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JOBHI'Il I'. AI,l\XA,
l'lal nll II
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IN nlll COllRT Oi" C0l1110N
l'I,l\AB OF ClII1DERI,ANIl
COllN'rY, 1'~;NNBYI.vANIA
VS.
CI VII, ACTION - I,AW
NORTIlWJlB1'ERN 1111TIlAI. LIt'1l INBlIRANCIl CO.
DelendanL
NO. CIVIL 199~
(:P!!!'hMlij'
AND NOlI, comes the PlalntJ/l, by his allotlleys, Andcs, Vanghn & !Iangs, and makes
the 10IJowlng cOlllplalnL:
J. PlalnUII, ,Josellh 1'. Alexa, Is an adult Individual who resides at '14 Drexel
I'lace, New Cumberland, Cumberland Counly, ('ennsylvanla.
3. Ilelendanl, NorthwesleHI l1utual l.lle Insuranl'e Comllany, Is a corpora lion IhaL
regUlarly conducts business In the Btate 01 l'ennsYlvanla and has a local oiflce located
at 100 1'llIe Btreet, Harrlsbnrg, Daullhln eounly, f'ennsylvanh.
1, III 198~, Plalntlll was aPllroal'hed by Delendant's agent at his place of
elllploymen1. 43 Wcst MaIn Btreet, l1echanie/lburg, Cumberland Counly, ('ennsylvanla,
concernlnq the Ilurehase 01 a certain dJuabllILy IlOlll'Y Irom Delendant.
4. On or about August I, 190!>, aller dIscussions wllh Ilelcndant'u aqenls,
PJalnll /I Ilurchased a dlsabll It y Ilolley I rom Ill'lendan\. AUached hereto and marked as
ExhlbH A In a lrue and eonl'e\ 01 the Illuablllty I'ollcy.
!l. 1'111' Illsablllty "olley I,urchased hy l'lalnllll Irom Ilelen~ant on August I, 198!l
calls lor a maxlmnm dlsahlllty In,'ome helwlIL Ilayahle 0191,100.00 per month.
6. On or ,1hout Beptember 1'1, 1986, I'Jalntl1l l'lltchased an additional disability
IlOlley lrum Ilulendant ill his "hel! 01 I'mll!oymenl, 4] WI,sl 11.11/1 Btreet, l1eehanleHburg,
Cumberland eounty, I'ennsylvaula. Allal'lll!d IlI!reto dnd marked as l~xhlbH 0 Is a true and
(,oncel 01 nald IlllHlhlllty 1'01I,'Y.
~
1. The maximum dlnablllty Income benefll payable to PlaluLllf under thin policy
was $1,O!lO.OO per 11l0nLh.
O. The l'Ialnllll'll uccupaLlun an dellcrlbed In the diuablllly 1101 Icy wan that of
an altorney.
9. Plaintiff wan injured In a motor vehicle accldenl In ~ebruary 01 1991, which
rendered him totally disabled.
10. PlalnLlff made a claim ior dlsabllfty paymenL under the nald polfclen In
March of 199~, and Defendant paid the maximum benefll undor each policy froll February
of 1991 and thereafter.
II. Plaintiff began working on a parl-Lime banln In Oeptember of 199~.
l~. As a result of his disabfliLy, PlafnLilf has been unabie to work sufficient
hours to produce earned Income Lhat would result in payment oi anything less than the
.axi.um benefit available under the said policies.
13. Defendant continued to pay Plaintiff the maximum benefft avaflable under the
said policies for his partial disability In Lhe amount 01 $~,IOO.OO per month through
April of 199~.
14. On or abouL May 0, 199~, llelendant nollfied PlalnLlII that H would cease
paying any benefils under the policies In lorce. ALtached hereto and marked as Exhibit
C Is a true an~ co....ect (!Ollyof iLs' denial II,UN'.
I~. 1'lalnLllf ('onlinues lo be I,artlally disabled Irom the Injuries he recoived fn
the molor vehicle accldenl In 1991, which partial dlnablllLy makes him Incapable oi
producing earned income that would excludc him Irom payment of the full benefit under
the dlnablllty Innlll'<ln('e l,olll'llHl that he han wllh llllfendanL.
16. 1'loIlnLlII has Ilaid the semi-annual Ilremlum tor each pulley from their
I necllllun.
1
'.
11. D~iendant has lailed or rei used to make any lurther disability payments to
Plaintlll despite hIs continued partial disabIlity and inability 10 produce sufficient
; earned income Lhat would permit Defendant Lo cease making said payments.
18. DeiendanL has breached Lhe disability policy wllh Plalntlfl by Its' failure
. or relusal to make the disability payments as required.
!;OUN'f !
19. Paragraphs I through 18 are incorporated herein by relerence.
20. Plaintiff has been damaged by Lhe breach 01 Lh~ contract wIth Defendant for
: paYlllent of Ihe disability benellts In the amount of $2,100,00 per 1II0nth lor the 1II0nth
of Hay, 199~.
21. Plalnliff has be~n damaged by Ihe breach of the conlract with Defendant for
paYlllent 01 the annual pl'emlums for the disability policy, said annual prellllums in the
; total amount of $819.64 per year.
22. PlainLifl will continue Lo sufler damages as a result of Lhe breach of the
agreelllent with lJefendant to pay disability beneUts in the amount of $2,100.00 per
. month as well as non-payment 01 the semI-annual premIums until the Lime of trial of
this case.
llllllREfORK, "!alnllll demands jUdgment agalllBt Lhe DefendanL In the allount of
$2,100.00 per monLh for each monlh mall I the Lrlal of Ihis case, plus any and all ...1-
annual premIums that are due all 01 the date 01 Lhe Lrlal of Ihls case.
!;QIJ"T U
23. Paragraphs I through 10 are Incorporated herein by relerence,
24. Plalnllll will conllnue to he damaged by DefendanL' s breadl 01 Lhe aqreeHDt
by ils' falluro 10 make Ihe dlsabllily paymenLs to Plalntlll whllo ho conLlnues to be
4
, partially disabled in the luLure.
35. Plaintill will be damaged by Delendant's lailure or refusal to pay his se.i-
. annual premiums during the period Lhat he conLlnues to be parLlally disabled.
lIIIBRBFORB, I'lainLlff requests Judgment all amoullt ill excess of $20,000 plus
I'
,
'! interest pi us cost of sulL.
ANDES, VAUGIIN , !IANGS
By M/(...(l I} ( " . J
~.Ban
Attorney lor 1'1 intill
Supreme Court 1 41263
.,
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Ills fl'('()IIlOll'lIded Ihal you. . .
11'1111 YOIlI pull! y.
Ilolify yow NMI "~(,1l1 or tht' Cumpany .11 710 I. Wi\{ om,in AVPIHJP,
Milwdukl'll, Wi\. !d202, of 1111 add,l'!'\ (h.HlMt',
(dll your Nf\11 IIHPl1t fOf inforlHation - parlkul.Jfly on ,,1 ",u',aw~liol1 (0
h'IInill.lh' or ('k,( hdllJ.W lhi... polky for iHlolher polity or pl.ll1. I
\
U...lion 01 fru.......
