HomeMy WebLinkAbout94-01443
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CINDY L. RIGG,
now CINDY L. RIDGE,
plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
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CIVIl. ACTION - LAW
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NO. tfl.f -- I Lj L/3' f {).'.- --.it 'l-~N
v.
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ARTHUR W. HARRIS,
Defendant
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NOTICE .tQ...J.2.El'END AND ..QLAIM RIGHTS
YOU HAVE BEEN SUED IN COURT, If you wish to defend aqa1nst
the claims set forth in the fallowing pages, you must take action
within twenty (20) days after this complaint and Notice are served,
by entering a written appearance personally or by attorney and
filing in writing with the Court your defenses or objections to
the claims set forth against you. You are warned that if you fail
to do so the case may proceed without you and a jUdgment may be
entered against you by the court without further notice for any
money claimed in the Complaint or for any other olaim 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 FINO OUT WHERE YOU CAN GET LEGAL HELP.
CUMBERLAND COUNTY COURTHOUSE
Court Administrator
1 Courthouse Square
Carlisle, Pennsylvania 17013
(717) 240-6100
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~OTiCJA
Le han demandado a usted en 11,1 corte. ai usted quier.
defenderse de estas demandas expuestas en las paginas siguientes,
usted tiene viente (20) dias de pla?o al partir de la techa de la
demanda y 11,1 notifico!Icion. Usted debe presentar una aparienoia
esorita 0 en persona 0 por abogado y archivar en la cor.te entorma
escrita sus detensas 0 sus objeciones alas demandas en contra de
su persona. Sea avisado que si usted no se defiende, la corte
tomara medidas y puedo ontrar una orden contra usted sin pr.vio
aviso 0 notiticacion y por cualquier quoja 0 alivio que eE pedido
en la peticion de demanda. Usted puede perder dinero 0 sus pro-
piedades 0 otros derechos importantes para usted.
LLEVE ESTA DEMANDA A UN ABODAGO 1NMED1ATAMENTE. SI NO T1ENE ABOGADO
o 81 NO T1ENE EL D1NE:RO SUFIC1EN'rE DE PAGAR TAL SERV1C10, VA'iA EN
PERSONA 0 LLAME POR 'I'ELEFONO A LA OFIC1NA CUYA D1RECCION SE
ENCUENTRA ESCRtTA ABAJO PARA AVERtGUAR DONDE SE PUEDE CONSEGUIR
AS1STENC1A LEGAL,
CUMBER1,AND COUNTY COlJRnlOUSE
Court Administrator
1 Courthouse Square
carlisle, Pennsylvania 17013
(717) 240-6100
Respectfully submitted,
D, SWAR Z & MORGAN
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DATE I 5-23,q4
BYI
JA
I. D.
InCH
I. D.
111 street
P.o. Box 889
Harrisburg, PA 17108-0889
(717) 234-4121
ATTORNEYs FOR PLAINTIFF
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/usr2/wp/tdl/MHP/rigg.comp
CINDY L. RIGG,
now CINDY L. RIDGE,
Plaintitt
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
v.
CIVIL ACTION - LAW
ARTHUR W. HARRIS,
Defendant
c,,,..1 Ti frY)
NO. 9 L/ / '-1/1.3
COMPLAINT
AND NOW, comee the Plaintiff, cindy L. Rigg, now cindy L.
Ridge, by and through her attorneys/ Hepford, Swartz & Morgan/ and
bringe a cl.aim againet the Defendant, and in eupport thereof
alleges ae followsl
1. Plaintiff, Cindy [I. Rigg, now cindy L. Ridge, is an adult
individual who reRides at 129 Mulberry Drive, Mechanicsburg,
cumberland county, Pennsylvania.
2. Defendant, Arthur W. Harris, is an adult individual who
resides at R.D. #1, New Bloomfield, Perry county/ Pennsylvania.
3. The facts and occurrences involved in thie matter took
place on or about June 10/ 1988.
4. Defendant purchased a life insurance policy from
Jefferson National Insurance company of Indianapolis, Indiana, on
August 4/ 1972. Said life insurance policy was labelled >>217661>>.
A true and correct copy of said ineurance policy ie attached hereto
ae Exhibit "A".
5. On June 10/ 1988/ Plaintiff and Defendant entered into
a lega11 y bind lng agreement.
A true and correct copy of said
Agreement is attached hereto BS Exhibit >>8".
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6. According to the aforementioned Aqreement, Defendant, as
the Obligor/was to maintain the aforementioned life insurance
policy with Plaintiff, as the Obliqee, irrevocably de8iqnated a8
the sole beneficiary of the life insurance policy. See Exhibit "8"
attached.
7. Plaintiff, in the summer of 1993/ became aware that
Defendant canceled the aforementioned insurance policy on Auqu8t
27, 1991, without notice and without information.
B. said action breached tho agreement entered into by
Plaintiff and Defendant on ,June 10, 1900.
WHEREFORE, Plaintiff, cindy L. Rigg, now Cindy L. Ridqe,
requests that this Honorable Court enforce the contract by equity
or at law.
In the alternative, Plaintiff requests that this
Honorable Court order Defendant to pay Plaintiff the face value of
the policy at the time of termination.
In the alternative,
Plaintiff requests that this Honorable Court order Defendant to pay
Plaintiff the amount due under the policy at the time when
Defendant turns 65 years old.
DATE I 3 -23 ~11
HE
By I ~ Jill};' li
JAM s~~
I. NO. 06097
MI IAEL H. PARK
I. . NO. 60952
111 North Front street
P.O. Box 889
Harrisburg, PA 17108-0889
(717) 234-4121
ATTORNEYS FOR PLAINTIFF
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Exhibit A
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...JEFFERSON NRTIONRL
LIFE INEiU~F=lNC::E C::OMPF=lN'"r'
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PALJL. W. EI8ENHALJItR-S.ICIAL. AOINT
10K '7
MICDLIIU"O, ,.INNIVL.VANIA 17'"
'HON'I ..11..11.3
''''DlA'''Il~m.~.r .~r:..\'" 4..04
For the Ooo.14Ir.tloo ot.
Arthur W. B...rll
mS\I\A1fOE,SAVINOS,ANJ) mrSIOI PLAI
~41.telT lnto )'Our oa.b aooount.............................12,768.00
Plu. Oheoll: 10. :Ii tor all dhid.lld. and intll'..t Itter 2Ild ,.....
In tw.nt, ,..... tbl. will inorla~. to..........................14,139.60
TRD fftO(IUM WIll. om '38,30/..00 '1'0 YO\l\ BlRlrICIARY r<B AJlITYPI
,"CCmrPWI RIa.
At "1 65 )'Our OABH ACCOUNT will be...........................16,827.50
Wltb . oapltal nit ,aiD ot..........................,......... 6,339.60
At .,. 65 )'OU will reolhl . I<<)NTIILY LIPI mOM ot '105.04.
Tbi. 11 III U1Dual lnoOM ot 11,260.48.
-You woul4 ba.... to plaOI 10 IIl1 other t1Jll .aviOI' oVlIr 140,000.00 to
.aII:e '1,260.48. In ord.r to .a.,. '40,000.00 in tbl .... perlod TOu would
b.... to .a.,1 '851.06 per 'Iar.
A rAMILY fftOTlXlTIO\f 1lrJ/lV'n' KAYBE ADDED TO THIS PLAB AT TDIIl ar tUlUUA4!
WHICH COVlRa TIll liD'! ANJ) ALL OHIUlRUf.
THIS PLAIt HAS A WI1VJ'.a at DIP06n' J'Cl\ TOrAL DISABn.rrr.
-You ba". )'Our ow OUARAlt'I.'DD MaN PWi whiob lOU .., .uppl...nt to TOIlS'
own 41.1re4 inoo...
-IDolud.4 in th..1 11luetratlon. .re DIY1dlnd Aoouaulatlon bal14 on our.rent
D1Y1d.tl4 SoalA and rate ot inter..t. Tbe.l.re IlIUbel' l.t1u.te. DOl' IUlIl'lIlt...
ot D1v1d.IDd. pqab1e in tuture ,......
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POLICY IPICIPICATlONI
l'LAII 0' INIIJIIANOI-IAIIO 'OLIOV
ANNIJ~ ,IIIMIIJM
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ORDINI\RY LIFf:
$190.43
IOMIDULI 0' ADDITIONAL IINIPlTI ell provldod II~ Itllohl. o.,.,,,,,nll)
Am"n' DI..rt,Uln Annuli "I,",UIII
$25,536
r-CCIDF.NTflL pEI\TIl
WflIVER OF PRF.MIUM
$31.92
$ 4.22
IOMIDULI 0' 'IlIMIUMI (lnolud...1I oddltlon.llI,n,nll provldld II~ .tllohed ..,.'m,nll)
Annul' IIIIII-AnnUII QUlmrt, SPECII\L MONTHLY
$226.57 $116.93 $61.05 $20.00
DATA IILOW THII LINI lllLAT11 TO lAlla ,OLIOY
""'1' HUIII"'
IMIIM
217661
flRTlIUR W. HI\RRIS
$12,760
I'IlIow DI"
InuI All
I\UGUST 4, 1972
18
STflNDI\RD
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",,"lulII 'IWlnl 'IrtH LU'BTIME OF TilE INSUlUm
Mer
Th. In.ured, unl... odl.rwlll .ptel/I.d In
dI. oppllcadon, .lIbltct to chonl' II pro-
vldtd In dll. policy.
'.nllltlory
A. nom.d In lh. oppllcadGn\lUb1tct to
ch.n.. 01 provldtd In lhl. pol cy.
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GENERAL PROVISIONS
THI CONTRACT
!hll policy I. IlIue,1 In (()n,hle"lIun of the ~ppli<ilUun .nd
payment of Ih. pr.miulll'. 'J'hh policy .'hlth. ilpplk,'tlon for
it, a IOpy of whkhls ~It.,hed to aild llla.l. apMlof the polky,
mn,lItul. th. .ntir. "'otw'l. ^" .t.t.men" made hy ur fur
tho lnaur.d .h,,1I he ",n.ldored repreaontilt;on. 1111.1 lIot W~r'
"ntio,. No ,t.temoilt ,h~1I ~void thl, pnllcy or he u,od In
d.fon,o of ~ d,lim unlo.. it I, mnll.inod In tho wlllloo "pl,li.
cation and ~ "'py nf tho "ppllCiltion II illt"hod 10 thi, 1'0 icy
whon I..u.d.
1'hll policy .h~lI not t"ko dlod until It h", hoell doli vere,1
"n.l Iho first premiilm p"i,1 .luring tho lifetimo "nd (()ntlllue.1
InluNhility of tho in,ured, except iI' otherwi,e plOvidod III
th, IOceipt with the ,...no lIumher " tho "ppliciltioll.
ALTERATION 0' CONTRACT
!hll contr.l<t Ciln he "ltorod or ""Y of it, provl.lolI, Or rO'luire.
mont' willvod ollly hy tho wrlllon "gr..moot of the COlllpilllY
lignod hy tho 1'1OI1.lont or " Vieo Pre,idonl, ^ctu.ry, S<'I(~ilI1
or ^"I"ilnt So"et~I'Y,
BUIOIDI
II' Ihe i",ured .Iie, hy .ukhle, whllo ,~ne ", In501no, within
twu 1e.,,, (rl1lll tho p"licy .lillO, tho "mount p"yahlo hy Ihe
Cl1lllp"ny und", Ihi.. policy ,h.ll ho Iimltod to the "lIIl1unl
of the prelllluln' p"i,l.
INCONTUTAIILlTY
Thi. polky will be in"mtea'"hlo .iter It hilS beon In force
during tb., lifetime of tho In,ure,1 for two reilll fmm ill
pulicy d,lte, except for nonpilymont of premium,.
MISSTATEMENT 0' AGE OR SIX
II' the n"u,qd', "go or sex has b<tln mlsstat.d, ilny ilmuunt
p"y"hle h1 the Comp"ny will ho ,uch IS Iho premium, 1',,1.1
would h,lVe 11\ll(h~..d ,'t tho Comp"IY" puhli.hod ,~to at the
poli,y d"to (ur tbe COllect "go and lex.
POLICY ANNIVERSARIES AND POLICY YEARS
Policy ,\l1I1ive""rie. "n.l policy yem, "forred to in thl, policy,
,billl b. compute,j from the pnlicy .Iale.
PREMIUM PROVISIONS i'
PAYMINT Of PREMIUMS NONPAYMENT Of PRIMIUM
Premlom, arc pay"blo on 1lI ho(ore their du. dilte lit tho Homo
om" of the Compilny or to iln "uthorl...1 agont of tho Com.
pilny, but only In ox<h"ngo for iln official receipt ,ignod hy
tho President 01 Socret"ry and counterslgnod by th. porson
"'dvlng ,uch pil1mont. Tho first premium II duo on the policy
date. 5ub..quont premium, illt dllo ilt Ihe oxplr"tlon of the
, period for whkh tho pre<<dlng premlulll wa, 1'''''1.
Premlullll are p.y~ble for the number of yom ,hown on tho
"Policy Spoclflciltion." pilgO bllt no p"mium will f~1I duo
a'tor ih. .loath uf tho Inlur.d. If an ago i. Ihown ill tho
period p"yahlo, thon the premium period will ox tend to tho
policy ilnnlverlillY n...lOIt the blrthdilY on which tho Insured
aualnl th.t "{I,O. If a part of tho premilllll under Iho provl,lon,
of an attilche,j ~gr.omont "ue, to ho p"1ahle, the pr.llllllm.
Ihlll thon bo redll"d a<<ordingly.
CHANGE IN MODE OF PAYMENT
Premium. nh'y h. pal<l ilnnuilll1, ..ml'''lnllillly, ,)","ter/y, 01,
ill Iho optiun I1f lho Com p"ny, monthly. Ch"'lgo from one
mo.lo tl1 ~nl1the, (uth.r thalltl1 ml1nthly) m,'y b. 111,1.10 with.
out fllrmal rl'clu('~t ur utller r('(lulrcmc.'l\hi howevl'r, the llut'
tlllt.: of Ml annu~tl premium mUi\t be 011 ~\ POllfY MHlivcrlIiHY,
Ill" duo .I,ll.. III premlulll' (or ,hortor perll1.1. nlll,t b. Il"h
dut U111' l)( thr)5c prcmiufH:\ will bm:nl1lt: ,Iue nil l'rllh jloli,y
lann!vcuilry.
'O"M "..
AllY prollliulll not p"ld on or bofo" It, due dilte will be ill
dof"ult. Thl, puJicy ,hIli termin~to If any premium rem"ln.
ullp'lhl "ftor tho oxpiriltion of. tho grace period and Is not
p,,'d by "utOIll.tiC I'"mlll~~ 16.ln, IX"pt a, provld.d In th.
Nonforfoiture Pruv,lon..' '".
PREMIUM ADJUSTMENT AT DIATH
l'h..t portiun of any premium which apPI!~Il'l~~mfld *"y.Jr
tho p"licy month In which the In,ured ~I" i lit rePf\n~ ~
.11 p"'t of the 1"0"'''.1, to tho bellofidarf. " ',' .
GRACI PERIOD
^ny prollllum ilfter tho first I. In dofault If It remain, unpaid
~ft., it, dll. d"to, hut a g'"'' period of thlrty.one day., duro
Ing which the policy will continue in filICe, will b. allowed for
p~yment of .u,h premium. If tho in,ured dlel on Ihe due date
"' during tho 8r~ce period, ~ny premium duo will ho paid
frolll the pr",oo,1I of tho policy.
REINSTATEMENT
If tlm I'ull,y h,!' nllt beon ,ullondo,.,I, It m"y bo reln'liltod
w,th,ll ,\ 1e"" ~/ter dof~ult In p~Ylllcnt"f premium Upoll pros.
<lIt,'tiOIl uf eVhleoce "f in,u,ahllity IlItl,fwo,y 10 th. Corn.
I',my, p,'YIll.nt "f .11 overduo premium, with compound
Intere.t "t no Ill"rr th'lIl 6% per y..r ilnd pilym.nt"r reln,t"lo.
l11<nt .)( ,my hhlchtodnt.. on tho polley.
Pago )
OWNERSHIP AND CONTROL PROVISIONS
OWNIRIHIP 0' 'Olley
Whll. the InlurN II IIvln,. th. owner may nerel.. ovol}'
policy rlllht .nd tnloy ,v'l}' policy privll.~. wlthuut the con.
Itnt of Ih. Inlurtd or of .ny revocahlo hon.ficlary or con.
tl",tnt owner,
Any ben.fit p.yable at the dClth 01 tho IllIurrd will ho paid
to th. beneficiary .nd not 10 the OWllor, u,lIo.. utherwiso I'm.
vldrd,
CHANG I 0' OWNIItIHIP
Durin, th. IIf.llm. 01 the Inlurrd .nd whllo Ihla policy la
In fore., Ih. owner m.y be chana.d, .nd '0 Ions u tho owner
I. not the Jnlurtd, . conllnl"'t owner may ho d..l,nllod or
chlll,td, by lIlIna writ/en no/Ire In . form Sltilfoetory to the
CompIIIY, At .ny lime th. Jnlurrd bc.:om.. the owner of thl.
policy, .ny prrvloul dOllan.lion 01 a cnntlngont ownor ,hall
be void,
The ./feetIVl d.te of . new d"'gn.llon will ho tho dato tho
notl" I. .Ianod II the Comp'"y acknowledges In wrltlnll the
rtcelpt of IUch notlre, whether or not tho in,ured or owner
JI .livo at the lime of the ICknowlodgmont, .ubJ.ct to tho
rlllhh uf any collll...' 4I.lgntt uf record. .nd auhjoct to .ny
p'ymont ma,'o or olher actlun takon by Ih. Compauy l,.forq
tho acknowlodgmrnl.
\JJ~1Il tho .loath 01 tho owner while bofh Iho hllured an"tho
conllnllont owner arr living, all rlghll, titlo .nd hllere,t 01 tho
Owner of thl. policy Ihall VOlt in the co"llngent owner. .uhle,t
10 tho right, of ilny mll"to,,1 a"lgnre.
'\ CONTROL 0' POLICY
'''"-,
"'tt"'t~ A.r.,ured II a minor "..I thejllClt on lor tiha lOlIcy
I, ltt'l.."".a premium payor hy 10 III P
,u"J,~h~omlulll pay'" Ih.1I . 0 r
right or 1'~J'I4f ,4l"nto.1 to tho I I ,
Iho Inlurr" r~ I :''In of ag.. In , " a
uid premium p~~" r 10 tho Inlurtd'l .tt.lning tho .go
of ~ I YOilrs, conllll f.Jl'l~oJky ,h. II VOlt In th. fint of tho
followlog who II lIvl $;4IfgallY IIpahle: tho Inlurrd'a
gUiHdlan, lather, mother, ~"" 01d,1I bentfielery. Whon
tho Insured attalnl tho ,g. 0 21 ""'J}, tho Inlured without
tho COllsont of tho prrmlum r.ayor o1'l>.ii'0/iclal}' II enlitlod
to e,,1}' honofit, right or prrvi e/lo glillll,iT th~y thl,
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BENEFICIARY AND ASSIGNMENT PROVISIONS
IINlflCIARY
The Interest 01 .ny hon.ficl.ry who .II.. hofore the Insure,1
1ll.1l termln.tt .t the death of the hon.ficlal}'. 11th. intorest
of all desl,n.ted hon.licl.riCl hI! terminated, any pro"od.
p.y.bl. b.<luo. 01 the dClth 01 the In,ured will b. 1'.1.1 to
the then ownlll 01 thll policy, II liVing, oth.rwlae to tho
.Xcculor or admlnlllrilor of the owner,
Tht Company may rely on .n tllid.vlt by any person r.lallng
to the tXillenee, Idenllty, rtl.lionlhlp and olher f.et, conc.m.
Inl tach .nd IIV.ry honefiel.l}'. II. beneliel.1}' II a parto.rship,
.uch benefiel.1}' Ih.11 be th. p."neuhlp II con,titut.d at tho
dndl of the Inlured.
To th. ext.nt permltt.d by law, no p'ymont of procreda Or
Intertlt Ih.1I be lubject to the c1.im, 01 any crodiron 01 a
beneliel.l}', or tn any I.aal procm .galnll a honoficlary.
CHANGE 0' IIENEflCIARY
A chang. 01 bon.liciillY may h. mado only hy 1IIIOg ,
.i1I.hetol}' wrlt'.n nolln with Iho Company. A honefidary
..... .....
.Iesignatod Irrevoc.bly may not bo ,h,og.d o~cept with the
wlltton consent of that bono~d"y. ^ chilngo of bono~dill}'
Ihilll nut be .lIodlvo until ,,<0,.1..1 at tho homo ollico 01 the
Company. Wh.n '0 recordod, .ven if tho In,u"d il not then
living, lh. chang. of hono~dal}' .h.lltako o/T.et on tho .lat.
tho notice was .Ignod, lubjtct to any payrn.nl mado hy tho
COlllpilny b.(o" r<'Cordlng tho ch.ng..
ASSIGNMENT
No mi/lnlllont olthi, policy will bc hindinll upon th. Corn.
pilny un 1m in wrlth1!! I10r unfil ('/,,1 "t the HOll1e Ollice
uf Ihe C:ull1p"ny. Tho Comp"ny ".\.\UIII"I nn Il,.ponlihlllty for
Iho v.Ji,Jity uf ,ny illli/lllln.nl. Any Min!! of iln il.\.llgnmont
,lull ho without prejudice tn Ihe Cump"ny on il'COUnt of
"ny p;.ymont ma,'o by it priur t,) ,u,h fiJin!!. ^ny mi/lnm.nt
w,i1 bo ,"hJoa to .ny ilhlobl.dnell u" tho poli,y. II iln as.
Slgnment i, ahllllule, it will not .,Icelth. IhtcrClt of any benr.
ficiary. If 'n ~"lllnn1<'nt I. ,oll~lml, tho mllat.ul as.I/lnre
Will have prinrlty 10 tho extent 'II hi.llllcr..t over t~e intcr..t
of any henofidolry.
PallO 6
SEnLEMENT OPTION PROVISIONS
,Ullt N.'
Pog. 6
81nLlMENT OPTION PROVISIONS
OPTIONI
Subjcel to th. followlna provlllonl, the wholo or any part
(but In no m.1e.. th.n U,OOO) of tho proroeds ,Iuo tho
pAy" In ""tlemont 01 tho policy may be mado pily"hlo In ac.
cord.nct with on. 0, a comhlnatlon of tho lollnwlnH option.,
or In Iny other manner lareed upon with tho Company.
I. In.om.lo, FI.teI P.riod, Payahle .. a monlhly, quarlerly
0, onnu.1 Inmme for th. number 01 YOiln olected. not
mort than thirty, each payment U d.dared by tho Company
but not 111II th.n that determined by tho appllcahlo tablo
on th. followllla pai',
2. Llle Inrome with Period CArroln. Payablo IS a monlhly
Incom. for th. period mtaln Oloded and u long thereafter
u the payte may live, oach paymont IS dodared by tho
Company but not 1m than that dotermlnod by the appli.
cabl. table on the follow Ins page. The pcriod wtain may
he 10 yem, I' yoan, or 20 yo.n, 1'ho Company will re.
qui" ..lilladory evldenct 01 the ago of tho pilyee.
3, Int.....t Incom.. Loft with tho Company during tho life.
time of the poyte or lor a lpeclnod pcriod, with Interest
pay.ble at luch rate u the Company may d.dare, oot 10..
thon 2111% pc' year.
