the purpose of obta n ng insurance? I CONNECTICUT ] Have you or any Proposed Insured EVER, been diagnosed as having or been treated for Acquired immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or AIDS related conditions? [ FLORIDA I Have you or any Proposed insured EVER, tested positive for exposure to the HIV iofection, or been diagnosed as having ARC, or AIDS caused by the HIV infection? [ GEORGIA, HAWAII, ILLINOIS, NEW JERSEY1 Have you or any Proposed insured EVER, been diagnosed as having or been treated, by a member of the medical profession for AIDS, or AIDS Related Complex (ARC)? I MAINE J Have you or any Proposed insured EVER, been diagnosed as having or been treated for AIDS, or AIDS Related Complex (ARC)? ANSWER THIS QUESTION NO IF YOU HAVE TESTED POSITIVE FOR RIV AND HAVE NOT DEVELOPED SYMPTOMS OF THE DISEASF AIDS. [ MARYLAND, MASSACHUSETTS, NEW MEXICO, and NORTH CAROLiNAJ Have you or any Proposed Insured EVER, been diagnosed as having or been treated for Acquired Immune Deficiency Syndrome (AIDS) or AiDS Related Complex (ARC), or tested positive tor Human Immunodef c ency Virus (HIV)? MISSOURI, OHIO1 Have you or any Proposed Insured EVER, been diagnosed as having or been treated tot AIDS, or AIDS Related Complex (ARC) or tested positive for the HTLV-III test? NORTH DAKOTA J Have you been diagnosed or treated by a member of the medical profession as having AIDS, ARC or the HIV infection? VERMONT 1 Have you or any Proposed insured EVER, been diagnosed, by a person licensed as a medical physician, as having or been treated for AIDS or AIDS Related Complex (ARC)? WASHINGTON I Have you or any Proposed Insured EVER had or been treated or diagnosed by a member of the medical profession for immune deficiency disorder, AIDS (Acquired Immune Deficiency Syndrome) or ARC (AIDS Related Complex) or test results indicating exposure to the AIDS virus? WISCONSIN J Have you or any Proposed Insured EVER, been diagnosed, by a member of the medical profession as having or been treated for AIDS, or AIDS Related Complex (ARC) or tested positive for the AIDS virus? Tests for HIV/AIDS must be limited to FDA-licensed blood test. Test results received at anonymous counseling and testing sites or from home test kits need not be disclosed. l~Yes []No []Yes [2No E~Yes []No []Yes ~No [2Yes ~No []Yes []No E~Yes E~No [2Yes E~No [2Yes [2No []Yes ~No [2Yes [2No [2Yes EqNo ~Yes [2No ADDITIONAL INFORMATION Explain all "y~ ,nswers below Question I Name of Details NumberI Proposed Insured (Diagnosis, Dates, Durations) Medical Facilities &Physicians Names, Addresses, Phone Numbers · * LIFE INVESTORS INSURANCE COMPANY OF AMERICA FRAUD WARNING The following states require that insurance applicants acknowledge a fraud warning statement. Please refer to the fraud warning statement for your state as indicated below. I~,]~mnili~nl~ ARKANSAS, LOUISIANA ~- Any person who knowingly presents a false or fraudulent claim for payment of a Joss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. I ill I~'1 IJ PI I [~lil k~l III COLORADO ~ It is unlawful to knowingly provide false, incomplete, or misreading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include impdsonmenl, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Depadmant ot Regulatory Agencies. Im]m~nll~h]~ FLORIDA ~ Any p [son who knowingly and w~th intent to ~njura, defraud, or deco ye any insurer files asta emant of claim or an application ~ontaining any false, incomplete, or misleading information is gui~ of a felony in the third deg/r..e .e~.,~ ~]./')~ I_ .~-'"'x ..L~/ /~ · ,,,~,,;,m*,,,61G~ KENTUCKY, OHIO, and PENNSYLVANIA (~--~_~/~_~' ~/~z~ ..J2_.~.C.~)~ ~ A ~, ~., j/~.../d~/...~ y person who knowingly and with intent to defraud any insuraone company or other parson files an application for iosul~/ose or a statement of claim containing any materially false information or conceals for the purpose of misleading, infon'nalion concerning any fact matedalthereto commits a fraudulent insurance act, which is a crime and subjects such person to edminal and civil penalties. li,J~l,],].~mk'llil MAINE, VIRGINIA and DISTRICT OF COLUMBIA ~ It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. I in I~,1 m ] IT~RITii.'i u i MINNESOTA ~ A person who flies a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. lt"'"Ip,m'm..m,! NEW JERSEY ~ Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. ~la,~uum~,mC~11~ NEW MEXICO ~ ,,~ ~ Any person who knowingly presents a false or fraudulent claim or payment o a DSS or benefit or knowingly presents false infor~TO~in an mmn ~.