1111' nll'IIl""" of 1 Ill' Nurlhwl,.I""l Muluallife ImUlanre COlllpany ate
II> poliryholdl'" of imuranre polirie, and dl'fettl'd annuily lOnltads,
The nWIIl"e" e'''1l I"" onlrollhrough a Uoard of Ttu,tees. [(l'ctlons 10
the Uoard .IIl' held earh year at the annual meeling 01 memben,
Members ate enlitled 10 vote in person ot by proxy,
\
Olubllily Inmm.. Polley
IIlglbl.. 'ot Anoual OI.ldend.
NOli-Call( ellable and
Guaranlel'd Rl'newable to Age 65
Condilionally Renewable 10 Age 75
.
MMlJl
11Il1ll1l'1\IJtlll'<llo.
1':)<111111'1' "^"
BENEFITS AND PREMIUMS
DATE OF ISSUE - AUGUST 1, 19B5
PLAN AND ADDITIONAL BENEFITS
DISABILITY INCOME
FULL BENF.F IT
PER MONTH
~ , . 100 t
SEMI ANNUAL
PREMIUM
208, '2
PAYABLE
FOR
28 YEARS
R~NEWAL OF COVERAGE BEYOND AGE 66 MAY REQUIRE AN INCREASE IN THE PREMIUM.
SEE SECTION 3.
A PREMIUM IS PAYABLE ON THE POLICY DATE AND EVERY 6 POLICY MONTHS THEREAFTER.
TH~ FIRST PREMIUM IS $208.12.
TH~ PREMIUM FOR THIS POLICY IS ON A NONSMOKER BASIS.
BEGINNING DATE 91ST DAY OF DISABILITY IN THE FIRST lBO DAYS
AFTER THE START OF DISABILITY,
MAXIMUM BENEFIT PERIOD TO AUGUST 1. 20131 BUT NOT LESS THAN
24 MONTHS Of BENEF TS.
INITIAL PERIOD TO AUGUST 1,2013 BUT NOT LESS THAN
24 MONTHS Of BENEFiTS.
OWNER
JOSEPH P ALEXA, THE INSURED
INSURED JOSEPH P ALEXA
POLICY DAlE AUGUST 1, 1\185
EXCLUSIONS--SEE SECTION 2,
AGE AND SEX
POll CY NUMBER
37 MALE
o 420 702
MM 01
PAGE 3
072
SECTION 1, IJENEFITS
1.1 GENERAL TERMS
1 his polle)' plOvldes bellelits wl,,'n II". InsUf,'d is
lotalll' ()f paltlall). disabled. 5,'cllon 1 demli".s II",
bene Its 01 Ihe poliq' and tells wh,'n the)' at!' pa)'able.
II also gives Ihe meaning 01 sev",.,1 ItllpUfliltl1 ','rll1s
Ihat arl' osed In Ihe policy.
Ill5ured and Owner. The InsUfed and Uwn," at!.
named on page 3. The male prnnouns llS['d In Ihls
flnllq' fo, Ihe Insured and OWIll'r appl)' 10 holh II/ales
and females.
Dlubllltles Covered by Ih" I'lllley. flenehls at!. pt(J.
vlded for the Insured's to 1011 or partial dlsabllll)' onl)' if:
· the Imuled becomes disabled while this policy Is
In force;
· the ImUled Is under the COIle of a licensed phl'si-
clan olher than himself dUlln/l the tlII/e he Is
disabled;
· the dlsabllit), ,esults hmn an acrldenl Ilt sickness;
and
· the dlsablll)' Is nol excluded under Section 2.
Benefit Terms. The schedule of !Ieneflls and !'reml.
ums (page 3) has a number of Importanl lerms Ihat
are used In this policy, These terms ale:
full Benefll. This Is the ma.hnum amnunt of
monlhly Income payable under Ihe polle)'.
Beginning Dale. This Is the dale on which benelits
begin to accrue after the Insured becomes disabled.
llenefl15 are not payable for the time the Insured Is
disabled before the !Ieglnnlng Dale,
Mulmum Benefit I'erlod. This Is the longesl pc-
tlod of lime that benefits are payable lor dlsahilit),.
In determining the ma.lmum lenglh of lime for
which benefits are pa)'able. periods of lotal and
partial disability are added together, " llage 3 p,o-
vldes that the Maximum fleneflt !'elIO[ has a life-
lime benefit for tolal dlsablllt)', Ihen see
Section 1,7,
Inlllall'erllld. 1hls is a period of lI11/e thai starls on
the Ileglnnlng Date and wntlnucs, whil,' 1111' In-
sured Is disabled, for the length of lime shown on
page ), The deflnlllon of tolal dlsabilit)' rhan/l"S
after Ihe Inlllal !'ellod.
Occu,)allnu. IIw words "his oflupa!iOI1" 1l1(',III lilt'
OeCU\lalllln 01 1111' Imut!'d .,, Ihe 1111/" Ill' h""'II/es
dlsab I'd. " till' ImlJ/l'd Is le/lulall)' ''''/l.'gl'd in II/Ot!.
than one Ilnupallr"" all III Ihe 'Hlupallll'" lIf th['
IlI\U1ed at IIII' till/" Ill' 1",((lItll's dlsahled \\'111 IH'
nunhlrH'd IOgfltllt" 10 h.. IIhis oCfUIMlllllllI,
MM III
1.2 fULlllENEfIT roll TOTAL IJlSAIlILITY
lhe lull Ill' 111'111 Is pa)'ahll' lor eaeh mnnlh nf tolal
dlsahllll)' helween th,' Ileglnnlng Dale and IllI' end or
Ihe Maximum Il,'nelit !'l',lnd.
Total Disability. Unlil Ihe end 01 Ihl' Inl1ial !'erlod,
Ihe Insllted Is 1010111)' dls.,hled wlll'n he Is unable to
perform the prlnel\lal dulies 01 his ocrupatlon. After
the Initial !'enod, t Ie Insured 15 1(10111)' dlsahled when
he I, unahle 10 pellorm the prlndpal dutil'S 01 his
oew/lalion and Is nol galnfoll)' employed in an)' oc.
cupa lon,
lIenell. Amount for "artlal Month. When a tolal
disahllity lasls lot a flart of a month, 1/30lh of Ihe Full
lIenelil will be payalile fot each da)' of tolal dlsabllft)"
1.3 PROPOllTlONATE IIENEFIT fall PARTIAL
DISABILITY
.
The Proportlonale lIenl'lit 15 pa)'ahle for each
l110nlh 01 pallial dlsabllfty between the Beginning Date
and Ihe end of the Ma,'mum Ilene fit Period,
I'ltllal Dlllblllly. The Insutl'd is parlla"y disabled
when:
a. he Is unable:
· to (lerform one or mote of the principal dulles
01 lis occupallon; or
· to spend as l11uch lime OIl his occupation as he
did hefore the disability started;
and
b, he has at least a 20% loss of Eatnl'd Income.
Until the Proporllonale lIenefll has been payable for
six monlhs. Ihe Insured need nol have a 20% loss of
Earned Income to be parllall)' disabled If:
· he Is unable to perform one or mote principal
dulles which accounted rot at least 20% of Ihe
Iil1le he spenl at his ocwpalfon helotI' the
disability slarted; or
· he has OIl least a 20% loss of lime spent at his
oecupallon,
If Ifll' Itl5ull'd qualifies fllt hoth the lull and I'mpor.
Iinn.,Il' Ilenefit, Ihe lull Ill'nefil onl)' will he paid,
lIenefll Amount for J'attlal Monlh. When a parllal
disahllit)' 1..,ls lor a p.ltt of a II/onlh, 1/3lJlh of the
!'ropllttlonall' lle'lI'fll \\'111 he pa)'ahll' lor each day of
I ioU tI 01 I dlsahilit)'.
r.