4, lncom. 01 Fbtel Amount, Payablo u " monthly, quar.
terly or annu.llncomo 01 the ilIllount elo<led (but not less
th.n "0 per year per '1,000 01 proceed. applied) until the
procttd., with Intomt at ludlllt. II th. Company may d..
dart, not lell than 2111 % pt, year, 110 exhaulted,
,. Llf. Income with In'lIl1m.nt Rtlund. Payablo IS a
monthly Incomo for. pe,lod ,uJliclent to refund the pro.
end. applied under thll option and II IonS thereafter u tho
paY" may live, .ach pAyment II dedared by the Company
but not 1.11 than that determined by lb. applicabl. table on
Ih. followlns paae. Th. Company wlll require latllfactory
tvldenct of the 'i' 01 th. payte.
6. Joint .nd Survlvo, Llf. Incom,. Payahl. II a monthly
Incom. during Ih. joint lifetime of two pilyee', o"ch pilY'
mrnt as dtclared hy tho Company hut not I", th.n th"t do.
ttrmln.d by tho applicablo t.ble On tho following pilgo,
Mto, th, death 01 either payoo, tho ilmount 01 oach p.y.
mont will be two thlrdl of tho lolnt Iifotlme pilymont. Such
reduced p.ymont wili continuo for tho Iilotlmo 01 Iho
.urvlving pilyoe. The Comp.ny will require wl,'actory evl.
dence 01 tho age 01 o.ch p.yee.
,0"'" N.?
ILICTlON
Nu ..ttlomont option will he avall.bl, .xcept with conlCnt
ul the CAlmpany If the policy I. ullan'" or If th, pay" /I
a ClI'I'",atiun, modallon. plltnenhlp, trult" or rllato. Ill".
tlulI of "n optiuo or challgo of an elcelion may he mad. In
tho 'amo manner" a chango of benonclary, II no .Icello/! II
III oll"t on tho lottloment dato, tho P'Y" m.y at that tlm.
milk. illl e1ectioll.
CONTRACT AND PAYMENTS
^ lupl'loment.ry contract Itatlnstho terml of lettlomont under
tho option el,<Iod will bo IlIued to the pay...
Tho frr,t paymont under Option I, 2, 4, , or 6 will be mado
and tho right to intereat under Option 3 or 4 will accrue II
01 tho d"te tho procoodl of tho policy would olherwllO hcrome
payablo.
If "ny monthly ur quartcrly paym.nll to any pay.. would
amount to I... than '20 each, tho Comp.ny may chilngo the
p"ymont' to . lell frequont b..ll.
BALANCI AT DEATH
If at tho death 01 ony pay.. there II no IivinS penon d..lgnatod
to recolve .ny remallling paymenll, tho Conlpany will pay In
a .Inglo som to luch p.)'."'I"..t.te any btJance of the pro.
md, bolng hold under: Option 3 or .. with accumulated In.
terOll theroon or tho valuo of any remain InS Income pAymentl
cerlain undtr Option I, 2 or " commuted on tho b,,11 of In,
tm,t at tho rat. IIlumo.l In dotoonlnlna the amount of the
incomo p.ym'nt.,
PROTECTION 0' PAYMENn
No p"yeo ,h.1I have the right to commuto, 1II1an or oncumber
.ny of tho paymontl unlell ,uch r1aht Ilalven In tho IClectJon
of the option, and, to the extont permitted by law, the pay.
menta ,hall not be ,ubject to dalm. of credlton nor to leaal
proce...
EXCElS INTEltlST
In ilddilllln to Iho payments guanntoed under ony Itlllemrnt
option, OX".. Int.rest m"y bo paid or crodlte,l at .ny time
"llhe di.mlltlll0f tho (llmp~ny.
Page 7
SETTLEMENT OPTION TABLES
MO"lhl~ Inoom. p., '1,000 01 PIOOtt'.
OPTION I OPTIONS 2 and 5-UI. Inooml
Inooml lor
PI.,d '"Iod "" Im.un' of 'num, I. b.... In Iht ... In'" ." ".".., bh1hd.~ If U" p,~" In thl ",f. If Iht "'11 ,.~ml"l,
~."'" - ~'--'-'-'--'-- .-.-.-......, -- -, -,--- ,----'--,---",--, '.-..-..-...- -. ,- . - ,-.- ._~~-
1I'.I~ll I.. .., q. 'UIOD CUr~IH au In. "I' 'UIOO DI~r.IH
1/ 1/ ,.,.. .._-.-+...._-----.-.__.-... " If "W'" ""'__H'__ .. _ _ ..__.._ ..______.._ '_n _._--,.,,-
,..,. I,...", II , " VII" " Vu" 10 VII" '''''m'' II , n Vu,. "Vu,. II y..,. It."",.
.__.._-----._~- --.--- ---_..- . ....... .-, P. .__ ___~ f----.-..,.- ------".___.. _._-_.._~---~
t ~:I 'J "U" a... 1:'1 HI I'} ~ it HI 1:~ HI lfl
u. a.1 1'1
161 au I, 1:
,69 16 U 2.16 I. 1.41 d
.71 .7 a.7C UI .10 ..
J Il:l If ~ m ':!I I.Il 1:II it II l~ lH Ii~ l:~
i:a
a. d II 1.1 ..7 U
II II ~ ~ I:~ Ul w I'u II ~ UI i:~ HI j:;
a..:
ut
~ il ~ I m all Ui 1.11 It II [U I:U .~ i:~
I.
i:n j.9 l'
:8. 1.6. .: . U
I I:~ I II If I:~ I'C' r I It In !:~ 5,0'- !:~
Il .il7
:d :!l ..! !:
f,i U H
I m I I 1:1 I:!! 1:" J.j~ Ii ~ r m m
Pi .Jl
HI .1
.I. "1
..
I ft HI ul l~~ I:l~ II Ii j:i lUg' HI
r
rc~(1 I.cam. I. .. sa j:l~
' llm.. the .6 ,.
Mont I~ Income. II ./1 .64 ,II M ::M,l.
Oll.r'.rl~ I ncom" B H 1'" r': HI III it II ..1). '-.",me't JO
.N
I, 2.884 ttm,. thl tU I:!g
monlhlv lncom.. :!! t Th'~' iml)~nt. o~ Income
IpP ~ ,',e) I) tH. I' .....
0.. .0' ~I'
1/
I'a'1 ,.~.
OPTION I-Jolnl .nd Survivor UII Inooml
n, .m.w,U I' I""m. I. .....d on 'hi nil Ind "1 nll'u' bhthd.~ of uch .f 'hi P'~'" 1"lhl .,1, .f .", f1r'llfI~m."I.
.U Iftll AI' ."nlurl" -i;i..in~-__..- --'-'--i..-.nd.... .;.'j~,Ur~--
.f
II'" 1101. II... 1101. "'.11 11./1 11..0 lalnl ,.,.. 11.10 II." 11.'0 II." 11./1 11./1 II'"
'01' '01' ,... 'oil ,./0 ,.,1 ...0 ,... II' '010 ,,11 '010 ,." NO N. '.10 ,...
.
t
1: f.
h. ,:1
1: l~ lU 1:;1 '1:1 U
1: !: 1:1~ 1:1 1:1 ".l!
i: ,: i:y" d !:u 'IU
. . . 1.1.. '1
. . · II t '
I: i: i,nI6:u1
: I: I: I:i\ .:~ :11
. ' . "ll" '.11
. . .. I. .. ..
, , , IS. 6.) e.6
. I.. i~ ..01 .} I}
, I., J! 6.1 6.11 I.,~
10 II 'j.! "'1"'1! "'1.1-1 II. "'f t.2J
tl. l 1 I' I' i'f U . '1
II I .: i':a : I : .: l:' : :
Ii \ l I'~ hi' t.~' 1:1 :: : :
! I i. j' i'l .. 6. . . .
I I I:":' j: :: : : : :
I I~ . I . U . . . I'
':11 I: :8!: : : : :
II i:lr.n tit ::1 :1 :1 :l .
· i.i'!, :.R . .1' . . .
i U hi .:U .:I. U.,! :!c I:!! !:
Income'OJ' olhltf combln.tlonl or .... will be rurnllllld on request. M .M.le f~'nl.l.
"It"... N."
l)~go 8
NONFORFEITURE PROVISION"
rgaM ".7
Page ij
~..
f' ~
I
I
I
I
I
NON'ORfEITURE PROVISIONS
CASH VALUI DEPlNITIONS
The I.rm "lnl,,1 f~,h v"rue" iI' used in thl.!ulky flh,,1I ",o"n
the cuh valuo (il' .Iefiued in Ih. Da.i, u Valu.. mtlnn)
plu. Ihe cuh value n( any eNI.tlnll divl.len,1 ad<litiulll ",,1
dividend accu",uliltiun,. 'l1,e I"'" "lIet ca,h v"IUt" il' u,ed
In Ihl. policy ,h,,1I '''.In tho totd cilSh v"lu. I... ""Y in.lcbto<l.
nCII tel the Company on Ihl, polky.
SURRENDER fOR CASH
^t any lime while the in.ure.1 i, living thl, pulky milY h.
surrendered h) the Comp"ny (ur II. ntl cash v"lue. If Iho
policy I, .urronderod within 61 ,lily, after tho ,Iue .t"o uf "
premium In <lefillllt, the nel ...h v~loo will he ,let"nllu,,1 iI'
of .uch due .I"t.. If Ihe pulicy j, In (oreo ., p.hl.up 1/I.ur"'K.
or 11.I uten.led twn in,urilnco and I. ,urrondorod withl/l \1
daYI aft" a pulky onnlv"suy, its cash villlle ,h,1I bo the ',lIno
u the mh v"luo ilt 'Ucll pulicy anniversary,
The Compilny milY ,Ief" p"yment of "ny net ""h v"lu,' fur
nolmore than 'IX monlh, but wlll.lluw Inlemt "I /lot 1m Ih"n
2Vl~h 1''' ye", if pay",ent I, deferred fur 30 ,IJY' ur ",ore,
PAID.UP NON'OR'EITURE OPTIONS
If a premlwn in default I, not paid hy Iho en.1 uf the 8'"ce
llerlod hy "UlOllliltlc premium lo~n or ulherwi.., ~ny /lot c....h
value will he "pplle.l ilutom.tlc.lly as a net .Iingle pre",iu",
on the due d~te of ,u,h premium In default to nllltl/lue the
policy, ududl/lg '/lY [leneflts provided by "uilCho.l '8'oe.
/mnla, under one uf the following opllu/l51
a. P.ld.up In.uran..-JII nlls POLICY IS Df'SIGN^TI1l>
^S SPECIM. PREMIUM CL^SS ON PM", .\, Itlhilll
conllnue as partlclpaling pald.up Insur"nce uolc.., wlthl/l
62 daya a(ter Ihe due dilte o( Ihe pre",iulll 1/1 .lcf'lUlt, It
Illurrondered for II' not rash valuo. The pilld,up Irllurp/I..
will b. of tho kind provlde,l by thl, pullcy, fur ,u,h lovol
ilmoonl as tho net ca.h valuo will pureh,...o ,11 tho then
au.lned aile of the In.ured,
b, Extended Torm h...ur~/lce. ,II' TfIIS POrKY IS rWSICi.
NATl!I> ^S S1'^NO^Rll I'RFM!lIl11 C1.^SS ON PMiE
3, it ,hall ro/lti/lue ~, /lu/l,pilrticip"U/lg exlo/l,lcd I.,,,, hI,
&urllr1cC' unlcul within 6l 11~IY~ il(h'r the lllle "lltC 1)( the
prrmlum in ,ll'L1UIt, il Is aurrent!t'rcI) (ur ils lIl't (.uh v"I\ll'
ur cfcdiun i~ lIlJ.llc 10 1I111tinuc the POIlI Y MI Il.lrlldl',llin~
lli1hl.lIp itUlIfilllU.',
The IlUlQUnt o( clttl'ntft'd !crlll ill.1llr.tIlt(.. .\11,111 hl' till' F,Ul'
Amnu,,! dwwn un pil,ltl' .~. innrlur" hy Ihl' lllllount or
dny ,livhlt'I1,1 'llrulUul,lliIIlU 1U1l1 .livldl.'l1d ihlditiom lllld
t1l'rrcllu't1 hy 11ll' ,1Illounlnr MIY, i'hl['hll'dlll."~ 011 thl.' /llllllY
Thl' pl'ril)a! o( l')llcllllc.-,1 Il'rn\ lIl~lH,lllll' I~ IIIl'II'IH(,'1 "'1I1Il
'0'"'' NoI41l
tho ,llIe ,1,'1" IIf Iho unpAhl promlum on.' will ho (01 th,
nlllllh,'r IIf yom illlll ,I~YI which the net Cil.h v~luo will
p""hilSO ill the Ib<'ll "1I,,lned "Ile o( tho In.nro,l.
The Pilld,up lI111llallCC "/'ti"n will roplA" the oxtend.d terlll
lIUUrJIIU: nprum ,(, 011 t 1C' llJle to which p'tmlum~ "" F."ld,
IlIIu,,,,,,e IIf .1I o'lu.1 or g,o"ter llIIlount i, thereby prov ded.
BAliS 0' VALUII
C,"h V.rllleI ilr<' mmpule,1 by the Stand.,,! Nonforfellure
V"luo Metlll1d (oxdudlng ony benoflll provided hy dividendi
IIr ,1l1,IChed ilgrcernellh), u,ing the nonfurfellure (aeton
.thlWII III the 1'.hle of Villuel. The cuh voluo of any pald.up
lIuur,ulre or c)llclIJrd trrm inauuncr ih.1I bit' th~ ntt .lnSI.
prelllillm for ""h illlur,,"ce ilt the .IIAlned age of the lnlurcd.
't
Net .in~le pr.mium, "nd prel<nl values of nOIl(orfolture fac.
tOil ",. determined "t pnlky ~nlllverml.. ac<o"lIl1g 10 og'
IIwe.t hirth,I"y, will be proporlioo"te At other .IAtol, Alld
il,e b,lIr,1 Oil the Commllllonen 19\H StAndArd OrdinArY
Mort,'litr T"ble (ox..pt thai tho net .Ingle premluml for
o.ten,lo, torm insUlin.. "re hued lJ/l the C.ommllllonen 19\8
bten,led Torm In.u",n.. T.ble) ",umlng (a) Interest At
2Yl7o per yeAr ilnd (b) de"th, occur At tho elld of Ihe
policy year.
^ det"lIed ,t.lle/llent of the melhod of oleolaUng the val~CI
I". beon fllod with the In,urllll" lupervl,ory official of the
,t.te In whid) Ihl, polll}' Is delivered, and th..e values Are
nol 1m th,," thOlle IC<lulro.l hy tho law of ,uch Itate, Values
for yo", not ,hown In the Table of Valu.., computed In the
IIlilllllcr de",ibed In thl, par"grilph, will he (urni.hed on reo
'luClt to tho lIome Office,
TABLE 0' VALUII
The v"III" for Ihl, policy ilro ,hown III the TAhle of Valu"
for tho <IIlO ,'ollO,pll/hling to the Issue a8e of the Inlured.
V~lu", ",e ,huwn (or the end of Ihe policy year In,lIcated on
the ,1I,umptlon thill I'rollllum' hilve h.ell 1'.1.1 to the end of
thM ye"r "nd ,hilt thOle ilro no ,lIvhleo,1 "e.llt, or Indtbtcdnell,
The "..h v"luc ~t ilny time within il policy yeAr will be deter.
II1lned by the CompAny with allowilnce for the Ume elApaed
III IIlIh ye", ",,,I fur tho 1'0,10,1 premium, h"ve been paid.
Cl,jh v,lhl." "nd pAhl,up 1'lIu"n.. v"lu.. ,hown are per '1,000
or r,ltl' ltmllllnt, hut thC' pl'rilHI uf exlt'Ihlr:d term huurlincf it
the "lIno fllr <lilY (~.. ilnblUnt. Whore iln ilgo I, shown In the
...11111111 ho.",,"d "I'n,1 of I'ulicy Year", the villu.. arc thOle
<'I'flli,."", ,Ii the fI"r"y <Innl'e,,,,,y no",o.t Iho hlrtl"l~y Oil
whidl "ll' inm't'11 IHtJim thllt lt~c,
Addltlllll,11 hl'flCC!h, i( IlIlY, pflIyhlcll hy lIJ.(rCt'l11rnt Ilt!,ld1rll to
,lIld IIM,de pMt 1)( 11m roller !IIJII nut Inrrr:II~f: the v~1I11c5 of
lilt..' POh,y 1I1lku ~l) I'rl)'rhl"'l ill the ,1,l(rf~r:lI1c:llt,
1''''''0 ~
POLICY LOAN PROVISIONS
LOAN VALUE
'I'h. 10.11 valu. ,hall he Ih. 1<11.1 ..nh v,llIe (.. de/ill,d ill the
NOllforf.iture I'rovl,ioll').
POLICY LOAN
^t .ny tlm. whll. th. p"l"y i. ill ("rl. eNl.pt .. .Nlellded
I,"n in.unlll(c~ anll hill i1 IUoll! "JI\It" the Cumpany will Illdll
.ny .um lI"t eN,..dillglhe 10'" v.lue ~t I/l< lI.xl p"liLY ,""i.
v,nary, ur thu Iniln VI\lUe: ,It Ihe next premium llue ,I.&h.' jf
oarher. ^"y ~xl'lllIg illd.hledllm "" Ih. 1"Ii,y, ,illY pl'lIIilllll
.Ju., .11.1 Int.",t t" the lI<Nt p"'IIY il'"l1VL'rury w.1I b. d.dud."
from th. 1'",(...11 of th. 10'". 1'h, ....,/It "f , l..h 1".11 or
thl tt'qLJClit (or an l1UIUlI1illk premium IWl ",lull wmtitulc
'"lgnm.nt of the policy.. ",urity whll. the I"illl II III elred,
The Company m.y defer aoy I"all, ,~h.. th.1I il I".n I" pilY
premium, on polkl.. of th. COlllp,ny, for not 1II0re tholl, ,ix
month..
LOAN INTI REST
Intereat will be .t not more thall 6~'" p.r y.ar p.y,bl. III ild.
vance Oil the dot. of the I"all .".1 "" ...h ,,,Ii,y illlniv.lIilry
",hll~ the loan i. III ell"t. ^ny interest ""t Pilld when du.
",ill be 0.1,1.,110 the hlan and be", int.r"l .t Ih. 'illlle rat..
In dot""nllli"g Ihe Ind.ht.dnm at ."y dot., credit will b.
.110.....1 for .IIY int.reat (harg.d fOI' the p.rlo.1 f"'lII.u,h .J.te
to the lIext policy onnlve,sary.
INDt:8T1DNI8S
Any InJellte,lneu to tht Comp.lI\Y on ih:nHIIH II( or 5('(UrCll
by thi, polic)' will he d..Iuct.d ill '''y ..Uklllelll her,ulld.r.
RIPAYMENT 0' LOANS
AllY lII(fc:hl(.'iIIU'U m.lY "1,.' ICI'Jhl In whlllL' or in I'Mt 011 any
lilliI.' whHc Ihl' imillu'" h hvin,L(llIhlllcfort' 1111: l,.'Jhlllf thl.l WJl.C
Pl.'fllli! IIf ,I IHL'lIIHlIlI Ifl dd,lull, F,lIhHL' II) rc.'JlolY i,hl'lhlcdm:u
1)1\ IhL' POlhY or II) P,IY 10,11I IlIlt'rl:~t ,hJII tl:rmin,lll' th... polity
when "uth IIhll;'hlC'd/ll..'.\'I C.':Hl":115 th... IaMlI VJluc:, bllt only dle.'r
IhirtY'llJH,' \IJY~ lIuliu.' In 111.11 ,,-,,rl'd III 111.1I11.'11 hy the Cllmpany
10 thr: IJ~I knuw" Jlldll'~~ III the.' lIWlll'r Jlhl Ill' JflY Juil(nct
of rr:tlJhl.
AUTOMATIC PREMIUM LOAN
'l'hi. provi.ioll ,hilll I", ",r.,live if rO<Ju"le,1 III the .1'1'1"0'
IIUII or by riliog wrillell 1I0tl... at 111<' lIom. Ol"co of lhe
Cum POllY, .nJ will ..CillO to be .1I.<live if r.vok.d hy filing
wtltltn notice Ilt the lIome om,e,
Whil. Ihi, provi,ioll i, III 011.<1, if " pr.mium olher than a
IIhllllhly premium r.m.illl ""1"101 .t Ihe .0.1 of the grace
1"110,1, il WIll be /,.i.1 aUlum.tk.lly ., uf it, ,Iu. .lat. by
llIe.n. uf . 1"Ii.y o.n, provid,d th. .vilil.hl. 10.11 value i,
,ulfici.nl. If the ",.il.hle lo.n vol". I, nol ,uJlici.nl to pay
th. unp.id premium hut" .uJlicient to p.y ilt I.~,t on. qu~r'
I('rly pr.mium, ,uch fr.'lion.1 I".mium will bo 50 plhl. In
'''' "II. will ~ l"Omllll1\ fur lea. t 1~1I nile 'I""t.r b. paid un.J.r
thl. provi.inll, If Ih. .vail.ble In.1I v.lu. i, ill.",rlllent tu pay
,t Ieil.t ~ 'Iu.rl.rly pr<miom. th.1I Ihi', pnlicy ,h.1I termlnat.
~uhle't tn the nonforfeiture pro'flsion.'i
DIVIDEND PROVISIONS
ANNUAL DIVIDENDS
1'hl. I, a pilIlicipolilll,l policy. It, ,hare, if .ny, of .livi,ihl.
lurplu, from th. pilllICipolinll bu.in... 01 Ih. CnmpallY will
bf determine.J .nnuillly by the Comp.ny ,nd cr.dit.d ., il
.Jlvi.J.n.J beginning not later than th. .nd of the third policy
year.
Each diviJ.nd may b. oppli.d unJer on. of the follnwing
01'11011', but If no olher optioll I". h..n oI'ded wlthill ,\ I
d.y. aner allY .Jividelld I, cr.dite,l, the ,livld.'hl Will b. ilpplie.1
un .lor Optioll ~.
l. Ca.h.--P...J in mho
2. Premium I'ayment-^I'pli.d toward paym.llt of .IIY 1".-
mium d"e on th. policy, If the r.m.ind., nf the l"omlulll
I, p.id wllhln tho grace period; olherwi.. th. drvi< .n.J will
he applr.d U'I.Jor Option 4.
~. Dividend ^ddldonl.,^p/,li..1 III pOl<h..., .t net 'ingl.
premium '.tea, a p~rtidp' ing p"d."p Icvol ;Id,htinll tn th.
amount uf il)SUrllIlCe, Pilyable I1t tilt sl1l11e time d.lhl under
the ,.m. londitl"," " Ih. f". omnunt of Ihl, policy.
4. Dlvld.nd AccumuIOllon.,.,r..ft In """mulill. .t int.ll'Sl.
lnter.,t .hilll be <I.dite.l ,\I1I1"illly .t , 101. In he ,'elcrr1\ille,f
by the C",np.ny, hut n,,1 I... liun lVl~IJ per 1e",.