~nn application for insurance is guilty ota cdme aed may be subject to gnus and criminal penalties. ~j tA, N ~)~)~ ' Under penalties of p~rjury, I hereby certify (1) thai lhe Social Securily or Taxpayer I.D. number above on Ibis applicafion is c~Jrrect and ,(2) lhaf I am currenlly nol subjecl to backup wilhholding. [Cross oul (2) if not correct.] See below*** The statements and answers on this Application are true and complete to the best of my knowledge and belief. It is agreed that (a)'this application and any amendments hereto, shall be the basis of any insurance granted; (b) no agent has authority to waive the answer to any question in the application, to pass on insurability, to waive any of the other Company's rights or requirements or to make or alter any contract; (c) acceptance of any policy issued shall constitute ratification of any endorsements in the space entitled "For Administrative Office Endorse- ment,'' except that no change in the amount, classification, plan of insurance or annuity, or benefits shall be effective unless agreed to in writing by the Applicant, and (d) no insurance or annuity shall be considered in force unless and until a policy shall have been issued by the Company and said policy manually received and accepted by the Applicant and the full first premium paid thereon, all during the lifetime and before any change in the insurability of any person proposed for insurance from that stated herein. The Company shall have sixty days from the date hereof within which to consider and act on this application and if within such period a policy has not been received by the Applicant or if notice of approval or rejection has not been given, then this application shall be deemed to have been declined by the Company. Unless otherwise stated the undersigned Applicant is the Premium Payor and the Owner of the policy applied for. AUTHORIZATION: I authorize any licensed physician, medical practitioner, hospital, clinic, medical or medically related facility, Medical Informa- tion Bureau, the Veteran's Administration, or other health care provider, my employer and any consumer repoding agency or insurance company who possess information concerning any care, treatment or advice rendered to me to provide such information to Life investors Insurance Company of America, its representatives or its reinsurers. A photocopy of this Authorization shall be considered as valid as the original, which I or my authorized representative may receive a copy of upon request. Life Investors Insurance Company of America, or its reinsurers, may release this information about me to its reinsurers, to the Medical Inlormation Bureau or to another insurance company to which I have applied. This authorization is limited to a period of 30 monti)s commencing on the date of this application. I represent that the foregoing statements are complete and true to the best of my knowledge and belief. I understand that the date coverage becomes effective for any policy applied for on this application will be the date recorded on the Policy Specification page, not the date the application is signed. I understand coverage will be effective when the first premium is paid, provided all persons proposed for insurance are acceptable to the company under its rules and limits as s~andard risks, on the plan and for the amount applied for and the rate of premium declared. I authorize payroll deduction of tile premiums, and 'acknowledge receipt of the MIB Disclosure Notice and Fair Credit Reporting Act Notice. The Internal Revenue Service does not require your consent lo any provision of this document other than the certificalions required to avoid backup withholdirlg. Signature of Proposed Insured day of -~'('"/ ,; month Sign at u r e/o~",~d d i"ti~o n al Insured year Signature of Applicant if Other Than Insured ~ Owner [] Other Best time to call for a personal history interview Signature of Parent or Legal Guardian for Insured's 15 and under p.m. Okay to contact at work? Yes [] No,l~r ~Ji~'ature of Agent (Print Last Name) Agent # Telephone Number Split Agent Signature (If Applicable) (Print Last Name) Agent # Telephone Number Do you have any knowledge or reason to believe that the insurance applied for will replace or change any existing insurance or annuity? Yes [] Ni~ If yes, what company? Policy # SUMMARY OF POLICY BENEFITS DEATH PROCEEDS EXTRA BENEFIT RIDERS The amount payable to the beneficiary is the total of the following amounts determined on the date of the Insured's death: PLUS PLUS MINUS - The face amount of this policy (see page 3). - Any additional insurance on the Insured's life provided by an extra benefit rider (see page 3). - The part of any premium paid which applies to a period after the Insured's death (see page 8). - Any indebtedness (see