1.4 1l0W TIlE l'Il0l'OllllONATE IIENHIT IS
DHEIlMINEO
11", Proportional., III"wlil i> Inll,,"It.d 10 1111"1"'0'
sate for a luss 01 PiUlWd Incollw I:01ust.d hy tht' 111-
Silled's disability. 1111' .1nlllunt 01 ea,h Illolllhly h"III'lil
Is the rull Ueoelit l11ulliplit'd by Ihe 1I",""d\ 1.1'" III
Earned Inml11e alld divided by his lIa", 1,II1ll'd III'
come, 1hu5, Illl! Proportionate Benefit JllltHlIlt 1'(llIal..:
rull l m~!lLt,)!!"'IJ 1nloll1l'
!Ienelil X lIase Luned Inmn",
As required by I'ennsylvanla Law. the PlopOltlonal,'
Uenelit will not duplicate benellts payable undN all
automobile Insurance policy Issued to comply wilh Ihe
Motor Vehicle I'Inancial Responslbilil\' I.aw, 1he Illakl.
mum amount payable Is 100 K. of Ihe r"lIl1enefit.
Choice of Benefit Amount for First Slk Mlllllhs. ror
each of the IIrst six months In which a Proportional.,
Benellt Is payable. Ihe Owner may chome:
. 10 receive 50% of the Fulllleneflt; or
. 10 receive a Benellt based on Ihe Insured's LllSS
01 Earned Income,
The Owner may alternate between Ihele two cl1IJlces
as to each 01 the six monlhs. However. the Ownl'r
may not change his choice after Ihe lIenelllls paid lor
that monlh,
The Choice of !Ienelll Amllunt does not apply tll a
Translllon Benelll payable under Section 1.5,
LOll nl Earned Income. This Is:
. Ihe Insured's !lase Earned Income; less
. his Earned Income for the month lor whlrh the
Bene lit Is claimed,
Earned Income Is credited 10 the period In which iI i>
earned. nol Ihe period In which Incollle Is aelually
received,
EaFned Income. Earned IlIlOme Is:
. Ihe sum 01 salary. wages. Cllmmlsslol1l, Ices,
bonuses, and other compensation or Incon",
earned by the Insured lrom all SOlUres for wlllk
performed by him; less
. normal and customary bUllness expl'nses.
It Is determined belore Ihe deduction 01 lederal, sl,ll<'
and local Income lakes,
Bue Earned InCllme. DlJIlnll 1111' Ilrst 12 mOlllhl 01 .1
disability. lIase Lamed Inwme is Ihe ilveral\e mllnlhly
Earned In(orne of 'he Insured for il 12 rOIl\cruti"t'
month period durlnll Ihe 24 monlh pellod heloll' II...
slart 01 disability, rill! 12 monlh period whilh \:"".
crates Ihe hlghesl .weralle (ilnd Iherelore Ihe hlg "'II
henelll amount) williII' lIsed.
Aller Ihe firsl 12 1II111lthl 01 a dlsalllltlY, 11.,", rollll""
Incnnw hi the .wer.lUI! mOllthly LJIIH'd Illumw of thl'
MMDI
IJCnIlS\'lvilfll,l
hl"'ur('t~ l1Iulllplll'd II)' .111 lrult'"illH I ,\I tOI tllt' hutl'''lln
I.\llllll"'.
. till' 11111""111'1'1 plit I' indl'll lill IIII' C 111I1'111 "{I,ll 01
di;,lllIlIly; ,1Iv,d,.d h\'
. tlw ItlI,,",UI1WI pill I' Incll'll ItH llw "t~,1I lilt- di'tllhil.
ily,tarl,.<I.
1 hus. .11l1'r 11 1I1111llhs 01 .. dllahllll\'. 11.15,' I allll'd
hit Illl1e t~qlJlll..:
lUmlJIIW, plln' hllll!1l
'or till' CU'"'1I1 year
_~ '11. !!.l!~I!I1llic
conlUmer prire liillex
lor Ihe \'ear
dllahlllty Itarh,d
In Ihe evenl Ihe IlIdeklng Filetor II lell Ihan one, a
value of orlt' will he used.
COlliumer Price In~ek. lhe "cunlumer p.ke lillie,
lur the }'ear the dlsabUlly starled" Is Ihe C~1'f~!
!~" loll ex lor All Urban Cqlllli!!lcrS'nVn1.l!! Ie!
W1Y~r.tiillr. AlllfellJ} ("C~r.U'llur ITll'lourt 1 mont,
hefore the slart of dlsabllily. 1he "(()nlumer price
Index 1m Ihe curreot year 0 dllabillty" Is Ihe CI'I.U
lor Ihe lourth monlh Iwlore till' most lecent annlVN'
sal)' of the Ilarl 01 dlsahillly.
1he CI'I.IJ Is published by the !Iureau 01 labor
Statistics, II the melhod fm tletermlnlng the CPI.LJ Is
[hanged, or II II Is no longer puhlished. II will ht!
lI'placed by snme olhN IlIde. found by Ihe Company
to 'iervc the same pUlpO'il'.
Proof 0' Earned Incullle. 1 he Company may rt!'lulre
\"001. Including Income lak rei urns, of the amounl 01
earned Income lor periods belore and all"1 lhe sial I
01 Ihe dlsahlllly.
\.5 TRANSITION IIENEFIT
.IVI'lilgC monthly X
I allled tnconw
1 he Company will pay a Proportionate Ilenelll 101
up 10 till' IIrst three months allN Ihe Insured's relOY'
eoy lrom a disability, provided:
. the Insured was dluhled at lealt 11 monlhl
durlll11 lilt! 14 month period allN tilt! starl of
dllabllity;
. the Insured has relulIlt!d 10 lull.llllle employ'
I1wnl;
I IIIl' Insured has at I"all a lll% Iou 01 lamed
1I1l11l1ll! lor Ih,' monlh 101 whll h tl", 1ll''1l'101 Is
r lall1ll!d: and
I Ih" monlh 1m whir h tilt! III'n,'11I I, (I,.inll'd "
wilhln the Maklmnm lI,.nelill'eriod
1111' inllounl 01 Ihll 1I,'nelll will Ill' del"lmllll'd un.
d"l SI'llinn 1..1 l'''linds 01 lolal alld pa'tlal dilalllllty
ITMY hi) ,uldl'd tow'lller tu IllPt., lilt' 11 fllonlh ft'-
1111irt'rnt'''I.
Ihi'i nl'l1t'fil i... I IVilhlp for up '0 Ihll1e lJ1ol1th\ Inl
('.It h S(!I)llliltt> .lli"'1IJ1Htr' for 11l1Y l.ll011lh t111'i IIclwllt h
p'lY.Ihle. l)ft~nllum'i wll tw waivl'd
h
1.11 lIlANSI'IANT UONOIl
If lilt' hl\llIl'cJ dlJllilh'\ jlll 011\1111 Inl tlillll,lll,11I1 III
illlnlh." Pt'l\lIl1 il tlt....II"ljl) ItIU\t'd by till' IOlhllllll1
\\'11/ hI" (olll.ldl'f('d il\ ( <llI',t'd 11\, \11 ~lll'''~
1.11 WAIVIIl OII'IlIMIUM IIINIIIl
1111' CIHIlIMII)' will waiv(' IH('llIllIlTl... which lH'rolllc
dill' Oil Ihll poli( \' \lIllI., till' 1"'"IPd il lul;IIII' tIf
p'"liall\, dl"lhlt'd iI.