CASH VALUE 0' DIVIDENDS
^ny exi.t1"g divl.l.nd ildditlnn, u, aWlIllulatlulI' m.y be ,,,,.
re.'uden'a! ilt JII}' time (llr their r,.Jsh 'f.l.lue, provided they h~v('
not h('('1I lI.j1phcd uudcr tllle o( the lIon(or(elhH(' opfiom lUlll
ire nol rr:lllllCed 11.$ IiClurllY (or II. 11l,ln, The ('l'Ih \'l1lue of dlvi.
dend ilaldi 10115 will he rtlU~11 tll Ihe net Iiingle prl'I1IlUm (nr
'OIU" '" I"" Pllge t ()
IIlCh .d,lition, at tho dilte of IIl1lOn.ler, but uut I... Ihan the
drvi.J.n,1s ilpplied. The "..h villu. of divid.n.J ~((ul1lulotlon'
.h.1I b. Ihe ~wullul~t.,1 v.lu., including int.r.,t.
DIVIDEND AT DEATH
II Ihi, policy l11ilture, hy tho ,Itath of tho insured, .ny onop-
plied divid.nd arId illl ..i'ling divid.nd addition, and 1(.
<lIl1lul.tion, ,hall be p.yabl. with .nd ~, a part of the pIOC...J,
"f Ihe poli()'.
PAID.UP POLICY PRIVILEGE
When the ClSh "Iue of thl, policy, In<l....d by .ny divid.nd
l1(lllmulJtl1l1l5 IInd by the eluh villlte o( I1I1Y JivlalcnJ I1JJitions.
e'lu,", the net 'Ingl. p,enllum .1 the .ll.ined age of Ihe In.
,0,e.1 fnr ~ 1'.1,1'01' l"lky of the "Ille kind .nd .mount as
this jlO!llY, upon requestd.llll relC:il5e of the dlvidenJ il((umulll-
tlOI1l .,,,1 dlvld.nd ,ddltion, the Comp.ny will .ndorse the
policy ilS fully p.id.op.
The (J\1t 'f.l.lue o( llny divitlrnds in OC('5\ u( the amount re-
'1'"re.1 10 p.y up Ih, /"'licy will be ilpplied trl redoce any
.n,l.htod"... on tho 1") icy. ^ny remaining Indeht.dnm will
",ntlnu. .~"in't th. p,id.up polKY. Th. b.l.n,. of .ny divl.
deod" not u,.d oilhe' to p'y up the polICY or redu,e any in.
t1dlICllnl.',',' will he (t}ntinuc~1 115 a!i'fhlcnds credited tl) the
1',1101.,,1' IX)IICY. '
ENDOWMENT PRIVILEQE
When Ih. ""h v.l"e of thi. polICY, iner....d hy any ,lIvid.nJ
iluUIIlUI,lllllll\ itlld hy the (iH.h Vil\ue II( ilny lh'fiJcnd I1dtlltiun5,
l'llu,lh till.' (,lll' lllllounl IIf jJUlIr,lIlll\ upon tlllUl'st 11.1111 sur.
,",Ider of Ill<' l'olICY Ihe Coml'ilny will I',IY Ih, net mh ,,100
~I' ,In ('Iltlownlcnt,
,......".. ..,1...,..,...., .... u,.......__ __.._ ,.
"
'0'''' N,,'Q
/'"go 10
".".lSON NATIONAL LlPl INSURANCI COMPANY
IND'4N4'OLII, IN0I4N4
hu Iuued this aaraement as part of the policy to which It Is attached
PENSION OPTION
,
While the policy to which thi.l "green1<nt i. "u",hed I.. In (orce,
the owner .hall h"vo the right to p"y optional premium, to the
Company to purchilse " Single PremluOl ne(ell..1 ^nlluity on
the lif. of the inlured pmvidinll monthly Inmme mnllnendoll
on the m;lturlty ,late of thl. option ;IIhl pa1Bblo for lO yeB"
and for the duration o( the In,ured', IIfetlrno Ihoreilfler.
Tho maximum optional premium which m"y he pill<l to the
Compilny ,hall he iln "mount which, hlll.lher with the c..h
v"lu. of the ,"licy ("' deflnod In the 0",1, of Value. 'W;on
of the policy) an,lth. c",h ,umnder value of thl, option will
provide. monthly ineoOlO "Iu,,' to 3$~ of the f,\(e "mOllllt of
the policy under ,eUI.monl option 2. (lnitl.,l "mount ,hall ho
con,ldered ill tho fill'e .mount If Ihe policy provid.. for iln
Initial "nd ultimlte "mount.) The minimum OPI;o,);11 premium
Ih.1I ho $50.00,
Unl." lome other Oliltority dilte I, .gree.l to hy the Comp.ny,
the maturity d.to of thl, option i$'
(I) tho policy ilnnlversaty oe....t tho 65th hlrthd;,y of the
In,ured, for I,me .ge 60 or Ie.., .nd
(2) tho policy ilnniversory no"",t the 70th blrthdilY of the in-
lured, for illue .gc. over .ge 60,
SURRENDER V ^LUES, Thi. Pen,ion Option "Il"ement
milY ho ,ullondered in whol. or In pilrt without ,umn.lerlng
the policy to whkh it i, ilu",hed. The ",h value on ,,,rrender
of tJ,e Pen,ion Option will he 97~h of tho optionill pr.mium,
paid with intor..t .((umuliltod from the d.tea of p"yment of
,u,h optionolpremlum, to Ihe policy "nnlver""y ,I lie Immedl.
ately pr",eding the d.te of ,orronder, I.., ilny prior ,u"0I1der
unount, paid un.ler thil option phu Intereal .((umulilted from
tho policy ilnnlversary ,Ill.. immedi"tely p"..ding the dille'
of lOch prev;oo, ,ullon,lers. Intereat will blilt the r"le of 2Vl ~f,
per yur or ,ueh higher rilte a. milY ho illlow.d hy the Com-
pany, If, ILl the remit of Ihe "IIowance of il hillher Intere,t r"le
or .ny other reason, the 1I0t ""h v"loe of the policy togothor
with the c"h ,u".nder villuo of thl, option on the milturlty
dBle of thi, option e.".d, the "'Ilnunt needed to provldo the
monthly in"'m. dc/ino,1 In tho second paraB"'ph .hovo, the
excess will bopilhlln ""h to the owner.
Mter tho policy ha, heen in force for 5 ycm ilnd prior to tho
nl.llurlty ,I;lte of thi, option, tho oWner m"y, upon written re.
'jue.t to the Compaoy, elect,
(I) to havo tho mh v"lue of thl, option plul tho net mh value
of the policy "pplied under ilny one of tho Settl.ment
Option Provi,ion, of thl. polky, or
(2) If Ihe policy '0 provldea, to continuo tho policy on a pre.
mium p"1hI8 basi, heyon,1 the m"turlty dilte of thil option
wilh the mh value of the Option left with the Company
10 "..cumul'I' with iotereat .t the rile Ihown above until
" IUhSl'<JUcnt Bnnlvon.ry of the policy, "t which time the
mh villue of this option plul the net cil.h valu. of the
polky m"y ho ilpplied under ilny one of the Settlement
Option pmvl,ionl of tho polky,
If the policy tormlnatea for .ny CilUse except th.t Itated In the
prccedinll polr;IHr~plll, or Is continued In forco under ltspald.up
nonforfcitore option provi,lonl prior to the milturlty date of
Ihl, option, the wh v"lue of tho Option will be paid In clLlh
to Ihe owner, If living, othorwlse to the benefidary,
If 'lilY premium for the policy I, not pili,1 when due or within
the gril.. period, "nd If ,uch premium has not prevloully beon
I'''id In adv"n.., . ,ulliclent porllon of tho Pen.lon Option
will he aUlomiltic"IIy lurrend"ed to create a C1L1h fUnd equ.l
to ,uch premium, ilnd ,,1.1 mh fund will he applied to ray th.
promium thon due on the policy. The .ulom.tic promium lo.n
pmvi,iou of the policy Ihilll not be used to p,y a premium un.
I." tho ,urrcoder v;lluo of thll option I, not .ut!iclontto pay It,
Thi' ilg..oment doea not ch.nge or iltled the nonforf.lture
v"llIo, of tho puliey.
Thil ag..ement ,hilll ~e ,uhJect to illl tile provlllonl .nd con.
ditinrll of the puli", not Incon,i,tent with the term. M thi.
~g..emont.
Thi, agreement I, m"de " part of tho polity tu which it 1,\ Ott"ched elTcctive as uf tho I'ulky Dille of ,,101 policy.
Signcd for tho Company "t Indilllllll",li" Indian~
<JZfd'li
'O,.M N.jOO
~~
I'm"'In'
J."1Il10N NATIONAL LIP. INIUIlANC. COMPANY
INDIIINII'OLII, INOIIINII
haaluued Ihls allreemenl 81 pari of Ihe polley 10 which I1II attachad
ACCIDINTAL DIATH IINUIT. . lor death by accldenl
BINlfIT
The Comp"ny will p"y to th. heneficlary "n accldent"l death
benefit In tho amount ,hown un the Pulky SpeciflC.tlun, p"ge
or In th~ Schedule "t tho bottom uf thi, "8reement upon receipt
lilt. Home Omce uf due proof that the in,ured'. ,I..th: (I)
occuIIN as the re,ult, directly Bnd indopendelltly of all olhor
cau.." of accldentill bo,lily injury ,wtilined whilo thi, Bgr...
ment Is in foreo, which injury (ucept In the COle uf ..d.
d",tal drowning ur of inlOrnill injury reveilled hy an autop'y)
II avldenced by a vl,lble contu,iun or wound on the exterior
of tho body, and (2) o((ulled within 90 day' after the .I.te
of luch Injury ilnd prior to the lermin~tion of thi, ilgrooment,
and (l) did not occur In ilny way"" the molt of .ny of the
rllk. not a..umed, " Ipeclfied h.low.
Th. CompilllY .h,,1I have tho right .nd opportunity to Investl.
glte tho circum,t.oc<s of deBlh, tu e..mln. the body ,,0,1, If
not prohlblt.d by law IUld at it, own expense, to m.ke an
autop.y.
Paym.nt of thl, be",fit .h,,1I bo In addition to and In the ..me
manner a. the other procood, of tho policy,
RISKS NOT ASSUMI!)
No benefit will be pilyabl. under Ihi, ilgreem",t If the In,ured'.
dealh mull" directly or Indirectly, wholly or putially, from
any of the following cau,."
(I) .ulcld., .ttempt ill .ulcide, or Intentlollillly "U.lnRicted
Injury, whllo sane or Insano;
(2) putldp"tlnll In or attempting to commit .n USilult or
felony;
(l) puticipaUng In a riot, or in,uII<<tlon;
(4) war, Bny ,,(/ of war, or ,",vice in Ihe mllituy, n"ilI or
air forc., of ilny country or comhinlltion uf countri., or
Int.rn"tionill orllilnlliltiun In limo of war. 1'he term "war"
Indud.., hut I, not limited to, dee/ilr.d war, and armed
agllreSlion hy ,me or more wuntrl.., real,ted on orders
of ilny uther wontry, comhlnation of countri.. or Inter.
n~lIonill nrganl"iltlon. "^ct of Wilr" mean, ilny ilCt pl'Culiar
to militllry Upl'rd,tions In time of war;
<') any .hug (."ept drull' pr.lC"b.d as medk,ltion by .
'''I'M N.U..I
phy.id.n), poi,on, gilS or fumOl, voluntarily or Involun.
tarlly, il<<;.lentally or olhtrwl.., taken, admlnl.t.rcd,
ab,mbed or inhaled (o"'Upatlonal accident cxupt~d);
(6) .Ii,.... or Illness of any kind, phy.leaJ or menial Infirmity,
or medical or ,urgleal treatment therefor I
(7) h"terl,,1 infedlon (other than pyogenle Infection occur.
rinll ,Imult"neously with and through an ..cldental cut
or woond);
(H) tr"vcl or llight in ilny .ircraft, or as a ",ult of de..",t
thmfrnm while In Right, If tho In.urN
(a) h"d ilny duti.. on or relating to .uch aJrcroft or
llight, or
(h) was being Rown In ,uch aircraft in the cour.. of
ilny aviation t"lnlnll or in,trudlon, or in the coune
of any tr.inlng, maneuvers, or operation. of any
mllililry, n"",I, or air forcOl of any country, com.
hiMtloll of coulltrlea or International organlaatlon,
or
(c) WilS b.lng Rown for the purpolC of dment from .uch
alrc"tt whll. In Right,
TlRMINATION 0' COVIRAGI
Thl, allreement will terminate:
( I) on the policy anniversary nca",t to the 65th birthday of
tho In.ured, or
(2) upon receipt by tho Company at It. Hom. Office of the
owner'. written rcquOlt for termination of thl. agmment
on ilIlY premium due date, accompanied by the policy (or
cilnceUatlon of thl. .grcomont, or
0) upon termination of the policy, or
(4) if tho policy I, lurrendered or continued under any non.
forfeiture provl,lon, or
(5) If any premium for the policy or agreement remain. un.
p~hl aft" the end of th. grace period.
CONSIDIIlATlON
1'hi, ilgreement I, luued In con,ldmtlon of the appllcotlon.
il wry of which I. au"hed 10 thf policy, ilnd the p'yment of
the II,ldltlonal premium.
PREMIUM
Th. .ddltlonal annualp"mlum fur Ihl. agreemont I. .huwn on
lh. Policy Specification. pago or In tho Sch.dule at the houom
o( thl. .grccment. Thll premium I. pay"hle tUllether with,
In addition tu, and In the ..me mum" and for Iho ."me nUIll.
l>cr of yem .. th. prrmlum (or thl. policy ..<opt that Iho
premium fnr thll allrerment Ihall co..o 10 he p,y.hlo when..er
thl. as,oom.nt t.rmlnatoa. ^ny prrmlumpaYilhlo nn tho 1~)Ii,y
a(ler Ihl. allrotm.nt terminal.. .hall nul include Ihe prrmlul1l
(or Ihla 'arcement,
INCONTlITAIILlTY
Thl. Ijlreement Ihall bt Incontoatable afler It hill bten In foree
dUlin, Iho lifetime of the In.ured (or a period uf two yom
from l~ eRective dat~, except (or non.paYIll.nt o( I'rellllulll,
NON.PARTlCIPATING
'11,1, "w.omrnt I, jlllled "t nun'pilltlclpallnll rate. ilnd .hall
lI"t .h",. in ilny .url'lu. earning' of the Compilny ...n thollllh
it h. "1I,,chod It) a partidpiltlng 1~)Ii<y,
E,nCTlVE DATI!
Tho e/l<<tlve ,I"tr uf thl. agroomrnt I. tho Policy Date ..
.hown on Iho Policy Spodljcallun. I'ilge. IInle.. a dUfor.nt cf.
(c'(tlvo date la .hown In the Ilchedule below.
GENERAL PROVISIONS
TIll. illlreol"enl .hall be .ubjecl to .11 tho provl.lon. and con.
ditlon' uf the policy not inronli,trnt with the ter/lll o( thla
.greement.
SCHEDULE
(To 6, tOmpl",d ollly ",h", dgrt,,,,,,,, h,1I h,,,, ddd,d 10 dll ,)(1111"8 polity)
""om or "",;,;;" T '" """. 'MMI
!lllth B.n.fIt C Premium
Slllned for tho Comp.ny ill Indlanilpoll., Indiana
'0"" N......
<r:!d~
,
"
~tw\
Pm""'"
. ,
, I
"
, '
,
I,
'~
.I1"IIION NATIONAL Lilli INIUIANCI COMPANY
JI"IIIION NATIONAL LIP. INIUIIANCI COMPANY
INIIIANA'O~II, INIIIANA
Hu ISSUld Ihls IlIreemenl as plrt 01 Ihe polley to which IIII attlched
WAIVIR 0' PRIMIUM IENIFlT.,. In evenl 01 lotal and permlnent disability 01 In lured
,
COVIltAGI
Upon r....lp' hy tho C:ompiUlY at it. Homo OffiCI of du. prool
Ihal'h. Inlur.d hilS become Illlally di",bl.d .nd thiltluch totill
dlublllty, ... d.fin.d below, (I) comm.nc.d before th. policy
annlvfllary n....lt the IIlIu..d'. 60th birth"1 and whllo thl,
agre.m.nt wa~ In lore., and (1) hilS mntlnu. unlnterrupt.dly
fo, at I.ut 6 month., th. C:omp.ny will w.lvo th. payment
of .ach pr.mlum becoming du. und.r the polky after tho
commencem.nt and during 'ho continu.nce of .uch tot'" di"
ability ilnd relund ..ch premlwn pilid which h<<am. ,Iue duro
In, .uch diuhllity, ueept that, ,uhl<<' to th. condilioo. re.
laling to nolk. of e1aim, no premium will he willved or re,
lund.d If il. due d.t. occurrod more th'n 12 month, prior to
rrrc.lpt of written notice of e1oim.
Any premium. woiv.d ,hall bo in ,ccordonc. with the mod.
of premium paym.ntln .lTeet wh.n tot.1 dl..billty ",mm.need.
Surrender or loan v"lu.., if ilny, of the polky (iln,1 divid.nd"
If th. policy Is a partlcip.tlng policy) will illl be the .om. ilS
thoullh th. premium. waived had been paid In cash.
DIFlNITION 0' TOTAL DISABILITY
Total dililhility m...n. the complete ioabllity of the In,u..d, il'
. IOIUit 01 bodily in/urle. ,u,t,in.d or di,el\.!o con'r.ct.J while
thl. agre.ment I, In f,)"e, to .ngage In iln occupiltlon lor re.
muneration or profit. During the first H month. of a pcrlod
of tot" diuhillty, occupation mean, the in.ured'. resolar oc'
cupatlon; thereafter II lllCllOS any occup'tion for which h. Is
0' bcrom.. qualified by .ducalinn, training or .xperlenCf.
If tho 101. occupation of th. In.ured i, that of a ,todcnt, the
refer.nce to .ngaging In "an occup"lion for rrmuneralion or
profit" Ihall m..n "allcnding "hool",
RIIKI NOT AIIUMID
No benefit wlll be granted for dlublJity rcauhlnll directly,
0' InJlrtctly, wholly 0' In pitt, from any of th. following
UlUnl
(I) Int.ntlonally .elf.lnflict.d Injury, whil. Uno or In.anel
(2) war, any act of wilr, or ,0!Vice In the military, naval or
.Ir fure.. of any mUlllry or combinolion of countri.. or
Internilllona' o'llanlutlon In time 01 Will. The telm "war"
Ineludca, but i, not Iimit..1 to, .lecl"re,1 Will, ilnd armed
'urrssion by anr or mort countriC's, reSblt,1 on or,fen
of any olhel country, combllliltion of ",untri.. or Inler.
nationil' orllilnization, "^et of Wilr" meiln' "ny ilet pt'euliilr
to military operation, In tlm. <>f W"r I
0) bodily Injury ,u,tilloo,1 or di,Cil'o ",ntlact.,1 before th.
.lTnll" ,late of thl, og..oment unlelS di,e1m..1 in the
applkatlon 1"", thi, agreemenl,
'0". "..,.,
NOTleI AND '1100' 0' CLAIM
Writt.n notice and ploof of total dllablJity mu.t be given 10
the Company at Ita Home Ollic. (I) durlnl! Ih. lifetlm. of
th. inlll..d .n.t during th. conlinuanCl of total dllabllity, and
(2) not J.ter than one y..r .lter the termlnallon of th. In.ur.
.nee pro,.;,I.d hy thll 'I!rcement; and (3) within on. year
of th. du. date of the first premium In def.uh. ^. part of
any pmof, th. Company may require medlul ...minallon. of
the In,ured by phYllclanl d.llgnat.d by tho Company,
J'.llure to give .uch tim.ly notlc. and proof wlll notlnvalldat.
ilny e1.im if il Is ,hown 'hat nolice and proof wer. lliv.n ..
'oon as wu r....onably po"lhlo.
PROO' 0' CONTlNUID DISABILITY
Tho Company .hall havo the right at any time or limes during
the fillt two ycars following receipt of due proof of tot.1 dll.
ability, and thereafter not more often th.n once a yea,. to
rnluire the illlured to furnl,h due proof of the contlnuanCf
of total disability. ^. part of any .uch proof, the In.ured rooy
he rnluired to be examin.d by physician. de"gnated hy the
u,l11pany. Upon failure to furni.h ,uch proof, or If It I. e.tab.
li,h.d that the in,ured Is no longer totally dl"bled, no further
benefit, ,hall bo provided and therufter all premium. which
filII due ,hilll b. paYilble.
TEllMINATION 0' COVERAGI
1111, agreem.nt will terminate:
(I) ,ubjoctto .ny th.n existing claim, on the policy .nnlver.
"ry n.arestto the 60th billhday 01 tho in.urcd, 0'
(2) upon realpt by the C.ompany at It, Home Offico of Ih.
owner'. written roque't for termination of thll .sr<<ment
on any premiwn due dato, accomp.nied by th. policy for
(ancellatlon of thl. 'I!reemont, 0'
(3) upon termination of th. policy, or
(.1) If th. policy I, surrendered or continued und.. any non.
forf.lture provision, or
(') If ,ny premium for the policy III illveement remain, un.
poid after the .nd of th. grace pcriod.
CONIIDIIIATION
Thi, "Ilr..mont I, ilSu.,1 In (l)ll,I,t.ratlon of the application,
" "'py of whilh i, iltlach.d 10 the policy, and 'he payment of
the ild,litillllal premium,
PRIMIUM
Th. .ddlllona! .nnual prrllliulII fur thi. "~Il'elllellt I, ,huwn
on lilt Policy Sp.dficillionlpa~. nr In the S,h."n'. ~t tho h"t.
tom of thll .~rtcment. 1'hll prellliulIIl, parilhlr tu/o\ether with,
in..ddlllon to, an,lln the Ian'" m.nner an, for tho 1011I0 n'l/n.
be, of y.a" II tho plflllhun f"r thi, 1.,liLy OX'"p! thilt th.
pllmium for Ihi, allreemenllh~1I <0.\50 to he paYilhle wh.never
thl. ..rrcm.nt termlnatel. /lny premium payablo un the pnliq
oft" Ihi. .gr.em.nt termlnatrl .hallllut inclu,le Ibo premium
fo, Ihi. ..rtcm.nl.
INCONTlITABILlTY
1'111. ..reemontlhaU he incont"tahlo ilfter It has been in force
durin, the lifetime of the In.ure.l and WIthout the occorlQnco
of the tol.l dl..bJlity nf the In,ured for I perlo,1 of twn yeilll
from It. ./foetlvc d.te, except for non.payment uf pr.mlum,
NON.PARTlCIPATING
1'111. .grtcmont Is I..ued at non.particlpilting rat.. iln.l ,hall
nol sh.n In .ny surplll.l ..min.. of the Com pIny even Ih"ugh
It be a1t.ched 10 a partid p'llng policy.
TOTAL DISABILITY BIGINNING
DURING GRACI PIRIOD
If ,,,t.oI .1i"lhilily h.~llII ,Iurinllthe grIn period of a premium
ill dd"ult, IUd, premium fllu,t h. paid to tho C.ompany wRh
illl.,.,1 .,1 IIUt mulO Ih.,n 6';, J><r ye". 1/ nut prevlou,ly "1'.1".
.\u,h onllllllll,holl he ,Iedud. from thoproctcdl of tho policy.
IIINSURID" DlflNID
Th. word "Insulfd," whonover use" In this agreelll.nt, .hall
br: wnSldern.1 to mean "annuillnt" If thl, agrtcment Is ,uached
tu Oil aonu,ty policy.