definition, page 2). The extra benefits, if any, listed on page 3 are fully described in the extra benefit riders that are attached to this policy. YOUR RIGHTS During the Insured's lifetime and unless otherwise provided in this policy, you have the exclusive right to assign this policy and to exercise every right, privilege and option this policy grants or that we allow. Some of your rights are: - To change the owner or beneficiary, (Change of Owner and Beneficiary, page 5). - To change the frequency of premium payments. (Payment Intervals, page 5). - To reinstate the policy after lapse. (Reinstatement, page 6). - To receive policy proceeds as income. (Settlement Options, pages 7, 8 and 9). - To convert the policy. (Conversion Privilege, page 6). To exercise any of these rights, or to apply for the proceeds or any benefits under this policy, communicate with our nearest representative or directly with our home office. Please notify us promptly of any change of address. BR669 PAGE 12 Life Investors Insurance Company of America Home Office located at: 4333 Edgewood Road NE, Cedar Rapids, Iowa 52499 LEVEL TERM TO AGE 95 LIFE INSURANCE POLICY CONVERSION PERIOD SPECIFIED ON PAGE THREE TERMINAL CONDITION ACCELERATED DEATH BENEFIT FACE AMOUNT PAYABLE AT D~ATH PRIOR TO EXPIRY DATE NON -PARTICIPATING Page Assignment .................................................................................... 4 Basis Used for Calculations .......................................... 6 Beneficiary ..................................................................................... 4 Change of Owner or Beneficiary ........................... 5 Contract ........................................................................................... 4 Conversion Privilege ............................................................. 6 Definitions ...................................................................................... 2 General Provisions ................................................................. 4 Grace Period ............................................................................... 5 Guaranteed Premiums .......................................................... 3 Incontestab ty ........................................................... 4 Indebtedness .................................................................. i ............. 2 INDEX Page Interes{ from Date of Death ................................................ 8 Misstatement of Age or Sex., ............................................ 4 Nonparticipating .............................................................................. :.. 6 Paym(~nt Intervals (Premiums) ................................................ ,5 Payment of Proceeds ................................................................ 7 Policy Specifications ..................................................................... 3 Premiun~s .................................................................................................. ,5 Reinstatement ....................................................................................... 6 Settlement Options .............................................. ~. ....................... 7 Suicide Exclusion .............................................................................. 4 Terminal Condition Accelerated Death Benefit. 10 Please examine your policy and the attached copy of the application carefully. Contact your agent If you desire additional services or Information. - If you change your address, please notify us at tile home office giving your full name end policy number. -Your policy la · valuable asset. For your own protection, let us advise you regarding any suggestion to terminate or replace this policy. B669 CERTIFICATE OF SERVICE I, R. Mark Thomas, Esquire, hereby certify that I am serving on even date herewith a copy of the within Complaint on the Defendant as prescribed by Rule 403 of the Pennsylvania Rules of Civil Procedure by depositing a true and correct copy of same in the U.S. Mail at Mechanicsburg, Pennsylvania, Certified Mail, Return Receipt Requested and Regular First Class Mail, Postage pre-paid, addressed to: Life Investors Insurance Company of America 4333 Edgewood Road N.E. Cedar Rapids, Iowa 52499 Date: ! R. Mark Thomas, Esq. KAREN A. WERNER Plaintiff PENNSYLVANIA LIFE INVESTORS INSURANCE COMPANY OF AMERICA Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, JURY TRIAL DEMANDED PRAECIPE TO DISCONTINUE TO THE PROTHONOTARY: Kindly mark the above captioned matter as settled, discontinued and ended. Respectfully submitted, Attorney for Plaintiff ID#41301 101 S. Market Street Mechanicsburg, PA 17055 (717) 796-2100