· IIII' dllo1hitil\, 1."" fo, ;,, lt'a,I 'HI dal'l; III
· till' dll;lhitll\, 1.1\1, IH'\,U,"1 Iht' 1l1'U'III1IHIl Dall', II
"(II)flPl,
1.7 IIHlIMIIIINlfll '011 lOlA'
UISAIIIIIIl'
If pag.. "' I"ovld('\ lhill IIII' M,I-.iltltJlTl BI'lIdil I'.',illd
hdl .1 1ift-li'H,. h"Ilt'111 I," 101.,1 dildhitll\.. IIII'll till' 11111
IIpllf'lil j\; fJiI)".bll' il\ IOllg flit 11lt.11 ell!.;1 Jill1r (11111111111'\
dUll/Ill tht. IiIt'luw' III Ill(' IIlt,UIf'c1. Pfovldl,tt
I till' 11II1I1I.d " IOI.,II\, d"dhl,'d UIl till' 1'0111 \' .,".
lliVI'lld'\, Ihal 10llowI 1", hOlh hilllll!il\,. ;"",
· Ihl' toldl dl,.hllll\' (nlltllllll'l 1"')IlIIlI 1111' pollll'
a'lIIlvella')' Ihal loll OWl hll hr,Ih hlltllll.l\,
1.8 lIIfllMf IIINIfIl fOIlI'RISUM"lIVI 10lAI
IJI5ADILIlY
IVPI1 iI Ih,. Il1Iult'd II ilblt, 10 wlllk. hI' will I".
IUl1Sldell'd Inldl/\, dllo1hll'd iI Ill' 11111111 till' 101011 alld
IIIt'( uVl',ahlt, lOll 01
· Ilnhl III hnlh P\'t'I.
I U\[' of holh hillld,;
· UIt' uf holh ft'I'I,
· USlt' of one hiHld and 0Ilt' 1001;
. Spl'I'111. (JI
. ht'iuing III hoth l'at~.
'he full llell,'lit II I'dl'ilhll' I,,, Ihi, lOll p'ovided
till' It". lJ( CUll wIIIII' hi> polilY 10 10 lOll I'; till' lOll
III tillS Ill' I III I' '"l' 11111 1'01111' alllllwl\;uy IIIal lollo\\'1
the 651h blrtlldilY 01 till' l"'lIled, Ihe Ims ""Ulll hOll'
an an Idl'nt 01 III kill'S'; and till' In" I, lIul e" luded
und(', S(l(~lj(J11 1" lIu> IlluHed dOl'S 1101 Il('(ld 10 1)('
und"1 "ll' la,I' 01 d phyoll lall.
Ttll' I ulllh'llt'lIl fill till' 1,,,,
· Is payable "'UIIIII'I';
· Ita,', willi thl' dal,' 01 10". 1101 lilt' llenlllllllln
llall';
· Is IMrllbl(. fo. d.. Illllg it" tIlt' IlJ\S (OlltllltJl'\ dU!.
h'!llll,' lill'IIII'" III tl". 111","'d; alII!
· i, 111 I".u 01 1111"., '"'II,'lill p.lyalll.. 10, lolal 0'
pa'"dl dl>illlilll\
1111' 1\';llv"I ull'll'II""11' 11('111'111 10 1Il1lllmlll.d hI' tI".
"'it ~ irnullI Hl'lIefil !'t'/lod
II I"ell,illllll .111' \\,illvl'd, III" (omp.III' will 011'1'
1I'lUlld Ihal pllllloll 01 ;, 1"l'mllllll paid which applll'l
10 ., I"',illd 1I1 dlsahlllll' hl'l'lIIld 1111' plllitl' ",o"lh 111
wll"h IIIl' dllillllllll' hpgall. II a p"'mlum II to hI'
\\'ilivl'd 011 it p()lir~' iIl1l1Ivprs,uy, all dnnual premium will
ht, waivlld.
I he Compal1l' will 1I111 waive Ihe paymenl of 1"1"
111111111\ altl'l Ihe clld 01 Ihp dlsaulllly (ekeept whetI'
Ihl' walvl" "mlllllle. Ulldet 51'111011 1.5), lhe Ownt'r
"'al' thl'l1 h'I'p 1111' IH>IiC\, 111 flllce hI' resuming Ihe
pil\'llIelll 01 p"'mllllm as Ihey hClOme due,
1.10 IlEllAlIlLllAlION DINfFl1
At thl' Imll'l'd's 'Nluell. the Companl' will cons!\Jet
IIlIIIIIIIl 111 a p,ollram III .chahllllale the Insu'ed, The
C olllpallY's role 111 Ih" program will he del"nnlned bl'
wrllll'n agrl'emenl wllh the IlIlured. lIelleflls will con.
Ihull' durlllg Ihe pWllIam um!et Ihe le.m. 01 th"
agrPC'I1ll'1l1.
1.11 1>15AOIIIlY WIT/I MUlTlf'Lf CAU5tS
II the Insured is disauled flOm mote Ihan one
laUle, the amounl al1d du.allon ul ueneflls wll/ nol be
1111111' Ihall Ihal for allY IlIIt' of the causes,
1.12 DENHlTS rOR 5E1'ARATf IJI5ADILl1IE5
I.alh sl'parale lime the Insured Is disabled, a new
IIIllIa' Pe,lud, UI'glllnlng Dale and M..lmum Benefit
P",lud slarl. A disahilily II separale. and not a conllnu.
allon 01 o Ill' Ihal sla'll'll ear/fer. II:
· Ih" cau.e 01 Ihe laIN dlsablllly Is nol medically
Iclaled to Ihe [au Ie of Ihe 1'01,111" oneb and Ihe
ImUl"d had '"surned on B full,lIm" asls Ihe
IHlnrlpal dulles of all occupation for al least ]0
conleeutlve doll'S; or
· Ihe lal/H' uf till' 101 let dllabllity I. relaled 10 the
lause 01 Ihe cadi", oue. amI Ihl' lalet disability
slart. 011 lea,1 (. l110ulhs allet Ihe end 01 Ihe
earlir, Ofl['.
SECTION 2. EXCLUSIONS
1,11'1l1.IXI~lIN(O (ONIIIIHIN~
If If' ff' \\HlIH' 1111 11I'IH'II'" 1111 .1 df\illlllil) III 111"1' lh.ll
· "I.llh wlthill 1\\11 }'LtI... ,tlll'l HH' (lilll' III h\III',
,Hili
· 1f'\llltl, flit/II ,HI .Hllth'", Ih.11 III I tHll'd II' '/filII ,I
~il ~11t'i\ 111t11 H,I', III.lI:IIII,,('d III IH'lill'd willllll
1\\1; \'hUi 11l'1(tff' 1111' n,rll' ot 1""111' ,11141 \.\',Ii 11111
d'\lln..t.t1 "' lIll' ''1lplll dlll"l
~1~' III
"f'IIJI.,\kolfll,1
1.1 01llEH IXCLU510N5
111I'1I' willi". '"> b","'1111 for a dllahitit) Ul loss thai:
· j" {.Ill\l'd III (onlrilHlll'd to hI' iJll ilrl or incident
(II WIlt, dt'llllfl'd fII IJfl{ft~lla'l.'( ; or
· j, t'~( 11Idt'd from (()\'t'IIIIW h~' all ARret'ment for
lilllilillllllJ 01 ('OV('li1lW
SECTION 3, CONDITIONAL RIGHT TO RENEW TO AGE 75
On load, polky ,Hllliv"'''iiUY 1H'I\\'PI'11 IIH' hl"U1I.d'"
115th .lIld 751h hhlhd"r~, 11ll' OWI1l" 1I1.1Y "'lIpW Ihls
pollq IIlI on" \'l'.1t II Ihp lr"uII'd Is a'IIVO'ly .11111
galnlully emplnyed on a lull-limp b"sls, 1 n ".IIt'W Ihls
polley, Ihe Owner musl send a w,lllI'n lellue~1 10 Ih"
Cumpany each year. 1hl\ fiJjht to ((~IWW ,'nd'i 011 1111'
IIrsl annIversary nil whlrh 11ll' I",wed is nol Sll "m.