I"ICTIVI DATI
The offectivo d.te of thi. agreement I, Ihe Polk)' Dale.. ohown
on the Policy Spedficatiolll plge, unle.. . dl/feltnt e/fectlv.
dale is ,huwn in tho Sch.dule helow,
GINIRAL PROVI8IONI
l'hi, agr.ement ,hall he suhJoet to all the provl.ion. and con.
d,tion. of the policy not IncoOlI,t.nt with the terms of this
agrcc:mrnt.
SCHEDULI
Annu.1 Premium
(7'0 b, ,Off/pi"", ,,"ly ,,,hln ogr""IIIII lIdS betll odJ,dlo _II ,x/rill/I( polity)
EH.ttlve 0.1.
l
Signed for the Company at Indi.napoll., In,liana
.(JZfd~ ~:~
PO." H.''''
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;
TAILI 0' HOH'OR,.ITURI VALUII-PIR 11,000 OF 'ACE AMOUNT OF INSURANCE
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TABU, OF NONFORfEITURE VALUES-PER $1.000 OF FACE AMOUNT OF INSURANCE
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[J ""'_~J~__~o~l.d [J WI,'o..J 10' No.Lt/ ~ i"y.. c: :M'
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AllOmS '->7,' I /.')~ / ....~.~ /-'''it J-~~:~,~,
___. '" ~11J'd/E~u;fI _ n. ..1 Y.
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~~~~~~}t--?5lif7zb~J!~,;~!.~~-! .t'/tlW
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IllnlUrld.-Rutd'l'Icl Add"" 0 Own.,~-Addr.u ,huwn In 11h,
9-.!.~~~~::-~.~~.~~~,r!_I.' [) Qth.r-GivQ In,lruclill"I in 'I
I. LIPIINIUMANCE N.2W_I!l.LO.M_C_E-:JIf~~n.~-~o "0'_.'
, h., Auldalllal
C '"~~~~___._ .~~~__ .~~~!.~_ _-1?!.~!~t_ _
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O. OQ yOIJ hove Qny PQr. tlm. jobl, 0' do ~dU "HJQl)' in Qny
ho,.,doUl,po'h 10.'0 '.""9, .~y" .lln dl,I"9, .lc.11 .... ,n
b, Will .hll 11\.1J'l)nce replo(. Inlu,oncl In Ihll 0' Qny olher (011I'
pony, If )'.., 1)1.... cornpol'ly, omounf. pIon, ond ,.oll)n 'or r,.
pll)c.mll'lf .......,... ..,............~..,....,.".".."..""...,,,...,," [J
C. HI). yo..., oppllcation for Ilf. 0' h'l)lth Inlll,one, ,vllr bun de.
clin,d, IPltiol ,ol.d. ,,,hld.d 0' pl)ltpon.d1....,......... [J
d. ^" you now QPplylrllJ, Of do you hove 0 Uf. oppllcotlon plnd.
In'.lln any othflr compony?,......".,...".",.... .."...."..."". .......",.. 0
'0 el~hrno~h~I~:.f.O I ~o~~~lhf.I.~.',I.~~..~~~,~~~.~.. ~.~..I.~~..~,~,',~~~" ,~.I.~.I,',~ 0
t, HQv. )'ov in po.. 5 '1'"'' PQrtlclpol,d, Of do yov pIon fo P(J"
Ildpol. In o...lollon olh., .hon Ol 0 '0"'PQyln9 pouln9.r11f
Y", compl.l. ^YloUon OUII.lollf'lof,., Po,. 3,..,,, 0
9, ^,. you 0 mol. opplieo,,1 01{' I' Ih,u 1&. 0'0" you 0 m.m.
ber 0' the ^rm.d ~orclI or of ony 1t,...,Y. 0' NQIlonol GUQ,d
~~~~~_'~_~~~~.'.!. MI~'y OU'!~~~QI'" Po,. ).....,."... . j(I
'hlllpoe. '0' d.lolt. 10 )'.. onlw"'I,
'0'.___.._ .__~____,_""'I.
[J M,"h,,(IIlt) '"m
II MIIII"n P,nm;llm If..)., - In' '''Inri'H'' lJllIlulll bote polley p"ml"",,
(I (JlJ,H""tllld Irl\lJ,obillly RI,j., (mlnimlJm bOil policy 'PJOOO).
~ ^uldnnllJl n.nth 8.".flt 'on n AmQu"t of It1! TwIce amount o'
Of P",,,!,,m Wulv'H bIll. policy bOil policy
rJ Fomlly Pmhdi(}/'t Ben.lit '0'1 n, Unit 0 1 Unl,. 0] Un'h
--1L-",..------------'--.------..5 -
II. ~OOE OF PA,Y, ~ENI, [) \,1 10'. I,I,~IOIAL MODI P~I"'IVM
r:J ^ n SA r1 Q n ~ [) PIlC Ii<l PAC 'iQ c. c CJ ~ ;PHt!.
1~4..0_1 .~.:::__::::..___:.~~::::~~;.;j~.I,. .^~~~Q~;-p,-~~I~;L;o~i~~~lIobl.,
I'. OIVIOHIO OPIION-..IF POLICY I~ PANTlCIPATING,
I IIlltd Ih. POt".up oti,Jltion "plinn unr.u on. of Ih, 'otlowlnq option. ,.
~l.!.~.:_ _g.!~!~j~.:.2..~.L!l.!!dllc. premium .JJ_~~c"mulot~_.5!!.~I.!!!!.!lL .
f.. PRIMARY BENfFICIMiY.-P,inl filUM"'. and r.lotlon,hlp, IUnltu olh.,,,11I
""i'1MI'.). ,Hou,d, ",,11 b. poi,J I'll/oily 1<) 011 ~,Imo'., b,n,flc'c';" 11,,__I'fI"?, ...
IIII'III.J. II IInlll IW'~I~'. .,'OU,ri, 11I"" b. pQld '<1"'011., 10 1111 cOflllflq'f'Il DIIFI,'le 0"1'
1"''11'1'"'' Ih. In,,,,.., II II" u,'..,I'f11l1J lUII,UcIOI'n. p't1ulth Qt, poyobl. 10 the .'101'
III th, <1wn,'. "'I bln,'ld",I" <,lf' rjtl''Jno ,j wllh rllJllI I02hon . ""t'lI ',q",,,I,.,
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CON TINGEN' BENEFIC'.ARY.-P,r,,1 lull "0"'" o"d reloUo",hi'f--
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Chltd 'ollllwin? il d.,iIGeI Q"d only If 'f:)OV" of In'u"d II nom.d 0' b.n,ncl.
ll'y: r:J An.' llny (hiItJr." horn nf Ih. mo"loq. 0' I",u,.'" and loll, aolo
'pOU\n, 'IICt-. children In b. [J primo'y b.".ficlorl" 0 (ontln9."t, bln.fler.
Qrin I u.pu Ihol Ih. CQmprll'lY moy rely compl.t,ly on proof of omdo'Vlt
I" d..I.,milli"., IlI(h unIlQm.rJ b.",fi<<.lo,I..,
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11. OWNEItS~HP--ro h. (ompl.I,d 0,,1~ I' P,opolld In",II.d II 09' '10' ov"
and PropOlld Own" I. olh., than P,opolld In,v,.d,
o Own.r'. Nome __ _ h___". ._._._______.___._ __ __+._____.___
b, ^ddr," of Ownlt'_
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II, SPECIAL DATING INSrRUCIIONI OJ OIH~ MEQ~'~
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tlon. and I "'l'lIf' 10 11111 I",m, of 'old ,,,~"(pl. I '"pre.llnl IhQI Ih" "olemllnh '''fll/rllld un Ihi, IIflpllrllllol1 Oil Injlf Ilnd templelll Qnd ,hQII 'firm th. bOlla of
""'" polky lu",...I. III'J'III Ihllt!
111~il '1fI1,t'~III"M 'lM,J "M~ I",I..W .11 prJl,riu '\111"<1 hl)lI.1 I)" Ih" npphr'lt OM '''nil rIlMI,I",,, '''ft "MI'r~ ,,,MI,,,,t d iM"JI'ln,,, Thl! r'HllprJMY ,Ilflll MI hI' hlJllnd In I'Iny wit. "I
r'jM1 I"II""~"'I, ~"u.",'" ", 'nlo"n.)...,~ m'ld" 0' .,I~.n h1 Il' I., ,,". 1)'1,,"1 M ..I~.., 1i1""lM ",,11'\1 Ih,. 1'1,11" lilt '".hJu,J I., w"lon'l '1",1 ,,,,bn\dl,,,l 10 Ih, CO....P<)". 01 ,II ~loM
01/,(. 01"'1 1"'1'/'" 111111 "'Iurh {OIlI,"rI
II "'it (,)I"~','~~ !holl III ,,~I,'I",J In III .ll!" "0'1" Ih. dnhr "I Ihl, <lppl'/"I;,," 10 r'J~\"'''' "lId oJ.1 "r"l~ ","'.. 1/" '''ll.,~ 01 ~ol,rll IJ' 'lllp'Oull 01 .h'l r'ppt'r'll,,,n "". nol b,,"
ffft,,~ I ...I~I" 'h'l p,I,,,.I. th,n Ih'I'IJlpi.",I."" '''<lit b" fljn",jl"'.l I" ""~I 1:"," rl~tl,~,.oJ
)1 II Ih, .." pi rO"""'n~"''''1 ," .h,., '1'111 """'''r. wil~ Ih'l "ppllr"I,t1n 'I ",,,.., ill f~I~," I.j/ Ih,. 1.)1111'11 PII''''',,,, th~ (1H"II'I~.'1 1"lh,',I. ..;11 h. ')I \,,' IOllh '" w~h "etIDI.
'1" l~, "'r tI' "," I'llt h,," 'u""I Ih. C'P",,,,,,, \~'III .","', 1..lhit'h II""'" 11I'111"JlI"'II")1'\ ,",1, ..h," 'I ,")I,,~ ~'l' h'/~ "I'I..~,"" 'I",J I", 1,,11 /1'11 '"'"''11''' Ipu,I.,., ," Ifl.
t'Jol.c. ~'H hun J'l""j '1"'~",1 h. ,,,,,,m. """ ",,1'""..1 ",,,,,,1.,,,, .1 ... p"""",, I.."..., .
L ,-. /,r / ' 'J//,,1 ~t ~ '
.'~d 0' L?;J),1cZ(!_'/,r: ~O"#" _ "I .__Ihi._'!::-?r - '(oy,I.. . -V ((,"}':, "'._ n " __ ,,,-?L.
V. / 4"".,......-'. ~L /~., 0. :.. ~ ,y-"
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NY 225902
.'1' ...,,,.,.. ,,,.. WII'lrll
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I, '1l0'OSlD INIVIl D AND 5CHIDVLI 0' COV.UD DtplND N
"'II thm. .,I.flu 11,.h4.., , ."I,M W,I,h~
7L(l'~lk:-:d'~~1 j!lli_;~~,__ fX~- .4~Y ;;4':
.-----..---- ..< --.-- ....-.- ..--. .
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--.----
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2. "mIC"NrS A,. If H..llh-Il..... ""01 C.... .f 4. HAS ANY PROPOSED INSURED NAMED IN NO, I. PART 2
~1_Lrll~9}.DU~'_'1_!!1l!!_~"~/_ !l_~.!h, ,__D".',h__ _ EVER HAD OR NOW HAVE, V., N.
-f:~~h,o.~.._..-.. -'t ~. --~,-,;; !..-,t!L- - -- ,--. o. S.V". h.odaeh'l, 0' ony b,aln, m.nlal 0' n"vou, 1,II.m
Moln.. J .;; &....., dlllall 0' dllo,d,,7 '" ,.' ,........, ,........'...
8;cilli.,.---,,_-_ ._/. ~:, '--7.-"'''-" '~' - - - b, ,Epil,plY, 'alnlln9 Ip.1I1 0' canvulllonl7.. ,..' ,........."..
and -=J_ ,\ ---..---,..-.---- --- c, High 0' low blood proIlU'., 0' apopluy? '...........
S . 1: - ,-...--.-..-..---- - d. H.a,l, blood 0' oI..ulalo,w dlllall 0' dllo,d,,7..,.. ..........
III.,. _,~,_ -_/ _ ...___ _______ ..,.. ..___________ .. Ch.11 pa'n, Iho,ln... of b..olh, 0' h.o,1 mu'mu,7.".........
. " Suga" albumin, blood, eOI" 0' pUlln u,ln., 0' dlob.llI?
J HAS ANY PROPOSfiD INSUR D NAMED IN NO. I, PART 21 9. Kldn.y. blodd", 0' u,lno,w dllloll 0' dllo,d..7........"....
, V.I No h. P,allal., rep,oducllv. o,gon 0' v.n...ol dllloll?...........
a. LOll 0' aln.d w.lghl du,lng Ih. 011 2 .0" I. EW" '0', nOlo, 0' Ih,o.1 dlIlOI. 0' dllo'd..7.,..........,.....
Ilh ~h nomoi Ih' h~d )7 Y [] M j. Slamach, In'"l1nol. 0' ..c101 dlllOIl 0' dho'd..?..,..,....
0" 0 n, g'ow 0 c ..n.."" ." ,. Gall bladd.. 0' IIv.. dllloll 0' dl.ordtr, 0' loundlcI7....
b. Conlull.d 0 phYllclon du,'ng Ih. pall 5 W.a..? "riJ 0 I, 0111011 0' dllo,d" 0' boe., Ipln., bon.. 0' mUlCt..?"..,..
E h d I I 'd bl d m. Tub..culoll., 0' any lung dllloll or dllo,d..7 '.. ......',
c. VI' 0 on... ,oeo, la9,om, ,.,aw, 00 n. Any dlloall 0' dllo,d.. 0' Ikln o'Jo, In"7 '" ',..... ,......
Iludy, 0' any alh" dlagnolllc Iludlll?.., ....,...... 0 [jIJ 0, Canc.., CYlt, 0' lumo,oul g,owth ' , ,,' ....'....'....
d. Ev.. hod 0' bltn odvllld 10 hove ony lu'glcal p. UI.", flltula, h"nlo, 0' va,lcolI v.lnl7 ",.." ....'
op"allonl7 II any conl.mplal.d7 ' [J 1:!0:1 q, A,lh,lIll, ,h.umolllm, rh.umollc ',v'" ..1011.0, 0' goul?
,. Allhmo, b,onchllll, pl.u,IIYI 0' p.,.lllonl cough?,......,....
., Ev.. bltn 0 pall.nlln any ho'pl'al, l"ltl/ullon, 0' I. Goltr., 0' olh., glandula, d 11011 0' dlla,d..?",........
lanlla,lum7 ' " .."",.. ' ""..,.. ..,..'.... " ,Ilil 0 I. Impal..d Ilghl 0' h.a,lng, 0, phYlleol d,'o,mlty7
,. Ev.. ....Iv.d 0' bun advll.d 10 hove I..alm.nl u, Pallomyolllll 0' pa,olylil?,.. " .." ,... '..
'0' al.oholllm 0' d,ug addlcllon 0' bltn 0 v. AnW olh.. dill 011 0' dllo,d.. wllhln pall 5 .0..1,
m.mb" of Alcahall.. Anonymoul7 [J ~ 5. GIVE FULL NA~ AND ADDRESS Of FA,MILV DOCT9lth
Nomll'~'" """,,,.., "'1:11 (t";.....' " It ,-~./
9. Ev.. ....I"d Ind.mnlty fo, II.kn... 0; Inju,y ',om .dd ";";F)) -11/;'" 5 1"ifl'~- " ,,,,, If' I,(l';if.'".", "7~.
any In,u,anc. campony, gov..nm.nl 09.ncy 0' ,., rllll ., / 1/ i/./
olho, IOU''', 0' II th... 0 claim now p.ndln9 '0' Dol. 1011 canlull~7 ~ /r ,- ff~"/ /A ....:
luch? ' ",'" ..,.. "..", , Wh conlull.d? ~ , . ".I' "
6. ARE ALL PROPOSED INSUREDS LISTED IN NO, I, PART 2, NOW FREE FROM DIS ASE AND IN SOUND V.I..
HEALTH TO THE BEST OF YOUR KNOWLEDGE AND BELIEF? .. lRl 0
7. IF ANY PROPOSED INSURED IS FEMALE, hav. ony .... hod any '.mol. dllo,d...? ... 0 0
A,. any now p,.gnonl? [J VII [J No How 'a, odvan..d? _.. _ _ monlhl. How much w.lghl 90In.d? _ Ibl,
I. GIVE COMPLETE OETAI.LS OF ALL "YES" ANSWERS TO ANY PART OF QUESTIONS J, 4 OR 7, OR "NO" TO QUESTION',
-;i- -:.;.~~~~~-I--I/o~t.t-,I,.,,::::_~~~;~I~~!.-')-;;,~~I;,.I~~~I;;/~..tl_;_=-__O~;~...~;:~_ ~_~~!~~~d~~i~~;.!_'_i~.~, .~~-;~.~
_ 1It.J':tfJt#__f:.:;5':r;u _ /1 .l'rtIl,lJ..____9..utf_y-.f_..__ _L, C__ d/-...I.,Iks~__E.!'. __
'iLL &..~-L;j:;7i. o;~J:;it.._;:~.~'J~'(&.~dt..-;;~-;;.-;- ~//,)~-1,1:::!'.'tf:;:j}:f/7,~~-'~ ~.:/
- "'--n,- -1./'// ui:., sL____L___. ___7.~.---'I.h-d-~f~Z:.LE,L~, ~.z-
..1...~_1I~._~!a__,-//lfIoj J 'L.-(fY_VtJ '7k-.t'u"---I.4/!.'/!. ___~ '/L_ A.~"-1-:i'-'.~L:~"a- ". .
- --.- . -.-.-- rl:t:i~:" -"/:-f'-'J'7;,--:- -:- - - - _n _',,)ktlJ:!_/.c.~rN'/. 'Ct!U_
__ ____ _ _ _ . _ , /~/r~"" _r")n_~,,'-_6"/.&.z.. ________ .____..._________
I d..lo,. Ihal I hove .."d ond und"ltand 011 Ih. Ilol.m.n" ond onlwtrl h.,.ln and In Po, I I 0' my oppllcallon ond Ihollh.y 0"
com pl.,. and I,u. 10 tho bllt of my knowl.dg. and b.Ii." ond 0" .0",,'ly ..co,d.d, wholh.. w,ltt.n In my own hond 0' nol,
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~GREEMENT
AND NOW, this 10th day of June, 1988, comes ARTHUR W, HARRIS
of R. 0, 11, New Bloomfield, Perry County, Pennsylvania
(hereinafter referr~d to as "Obligor") and CINDY L, RIGO of 20
Benvenue Road, Duncannon, Perry county, Pennsylvania, by her
lawful attorney, CHARLES 0, VANCE, JR., ESQUIRF. (hereinafter
referred to as "Obligee") and both of the parties hereto
intending to be legally bound hereby, witnesseth thatl
WHEREAS, the Obligor has a Life Insurance POlicy, issued by
the Jefferson National Insurance company of Indianapolis,
Indiana, bearing a date of August 4, 1972 and having a policy
number of 217661, and
WHEREAS, the said Obligor has heretofore designated the
Qbligee as the sole beneficiary of the said policy of Life
Insurance, No, 217661, for the purpose of ultimately satisfying
an obligation between them, and
WHEREAS, the Obligee is desirous of having her designation
as the sole beneficiary of the aforesaid policy of Life
Insurance, No, 217661, maintained irrevocably so to protect her
interests, and
WHEREAS, the Obligor, acknowledges that he couLd
permissibly change the beneficiary designation for the said Life
Insurance absent an agreement to the contrary, and
~
,
,
I "
WHERE~S, th~ Obligor is in agreement and accord with the
desire of the Obligee to have her irrevocably designated AS the
beneficiary of the aforementioned Life Insurance Policy, No,
217661.
NOW, THEREFORE, in consideration of the sum of One And
No/IOO - - - - - -($1,00)- - - - - - Dollar, in hand paid by the
Obligee, the receipt whereof i8 hereby acknowledged, the said
Obligor does hereby agree with and covenant to the SAid Obligee,
that he does hereby irrevocably designate, name and otherwise
constitute the Obligee as the beneficiary of Life Insurance Policy
No, 217661, issued by the Jefferson National Insurance company.
It is further agreed that the Obligor will at all times
continue to maintain the said pOlicy of insurance, and not take
any action which would cause the said policy to lapse and/or be
of no force and effect,
This Agreement shall be binding upon the heirs, executors,
administrators, successors and assigns of each of the parties
hereto.
IN WITNESS WHEREOF, the parties have hereunto set their
hands and seals the day and year first above written,
In the presence ofl
1" ~-1'f1
4:;"~ y
~ ""';4::..
(SBAL)
re
Obligee
(SE~L)
-2-
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.,
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COMMONWtl~LTlI Of'
COUNTY OF
P~:NNIlYI,vMII" )
I
CUMBERLAND)
SS.
On this, the 10th day of June, 1988, personally appeared
before me tho abovo-named ARTHUR W. HARRIS, known to mo (or
satisfactorily proven) to be the person whose name i8 subscribed
to the within instrument and aoknoWledged that he exeouted the
same for the purposeo therein oontained,
IN WITN~SS WH~REOF, I hereunto set my hand and official
s.al.
el'li' . ~J /~
. I aJ1"... DNo ary ~6~Ji~ ...-.1.'
COMMONWEALTH OF
COUNTY OF
PENNSlIt,vANIA)
I
CUMBERLAND)
My Commiss ion Expires I 6l n, In"
CAIH~.INII, IOU'US, NotAn ,utile
IIIClj~NlnnU.Q 10110. CU.".LANO ClIlIHIY
Mr COIl.,IIION rxmn fie, 27, ItIO
11111I,"'. ''"11''''''1110 Aolollltlilll 01 HOll,I.,
SS.
On this, the lOth day of June, 1988, personally appeared
before me the above-named CHARLES D. VANCE, JR" ESQUIRE, know~
to me (or satisfactorily proven) to be the person whose name is
subscribed to the within instrument a$ attorney for CINDY L. RIGG
and acknowledged that he executed the samo for the purposes
thArAln aantalno~,
IN WITNRIlS WlIEREOF, I hereunto set my hand and official
seal,
;;.;J .-1 '-Ii:<' d...~n
L~l!.~'/tU.it~ta~y PUbI1'C rJ
My commiuion Expiresl 1'SI,J-),7,lftld
CAtHA.'N, ,
"'~~AN/ClluRli :::U:u:orA.r 'U'IIC
1I.",..~~:'~:!t~. U'1I1t ~~:~W) .0...011.'"
,...1\/1 AIlO"lf'O<lIl".
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~11 TMfJ Court C1 C.:::mmcrI Pla=:3 Qr C:.J:..;.:~;d=nd c,::Ju,;;',',/, ?8nn:syl'lc::r:f=
Cindy I.. Ili!!g, now C1ndy I.. Ridgo
'IS,
Arthur W. Harris
~oo, ') 4 - f 4 4 3...f:lY..li...!.!lLlll.-.._-. ;3.._._.
:-row,
March 25, 1')')4
:9_ I. S;U:~'1 O? Cr..~r3zar.A.'lD COt.~'l"Y, ?A... lio
hnby dcj;u= cb.t :lb=l4 01
Perry
C~W111 to tl.'1r.:".u.t t!:iI Wrl~
:.!:!.a C!CPU=tLoD ~W1r ::a.iIr ~l ~ nqucn :.::ei :Uk 01 t.!:&; ?!3.!::d.
..'I' ~/.d
...or",-',.., , ,~.y.
... , ". .,'
~ .~. I" t, i,~ A'
1. ,6, ..~. .1
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!lien:! at Ca:::!arUlllt C~UIIrr, PII.
A.5ic1..vit of Serri~
:-row,
March 29
..
. .. I
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3lB
o'.:.!c=
l' ~[. Ic-.-ri
:.:.. ~t.!:.iD ComDlaint
O~FOIS
Arthur W. Harris
u R,D!,. 1 Box 110 Paradise J.>arlt. Hew JHoqmfie.!.!!.tJpeatfield ~1!' Per~y
county
'=r lI:u:Ici!:lf t.O Kittv lIarris. wUe ~'!"'pef.
,
true and attosted
-
"
~P1 of =1 ori~ ('n....plAfnt:
l.I1ei c:wie ~ to
her
I :!:.t .::t1tc:::a ~he:={.
$0 IlJ:I.IWm,
, .
~p :Y4Z__.
!h.a'4 .t Perry COWlrr. P:Io
lleput:y
5wor.l ol.I1d Nbaibeci beiore
=1 tl:!& .J.J.!!.. dAy 01 A~.... J.
cern
SU"ilCZ
~l1I.L\C Z
A:"7iDA. v17
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19.u...
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.---.--"'---.--....
~
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"
PRABCIPE fOR LISTING C~BB~~!~
(Iot!st be typewritten and subnitted in duplicate)
'l'O THE PlPntamARY Of' ClHl.EIlLAN) COONl'Y
P181111e lbt the following ClI&el
(Check one)
x
for JURY trial at the next teXln of oivil court.
for trial without a jury.
------------------------------~-----------
CAPl'IOO Of' CASE
(entire capt:ion 1IU8t be stated in full)
(check one)
( X) Civil Action - Law
CINDY I.. RIGG,
now CINDY L, RIDG~,
)
)
Appeal from Axbitration
(other)
(PlAintiff)
vs,
ARTHUR W, HARRIS
'~ .. )
...
The trial list will be called on
llI1d
TrialB COl1111Bnce on
(Defendant)
Pretrials will be held on
(Briefs are du.e 5 days before pretrials,)
('llIe party listing this case for trial shall
provide forthwith a copy of the praecipe to
all counsel, pursuant to local Rule 214,1,)
VI,
No. 1443
Civil ActiQn Law
19 94
Indioats the attorn.y who will try case for the party who files this praecipe.
James G, Morllsn, Jr, , ~sqllire. lIepford, Hwnrt1. & M'!rKon. 111 N, Front St, , Harrisbllrll. 'fA 17101
COllnse1 for ~laintiff
,I Indicate trial counsel for other parties if known. Jlldith T, Wal1., ~squire,
,
Wal~ & Wal~, 341 Market Street, Newport,
Couneel for Defendant
1~is cllse is ready for trial,
Signed.
\ '
Print Name.'_ JB~es G, Morllan, Jr,
Oate.
7/27/94
,
Attorney rrl
PlaIntiff
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::ZOo
CINDY L. RIGG
NOW CINDY L. RIDOI
plaintiff
V
ARTHUR W. HARRIS
Defendlnt
a IN TUI COURT or COMMON ilLIAS or
a CUMB.RLAND COUNTY, PINNSYLVAHIA
a
a
a
, a
a NO. 94-1443 CIVIL TIRM
a
OUIa or COURT
AND NOW, Ootober 20, 1994, ooun.el having failed to
call the above ca.e for trial, the oa.e i. .tricken from the
November Term 1994 trial li.t. Coun.el may ruli.t the oa.e for
trial when ready.
By the Court,
\ IL c.(L-( (:
Harold I. Seely,
5h-u.~
P.J.
Jame. a. Morgan, Jr., I.quire
for the Plaintiff
Judith T. Walz, I.quire
For the Defendant
Court Admini.trator
add
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ridge.ans
CINDY L. RIGG,
now CINDY I.. RIDGIB,
Plaint i ff
IN 1HE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
v.
NO, 94-1443 Civil Term
CIVIL ACTION - LAW
ARTHUR W. HARRIS
Defendant
1f9TIC. TO PLnD
TO I Arthur W. Harris, Defendant
Shaubut C. Walz, III, Esquire
341 Market Str~et
Newport, Pennsylvania 17074
You are hereby notified to plead to the enolosed Answer to New
Matter of Plaintiff, Cindy L. Rigg, now Cindy L Ridge, witpin twenty
(20) days from service hereof or a default judgment may be entered
against you.
DATIBI
!O/5/Qj
Respeotfully submitted,
HIBPFORD, SW~# & M~GAN
[ ;\/1>( /7
G. MORG IiJ./
I.~/, No. 06897 '
11~ North Front Street
P.O. Box 889
Harrisburg, PA 17108-0889
(717) 234-4121
ATTORNEYS FOR PLAINTIFF
BYI
j, 11'..\
ridge. anll
CINDY L. RIGG,
now CINDY L. RIDGE,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
v.
NO, 94-1443 civil Term
CIVIL ACTION - LAW
ARTHllR W, HARRIS,
Defendant
~8WIR TO UW MATTIR
AND NOW oomes the Plaintiff, Cindy L. Rigg, now Cindy L, Ridge,
and avers in answer to the new matter as folloWlI1
9.
Denied all stated.
It is specifIoally denied that the
insurance policy lapsed in 1993.
To the contrary, the insurance
company, Jefferson National, advised that the policy lapsed in 1991 and
speoific proof of the al.1egations herein is demanded at trial.
10. Denied. On the contrary, it was only after suit was filed
that any effort to pursue the purchase of another policy was made. In
further answer, the policy is not similar. In further answer, total
breaoh of the agreement in 1991 by the lapsing of the policy has
adversely affeoted the Defendant. she is entitled to the entire amount
due. Further, nothing in the policy indicates as to what extent and
what terms payment would be made.
11. Neither admitted nor denied. After reasonable investigation
to the plaintiff it is without knowledge or information sufficient to
form a belief and strict proof thereof is demanded at trial.
ridge.ans
12. Neither admitted nor denied. After reasonable investigation
to the Plaintiff it is without knowledge or information suffioient to
form a belief and striot proof thereof is demanded at trial,
WHEREFORE, we respectfully request the Court to dismiss the New
Matter and to find the judgment in favor of the Plaintiff.
Respectfully submitted,
DATE I /D/5/9.5
ATTORNEYS FOR PLAINTIFF
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AND
NOW,
this ~7day of October., 1995,
I, P~nelope J. LaFoe,
,
Ilj
.J
Legal Secretary, for the firm of Hepford, Swartz ~ Morgan, hereby
certify that I have this day Ilerved the within Answer to New Matter by
depos~ting a copy of the same in the United States Mail, postage
prepaid, at Harrisburg, Pennsylvania, to the individual addressed
belowl
1,_:
Ii,
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Shaubut c. Walz, III, Ellquire
341 Market Street
Newport, Pennsylvania 17074
(J.~9IZ1 cYfJr:
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CINDV L, KIGG
now Cindy I.. Kid..
PI,lnllrr
IIN TilE COURT en' C()MMON PLf:AS
I CUMBt:RI,AND COUNTY,
I PENNSVINANIA
I
I
I N() 94.1443 Clvlll'erm
I CIVil, ACTION. 1,,\W
I
V,
ARTlIUR W, IIARRIS
D.tendlnt
NOTICE TO PU:AD
You Ilre hereby notified 10 file II wrlllen response 10 Ihe enclosed Answer with New
Mllller wilhin twenly (20) dRYS from service hereof or II judgmenllllllY he enlered IIgftinlt you.
(./ - w-kf1JLdt
~ Wlllz, III, Esq, r'l
341 MRrkel Slreel
Newport JlA 17074
(717) ~67.6993
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CINDY L. RIGG
/lOW Cindy L, Rid..
Plaintiff
V,
I IN TilE COURT 01>' COMMON PLEAS
I CUMBERLAND COUNTY,
I PENNSYI,VANIA
I
I NO 94.1443 Civil Terlll
I CIVil, ACTION. LAW
I
ARTHUR W. tlARRIS
Ddendanl
~ AND NEW MA1"n:R
AND NOW, comeslhe DefendAnl, Arlhur W, HArris, by hlsAllorney, ShAUbul C, Wal?:,
III, and flies his Answer to Ihe Complaint And New MAtter and Alleges AS follows:
1. PArAgraph # I is admilled, on informAtion And belief,
2. PAragraph 2 is denied in pAri; DefendAnt'sl~orrect Address is R.D, # I, lot # 198,
Paradise Park, New Bloomfield, PennsylvAniA 17068.
3. With regArd to PAfRgrnph 3 of Ihe ComplAint, DefendAnt, after reasonable
investigation, is without knowledge or informAtion sufficient to forlll A belief AS to the truth
of whether the fllclllAnd occurrences involved in this IIIAtter look plAce on or About June 10,
1988; however, the DefendAnt Admits thAt he signed PlAintiff's Exhibit "B" on June 10, 1988.
4, ParagrAph 4 Is Admitted,
~, PArAgraph ~ is admitted.
6. Paragraph 6 is admitted in pArt. By WilY of further explallRtion, It should be
pointed out that Plaintiff was only to be A death benefidAry l)f the policy, so that upon his
death, she would receive proceeds liS the designrtted beneficiAry, At no time Was Plaintiff ever
to receive ownership rishts of the policy,
7, Defendant spel'ifkally denies the AllegAtions of PArAgraph 7 And proof thereof.
if rr.levant, is demanded lit triAl, By WAY of further Answer, see New Matter,
8. Paragraph 8 slales II conclusion of IlIw 10 whkh 110 answer is required.
......MI"Ilo~/.I-.'ilj.\'l.i ,
N~;W MATn:R
9, In approximately the summer of 1993, the life insurance company, Jefferson
National with whom Defendllnt had four insurance pl)licles, moved from one buildlna to
another and mistakenly caused Defendant's policies to lapse through 110 fault of Defendallt,
10, III an effort to remedy the situation, Defendlllltsubsequelltly purchased another
policy on his life similar to the policy orlglnlllly owned by Defendant, lIaming Plaintiff as
primary death bellefit bend'ictary,
I J. A true and correct copy of said substitute policy Is attached hereto as Exhibit
ItA",
12, Said substitute polley Is currently III effect.
WHEREFORE, Defendant prays Your Honorable Court to di.mlu Plalntlfrl
Complaint.
Respectfully submitted,
'in
Shaubut. Wall, III, Esq.
Attorney J.D. # 1~277
341 Market St.
Newport PA 17074
(717) ~67.6993
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VEI{'flCl\r,O/ll
., Alrn.lIn W, rrArmlS, verify thAllhe stAtelllenlllllAde In 11111 Alllwer wllh New
MAller lire lrue And rOHerl. . understAnd thAI (Aile IIAtements herein lire mllde IUbJecllo Ihe
pellAlllea 1)( 18 "11, (',8, Scrl/on 49114, IclAIfIl,lo UIISWorn (AlllffcAlfoll 10 1Il/l,horllles.
.
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~ .~!~~~~D NATIONAL ~'!~'!~~M~~~~~~ ,~~~~~!!,,!
In this Conlract, Ihe telms "We", "Our",
and "Us" are used to ref 01 10 Midland
Nalional Lila Insulance Company: Iha
telms "You" and "Your" refer to the OWII.
er of Ihls Conlrocl.
We agree 10 pay Iha Procaeds of !tIlS
Contract to the Beneficiary If We receive
due proof 01 the IlIsured's dealh pllor 10
Ihe Maturity Date and while thiS Contracl
IS in force. II the Insured IS living on the
Maturity Dele, We wliI pay the Cash Value
10 You. Other rlghls and benefits wliI be
provided according to Ihe lerms of this
Conlract.
This Contract is a legal contracl belween
You and Midland National Life Insurance
Company. READ YOUR CONTRACT
CAREFULL Y. A gUide to 115 conlents IS on
Page 2. A summary Is on pege 3. II there
Is a question aboul It, or II there Is a
claim, contect Your Midland Agenl or Our
Home Olllce.
Ten DIY Right To E..mlne COnlrlCI
Within 10 days after You reoelve thiS Con.
tracl, You mey return It 10 Us by de.
Iiverlng or mailing It to Ihe Agent Ihrough
whom it wa, purchased or to Our Home
Office. We will then deem thiS Controct
void from the start and refund, within 10
days 01 Our receipt of thiS Contract, any
premluml paid.
Signed for Ihe Company al Its Home Of.
flce on Ihe Contracl Date.
r~
~e~~~~
JlLIXIBLI PREMIUM ADJUSTABLE
LIIJIIN8URANCI CONTRACT
Proceeds Payable Upon Deeth Prior to
Ihe Maturity Dale. Adlustable Death Bene.
fit. ClSh Values May Exceed Guarantaes.
FlsMible Premiums Payable DUling the
Llletime of the Insured Pilar 10 the Malur.
Ity Dale. Not Eligible for DIVidendi,
I, Contllotlnlormellon
Policy Number: 02001074,
Premium Payable: Life 01 Inlured
Is5UO Age; 40
Planned Periodic Premium: 137.00 Speol.1 Monthly
(Including Premll/ms shown below for Addlllonel Benellls)
M,lllmum Annual Premium: 1183,80
Contracl Dale: 12/011I1884
Premium Clllfls: Non-Smoker
Matullly Dale: 12/011I20114'
BenefiCiary: Ae Ipeclflld In the eppllclllon unl..e
changed a. provided In this conlllC\.
"Current risk rates and Interest ratos are not guaranteed. Therefore, the
planned periodic premium shown above may not be sufliclenllo carry Ihe
policy to Ihe matullly date.
Based on tho Planned POllod,C Premium and Guaranteed Risk Rates and
Interest Rales, coverage Will expire on 12108,54.
II coverage continues unlll the Maturity Date, there may be hili" or no
Cash Value.
Additional Baneflt
DI..blllty Benelll
Annual
Premium
Years
Payable
20
Insured: ARTHUR W HARRIS
Owner: ARTHUR W HARRI'
SpeclfllId Amount: 120,000,00
Delth Benefit: Op,lon 1
PI'" ,
EXHIBIT "A"
LueOet
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,01,701
,...
N.,
Amount 0' In.u'.ne...........,........,............................,
AIIlgnm.nl.. ",........ '........' I~
Bon.,lcllry........,.... '........... ..,6
CI.lm. or C,.dltor.. 12
Cont,lct 0.1.....................,.......... " " , 1
COrrldo, P.'c.nllg......... ..,....,............ ,..,,6
O.flnlllonl....,........................... .....3
In.u,ed ...."........,...........,.......,...........,.....,............., ,3
IIIU. A(I' ...., ..,...........,....,......,...........................1
Own.,shlp .nd Cont,ol... ..................,................1
Plym.nl of Procellds. ............' ,.....12
P,emlum CIIIB.. .. ......... ....,........1
flremlum Period, ,.."..,...,....,
Premium..... ...............'... ,....1 ,4
Rlder/.) ., ,..,............3
~ph.b.lIoll Quid.
Contrlot P,ovl.lon.
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Conlrocl Inlormallon .. ....... ,
Conlract Summary. .3
Definitions.,....... ' ,3
Premlums....3
Proceeds....,.........., ,,4
=~h~'\~~~a~ge.Deaih 'iie~eill :::: ... J
Conl"C! V.lu8$ "....,..", ".,....,..,................ .....,.........6
AnnUli Reporl 01 Contract SllIus,..........,..........,...9
Conl"CI LO.nB....,..,..........,...,..................,.,.........,...9
Gone,,1 P'ovlslons...,......... .......... '.............',. ....,..,...9
Olublllly Benefit Rider ......,.........'............'......'.. 10
Endorsemenl.....................................................,...11
Payment Opl,ons ............,........,...,........................12
I."
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2, Contracl 8umml/Y
We oller this summary to holp You undoraland Ihls Con.
tract. This summary doos not go Into doloil. Wo do not
In lend thalli change any of the provIsIons of Ihls Contract.
You should reed the actual proviSions for full Inlormatlon
and any limits which may apply. Tholl "Contracl Provisions"
secllon on the Inside of the Iront COV9r shows where the
provisions may be found.
This IS a Contrecl 01 life Insurance. We will pay a death
banafll (Proceeds) If the Insured dies while thiS Conlractls
In force. ThiS money oftan IS not takan In one sum. For all
or perl 01 It, another farm 01 payment may be available. If
lhe Insured dies and l~e choice 01 peyment has not been
made, the person who Is entlllod to receive tho money
may be able to make the cholco of peyment.
Prl/mlum paymenlS 10' this Gontracl ere lIexlble. We allow
an axtra 61 days (Grace Period), beyond the first Monthly
Anniversary on which the Cash Value,lel$ any Contract
Debt, Is Insufficient to cover the next Monlhly Deduction,
for the peyment of enough premium to keep Ihe Cont,acl
In offect. If no p,oflllUm IS paid by tho ond 01 tho Grace
POrlod. all coveraqo undor this Contract ends.
ThiS Contract 110S guaranteed Risk Roles and a guar.
anteed Contract Fund Interest rata. Rates more favorable
may be declared by Us.
Thero are other nghls avallablo to You, Unle85 We amend
It to say otherWlsa, tho Contract gives You lhese rights,
among others:
e. You rTlllY request a change In the death benelit;
b. You may assign the Contract:
c. You may change the Owner or Beneflclery:
d. You may borrow or Withdraw part or all at Ihe Cash
Value.
This Contract. as Issued, mayor may not have extr"
benefits. lilt does. We add them by Rider.
3, Olllnltlon.
E~ample: Suppose We Issue e Contract on the life 01
Vour spouse. You applied for II and named
no one else as Owner. Your spouse Is the
Insured and You are the Owner.
tllU. Ag. . the Insured's age. on the last birthday prior to
the Contract Date. es shown on lhe Conlrecl Inlormatlon
page,
A"lln.d Ag. . the Issue Age plus the numbor 01 corn.
plete Contracl Years since lhe Contract Date.
Owner . the person who has control of the rights end
valuBl provided in this Contract. Often the Insured Is the
Owner, bul not always, The Owner Is specllled on the
Contract Information page. "You" or "Your" IS often usod
to refer to the Owner in thiS Contract.
Policy . lhls basic document plus eny amendments, but
not Including the application or IIny Riders.
Conlrlct . this Policy, plus any endorsements, and Riders,
"Contract" also Includes the application. and any future
4, Premium.
Soml of the main words and phrases used In thiS Controcl
ore dellned hore. Many other words ond phrases ora
e~plolned in the Contract provisions themselves.
In.ured . the person whose life IS Insured by thiS baSIC
Contract (not Including Riders). rhe Insured IS spocified on
the Controcl Information page. He or she need not be the
Owner.
supplomentol oppllcalions for changes In SpeCIfied
Amount.
Rlder(.) . the fOrm( s) attached to thiS Contract which
descrrbe any additional benellts prowled by Rider.
Annlver..rv or Cont'lIot Annlver..ry . the same month
and day as the Contrecl Date. In each later year.
Example: If !tIe Contract Date IS June 3, 1988, the first
Contract Year starts on June 3, 1968; lhe
second Contract Year Slarls on June 3. 1989,
and so on.
Contrllct V.lr . a year which begins on on Anniversary,
Example: If the Contract Dale IS JUlie 3, 1986, the first
Contracl Year starts on June 3, 1988, end
ends on June 2, , 989: the second Conlract
Yeor storts on June 3. 1989, and ends on
June 2. 1990, and 60 all.
Monthly Annlvlrllry . the day 01 flach month that hes
ttle some numerical date os the Contract Date.
Conlllct Monlh . 0 month which boglns on a Monlhly
Annlvorsary.
Example:
If the Conlracl Dete IS June 3, 1988, the first
Contract Month starts on June 3. 1988, and
ends on July 2. 1988: tho second Contract
Month storts on July 3, 1988, and ends on
August 2, 1988, and so on,
PI",- j
LOOm!
'avmln, of Premium., The flr~t prermum I~ dUll on the
Contract Date. You may pay premiums after the first at any
time, You may pay any amount over $60 .ubject to the
miNimum prllmlum "mils, Premiums must be paid to Us at
Qur Home Office or through an Agent ~uthOrlltld II) roo
celve premium payments. A rocelpt, SIgned by Our Prosl'
dent or Becretary. will be lurnlshed and counterslgnsd by
the authorized Agent.
W. Will I8nd premium notlclls to You annually, semi.
annually, or quarterly. You may ask Us to change the
amount or Irllquency. Tho amount of the pramlum nolice
must be at least $100. You may also pay pramlums uSing
monthly automatic payment plan. The amount must be at
I...t $10.
Continuation 01 In.urlnol, If dUring the first ten Contract
Y,,", You stop paying premiums and the sum of the
premiums paid, less any withdrawals of Cash Value or
Contract Debt, IS at leBst the sum of the minimum premi.
ums dUll. a Cesh Velue less any Contract Ollbt that IS less
than a Monthly Deduction will not terminate this Contract. If
Biter the tenth Contract Year You stop paYing premiums,
this Contract will continue es long es the Cash Value, less
any Contract Debt, 15 SuffiCient to make Monthly DedlJo'
tions.
The Minimum Prtlmlum Period is the first ten Contrect
Years Irom the Contract Date.
M.xlmum Premium Limit., Federal Law "mils the preml'
ums that can be paId If thiS Contraot IS to qualIfy as "fo
Insurancfl lor tax purposes. Wo will not accept a premium
which WOuld cause thts "mltation to be violated. We may
II so refuse to accept a premium If Ihe Death Benefit IS
equal to the Contraot Fund multiplied by Ihe Corridor
Percentage. If the sum of the premiums paid reaches
$:26,000, or one half of the gUldllllne Single premium as
defined by lederal Law, We rlllsorye the light to refuse to
accept any further premium. If We accept a premium In
ellor, We will refund It with interest as 600n as the errOr IS
discovered.
Additional Informallon regsrdlng mSNlmum premiums for
thia Contract will be prOVided upon request.
Or.ee Period. If the Cash Value, less any Conlrect Debt,
Is 11111 tharl the Monthly Deduction on a Monthly Annivllr.
Illy. a Grace Parlod of 61 days will be allowed for the
payment of additional premiums so tho Monthly Deduction
can be mada. At leut 30 days before thiS Contrect ends
without value, We Will mall to Your last kllOwn address a
notice 01 the amount of premium nellded. We will send a
Pig. 4
lOUID'
copy of the notice to the IBSt knoWI1 addrass of any
asslgnlle of record. That prllmlum will bll due on thll
Monthly Anniversary on which the O..h Value was lirst
InsuffiCient. If that premium Is not paid within the Grace
Pellod, thiS Contract wlllllnd without value,
Contract Information on Paga 1 showl the amount of the
Mlmmum Premium and how often they must be peid.
During the lirst 10 Contract Years, If the sum of the
premiums paid, less any withdrawals of Cash Value or
CQntract Oabt. Is at least the .um of the minimum premi-
ums due, a Cash Value less any Contrlct Debt that I. leIS
than a Monthly Deduction will not terminate this Contract.
Relnalltem.n" If the Grace Period eNplres without suffl.
clent premium being paid, this Contraot m.y be reinstated
within five years aher Its expiration. Relnstalement I. sub.
ject to these conditions:
a. Receipt by Us of Your application for reinstatement:
b. Receipt by Us of satisfactory evidence 01 the In.
sured's Insurability;
c. Payment of a premium that Is enough to keep the
Contrar.t In force tor two months following reinstate.
ment: and
d. Payment or rostoratlon of any Contract Debt.