1,loyed or on which the OWIll'r . III lilies nnl In I.'''PW
he policy,
lor .1 poli( y IhJI 1<'1 lI'Ilt'WI'd:
. lll'nl'lIl~ ,II.' p"y..b'" Dilly 1.11 1t)1,,1 dlsahillly; and
. till' premiullI 101 f';H It ~)f';U of u'uewal will 1)('
hased nil llll' 1r,,,uH'd'Ij JUP imd the Cornpilny's
rales In lIH' at till' tinw of H~IlC\\,jll.
SECTION 4. CLAIMS
4.1 NOTICE OF CLAIM
Wrlllen nollee 01 claim must be given 10 Ihe Com-
pany wllhln 60 days alter Ihe slart 01 any loss covered
by this polley, II Ihe notice cannol be given wllhin 60
days, II must be given as soon as reasonably possible.
The notice should:
. give the Insured's name and policy number; and
. be sent to Ihe Home Olliee or be given to an
aulhorlzed agent 01 Ihe Comp,lIlY'. 1 he Home
Olliee Is localed at:
720 East Wisconsin Avenue
Milwaukee, Wisconsin 53202,
4.2 CLAIM FORMS
The Company will furnish claim lotlns wllhln 15
days alter receiving nollce 01 claim, II claim lorms a,e
nol furnished within that period, IV/itten I"oof of
disability may be made wllhout the use 01 I te Com-
pany's forms,
4.3 PROOF OF DISABILITY
Wrlllen proof 01 dlsahillly must he given to the
Company within 90 days alter the end 01 each month-
ly period for which henellls are claimed. II Ihe prool is
nol given within Ihe 90 day~. lhe dalm will nol be
alleeled II Ihe plllol i~ given a~ soon a~ reasonahly
po~~lbll'.
4.4 TIME OF PAYMENT OF CLAIMS
Ilenellts due undel lhls polley will be paid monthly.
4.5 PAYMENT OF CLAIMS
Ileneflt~ will be paid to Ihe Owner or to his eslate,
4,6 MEIlICAL EXAMINATION
The Company. at lis own ekpense may have the
Insured examined as ollen as reasonahly necessary In
connection with a claim, lhls will he done by a physl-
rlan 01 the Company's choice,
4,7 LEGAL ACTIONS
No legal action may he hlOught for heneflts under
Ihls pollt:y \\'lIhln 60 days aller wrllten prool of dlsahil-
Ity' has heen given. No legal action mar. he hrought
aller Ihll'e years (or a longer period thai ~ requlred~by
loll\') from the time written proof Is required 10 be
given.
SECTION 5. OWNERSHIP
5.1 POLICY RIGHTS
All polley rights may Ill' .eke'rlsl'd by II", Oll'ner. or
his successor or transfCrel!
5.2 TRANSfER OF OWNERSliII'
1 he Owner may transler Ihl' oW'H'"hll' of Ihls poli-
cy, Wllllen plool 01 IrallSler salls factory to Ihe Com-
I)any must he 1I11:l'lved at Its I lOin!! Olflce. lh!! Irans.
er will take elled as of Ihe d,lle II Wil~ ~Igned. 11",
COlllpany Illay require Ihat the poll< y I", sent 10 lis
Ilorne Offkc (or tSndorscrnent 10 \how tlH' "i\nsh~r.
MM Dl
5.3 COlLATERAL ASSIGNMENT
1 he Owner Illay a~~llln Ihis policy .15 collate'ral ~ecu.
Iily.lhe CO"'I>any Is not respollSlhle lor the validity or
elfl'lt 01 iI .lllaleral asslgnlnent. 1 he COlllpany \\'il he
I ha.ged \\'ilh nollce 01 Ihe asslgnmenl only If a \\'rlllen
assignment is received ill the Horne Office.
A rollall'ral .l55lllnee Is nol .Ill Owner. 1\ collaleral
.",Ignllle'nt is not a Iransfer 01 owne"hll)' ownenhll)
ran hi! Ir.1I""',,,'d only hy complylnll Will Section 5,~,
II
SECTION 6. PREMIUMS AND REINSTATEMENT
6.1 "~lEMIUMS
l'o)'II1enl. All /,"'milllm altl'r 11ll' li,,1 '"l' pa)',,"I<' "I
thL' Ilome Of ire nI 10 an authorizl'd .1gPI\I. ^ pll'.
mlulll must I", p.lid Oil or 1ll'loll' ils ih,,' d"le A
recelpl signed h)' all ollir", of Ill!' Comp,,")' will I",
furnished Oil H'quesl.
Frequency. Premiums may Ull paid i1l11l1lall)'. ~('lIIi.
allllually nt quarled)' "I Ihe puhlislll'd "ll.'s 01 II".
Compan)". A ch"ngl' In pr,'mlum frequenc)' will I,rh'
eflecl on 1I11' Companl's acceplance of Ih., premium
lor Ihe new Irequenc)", Premiums rna)' h., p"id nn .111)"
olher frequenC)" approved by Ihe COlllparw
Grace Petlod. A grace period 01 31 da)'s will he
allowed for paymelll of a l"emlurn thai Is 1101 paid on
lis due dale, This policy w II be In fulllorce dllling this
period,
The policy will lrrmlnale al Ihe end 01 Ihe gran'
period II the p,emluln Is not paid.
Premium Refund al Death. The COll1pi\l1)' wiil rellllld
thai portion 01 any premium \Jaid for a petiod he)"ond
Ihe dale of the Insured's deal I.
6.2 REINSTATEMENT
Within tale Paymenl Period. The lale pa)'ment I""
rlod Is the firsl 31 days aller the grace reriod. Wit lIn
the lale paymenl petiod. Ihe poliC)'. wll be relnslaled
as 01 Ihe dale Ihe overdue premium is paid. No
evidence of Insurability will be required.
Aller the tale Payment Period. Aller the late pay.
ment perlodhlhe cmt 10 teinstate musl be paid to the
ComfJany, T e Company mar, also tequlre an appllca.
lion or telnstatement and ev dence 01 Insurability. The
policy will be telnstaled as of Ihe date Ihe cost 10
telnstale was paid to Ihe Company II:
MM D1
1"'nns)'lvilnl,'
· Ill!' application is apptoved h)" tI", COIllpall)'; or
· lIoti'I' Ih.ll 1111' ""plicallon has hel'lI llisapprowll
is lIul givt'1I wHlln 45 da)"s frolll tI", dati' the
(ompall)' H'C eives Ihe applicallon.