If this Contract lapses within the flrat ten Conlract Years,
We will reinstate the Minimum Premium Period, but In no
event will the Mll1Imum Premium Pellod extend beyond ten
years Irom thll Original Contract Date. The MInimum Pre.
mium due upon reinstatement Is the Minimum Monthly
Premium shown on Page I times the lesser of
a. the number of months this Contract was lapsed, or
b. the number of monlhs between the lapse date and
the tenth anniversary.
If thiS Contract lapses oller the tenth anniversary, no
Minimum Monthly Premium Is payable upon rlllnstatement.
Reinstatement Is effective on the first Monthly Anniversary
on or following Our approval of the relnslatement. On the
effective dato of reinstatement, the Contract Fund Is the
amount of Iho Contracl Fund at' the time thll Controct
ended, plus eny premium paid to reinstate the Contract
minus the Monthly Deduction due on the effective date of
reinstatement, Aftar relnslatement, the BUl/ender Charge
will stili be determined as shown In the SUl/ender Charge
proVision. Thus, Ihe SUl/ender Charge will be determined
using the orlglnol Issue Age and the Contract Year as
measured from the original Contract Date.
II. Proolldl
Proclld., The Proceeds IS the aum of:
a, The am'1unt of the Death Bonaflt; and
b. Any benefit provided by Rlder(s) at the dellth 01 thll
Insured: CORRIOOR PERCENTAGE TABLE
less Allllnld Corrldo, Allllnld Corridor
c. Any Contract Dellt; and A I Percellllg, A I Percenll ,
.
d. Any past due Monthly Deducllons. 9.40 260" 60 130%
41 243 61 128
O..lh B,n,"t. Under Dllath Benefit Opllon 1 the Death 42 236 62 126
43 229 63 124
Benefit Is the graater 01 : 44 222 64 122
The Specified Amount; or 46 216 66 120
a. 46 209 66 "9
b. The Contract Fund multiplied by tho COrridor Per- 47 203 67 ',6
centage. 48 , 197 68 117
49 191 69 116
Under Death B~nellt Option 2 the Death Benefit IS the 60 166 70 1113
greater of: 61 176 71 113
62 171 72 111
e. The Spllcllled Amount plus the Contract Fund: or 53 164 73 109
64 167 74 107
b. The Contract Fund multiplied by the Corridor Per- 66 160 76-90 106
centage. 66 146 91 104
67 142 92 103
Corridor perc,nllg... The Corridor Percentege changes 66 136 93 102
on each Contract Annrversary. The COrridor Percentage 69 134 94 101
depends upon the Attained Age of thll Insured on the 96.99 100
Contract Anniversary. (See accompanYing teble.)
6, Benltlclery
O..lgn,tlon. The Beneficiary named "' tho application for
this Contract Will receive the Proceeds upon the death of
the Insured unless You have changed thiS deSignation.
Chlngl, You may change any Benallclnry deSignatIon
While the Insured Is alive, unless the prevIous deSignation
provides otherWise. Such change will takn ,)lIoct ollly ntter
We racelve Your wrrtten request In a lorm approvod by Us.
Any previous Beneficiary's Interest Will end tholl oven II the
Insured is not living when We receive tho request. We
reserve the right to require that this Contract Accompany
such request.
CI..I 01 .enltlclarv. The prrollly of a Benefrclary may be
shown by using numbered classas, The class of first
priority IS called Class 1, the class of second prionty IS
called Class 2, and so on. When Wll USI numbered
classes, these statements apply to Boneficlarres unless
otherwlsll stetlld:
o. One who survives the Insured will have the right to
be paid only If no one in a prior class survives the
Insured;
b. One who has the right to be paId Will be the only
one paid If no one else In the same class surVives
Itle Insured:
c. Two or more In nIB sama class who have the right
to be paid Will be paid In equal shares: and
d. II none surVIVllS the Insured, the Owner Will be paid.
Example: Supposo tho Class , Benoflclary IS Jane and
tho Class 2 Beneficiaries aro Paul and John.
Wo owe Jano the Proceeds If she IS liVIng at
the Insured's death. Wo owo Paul and John
the Proceeds If thoy are living then but Jano
Is not. But If only one of them Is liVIng, We
owe him the Proceeds. If nona of them Is
liVing, We owe the Owner.
7. Right to Ching, D..lh B,n,lIt
Ching.. In SpecllI'd AmOUnl, You may change t~le
SpeCIfied Amount. You must send Us a written request lor
the change. You may not make chan!jos mora ollen than
once a year. If We approve the change. We Will send You
an amended Contract Irllormatlc:n page. rhe amended
Contract InformAtion pago Will show the chAnge and the
flltUII5
lI)IHl) I
Pallll Ii
lOO101
.If.Cliv. d.t. 01 the chanQe, Any chanQe In Specllled
Amounlll subjecl 10 the lollowlnQ condillons:
a. lithe Speclfl'ld Amount IS to be decreasod:
1. The Specllred Amount cannot bo decroosed to
le85 than $' 0,000:
2. The Specllred Amount cannot be decreased to
an amount that would causa the MaXimum Pre-
rmum Limits to be vlolaled; and
3. All decreases In Specified Amount Will decrease
prevIous Inorea"es 111 rel/erse order before de-
creasing the Inilial SpeCified Amount.
b, IIlhe Specified Amount Ie 10 be Incraased:
1. The increase musl be applied for on s sup-
plemental applicallon; and
2. We Will noed salisfaclory aVldence of the In-
sured's Insurabllily.
Chlng.s In D.alh ..n.lll Opllon. You may ch.nQ' the
Dealh Benefit Option. You musl ..nd Us I wrl"en r.que,'
lor Ihe change. The chanQe will be elfeollve on Ihe date
shown on the amended Contract Inlormatlon page. Ws will
require satISfactory evldenca 01 tha Insurod's Insurability to
make thiS change:
a. II tha change IS Irom Option 1 to Option 2, tho
Specllied Amount will be reduoed III equal the cur.
rent SpecifIed Amount minus the currenl Conlracl
Fund. ThIS change will not be allowed If II would
reslJIt In the Specified Amount being len than
$10,000; or
b. II the ohange Is Irom Opllon 2 to Option 1, the
Specllled Amount will be InoreBlod to equal the
current Sper,'fied Amounl plus Ihe currenl Controct
Fund. We Will not allow thiS ohange If it would CBuae
the MaXImum Premium L1mils to be violated.
I, Conlllol Vllu..
CI.h Vllu.., Minimum Cash Values lor this Contract are
ba.ed on the , 980 CSO Morlality Table on an Age Last
Birthday baSiS appropriately modified lor Premium Classes
other Ihan Standard or Orrllna,y, and 4,5 percent Interest
per year. A detailed statement of the method of computa.
lion of the Cash Values has been filed with the Insurence
Department In the slete which thiS Contrect was rlellvered.
All Cash Values are at least as great as those raqulred by
Ihat state. The Cash Value IS eoual to the Contract FlH1d
less a Surrender Charge. The Contract Fund 15 equal to
the accumulalion at Interest of:
a. The Contract Fund from the end 01 tho prevIous
Conlract Month; plus
b. Premiums receIved durrng the current Contract
Month; minue
c. The Monthly Deduclion made at tho beginning of
the current Contract Month; minus
d. Any partial Withdrawals of cash value made during
the current Contract Month.
The Contract Fund on the Contract Date Is any premium
received on or before the Contract Date mln~s the Monthly
Deducllon due on the Contract Date.
In,.,.., R.te, The Contract Fund Will accumulete 01 a rate
of Interest not lass Ihen 4.5 percont per year. Tho eqlJlv,
alent monthly rate IS .36748 percent per month. com.
pounded monthly. We may declare e~cess Inlerest based
on Our e~pectatlon8 of future Interelt ratel. We l11ay credit
. dlffarent rale lor the portion of the Contract Fund that 15
. Contracl Loan, If any. If 81 the end 01 Ihe tenth Contract
Anniversary YOlJ qualify for the Bonus Premium. Ihen for
tho portion 01 any Contract ~oan that does not excead the
Contract Fund, minus tha premiums paid, the rete credited
to thaI portion 01 the Contract Fund Will equal the rate
charged lor Contract Loan Inlerest.
Monlhly Deduction, The Monthly Deduction for a Con.
tract Month 16 equal to:
a. An Expense Cherge: plus
b. The Risk Charge, Including the cas! of eddillonel
benefits prOVIded by Rlder(s), lor that Conlract
Month.
Expen.. Charge. The E~pense Charge will not be more
than:
a. $4: plus
b. An E~pense Amount.
The Expenso Amount IS eqlJal to:
e. Tho dollar amount shown In the Expense Faclor
Tablo; multiplied by
b. The number of thousands 01 Specified Amount Ihen
In alfect.
Rlak Charge, Tha RIsk Charge Is determined on each
Monthly Anl1lversary. It IS equel to a. multiplied by Ihe
dlflerance between b. and c.
a. The Risk Rate;
b. The Insured'a Death Benefit dtvlded by , .0036748;
c. The Contract Fund alter Monthly Deduction;
d. DIVided by $1.000.
RI.k R...., Risk Rates are bosed on the Attained Age,
sox, and PremIum Class of the Insured. Risk Rales are
rleclered by Us based on Our expectalions of fulure mar.
tallty e~perience. If We change Risk Ratea, the change will
be made based on sex, Attelned Age, and Premium Class.
The Risk Rates for an Insured In e Premium Class other
than Speclel or Modllied Will never be more than tho so
shown In the Teble of Guaranteed Risk Rates.
Surrender Chlrgl. The Surrender Charge varies by Con-
Iract Year, Issue Age, and sax. The Surrender Charge that I
I
I.
11~U' ht:"" 11.UI I'~'n'e
gl tie ge .11
0 .07 00 ,n
1 07 61 2$
2 .07 62 20
3 ,07 63 31
4 ,07 64 32
6 07 66 34
8 ,07 66 30
7 .07 67 38
8 87 68 ,40
0 . 7 69 42
10 .07 00 44
II 07 01 40
12 07 02 40
13 ,07' 83 61
14 07 84 64
10 .07 80 OB
18 07 88 e4
17 .Q7 87 70
:1 .Q7 8B 78
07 89 83
20 ,OB 70 90
21 ,00 71 97
22 ,08 72 108
23 .OB 73 I 13
24 09 74 '21
26 09 76 1 30
28 09 7B 139
27 09 77 149
28 10 7B I 69
29 .10 79 170
30 ,10 80 101
31 .11
32 ,11
33 .12
34 12
36 ,13
38 .13
37 ,14
38 ,16
39 .16
40 ,18
41 ,17
42 ,IB
43 ,19
44 20
46 ,21
48 .22
47 .23
48 .24
49 .20
Is deducted 'rom the Contract Fund to determine the Cash
Value IS equal to:
II. The doUllr IImount Bhown In the 'ollowlng tllble:
mulllplled by
b. The number of thousands of Speclflod Amount.
If the Specified Amount IS chenged, the Surrender Charge
IS bUild on the number of thousands of the highest
Specified Amount ever In eHect.
Withdraw.' 01 Cllh V.lue. You may request In writing a
\'Ilthdrllwal 01 pert or all of the Cash Value on any Monthly
au RAN TEED MONTH LV RISI< RATIS
M~II
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128
lOB
410
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808
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1002
110&
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ft:I 1:11
1\9 , 1j/
76 I..
..~ 161
ijl 11\
100 I H'
\ 11 :lQa
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'.69
17 0'
lU aI
ilO 14
11206
j/,UO
n4;P
1....'"
".77
llll 00
U:)3:J
Anniversary berore the Maturity Date while the Insured Is
liVing.
If the total Cash Value Is withdrawn, the amount payeble
Will be:
a. The ClIBh Value on the date 0' withdrawal; minus
b. Any Contraot Debt.
A partial withdrawal of up to 20 percent of the Cash Velua,
less Contract Debt, Will be allowed In anyone Contract
Year. Withdrawals In excess of thiS Will not be allowed.
The amount payable upon a partlel WIthdrawal will be:
a. The amount of Withdrawal requested; minus
b. A Withdrawal charge.
When a parllal Withdrawal IS made. the amount of the
PII~1i ,.
0.
oe
o.
OQ
10
10
'0
10
10
II
"
li15
61
6B
69
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1112 lilO 10
Ill! 2..1 .1
1"'1 H" I)'
1"' :lit" Ill'
11111 :.I'" 1111
II
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Il
Illl 206 :144 III
III il ~" ~ 7) I "3
III 2'U~ 403 ,~&
Illl i/.1B 4:11l IIl9
10 304 ..n 111ft
71 :l:17 6 '4 20&
III 316 UQ 230
73 ..,It nil 2119
7" .1l11 "Ill 21))
'" III'" 7m 330
71l 1li"9 7119 371
17 nil" "IliO 411\
1Q ""3 012 4Il2
19 "0411 976 BI"
110 1:1111 10"8 &73
IJI BQ" 1I2n n42
6il 'IIIP lillQ 121
lJ:) 10 flO I~ 02 U OU
U4 II 811 IU\J 007
111\ 1;J'16 I.. Of! 1011
811 III 10 1&90 11211
117 IlIilll II\B8 1247
III Ie.... 1780 13704
00 170n 11I1.Ji) 11\10
90 11:1112 11)92 1111\4
91 20 2n ~l) IHI lit 12
IJil ;2 I'" 22 ~I 191111
03 n..a 1117G :11\16
114 2"82 2159" 2" no
01\ 203:'> 2Q3;l 28"2
IjHI :.11\06 :.11101 U4Y
G1 ""'fllJ 4111)6 ....17
liB n:.> 10 llil1f) 11200
')ij II:) J\l 11111 lIJ 11
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P'91' LOQIOI
will not defer peyment If e partlll withdrawal I. to be uud
"'UI AOII CONTJIIIACT YIAJIII to pay p,emlum. on Contract. with UI, " tha withdrawal I.
requested wilhln 30 days of I Contrlct AnnlverlBry, the
., 0.19 9 9 9 8 8 B 8 8 amount peyable on withdrawal will not ba leu than what
I..aa aNI 11 11 11 10 10 10 9 9 would have been payable on that Contract Annlvflrta,y,
aH8 aNO 13 13 1~ 1~ I~ 11 11 10
a8.~g 31.34 u 15 II 14 14 13 13 " laBS any Contract Loan. or parllal withdrawal, mado on or
30-3. 38.39 18 .8 17 18 18 16 15 15 after that date.
38,39 .0." ~~ ~I ~1 ~o 19 10 18 11
.0." .5..9 ~8 ~4 ~4 24 ~3 U 21 19 Wllhdrlwll Charll', There Is no Withdrawal Charge lor
BO 30 ~9 ~8 n 2b ~~ 24 u tho fll6t Withdrawal made in a Contract Yaar. There Is a
51 30 ~9 ~6 n 2b ~5 24 2~ $26 Withdrawel Charge for each subeequent wlthdrawel
5~ 30 29 ~s 27 ~B ~5 24 ~~
B3 30 29 ~8 27 26 ~5 ~. 2~ made In that Contrect Year.
5. 30 29 2S 21 2B 25 24 ~2
5~.51 30 29 28 n ~6 ~5 24 2~ Plld-Up Inlurlno.. You may change this Contract to
.5.BO 30 ~9 29 28 27 ~B 25 n Pald.Up Whole Life In8urance effective on eny monthly
BI 30 29 ~o 28 21 ~6 26 n
6~ 30 ~o ~o ~o ~1 26 26 n 8nnlverse,y. You mU8t send Us written request 01 for thiS
63 34 33 3~ 31 019 ~8 26 ~B chango beforo tho Monlhly Anniversary. Tho amount of
6. 34 33 32 31 20 ~8 26 a6 Pald.Up Insurance will be the amount that the Ca8h Value.
6H~ B8.S1 34 33 3~ 31 ~o ~B 26 ~6 leBS any Conlract Debt. will purchese when Ipplled as a
63-1~ 88.17 38 31 38 3. 33 31 29 n
+ nel SIngle premIum at the Insured's attained age. The
CONTRACT YIAR amount of Paid.Up Insurance may not exceed the Dealh
'8.nd Bonehl on the effective date of the change. less any
1.1 1,1 1& latllr
0.14 0.1. 1 1 1 6 6 8 6 0 Conlract Debt, II the Cash Value, less any ContrBct Dabt,
16'2~ ~0.~7 2 S S 1 6 S 6 0 e~ceeds the net SIngle p,emlum for the mexlmum amount
~3.2B ~8.30 10 9 9 8 1 8 6 0 01 PaId. Up Insurance, Ihe axceBS will be paid to You. II the
a6.29 31,34 12 11 10 0 S 1 6 0
30.34 36.30 14 13 1~ '0 0 7 6 0 Insured dies while Ihe Paid.Up Insurance Is In lorce, We
38.39 .0.44 18 16 '4 12 10 8 6 0 Will pay Iho amount 01 Paid.Up insurance, less any Con.
40... .B.40 IS 16 16 13 11 8 G 0
BO ~o 19 18 18 13 10 7 0 tract Dobt.
81 ~o 19 18 18 '3 10 I 0 You may make a written requesl for a Cont,act Loan or Ihe
8~ ~O 19 IS 18 '3 10 1 0
83 ~o 19 IS 18 13 10 1 0 Cash Surrender Value of the Pald.Up Insurance. The Net
84 ~o 19 18 16 13 10 1 0 Cash Value available on any date will be the net single
B8081 ~O 19 18 18 13 10 1 0 premium lor the Pald.Up benefit, less any Contracl Debt.
46.80 ~1 20 18 18 13 10 1 0
81 ~1 ~o 18 18 13 10 1 0 Within Ihllty-one d8YS afte, the Contrect Anniver8ery. the
6~ ~1 ~O 18 18 13 10 1 0 Nel Ca8h Value will not be le68 Ihen ,it was on that
83 03 21 18 18 13 10 1 0 annlver8a,y.
6. ~3 ~I IS 18 13 10 1 0
88'8~ 8B.87 ~3 ~I 18 16 13 10 1 0 BI.II 01 Plld-Up Inlurlnce VllulI. Net Single preml.
63'1~ 88.17 ~8 ~~ '0 18 13 10 1 0
73' 18 . 29 ~8 ~3 10 '8 1\ 7 0 um8 lor Ihe Pald.Up Insurance are basad on the 1980
CSO Mortality Table, Age Lost Birthday, and 4.6% Interest
psr year.
wilhdrawal Will be deducled from the Cont,acl Fund. The Rlderl. When Pald.Up Insurance takas effect, any oddl'
Spaclfled Amounl Will be reduced by the amount of Iho tlonal benefit prOVided by rrdars alJached to thIS Conlract
withdrawal unless: Will and.
B. Dealh Baneflt Oplion 2 IS In effect: or Bonul Premium, Or' the lenlh Contract Anniversary. Wa
b. The Contract Fund after wllhdrawal times the Cor- Will piece Into Your Conlracl Fund on amount equal 10 the
rrdor Percentage for the next Conlract Year exceeds Bonus PremIum shown on Page 1, If at tha end of each of
Iha Specified Amount prror 10 withdrawal. the flrsl len Contract Years, (a) Is 88 least as larg., as (b).
whe,e:
A partial withdrawal Will not ba allow ad if It would result in a. IS the sum of Ihe premIums You paid, lesa any
the Spaclrlad Amount baing less than IS 1 0,000.
ConlrBct Loans or Withdrawals,
For any wllhdrawal We reserve the rrght to deler payment b. IS the Bonus Premium times the numbe, 01 Contract
for up 10 SIX months after We receIve Your request. We Yea,s compleled,
2. The exerclee 01 eny right and privilege granted
In the Contract or by Us.
Contln".nt Ow"er. The Owner, II other than the Insured.
may name or chenge Ihe ConllngOl1I Owner whllo the
In lured Is alive. Upon tho death of the Ownl'lr, tho Contln.
gent Owner will become tho Owner. II no Contingent
Owner hal been named or is living, ownership will pass 10
the Owner's eslalll.
Aaal"nm.nl, Wo Will not be bound by any assignment of
this Contract unless We receivo Iho Assignmont, or a copy
01 It, at Our Home Offlco. Wo are nol obliged 10 soo that
an elllgnmenl IS valid or sufficlant.
'uleld. I.elullon, II Ihe Insured commits suicide, while
,"IliA I
PaUli '0
lOom!
sane or Inlane, wllhln two y.." of the Cont"ct Date, Our
totel liability will be limited 10 the premium plld prior to
deeth, less any Contract Debt Ind pertlal withdrawals.
If the Insursd commits suicide, while IIno or In88no, within
two yoars 01 tho effocllve dale of eny Increase In Speciflod
Amounl, Our totelllablllty with respect to luch Increase WIll
be limited 10 the Risk Charges made for luch Increase,
Mlaatlltmlnt of "", or ".. If the Contract Is In error
With regard to the Insured's age or sex, Ihe Death Beneht
Will bo the amount provided besed on the mOSI recent RISk
Charge allhe correcl age or sex.
Non-plrtlelplllon. ThiS Contract does not pay dividends
or otherwise share In Ihe proflls of the Company.
12, Dlllblllty B.nlm Rid"
S.n.lIl, ThIS Rider provides disability Insurance on the
Insured. If Ihe Insured becomes tolally disabled while thiS
Contrlct and Alder are In force, We will waive any Monthly
Deducllons whIch become due during the continued Tolal
Disability of Ihe Insured. While Monlhly Deducllons are
being waived, Ihe Death Bllnefll Opllon In effecl must bo
Option 2. II this requires a change in Dealh Benefit Opllon.
the Specified Amount Will be reducod 10 equal Ihe curront
SpecifIed Amounl mInus Iho curront Contract Fund,
Totll Dlllblllty. Tolel DISability meens that Itl0 Insurod Ib
unablo to engege for gell1 or profit In any occupallon lor
which the Insured Is or could become qualified by reason
01 educallon, Iralnlng or experience. Baing a homemaker
or student 15 consldored engeglng for gein or profit in an
occupallon.
To approve a claim for benellts under Ihis Rider, We
raQulre thaI:
a, You send Us proof of disability;
b. The diSability hilS continued lor six consacullve
monlhs;
c. The dlsabillly resulled from bodily Injury or dlsoase;
end
d. The disability began while this Conlract and Rider
were In force and altor age 15 of the Ins'urod,
If the Insured becomes tolally disabled while thiS Contract
IS In the araco Period. You musl pay enough premium 50
Ihat all Mont~.ly Deducllonthen due can bo mado,
Tolal dlsabilily Is presumed If the Insured sullors a lotal
and permanent loss while this Contract and Rider are In
forca Iher age 115, of:
a. The use of bOlh hands or both feet:
b. The use of one hand and one foot; or
c. Sight In bolh eyes, .
Clua.. of Dlllblllty Not Cover.d, The Monthly Deduc.
lion will not be waived If Ihe Tolal Dlsabllily results from:
a. Intenlionelly self.lnllicled Injury; or
b. Insurrecllon or war, declared or undeclared, or any
act InCident to war, whether or not the Insured is In
mIlitary service.
Nolle. Ind Proof of Clllm,
Inllla' Proof of Tot.1 Dlaablllty. Written nollce and proof
01 c1ll1m must bo glvon to Us at Our Home Office:
a, While the Insured IS liVing;
b. While lolal disability continuos: and
c, NOI moro Ihan ono year 8lter the beglnnrng of the
dlseblllty.
Fellure to give nollce ilnd proof within one year will not
VOid a claim If It is shown that the notice and proal were
given aa ooon 8S was reasonably possible. We will walva
the Monthly Deduction on each Mor\thly Anniversary aller
the slart 01 Total Dlseblllty as If We had received earlier
notice 01 proof. However, We will not waive Ihe Monlhly
Deduction on moro than 12 Monthly Anniversaries preced.
Ing Iha date We actually did receive nollee and proof.
Proof of Conllnulne. of TOIlI Dlllblllty, Proof of con.
tlnuance of tolal dlseblllty will be, reqUired at reasonable
Inlervals. We may require that the Insured be examined at
reesonable intervals. Any such examination will be at Our
expense by en examiner whom Wo Will name. If proof IS
not furnished on requost or Ihe Insured falls to submll 10
oxamlnalron, all benefits under thiS Rider Will end.
Cost of This Rid.,.
The cost lor Ihls Rider IS determined on each Monlhly
Anniversary. The Monthly Deducllon for this Contract IS
Increased by the cosl of this Rider. The cost of Ihle Rider
IS equal 10 Ihe rate shown in the follOWing lable multiplied
by tho number of Ihousands of the Insured's Death Benefit
diVided by 1.0036748 less Ihe Conlract Fund. In addItion 10
Ihls amount, Ihe follOWing costs are edded for any Riders
Ihat are a part of this Contract.
9. Annual Report or Conlract StatuI
We Will bend You IIn Ilnnlllll roport, lit no churqo. whIch
gives a summary of this Contract's status as of tlm und of
lJach Contract Year, This report Will give Information roo
gardll1g the Deuth Bonoflt, Cash Vollla, prollllulII pay'
menls, Risk Charges, Monthly Deductions, and 1/1Ierost.
In addltloll to the annual report, We will prepare at Your
ruquest a prolectlon of the results of Ihls Contract for
luture yoors. We Will nol charge more than $26 for prep.
Ilratlon of thIS report.
10, Contract Lo.n.
Contract LOin., While thiS Contract IS III forco, and the
Illsurod IS flvlng. you may make Wrlltell request for a
Contract Loan. The alnount of the loan con be any amount
up to the amount available for total Wllhdrawal. ThiS Con.
tract must then be asslgnlJd to Us as 5010 security lor the
loan. We reserve tho right to deler payment for up 10 SIX
months after the request. We Will not defer paymullt If a
loan IS to be used to pay premiums on Contracls Wllh Us.
The Interest rate that We charge on Contract Loans IS 8
percent per year Irom tho data of tho loan, payabla in
arrears.
Replym.nl of LOlna. At any lime, tho total Contract
Debt Is the sum 01 all Contract Loans and all Interost that
has accnJed ,on tham. Any unpaId Interest Will be addad
and bear Interest at thll seme rate. All or part 01 Ihe
Contract Debl mey be repAid et any lime while this Con.
tract is In oflect and the Insurod is living. If the Insured
dIes before the loan IS repaid, the loan Will bo deducted
IrOIll the Proceuds of thiS Contract.
EKee.. Conlrlel D.bl. Tho Contract Debt may grow to
be more Ihan tho Cash Valuo, If thiS should happen. we
Will mall a notico to You at Your last known address and to
any ASSignees of record. The Contract Will end 31 days
after We mall thiS nollce unless by then YOlj reduce the
Contract Debt to the Cosh Value.
11. General Provlllonl
The Contrlet. ThIS Contract 15 Issued III consldorntlon of
the applicallon and payment 01 the 1/1I1iA1 premium. The
Poflcy, the eppllcetion, and Rlder(s) ettached to thiS POliCY,
and any supplemental appflcallons for chenges III SpeCIfied
Amount form Ihe enttre Contract. We assume that all
statements in tho application were made to the best knowl.
edge and belief of the persons who mado them; III the
absence of fraud, they are doemed to be represontatlons
and not warrentles. We relied on thoslJ slatements when
We issued the Contract. We Will not use any statement to
VOid the Contract Or deny a clal/Tl unless that statement IS
made In tho application or a supplemental appllcetlon and
a copy of such application IS atteched.
Termlnlllon of Conlract. All benefits prOVided by thiS
Contract will cease If;
a. You request that thiS Contract be termInated;
b. The Insured dies. If Riders aro attached 10 thiS
Contract, Alder forms may prOVide for contInuation
01 Rider benefits;
c, ThiS Contract matures; or
d. The Grace Pflriod e~pires.
Inconllltablllty. We Will not contest thiS Conlracl efter It
has been In lorce. dUllng the Insured's Ilfellme for tWI)
years from the Contract Date except for
a. InsuffiCiency of Contract Funrl; or
b. Any prOVISions grenling dIsability benefits Or ac.
cldental death benefIts.
Any Increase In Specified Amount effecllve aftor the Con.
Irecl Date Will be Incontestable aller the Increase has been
III effect dUring the Insured's lifetime for two years follOW.
IIlg the offeet,"e date of such rncrease.
Contrael Modification.. Only Our Prosldent, V,ce.Presl.
dent. Secretary or Asslstent Secretery can aq,oe to modify
Ihls Contract, and then only In wrlttng
Right 10 R.qullt thl. Contrlcl lor Ching.. If You
request a change that W,)uld cause the Information given
on Contrecl Information page. the application or any sup-
plemental applications to be Incorrect, We reserve the light
to reqwe Ihat thiS Contract be returned to Us so that the
appropllate chBr\qe(s) can be made.
Owner.hlP Ind Control. Unless InconSistent With the
torms of any Beneficiary deSignation or any assignment or
change In ownership:
a. The Owner of thiS Contract IS shown on the Con.
Iract InformatIon pagei and
b While the Insured IS liVing. You alone are entitled to;
1 Any Conlrar.t benefll or vAllle,
1J,1I1UI)
l!}l)IIJI,
MIDLAND NATIONAL. LIFE INSURANCE C"'MPANV
On,'Mldland Plaza
Sioux Falls, SO 67193.0001
Data' 12'09,94
Agant EISENHAUER. PAUL W
The lollow/n(/ sllmmlfY was prepared lor:
Bas. Insured: ARTHUR W HARRIS
Cuntract Numbar: 02001074
lsau. Ag.: 40
Sax: Male
W.lcome to Midland Nallonal Life'
Pl.... take a mom.nt to ravl'lw this iIIUatrallon. Oallnlllons for the terms used can be found In your contracl. The current
v.lu.. shown are based on a 6.76 percent Interest rate and current risk rates. The projected results shown may change WIth
variation In the Interest rate, risk charges and frequency, liming and amount of your premium peyments. The death \)9rlellt
Illustrated Is the greeter of either the Specllled Amount you applied lor or, when nl/ceseary, the Contracl Fund multiplied by the
corridor percentage.
This proposel rallects the Premium Bonus being cradlted to the Contract Fund on the tenth anl1lversary, On a current besls.
the Contract Fund Is shown earning an extra .6 percent above the prolecled inteFest rate beginnIng on the tenlh annIVersary
Ind 1 percent above th. ploJected Interest rate beginning on the twentieth anrllveroary, If aller review you have any quesllon.,
please contact your agent or the Home OHlce.
Midland Nallonel Life was founded In 1906 and IS rated A + (Superior) by A.M. Best, lhe Illadl/lg In<1apendenl IIlsuranca
reporllng authority. In addltiol1, Standard and Poor's, a highly raspectad rallng service, gives MIdland a claIms paying ability
rating of AA + (Excellent). Thank you for selecllng Midland Nallonal Life to help maet your Insurance needs.
Type of Insuranca:
Death Benefit OptIon:
Spl/clfll/d Amount:
Planned PeriodiC Premium:
Fla"ble flrl/rruum Adl'JSlabllJ Lilli
1..~mt, Includes Contracl Fund
$20,000
$37.00
r-- .-----,---------..___-.-.._____._._________ ___._u._.._.....~.____..
.. -..'.'--'--'---,
I GUARANTEED VALUES CURRENT VALUES ,
f~ Annualized r----cSSK.-.+-co;;trect t--n.eath-nn~"""...casfi.--- r--CoritiiiCf-T' lleai'fl--1
Y,ea~ Preml~~ .___Va:~__. _._~und ,____~~n~~~__._+-_Valuo__ J ,_!'~~~ -----L-~~~~~___..:
I I ,
444.00 0 312 20,000' 0 333 20,000
I 2 444.00 I 158 I 638 I 20,000 208 688 20.000
3 444JJO! 494' 974 20.000 586 1.065 20.000
4 444.00 642 1,322 20.000 966 1.466 20,000
6 444.00 1,222 1,662 20,000 1,433 1,893 20,000
6 444.00 1,615 2,065 20,000 1,907 2,347 20,000
7 444.00 2,018 2,438 20,000 2,407 2.627 20,000
8 444,00 2,453 2.633 20,000 2,969 3,339 20,000
9 444,00 2.864 3.244 20,000 3,625 3,886 20.000
10 444.00 3.623 3.943 20,000 4,422 4,742 20.000
11 444.00 4.094 4,394 20,000 6,107 6.407 20.000
12 444.00 4,600 4,860 20,000 6,869 6.119 20.000
13 444.00 6,121 5.341 20,000 6.669 6.679 20.000
14 444.00 6.678 6.838 20,000 7.532 7.692 20.000
16 444.00 6.230 6.360 20.000 8.441 8,561 20.000
16 444.00 6,874 6.874 20.000 9.574 9.674 20.000
17 444.00 7,414 7,414 20,000 10,660 10.660 20,000
18 444.00 7,973 7.973 20,000 11 ,826 11.626 20,000
19 444.00 8,550 6,660 20.000 13.079 13,079 20.000
20 444.00 9,146 9.146 20.000 14,429 14.429 20.000
Total Cash i Contract Death Cash Contract Death
Age Premium Value Fund Benefit Value Fund Benefit
60 8,880.00 9,146 9,146 20,000 14,429 14.429 20,000
62 9,766,00 10,440 10,440 20,000 I 17,626 17.625 22,560
i 66 P ""~.~~Lifi.~~t~rr73 12.~_1~hO,0;~_-_L--23'~a:-.r.cl.-.-...2-3~~61.~ Hrli~_=f2~:606=__.
ra/ec,su va,ues an cos n exes sown ue,ow are .or. e aSlc covarage anu Inc,uoe sny op lona ene.1 s or /luers.
INTEREST ADJUSTED COST INDEXES
~ -r '""Md" ! No< ",m.m-' -..
, Cost IndeM ' Cost IndeM
ear lrUiiBnt"8idl- Current r'O'uaranieed i' ''Curre-nr----
10 I 6.48 I 6.46 1 2220 22,20
[!O--L___ 9.03 I 1.42 I 2220..E.~~9.._.
~
MIDLAND NATIONAL LIFE INSURANC. COMPANY
On. Mldllllld PIli I
SIOIlM FIUI, SO 157193.0001
'" Inllllld: ARTHUR W HARRIS
Agen!:
Ra7a
EISENHAUEf1,PAUL W
RD'4 BOX ,136
MIODLEBURO PA
17842
Policy Number: 02001074
$TATIMINT OF POLICV COST AND BINfFIT INFORMATION
'omlllm. on thl. plge If' b"ed on th, annllll p,emlum mode. The actual premlum5 for thle p'olicy mlly differ dUll to a lIIudo
hor thin Innu.1 belng 1.I'cl.d. Th. GUlllnllld Calh Surrender Value below doel not reffect the additional coat of any
'orl. The GUlrlnt,..d Inler,,1 RIte II 4.6 perc.nt.
II dlllh blnelll .hown II Ihe g,ellllr 01 either the Specified Amount you applied lor or, when necessary, Ihe Contract Fund
uitlpllld by thl eo"ldo, percenlage.
)\j mlghl choo.. 10 dlll,.l.. yeur Specified Amount 0' termlnlle any "der. it II also possible thlt you, Premium Cia" cOI;ld
t cI,anp"d I,om Splcl., or Modified, MY IUllh chlngl mlY to,ce you to reduce you, premium plyment 10 en lure YOur
Gnlrlcl I compllanc. with Federal TIM guldelln.., A premium declla.. could mike you Ineligible fo, the Bonul Premium.
,. ell.cllvl polley loan Inter..1 'lIe Is 8.00 percent In errea,a. Ploase conault your policy lor definltioM of terms und,
BASE PLAN INFORMATION. FleMlble Premium Ad,ustable lif,
~- AnnUli =HGUlrlnleed --.... r .O:~;~~~~~~C~Sh ' .-,
Yelr Premium Delth Benefit , SurrQnder Vllue
,.. 4'44.00 - 20,000.00-----.,---.-O~OO..--.
I 2 444.00 I 20,000.00 168.11
~ 444.00 20,000.00 509.65
,4 444,00 20,000.00 86273
! 5 444,00 20,000.00 1.248.39
10 444.00 20,000,00 3,424.41
, 6 444,00 20,000.00 6,033.07
20 444.00 20,000.00 8,981.76
Age
60
82
66
Jllrlllon Oate:
1108/84
,u. Ag.: 40
1M: Mil.
"cllled Amount:
10.000
11th Benelll Opllon:
.Sp.clfl.d Amounl
cludll Contrlct Fund
444.00
444.00
444.00
20,000.00
20,000.00
20,000,00
I 8.981.76
10,256.78
I 12,361.07
... - - . -- . .-... -... .. -,.. ~
L__
.-.....,._ ~__L__._._.______...,
SUMMARY OF GUARANTEED RIDER CHARGES AND BENEFIT AMOUNT
--j-------..-r----'--'--....,....
,-'_.._--'
I" I
VII' Wllver of Chera-.. -.. .
1 4,88 ~----- -
2 4.88
3 4.86
4 4.44
6 4.44 I
10 7.80
15 11.84
20 18.80
Agt
110 18.60
112 0.00
65 0.00
Amounl .....
l____j_.. __.___._
LIFE INSURANCE COST INDEXES
-I Surrender-irfrifPeYlne/1/ '.,
~~~ Cost In:~4--~..~~.~ln.;~:i6.1
20 9.27 L__.__.~~~o;
cpllnltlonl of the Intended US88 of the Life Insuranca Cost Indexes are provided In the InNurancB Buy"s OUlde
:complnylng you, contract.
OIlcyhOldl' IIlgnllur. '.
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II this Contract Includes: MONTHLY OISASILITY RATE' "ER '1,000
a. Term Insurance For Addlllonal Insureds . Add Ihe Atllln.d
amount shown In Itle following table mulllpliod by
Ihe total number 01 thousands 01 Benefit Amount for Aglof
Additional Insureds; In.urtd .m Ie Mee ".mlle
b. Family Insurance Rider . Add $.09 per Unit 01 Fam. 16.32 .01 .01 .01 .01
lIy Insurance Rider; 33 .01 .01 .01 .02
c. Children's Insurance Rider . Add $.03 per Unit 01 34 .01 ,01 .01 .02
Children's Insurance Rider. 36.39 .01 .01 .01 .02
Oenerll "roYI.lon.. 40 .01 .01 ,02 .02
41 .02 ,02 .02 .02
Iffeollye 011', Thll EffectIve Date of thiS Ridar IS the 42 .02 .02 .02 .02
Contracl Date of thiS PoliCY unless olherWlse shown on 43 . .02 .02 .03 .02
PaQll 1. 44 .02 .02 .03 .03
Termlnlllon of CoyerlliJe Under Ihl. Rider. ThiS Rider 46 .02 .02 .03 .03
will terminate on 1~le earliest of the follOWing datas: 46 .04 03 .06 .04
e. The Anniversary next following Ihe Insurad's 60th 47 .04 .04 .06 06
birthday; 48 ,04 .04 .06 .06
b. The Monthly Anniversary next following Our receipt 49 .04 .04 .06 .06
of Your request that this Rider be terminated: or 60 .06 .04 .07 .06
c. The dale this Contract termInates. 6' .05 .05 .07 .07
Olher Oener'l ",ovl.lon.. 52 .06 .05 .08 .08
53 .06 .06 .10 .09
a. ThiS Rider is a part of this Contract; 54 .07 .07 .11 .11
b. This Rider is ISSUlld In consideration of Ihe appllca. 65 .09 .07 .12 .11
lion and payment 01 the flrsl month's cosl for this 56 .10 .08 . '3 .12
Rider; 67 .11 .09 .16 .14
c. The terms and conditions of thiS Contract apply to 58 .12 .10 .16 .16
this Rider unless specifically excludecj; 59 .14 .12 .'9 .18
d. When the Insured has recovered trom TOlal D,sab,l.
Ily, You should immediately give Us wrtllen rlotlce; e. This Rider does not pay dividends.
and WPT.21
13, Endor..menl
The Interest Rate paragraph of the Contract Values provl.
slon has been changed as indicated below.
The following sentence la added:
Aller the tenth Contract Anniversary for the
portion of any Contract Loan that does not
exceed the Contract Fund, minus the premiums
paid, 1I1e rale credited to Ihat portion of the
Contract Fund Will equslthe rate charged lor
Contract Loan Interest.
5604
,
,
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LOg701
lL, '~.u~_~Jk.lILIII
PARn
I. PROP0510 IN5URI0
!IIIlf'tf; S
.
5'OUIl PROPOSIO 10' IN5URANCI (0' pltml'rn PIYO, 10' l'i1nll. poll'y)
~ A pllClllon 10: MIDLAND NATIONAL LIFE INSURANCE COMPANY, Slm fill., ID 11183-0001
-J 1Zll'iIrG'1I'JIilTT;';-' .
l 61NGU MARRIED AGE .l'.~."_~!~, ... P.~I~.'nUflUI' ,I" I_J tltl!
~t "'Au r t~' ,J /fI.1J' o/'() !!!. ~~ 1;:,~-.:;':'~;~'fm j :~,JI'I
OIPlNOINI CHI LORIN PROPOSIO 10' INSURANCI
"
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t. AUIOINCI AOOIlU~ / I P
1!lJ 1- ;P.r;.
I I 1
3.:!~~ I' F.n91h .i>d.
MY.,.. ifNI! CIIY t~1
4. OCCUPAIION (OlltllbllOd glY. ."'.. dull..) ,,~ C OCCUPATION 01 5POUSI III IPPlltlb1'1
'j-Rdt! K -:1.e(tI!'", - /y,Al" r
,C,tfCA-I.
Hl.1f'1I0NJ NIIMIIIII
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BI)n1NlfiBlIllI'IIf~1 NIIM~III CONIACI 1111 PliO.
"","",,.1/1 1oY-'1' , v~ I PO\II)INBIIIIWAI
fA IIIBIIIINCI
{1""BINISi.
l' I I A M
_<fL._III'M
lml.
5. WIIHIN IHI ASI II MONntS. HAS ANY PIRSON PROPOSfO lOll INSURANCE:
I. SMOkED CIDARIIlES? 0 YIS ~ NO (II YII. provld. d.I.III,)
b. uno lOIACCO IN IJIY 0111111 lORM? 0 YIS 18 NO (II YII. plovldl dllllll)
I.AMOUNI IJIO PLAN 01 O~POLICY
c:J ~ dOe). "0 ''/11 t ~ //
_I~~~~! _.._...t.,
011 All II
t1P~i1;;id-
lid Non.Smulll
115100111
1l1J1U~IIUII II.
OclOplluUI
111)pllllllll
It.d Auhlllllhf
PIIlIllumllll"
11lt,f ....I.hl. .~~ "'/I~,.ltl
1111111"''''1
MNIJMAlIIO
Il( RrslU!N~1
I I IIIJBINIIIS
7.RIOIRS
Ii W~Y11 0/ Pllm.
[J Actldonlll Ollth 01111111
[J flulbll PllnlluIII AunUl~ IIldlll .-"--c'r'~,- __ __," ,___ '"'\'" I I WP.n IPAlll
IMlcll/lll,wUlIIf!fnr "m, 1'~II'r'll)1I 1111/
o IJNIr 2 Plflnt fiR rJ --u;mr- Chitdlln'lllIl. nidi' [-J Autom.tlc WllhdllYl.llu ."Y PI.nUIlI'111 AIWIllly Ilhl., (nul nlUlbl.III 11ll11.n.J
O I' IIR (J (I OIlIl,RIIIII u__" ,'u'" _0.
___ 1 IIInt ~ -unr QUI"ntud Inl, Rldlr '"11 ""vy~i'
- .- . .-_. ..--....-
I PRIMIUM fRlOUINCY PREMIUM MODI Ao\ilUII' 01 Mod. Pllllllurn A II Jill' I
O 0 <:> [] ~ --) tIlDUn ',how 1,.,tllll.lIun
Annu~ OU.f1.rry... Chlel.O.Mllle "llltOllllng/Jllllthlll I) '~IRUIIIIIIIII"I,II.m"",,"[
[]51ml'AnnUIIOMonlh OOllletOllllng OGOYIrnmlOt.lllOlmlnl v ,IDJ'!::_, _ ".II~!"II"II"I,!:I"".llll),
01 WILL TflllNSURIJICfOllND APPlIEO lOR RIPLACE OR CIIANDI ANYEIISIIND lIFIINIIIJ,,^Nr:f OIlANNIIIIVl:lJNIIIAI:' I I 1 \IB R NlJ
'j i"~~~---I( h )
:=:-.:r~:=:;..=~~:;;:-;:-.,_ #
9b.IS IIllIIl ANY INSURANCIIN 10RCE OR APPlIC^,ION PINOINO ON 1111 WE/lIVIII or ANY I'IIIII'II~!I' IN!ilJllflJillI'l M. VI II I
k. Propo.fd Inll/Ud Him. ,lmounl ~;-- .AO'
,t!1"~o!' -- CIPlndln1fl, fi;>
Md~:- nPt
tJ' "9 CI
OI'lUIl_C1'
10, OWNIR If OlHIA IHAH PROPOSED INSUR!O II"';;~ ';;.'IIV""'''';~.'''''I
P,opolld In'ull~ ~'111'
1,lJlIlplnr
1 NO III ~11 pI".. tlJlopl.l. 0/; I
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ii'JI;i.lljmv-1- j"j.
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III PlIl'fARV Il~ffICIA;':.\.c'm I) (Intlud.Ilt.!J!A.hip '9 PIOPOlld I",Ulld,) I I lb co~i~;~~'~ooilli;i~nY-;-li;I~i'i>)i!i;;';;iiI'lill;~;I~~~~~t:~'~;'dl
Ct,tl 0'1' ~, r:7?1<9 9') "', J q ~ Kilt '/ V, /f,1 ".1If1 J - I,!t -I'I!''''.!I!'' {
L ~ "''''lr'1!. I '(....J,' (t f. r r, (I " {'I'ft: ,j
Ion .. not I uU DI eMdrtntnt'H ~nd" ,..~" Chlkl!f/'Il'tDI4'h~~II_. .__,_ __.. .__ _ ~. I L 'r,r.Ilt"!I~ ~.tI1tl~ ~I!'''.t ,1.nlf!l~1 ~r.I~'.' !l~~IY.!.!.~~1 !!~UlltIJ!'."!_,__.
12~PIF'AL RIOUESIS 1lJUl1lAILS r', d /J J 1".t"l" 13 CI)R/lEClIlIN!; Mill AMINI1M'NI~ II... II,,,,,, iIIIICI UIIOlllyl
1'1,.,.) A 11'1 o.f:j.~ 4lf /"{' 1#i(;1l ,N, .