11ll' polier will Ill' Ielnslaled as 01 1111' dall' till' Com.
pall)" "((l'pls pa)'nll'1I1 01 Ihe cost to teinslate II Ill!'
COlllpitll)' does not Il'qUjll~ illt application.
Coverage. II 110 evidellle 01 Insurability Is tequited,
Ih[' reinslaled pullC)" wiil cover only a disahilH)' that
slarts afler Ihe dale 01 leinstalement. It evidence 01
Insurabllil)" is re'luired:
. Ihe relllStaled policy will cover only a disability
Ihat results from an accidenl Ihal occurs, or ftom
a sickness Ihal was diagnosed or ttealed, alter
Ihe dale 01 reinstalement; and
. lhe Compaoy may allach new provisions And
limitallons to the policy al the lime of ,eln.
slatement. All other rlghls of the Owner and the
Company will remaill the same.
Duly with Armed Forces. II Ihe policy terminates
while Ihe Insllled is on acllve duly with Ihe armed
fotces 01 an)" nallon or group of nallons. lhe policy
ma)" be relnstaled wllhout evidence of Insutablllty, The
pollC)" will be telnstaled as of the date a written
requesl and Ihe pro.tata premium for coverage until
Ihe ne.1 ptemlum due date ate tecelved by Ihe Corn.
pOln)", TIll! request musl be teceived:
· no lalet Ihan 90 days afler the Insuted's release
from active duty; and
. no lalet Ihan 5 years after the due date of the
unpaid ptemlum.
'J
SECTION 7. TIt[ CONTRACT
7.1 fNTlllf (ONTIlAClj [flANGES
1hl5 polky wllh 1111' apphlalloll .11111 .11I.I,llI'd "11'
dorscmcnls is IIw t'ntiw t OlllliUI IH'I\\'I'PII 11ll' (hVIWI
and tlw Company. No 11",,'11" In Ihl, /lolil I' " ,.IIId
unlcn app,oved hI' .111 ollh ,., 01 Ih.. ('"I1P,I'y IIII'
CompallY may II'qulll! Ih;lt IIII' poh'I' hI' "'lit '0 .1 10
be elltlotsed 10 show a t hanlll'. No alll'nl h.1\ .Iulho,.
Ity to !:hange Ihc pnhr\' III 10 waive Jny 01 II, plllvl.
SIOIlS,
7.2INCONTESTAOILln
In I"olnll Ihls po he\" 11ll' Company ha, II.II..d on
the applkailon. 1he Company ma\, ,eHlnd Ih,' poll'l.
or deny a claim due 10 a mlulalemenl In Ihe applka.
tlon. However. aller this poliey has bCt'n In 101ll! for
two years from thc Date 01 luue. no ml..lalenll'1I1 In
Ihe applicalion may he used to leldnd tilt' poliry or
to deny a claim for a disability or Iou Ihat sla,ts allcl
the two year period.
In addition, a claim may he denied on the ha,l. that
a disability or Iou Is !:allied hI' a P.e.hllling Con.
dltlon Jsee See lion 2,1). However. tltl! Cnrnpal'y 1I!.l1'
not re uce or deny a claim on Ihat ha.Is If the disahil.
Ity or 101S:
. slarts alter Iwo years from Ih" Date ollS\lll': ilnd
. I. not e.cluded from rovera"e hI' all ^1l"'I'mt""
lor Limitation 01 COVl!lage.
7.3 CIIANGf Of rUN
The Owner may rhanll" Ihh pulley 10 Jill' plan 01
disability Imurance agleed 10 by tl1l' ()WIll" alld II...
Company. The !hallge will he sohlcrt to
, payment of requircd lUSts; alld
. compliance with uthcl "",dlllons II'qllil..d hI' Ihl!
Company.
All premium, and dlvhll'llIls all"1 1111' dall' 01
change will he the same a, though Ihl! flf'W pl.'1I 10,111
been In eftl!' I sln!:e Ihe I'ollry lJafr..
MM III
7.4 MISSlAlI1l Alii
II 1111' "pt.! 01 1I1l~ hl~lJIl'd hair! lH't,,, l11i~\tilled, tlw
1"""'1,1, \\,1(11... Ih",1' whio hIlII' p"'mlu,,,, p,tld would
h,IVI' IHllt h,I'lf'd lit 1111' (ollt'( I llgt'
7,5 CONfORMI1\' Willi STAll STATUTES
An~ I'IOvl,IIIII> 01 II". 1'011,1' whkh, 011 Ihe (Jail' 01
1"11I'. ;111' In (1I11f1101 wilh fI", .Iatull', of Ihe Itatc In
wille II tlU' OWIII'I ",.,hlt'., Oil Ih,lt DIII(' aH~ amendl'd
101011101'" III "W Ii Iolalult'!J.
7.6 IlIVll>ENUS
1I11s poli,y will .hart. III Ill!:' dlvl.Ible sUlplu,. II allY,
of tl", Coltlpany Dlvllihle surplus I. dell!rnllned an.
nually.1 his pull!:\, s .ha,e will be nedlled as an annual
dividend.
Dividend, wlil he:
. wiPd 10 ledun' pH~rniul1\s; or
. paid In 1Ill! (JW.WI wl"," p,emlums all! helng
waived.
7.7 OATES
PIl"id,'d th.. Ilrsl p,,'nllum I. \,aid, Ihls poll!:y will
lake "Heel on 1111' Datil of Issue. 'nileI' monthl, years
and annlvel.alle\ a", .ornpuled horn the PolI,y Date.
Iloth dalt., a,e .hown OIl pag'! J of thl. polley.
7,8 HIlMINAlION
II l"l'n'IlJIIII are I'ald when due, Ihls puli,y will not
11"11\(11.11" unlllll", I,.t 1'011,1' anl1lvclSal)' followlno the
(,"Ih hilthtlay ullhe Imuled or, II later, whell Ihe tight
10 'rnew Ihe polio I' ,'lid. lit.,! Set tlon 1). How,'vel. If
II", In<lJll'd I. dlSahl,.d 011 Ihe datc detcl1nlnl'd ahove,
110" le"nlnalion will 1101 lake rllert unlil henefit, are
110 IUI1I1'" payahle due 10 Ih,11 dl,ablllly.
HI
883642
NORTHWl5TERN MUTUAL LIFE
INSURANCE COMPANY
MILWAUKEE, WISCONSIN 53202
No p'!. ~.r!.?9.~,
DISABILITY INSURANCE APPLICATION
LJ lIle 1l(Qiiiib11i1blnsuronce
101. INSURED
(Print)
-k1!QJS0pIH]] " , ''If'[[J-tJ 18Ld~JtrJ~] l~~a:ale
F\tsl Mlddl4 Initial
102. A.INSURED'S DATE OF BIRTH__Q3L!'LLtfJ_
MOIl!fl 03, 'f..AI
B, PLACE OF BIRTH
M
' -1,,'tt.~I;~~-tA
103. APPLICANT, II other Ihan Insured
Relationship
________~__ to Insured
Filii Mtddlelflltlll lul
104. RESIDENCE OF INSURED ~ 2. E ~(d~ Sk~~
This address will be used lor M_ _ L ' ~ ~... art! oo~FI'
all 01 tho Insured's policies, -L1kr.:dJI'tAJI Q,! UIf!. YdUJ.WfjAJiJ
CIty Coynty
105. POLICY NOTICES Send premium and other notices regarding this policy
to: !Rfrlsured 0 Applicant 0 Owner In 113 0 Other
at ~sured's address In 104, or
M
State
/7asS-
lip Code
tFuU....mel
Sheet a. No Of ~FO
c.",
Stale
lip Code
101. Has on appllcallon or Inlormal",9ulry ever been made to Northwestern Mutual Life 1~!lIJ~II!!l t~ISObllily Insurence
on the lite 01 the Insured? [}fYes 0 No II yes, the lest policy number Is _ ;.LI 01
107. INSURED'S OCCUPATION
A. Whet Is the Insured's primary occupallon? -Aff{)It4J~t
8. List any other occupations 01 the Insured: ,,',Al
C. What are the Insured's duties and Ihe percenl of time spent at each duly for each occupation
...J I!.....'j 20% "1f.,._..J....~ 1tImhJ, '''% ",,~trl-~~/Jr wi 1/
~,.~~.hOI~ .