,4. p IF I: .il7'n,s.", "AI. VI. /,vS.",,~
f ,...,., "" ;J:,~u I , /.J F J J - /!i r4 .I. ,
tf..tJ !-/P F,vr .;B,H'~/irl'/A'I. AlII,n'-'
$ ';t;It~/'H'''II''. ~h ,,7':s I.A/I,/'-J~'
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h If\.
'1 12. A lIullo" 10 MIDLAND NATIONAl .llfE INSURANCE COM'AN~
OYIIU,n 14t, '.umpllt._,. lolh nln.mldln, In. ' ,nln.d .ppllllllm,
II. H'IIIlV pili'" P'ilPO'''' I', tnlurlnCl In S"lIon I on '''lIIl1ld. VII HI
(I) "ltllvld tllltmlnt lor dlug UII or IIgullIIV UIId mllllulnl: nmolle, hlllucIIlOg,"~ Ir hlblt
',,'mlnt dlUgl nol p,,,,,lbld bV I phVII,I.1I 0, III"V Iu,h plllO" ,ulllnlly ullng mllllulIll ,
b f4~':~v ~1':~v'hi,if'mQvi;;g'~IQi.iiQn;o;''';i~lnil';;iU;inih.'iiiiiWQ,i.,i1:.,.",..::.:.:: ::::::: U Ii!
1,llIln IIIlIlld 10' lilY 'IIIU" Othllthlll mo,'nu 1111110 "0111111111............................, ..'..,..,......, 1 1 i:1
dl flow. o!hlr !hili II . rlll,IItVlng pllllllglI wllhln Ihllllllwo VIlli, 01 colltlmpl"I"ch .
Ilylnt In IhlMUlll (II VII, compIIIIA"llIolI OUIIIIOII"IIII,/.............................,............ ........,.. [I 1;.1
(Il AnV PIli P'llIl1t or ..p"tld ICll"1y III II"IIU. Iklll or IkV d "lIg, 0, I"Y uthll hlll/doUl ,
,poll 0' hObiIV1111 1,"' co"'pl"III""d"l A'llYIlliI OOllllollnllll,),....,... ...........,.. .......... I I iii
(I) ~~~~~il~111~~'~~:~. .'~~ .I~",~.' ~'.'.~.I. ~~. ~'III.~'~tln,'~,".'. .01, .h.I,~ .~/,~Il.~~ .d.~,~I'~II,d:, POIIPO~~'~:. ~~~.~~ ' ..', " II!!
11.IIIII.r Plllln p,.polld 101 IIIIUIIII"'II S"lIol1 1 Oil "'"l1lldl iii, hid or blOlI ""lld 'or
(I) Chll PI''', hlln mUlmur, hlUIl blood PIIIIUII, or IIIV 011111 dllllll .,1111 hllll, blood. ,
b w.::~~li:~\~,~i.iiiQn:'Q;..j;,.oi;;ilJlii..i.o.,i;;l.iQ;ii";;:in'liliiiiii:oiii 'biidd"OrIIY.;1:.:: U ~
1,1 (mphVIIIIl', brunchllll, IItllllll, pIIUlIIV, U, Inv 011'" dllllll 01 Ihl chili or '""Ull................ [,I ~
dl ~ldnl'lllo"l, d~bltll; IlbulIllII, Pol, blood or IUUII 1'1 ",Inl; IInlllll dlllllO, or IllY olhll .
dllllll 01 !hI ~dnIVI, IIllddll or "~'OllUCIIII Olglllll..........................................................,..... r I Ii!
(I) ~1:'l~~~~:~~ij,~crh:'~lb~I~~~l.:. ~R~.(^.'~~. ~~~~'~~ .~.~.~.P.'.~~).~~. .b.~~~~ .I~~~ .~~.~t.~.~.~.UI~.~ . ' . . ... ., (" Ii!
(" 81V11. hlldllhll, Illnllng IPIIII, IpIlIPIY, PIIIIVIII, 1I11'10Ulnlll, mllllll dllO/clll, 01 IIIV
othll dllllll ollh. blllll or IIII'I0UIIVlllml......,...............,....................................,................... [~ !If
19! AnV Implllmtnt ill light or hllllngl................,....,..................,........",..,...."......,........,......",.... [, III
h A1cohllllll\1 or blOn Ulllld or OOUllllllld lor thl UII ill Ilcoh.,l......,..,...,................,................. r I\iI
I) CInc:II, lultlQr or IIlV olhll 1111111I or Inlury not 1Illllll0nld Ibml................,................,..........,... L ill
1&. Olhlr !hln Indl..lld Ibo>l, hlO InV PIlIOI\ PIOPOlld lor '''Iulln,,'n Sltlloll 1 on "'"11 lid.
II (VIIlppllld lor or I""'ld I pll\llon ilr dlllbllllV 1111111111..,..,............,.........................,.......,....., r~ 1M
II IlIn hOlpllllllld In !h. pili I Villi?......,......,......",......"....,....,................,..,..,..,.............,....... tJ
c COlllultldl phVlklln d",I"U th. PIlIIVIIII?....,......................,...................................,...,.,.... , ~
(: ~:: :..~~.ldf:t:1i~~~~~~\~:~I~:~':hi,i,~.Qi'Jii.bli..:.;;;i.ri'j8i:.n;;voo...;;.i.;,."...'.'.......'... rJ IH
clreulllorydllO'd..l.........,...........,..,.....".."",..,......,....,..,...........,....."..,....'.......,..,....,........."... II ~
11.1. .ny pIr.on propolld lor Insurance In SecllLl1I1 011 JlVlflllildl now under Oblll"IUon or
liking Irlltlllant 01 bUll 'd,lud 10 hm any 1111,. hll5pll.llllllol\ or 10'UIIV which hllllol
blln complllldl.....,......... ........,....""....,..' ,....,..... .......'........,............................ .... I] 1M!
Him. Add,... 01 Pllrnl PhV'I"ln (II not ,ptclll'd ,bOil, dill lilt oolllOllld )
77)# !Ua...
IT IS DECLARED thai the slalements alld answe,s In Ihls application or given 10 Ihe examiner In Pa,1 II, should examlllatlon be required, are
complele and true to Ihe best knowledge and belief ollhe undersigned. If IS AGREED: (1) Ihal no waiver or mod III cation of this application
8hall bind 1M Company unlue In WIlling and signed by the President, a Vice President, Ihe SocrelalY or an Asslslanl SecrelalY; (2) Ihal no In-
suranu 8hall be In eflecl under Ihls application (excepl as may be plovlded In Ihe receipt bea,lng Ihe same dale as this application) unless and
unllllhe appllcgtlon has been approved and accepled by Ihe Company 01 Its Ilome Olllce and Iha policy delivered 10 and accepled by the Owner
and Ih. full IIrsl premium has been paid while each person proposed for Insurance 15 alive and while Ihe slale ot health and olher condlllons
all.ctlng Insurability are Be stated In Ihls application anI! examination, II lequlred. (If a Frallchlse Autholllatlon or Governmenl Allolrnenlls hldl.
caled In section 8 and has actually been signed and delivered lor Ihe correcl amounl, Ihls shall be considered the some as payment of th_ full
first premium); (3) Ihatlhe acceptance 01 any poltcy lseued onlhls appllcallon shall conllllule a latlflcatlon of any correctloh or amendl/lenl
made by Ihe Company and noted In sacllon 13. Section 13 will not be used 10 make corrections or amendments In Kenlucky, Michigan, or Wesl
\llrglnla nor to mako corrections Or amendments perlalnlng 10 the plan or emount of IlIsurance, clmlflcatlon, bonellls or ege In Iowa, Oregon
or Pennlylvanla.
I also acknowledge recelpl of Fair Cledlt Repoltlng Acl and Medlcallnlolmotlon BUleau Nollllcollons.
AUTHORIZATION: I hereby authorlle any IIcen5ed phY5lclon, medical p,aclllloner, h05pltol, clinic or other medical or medically relaled
facility, Insurlnce company, the Medical Information Bureau or oilier organllatlon, Inslltlltlon or person, Ihol has any recold5 or knowledge of
me or my child for whom Insurance application Is made, or my health or my child's heallll, to give to Midland Nollonolllfe Insuranca Company,
or Ils reinsurers, any such Inrormollon. A phologrophlc copy of Ihls authorllatlon Ihall be os valid os the orlolnol.
,I s ~ I ISO LOI (5Ig"'""1 II IB (CI~. lillI'
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COOl NO
. "_.-JJa/l.-4.-!~-lHt--_
PII. :, luullo.1 .nlwllld 1I'lft Wlllon 14 !hruwOft
17, 1.lludl lUIIllo. nU",OIr, 'U I n'l\IlI .nd Iddllllll "
phVlllllnll"d nl",1I ollndl,lmlltl whom hlllDIJ P'"
lllnl.
It " ...1l f.l
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r; II "'./I~ 00.1 j.
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h' .,IYCt:
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p;1'-; fJ~J.S ~{/I..- .h1 /,7"S-:S
~ HI t' /s ,/o",.,t
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APS PII,PIV'llIl1l Amoullt
. -
IN51Jf\ NCI 15Ign~lu"1
14. Payment Opllon.
PlY", A Payee 15 person who ~las Iha right to recelvo Ill0
Proceeds under Ihls Contracl.
Opllon Dlte, The Option Date 15 Ihe date 01 death of Iho
Insured or the datil 01 any other ending of thiS Conlracl.
Plym,"t 01 Proo..d..
Plym,nt. The Proceeds may be paid In one surn or all or
part 01 Ihls sum may be applied 10 any Payment Option. Il
no Paymonl Option is chason, We 1'1111 pay Inlerost on tho
Proceeds from Ihe Option Oala 10 Ihe dale 01 paymenl,
Tho Interest rata 1'111I be Ihat being paid on Payment Oplion
4 on Ihe Option Dale. ,
Clllml 01 Credltorl. To the extent allowed by Law, Ille
Proceeds 1'1111 not be subjecl to .lny claims of a Payae's
creditors.
Ply""nt Opllonl AVllllbl"
II.ctlon 01 Plym,nl Option..
By Owner: While tho Insured Is living, You may choose, or
change the cholca at, any Payment Opllon, unless Ihe
previous chOice provides otherwise.
By Payee: It the Proceeds are payable Ir one sum, Ihe
Payee may choose any Paymenl Opllon,
Condlllon., Any choice must be In writing In a form
approved by Us. Our consenl IS n<loded for a paymenl
Opllon to bl/ used for any Payee under any of thoso
conditions:
a. Tho peyee is not e natural person;
b. The Payee 1'1111 be paid as assignee:
c. The amount 10 be applied tor the pnyee 15 loss than
S1.000: or
d, Ear-h paymenl to the Payee would bo 1055 Ihan 520.
Plym,nt Option 1. .. Plym,nt lor a Specified Period.
We 1'111I make equal monlhly payments which 1'1111 slart on
the Option Date end 1'1111 run tor one 10 Ihllty years, as
shown, The guaranteed minimum monthly payments 1'1111 be
based on Table 1. The payments may be increased by
additional Interest.
Payment Option 2. .. Plyment 01 Llfl Income. We 1'1111
make equal monthly paymenls which 1'1111 stert on Ihe
Option Dale and 1'1111 run es long as the payae IIvas.
The amount 01 Ihe payment 1'1111 depend on the age and
sex at Ihe peyee on the Option Dale. The payments are
guaranleed to be alleast at the rate shown In Table 2.
Such rates are based on Ihe 1983e Table ~t 2.76 percent,
except:
a. The male rates at ages under 20 are Ihe male rates
tor age 20.
b. The male rates al ages over 80 are the male rates
for age 80,
Monthlv Inooml PI; ., ,000 01 Prooltds
r.IL' I ___........!HL. I
t.'r~nlll..r' M~nlhlV "Ynl,nU 'or LIIe
p 1I1"~ .,otj
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10.nd "'lId
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on '31 II .. '" "I 31' '"
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" ... ., " ,"0 '" 311 UQ
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n ... " " 1UiI .., '" 31'
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c, The Iumale ratoe at ages under live are the male
rates lor age 0,
d, The lemsle rates at ages over four are thll mala
rates Bet back live years.
We must have prool 01 the Peyee's date of birth. Either at
the following tarms may be choslln.
a. Life Income. Guaranteed Pllrtod. .. Tha payments
will run tor the Iifo of the Payell with guarantellc!
payments for IIVII, ten, or twenty Yllars, as chosen;
or
b. L1le Income Only. .. The payments will run only
dunng thll Iifetlmll 01 thll Payee.
We reserve the rtght to require proof that thll Payee 15
alive when each payment Is due.
Plyment Qptlon 3, .. Plyment 01 I Specllled Amount.
We will make equal payments everyone, three, six, or
twelve months, as chosen. The payments will start on thll
Option Date and will run until the Proceeds applied, to.
gether with Interest at the ratll 01 at least 2.75 percent a
year on the unpaid balance, alii fully paid. The IInal pay.
ment will be sny balance equal to or less than one pay.
ment. The psyments mey be Increased by additional Inter.
est.
Ply",ent Option 4. .. Proc..dl Lelt .t Interell, The
Proceeds msy be lell With Us for sny length at time agreed
upon, Interest will be at the rste 01 at least 2. 75 percent a
yesr or the minimum aa required by the stata' the Insured
resides in. The Interest mey be left with Us to accumulate,
or it may be paid everyone, threll, SIX, or twelve months,
as chosl/n. II the Interest Is to bll peld, the first payment
will be at the end of the IIrst Intelllst pertod.
Plyment Option II. .. Annuity. We will make psyments
like those of sny IlIe snnulty We then regulsrly ISS4l1 which
Is bought by s single sum. (This does not Include contracts
whloh are used to quslily for special Federal Income T ex
trastment ss s retirement pll\l1.) Esch payment will be 103
Pig. I~
lOU701
percent 01 the amount We would pay if the Proceeds were
used to buy such sn annuity on the Option Date, The IIrst
payment WIll ba at the and 01 the IIrst Installment pllrlod.
We must have proal of the Payee's date 01 birth.
Othor Plyment Optlonl AVllllble. We may agrea to pay
the Procellds In any other manner.
Payment Contractl
I..ue. When a Payment Option is choaen, We wllllasue a
Payment Contract In exchange lor this Contract. The ellec.
tlve data of thll Payment Contract will be the Opllon Date.
A..lgnment. Payment Contracts may not be aSSigned.
Withdrawal 01 Proc..dl. The Payee has the right to
Withdraw the Proceeds under a Payment Option If so
provided In tha Payment Contract. Under Option 1, the
sum 01 the remaining guaranteed payments, discounted at
the rate used to compute each payment, compounded
annually, may be withdrawn. Under Options 3 and 4, all or
part of the remaining Procaeds and eny Interest earned but
unpaid may be withdrawn, The Proceads may not be
Withdrawn under Option 2 or 5. Any withdrawals must not
be less than 5100. If the amount ramalnlng unrjer a Pey.
ment Option Is less than S 1,000, We have the right to pay
In one sum. We may postpone payment 01 any amour\lto
be Withdrawn lor not more than Sl~ mC)rlths from the date
We receive the wntten request lor Withdrawal at Our Home
Office.
Chlnglng Optlcn.. A Payee under Opllon 1, 3, or 4 may
change to another option on using the sum which the
Payea could withdraw on the date tha new option Is to
start. In some cases, the Payee will need Our consent to
change an option, We describe these cases under Con.
dltlons.
Death 01 Pay.., If any payments remain to be paid under
a Payment Option at the death of the Payee, payment Will
be made according to the terms of the Payment Contract.
ARTtlUR W. tlARRIS
Defendant
IIN Tilt: (~()lJR'1' ()II' COMMON PU:AS
I CUMR.:RUNU COUNTY,
t 1'..:NNSnVANIA
I
t NO 114.144.. Civil Term
I CIVil, ACTION. I.AW
I
CINDY I.. RIGG
now Cindy L, Rldae
PlalntUr
V,
PI~ ETH IAL.MfiM.QJ~AN DlJ M
I. ~TATEMENT OF UASIU:,^CTS AS TO LIABILITY,
Defendant purchased life insurAnl'e policy #217661 from Jefferson National
Insurance Company of IndiRnllpolis, Indlanll, on August 4. 1972, In order to terminate
Plaintiff's allegations that Defendant owned her mouey (which allegation Defendant
disputed). DefendAnt ornlly offered to make Plaintiff beneficiary of said policy,
Thereafter. Plaintiff IInd Defendant entered into IIn Agreement dated June 10, 1988
in which Defendant agreed that he would il'l'evllCnbly designAte Plaintiff as beneficiary of
said policy,
According to the terms of the polky: the Insured Is Arthur W, Harris; the owner is
the insured; and the beneficiary is the person who receives the proceeds of the policy at the
time of the death of the insured, The beneficiary, however, has no incidents of ownership
such as cashing in the policy during the owner's lifetime.
Severnl years ago (the exact date is uncertain). Jefferson National, with whom
Defendant had four insurance policies, moved lis plal~e of business and mistakenly caused
Defendant's policies to lapse. Defendllnt did not purchase a replacement policy
immediately; after the ('oml)IIIint WAS flied by Plaintiff, Defendant repeatedly offered
Plaintiff (through her attorney) to purclHlse IInother polky to replace the rllpsed policy.
Thele offers bellan personally by Defendant In the summer of 1993, and then through
Defendant's attorney beginning wilh II leller to Plnlntlff's nllorney on April 26, 1994, with
a choice of two repla('ement insurnlll'e polides. Follow up lellers to Plaintiff's allorney
were mailed on eight (8) oc('aslons, Finally, since 110 response was forthcoming alld to
miliaate dam alles, Defendant pur('hased a replllcement lnsurunl'e policy lIamlng Plaintiff as
beneficiary; that policy is current.
II, STATEMENT OF TUE BASIC FACTS AS TO DAMAGES
Althoullh Defendant did unintentionally allow the original polley to lapse, he
milillated his damages by purchllsingll replncement policy which gave Plaintiff the same
benefits she had under the other polky: thllt of receiving polky proceeds upon the death
of Defendant and also wilhout any Inddents of ownership as pruyed for by Plalnliff.
Plaintiff made three (3) altenlllllve requests for relief in her complaint: that this Court
eilher: enforce the contruct by law or equity: 01' else direct Defendant to pay Plaintiff the
face value of the policy at the lime of tenninntlon: or, finally, order Defendant to pay
Plaintiff the amount due when Defendant turns sixty-five (6~) years old, Plaintiff made no
request for damages of legal fees In her complaint.
Defendant claims that any potential damage to Plaintiff (and there was none, sinee
Defendllnt lived through the period of the IlIpsed life insurance polley) was mitigated when
Defendllnt purchllsed a I'eplacement policy, Further, Plaintiff's request for cash relief was
never appropriate to this cnse, as Defendant's only obligation to Pllllnliff was to provide
Defendant wilh an insurance policy which would provide Plaintiff finances only upon
Defendant's death. By pur('haslng the replal'ement policy, Defendant has mitillated any
2
harm which would have occurred tn Plaintiff had Ih~ pnllcy nnt been replaced.
Wilh rellltrd tn the question of legal fees expended: in the first place, said lellal fees
were never soulIhlin the pleadings. The only time they were mentioned was in Plaintiff's
Pre.Trlal Memorandum, Further, If the court feels constrained to grantlellal fees to the
Plaintiff, the court should take ~'ognlzance of the numerous efforts Defendant, himself and
throullh his attorney, attempted to get Plaintiff's attorney to respond to cnrrespondence,
offers, elc" all of which corresponden~'e was 19nnred over the course of two (2) years of
neKotiations and further thai Defendant finally. out of exasperation wilh having no response,
purchased a replacement Insurance policy so that the period wilhoutthe policy would cease.
III. STATEMENT AS TO PRINCI.fAl. I~~UES OF LIAI)I'.'TY AND
I;)A~AGES
Defendant has millgaled any damhge which would have accrued to Plaintiff because
of the lapsed policy. She is now essentially returned to the status quo, The legal fees
expended by Plaintiff could have been reduced If Plaintiff's attorney would have promptly
responded to Defendant's continuous offer to purchase a replacement policy.
The cancellation of the insurance policy occurred unintentionally, and the evidence
will s/tow a serious effort on Defelldant's part to correct the situation.
IV, SUMMARY OF LEGAL ISSUES
Determination that the lapse In the policy was corrected by the purchall! of a
replacement policy and that no legal fees should be paid because of Defendant's continuous
efforts to correct the lapse were ignnred by Plalntlfrs attorney, and 1\0 claim for leKal feee
was mentioned in the Complaint.
3
ridge. pret.rial
CINDY L, RIGG,
now CINDY L. RIDGEl,
Plaintiff
It~ THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
v.
NO, 94-1443 Civil Term
ARTHUR W. HARR~S,
Defendant
CIVIL ACT~ON " LAW
PRITaIAL 1dll0llAlfDUK
I, STATIIdNT or BASIC rACTS AI TO TNI LIABILITY,
This is a breach of contract action involving Plaintiff Cindy L.
Ridge, formerly Cindy L. Rigg, and Defendant Arthur W. Hal'ris,
Plaintiff and Defendant were formerly husband and wife. During their
marriage, Defendant purchased a life insurance policy from Jefferson,
National Insurance Company of Indianapolis, Indiana on or about August
4, 1972, As the wife of Defendant, Plaintif f was a beneficiary under
the life insurance agreement under which she was to receive $38,304.00
if Defendant died an accidental death, The face value of the policy
when Defendant turned 65 was to be $16,827,50.
Upon the parties' divorce, Plaintiff ann Defendant entered into
an agreement on or about June 10, 1988 in which Defendant, as the
obligor, was to maintain the life insurance policy with Plaintiff, as
the obll.gee, inevocably designated as the sole benef iciary of the
li fe insurance policy.
Despite the existence of this agreement,
Defendant cancelled the aforementioned insurance policy on or about
August 27, 1991 without notice and without information, The Plaintiff
became aware of this in the summer of 1993.
dodge ,pre~rial
U, ITAT_ONT O' Tal BAIIC 'AC~" A' TO DANAaII,
Plaintiff userts that she hu been damaged by Defendant's breaoh
of oontraot. Plaintiff requests that this Honorable Court measure
damages by determining the faoe value of the polioy at the time of the
terminat ion.
In the alternative, Plaintiff requests that this
Honorable Court measure damages and the amount due under the policy at
the time Defendant turned 65 years old.
UI, IUTIMlNT AS TO PRINCIPAL I8IUIS 0' LIABILITY AND DAlfUIJ,
Plaintiff believes that there was a total breach of the
Underlying agreement and that the entire amount in dispute is payable
for the oancellation of the policy. The attempt to reinstate does not
make the Plaintiff whole. In I.Iddition, Plaintiff has expended fees to
enforce the agreement which should have been adhered to by the
Defendant. We believe the damages in this case for the intentional
cancellation of the insurance policy demands, in addition to recovery,
as the Court determines the attorney's tees.
IV, Bnuull.RY O' LIQjU. 18SUIS,
Determination that the breach was tot.al and the entire amount due
including attorney's fees should be paid.
V, IDINTIrY O' WITHISSIS TO II CALLID.
A. Plaintiffl Cindy L. Ridge
129 Mulberry Drive
Mechanicsburg, PA 17055
B. Defendantl Arthur W. Harris
R.D, 1, Box 110
Paradise Park
New Bloomfield, PA 17068
VI , UJlIIIT' ,
P-l l.ife insurance policy.
P- 2 Agreement executed between the parties on June 10, 1988.