D. Employer. Name Se1f--~~b
. Address!i'- t4.....1fMi,j S-h,,~"f...
SI. . No. Of RFC City
Eo How long has the Insured been employed by this employer? 8 t/~
--I
II less than 2 years, state the Insured's prior occupetion and employer,
F. lIthe Insured actively at work on a full-time basis without medical restrictions?
(B'fes 0 No II no, explain,
O. Does the Insured Intend to change occupallon(s) or employer(s) within Ihe nexl six months?
DYes [}}ffci II yes, explain,
..30
eJ
AL-..J.fj~lt:JA"ALf,. ~A- l'105:!r
SLlit: , lip Code
101. Complete Ihl, qUIIUon only II exercising an ADDITIONAL PURCHASE BENEFIT OPTION.
A. Stale the policy number(s) under which the opllon Is being exercised,
8. This application Is: [] Regular Purchaso [J Advance Purchase (Complete'
C. If this Is en Advance Purchase, theevenlls: / /-
[] Spouse /-
IJ Marriage Name 01: [-'-l CI Id------n--~--------
,_~J \1 ,ru.~ /.~ MI{Jd~'lfltl'.1
o Birth 01 child Dale and place olmorfloge, ~1!Ut;or hnal decree of adoption:
--
[]Adoptlon 01 child ____..L ",___L____ . ------------------------
t.AuIllh Ollr v.., ~.. Crt;' , - Cuunty
/
U11l
State
..",/
[J Inclease In Annual Earned Incol11o, $ _______ Aclual -- Ono calendar year ago 151\0ulll ago.. ""II' 118el
// $_ __n _ _______ Estimate - Current calendar year 15houlll ago... ",ifh lIBel
1011. flOllCY APPLIED FOR
Monlhly
Benefit
-....------ .-.--
Maximum
Denelil
Period
--.- .--...---.--
Beginning
Dale
Initial
Period
. ToADeJl.5.
Inllial
Period
.!Q~D~?.<L.
Guaranteed
Acceptance
(Prior Home OffiCI
approval ,~
DISABILITY INCOME POLICY
~evel premlum~
Qtta" Fat, IIran.:_...t# ~JOD
$ -=:. --- ---
$...... 7A'Ifl~ ~~
SOCIAL SECURITY SUBSTITUTE POLICY
o Level premium $
o Step rate premium $
o
rW'
o
o
o
o
to aQa 65
to aQe 65
o
o
o
o
DISABILITY OVERHEAD EXPENSE POLICY
o Business $
o Professional $
110. ADDITIONAL BENEFITS
o Additional Purchase Benefil (APB) $
o Social Security Substitute Benefil (SSS) $
Monthl)' Beneftt
o Annually Renewable Disability Income Benefit (ARDI) $
Monthl)' Benefil
o IndeKed Income Benefll (liB)
o Annually Indexing Benefil (AIB)
(II morllltln ani poIlc,,, IppIi8d lor, Indlcltolo
which poIlc,(lnll.c:h bentlllhould be .-.J
AmI. on eath PUft;h... Olle
111.1f Northwestern Mutual Ufe Is not able to Issue the policy and any additional benefits as applied for, should th~ S\lmpany Issue
a polley 1111 can do so only In a smaller amount, or on a different plan, or without an additional benefit? [Q'Ves 0 No
112. SPECIAL DATI NO
Prepaid: o Short term to I I o Date to save ege o Backdate to I I
Montl Day Yu' Manl1 ooy YOIl
Non-prepaid: o Specllled luture date I I o Date to save age o Backdate to I I
. Man" ooy 'u, Mon" ooy Yoa'
113. The OWNER 01 the Disability Insurance pollcy(les) will be:
~sured 0 Applicant 0 Other
IFull Ntmel
114. PREMIUM PAYABLE o Annually
~rnlannually 0 Quarterly
115. Has the premium lor Ihe policy applied for been paid to .Jt1Jl.agent In exchange lor the Conditional Disability Insurance
Agreement wllh Ihe same number as this appllcallon? lJd'Yes 0 No
118. A. Will Ihe Insured's e'Nlloyer paX)9,r this qlp,ability Insurance with no part of lhe premium Included In the Insured's
taxable Income? U Yes l~O AI/A.
B. The Insured's employer Is a: [B'S'ole Proprietor 0 Parlnershlp 0 Corporation 0 Subchapter S Corporation
o Other (Specify)
C. Does the Insured have an ownership Interoslln the business?
l1ffes ONo
If yes. what Is the percent?
/DO
%,
DISABILITY INSURANCE APPLICATION
INSUREO~]~JII]=:~.~=I~..]..-.:I.:_IJ1~Ji~J9]JJ
Fi~ M.ddlelllltlal LA,t
The lollowlng Information (pages 3, 4 end 5) Is required because Northwestern Mulual Ule's underwriting rules limit the amount 01
disability Insurance on the Insured in this company and elsewhere,
117.
A. OISABIUTY COVERAGES List and describe ell disability benellts including:
. disability Insurance;
. group disability Insurance;
. prlvete and government pension or tellrement plans;
. salary continuation plans;
. association plans;
. credit Insurance plans;
I overhead expense Insurance;
. Northwestern Mutual Llle disability Insurance; and
. any other coverage which provides disability benefits,
Aleo Include any coverage for which tha Insured will become eligible wllhln the next live years after a
qualifying period 01 employment has been met.
Identity: (I) In lorce, (P) Pending or (C) Contemplaled,
If none. check: SHONE.
Inlur.r
B.n.m
Typ. Amount
B.nent Period
Accident Slcknell
Check If Check If
O",.t by Non.
I, Po or C Socl.1 Security contributory
8. W~lIlhe Insurance applied for replace any Northwestern Mutual Lile disability Insurance? ... 13No
II yes, complete the Conditional Surrender lorm 17-0789, and the agent should submit any required papere.
C. WiIIlhe Insurance applied for replace disability Insurance Irom a source other than Northwestern Mutual Lile? 0 Yas IS No
II yes, complate the Information below, and the agent should submit any required papers,
When Issuing eny Insurance as e resull 01 this application. Northwestern Mutual Life will rely on the lact that the coverage
listed below cen and will be terminated on the stated date (usually /lIe ned premium due date), II the coverage listed below Is
not terminated on that date, any policy Issued and accepted will be rescinded and all premiums will be returned. North-
western Mutual Ufe may contact eny listed Insurer oller the stated dale to confirm that the coverage has been terminated,
Inlur.nc.
Complny
Group or
Anoclltlon Nlme
Policy
Number
Amount to be Premium Du. Olt.,
Repllced Termlnltlon Olt.
90.\ 01103851
11..
A. EARNED INCOME State Ihe Earned Income horn Ihe Insured's occupalion(s) as reported onlhe penonellederal income
lax relurn, IRS Form 1040, NOTE: Do not list undeclared income. lirnil nontaxable hinge benelils 10 Ihose which are
asked tor In 118 A.1. below,
Prior Calendar
Vear
Jan, 1-Dec, 31
Estimate Current
Calendar Vear
Jan, 1-Dee, 31
1. From primary C1CcupaUon:
lithe Insured is salaried, state the actual salery earned last year
end Ihe currenl salary, IIlhe salary has recently changed. shON
the date the change took effeet In "Remarks,"
II the Insured Is a commissioned salesperson, stale Ihe total
commissions,
Stale any bollus(es) Ihal the Insured recelvea on a regular basis,
Do nol stale It Included above.
II the Insured Is an unlncorporaled sole proprietor or a partner In
an unincorporated partnership, state the Insured's share 01 gross
Income less Ihe cost 01 goods sold.
Stale any nontaxable fringe benefits which are not Included above,
such as deferred compensation or pension plan conlrlbutions, thaI
would cease If Ihe Insured were disabled. Give details and source
of this Income In "Remarks."
e:
.e-
~OOO
abut .$;DtJO
,
~ DDO
-e-
3. Tolaleamtcllncome: Add lines A,1 through A,2,
eo
~O()O
2. From anv other C1CcupaUon: If none, so state.
II. NET EARNED INCOME Une A,3 minus line B.
$"0
~OOU
8. EXPENSE8 Stale Ihe Insured's tax deductible business expenses
from all occupations, If none. so state.
D. UNEARNED INCOME Stale that part 01 the Insured's net personel
unearned Income In excess 01 $5000. This Includes capital gains,
Interesl, dividends, tax exempt unearned Income, Income Irom olher
Inveslmenls, nel rental Income, pensions, annul lies. and alimony, II
none, so atate.
E.INSURABLE INCOME Une C minus line 0,
.#
-fr
~OOO
,
-t9
./I *;000
F. NET WORTH Is Ihe Insured's net worth, exclusive 01 primary residence, _~~Ier than $2,000,0007 (Include tha Inaured',
assets less liabilities such as mortgages, loans and debts.) 0 Ves i/JNo
If "Ves" complete section below, State lair markel value less any associated Indebtedness.
Cash savings, slocks, bonds $ Real estale (o,eludo pllmary ,..,done a)
Business equity (a,eludo gOod""II) $ Olher tGI.a dell,ioin ..nema'~'" bola"')
Personel property $
$--
$---------.---
o. REMARKS
__.___~r_~.. >..-----.----...---
------_.~.__._._.__.-.- -_._--_.._-~_._-- -.-~-.-'
.~.____~_.___.'d. -.
---_.__._--_.._---~----_.._~--- -_._--~.._.
DISABILITY INSURANCE APPLICATION
INsuRE~~e!ffLLl]JJJqLLL 1 M~Jj I ~L I
1,", M,d\II,llIlb.l t..1
1111. Compl.I.lhll qutlUon only Il.pplylng lor I DISABILITY OVERHEAD EXPENSE POLICY.
A. Whalll Ihe Insured's Ihare ollhe overhead expensos or Iho Insured's shere 01 ownership II this
II an Incorpo/ated bUliness? p .%
8, What II the amount 01 the Insured'l sharu 01 Ihe tYl'lcalmonlhly expenses?
s
Telephone
$ _.____ Mainlenance /.-:::::
$ _~____~ Real Estate Taxes/ $
$ _~___ Other lax ~,lyl $
S
~ Accounlant'l Fees
Depreclallon S
TOTAL
s
Rent
Insurance Premium.
$
tieat
Protelllonal
Dues and
Ucense Fee.
Emr,loyeel' Salarlel
(Pro nllonll DOE)
Olhar Normal Expenlel
(ltemill)
$-- Electricity
$
Inlerelt on BUline.. loanl
C. How many people employed by Ihil lirm? (Do not Include the Inlured In the total.)
ulIllme - Part tIme
1 tha employeel are In tha I18me occupation ealhe Inlured? (Do not Includa lha Inlured In tha totaL)
Full time Part tlma
Thelnlured conltn" 10 \hI. .pplle.llon .nd d.el.rts Ihllthe .nlwe,. Ind 11.I.m.nll m.de on Ihll appllelUon .re eOl/eclly
recorded, complele .nd \nIe 10 \he btsl 01 hll knowledge end b.llel. BI.t.men" In Ihll .pplleaUon .re repre..n""o1\8 and nol
w.rr.nU...
1111 'lIIeed that
(1) IItha premium II not paid when Ihe application Is ligned. no Inlurance will be In elfect. Thalnsurance will take elfeclallhe
time Ihe potlcy I. dellyered and Ihe premium II paid II the enlwers end ltatementl In Ihe application are llilllrue 10 lhe bell
01 the Inlured'. knowledge end belief.
(211l1he premium la paid when tha application II laken, no disabilily Inlurance will have baan In eUecl1l SeCtion " 01 the
Conditional Ol.ablllty Inlurance Agreement epplles.
(3) For each separate p8l10d 01 dllabllity no benelltl will ue peyable until the Beginning Date In queltlon 109, Receipt 01 an
outllna 01 covaragalor the policy applied lor II acknowledged.
(41 No egent II author Ired to meke or elter conUscl1 or to wBlvllany 01 the Company'a rights or requlrementl,
~'.I r~.'
f -.".-....r-. " , j '.-. .
.. r.' ..- .---.----- ~-........
Shgn,lul' I,Illfl'lIl~ (II oil" .,.n AI"lh~nl) - 6u.n.lu1. 01 "'pplll:..nt .'
81gned st 1fr-d4tJClftJc;~~GIff4,,;4j,AII} t.A
OaILQe.LOI I a5
Month 0.." YeI'
(pog. &1
TIlE NORTHWESTERN MUTUAL LIFE INSURANCE COMPANY
., -----___m__nn
TO BE COMPLETED BY-THE INSURED OR INFORMANT - -
INSURED (Please Print) [;2Q-~~~~------__f!-
FI"I MIddle Inlll.1 ._..___....,_ __~ _ ____.J~.t___+__________
-It SUbmmlidToi-purpos-e-otiierlha-na-iiewlnsuraiico application, please Indicate-,
o Policy Change I.J Conversion fJ Adding --- - __ (Jenellt U Reinstatement I] Rating Reduction
for Pollcy(les) Number h_____ ____ __ ____ ____________
o Payor Benefit for Applicant (Payor) - ______ Relationship to Insured ______
rIll' Middle Inl,..1 l "I
Payor's Date of Olrth Policy Number
---~!:._~-_I!'}'-_.. .__'!!'_. - ____~___._.
20. Have you ever had life, disability, or hospital Insurance
declined, rated, modified, cancelled, or not renewed?
(II "Yes" .rpl./n /n ROIARKS) ---_ill_~~ ~ _1i~
21. When was your last previous examination or application
for life, disability, or accidental death Insu~aj1~e7
Month ::L Year R~ ComfJanr...NA1L..___
22. lndlcale below whether any other Life Insurance on your
Life Is Individual IInd) or Group (Grp) and Identify In
Force II), Pending (P) or Contemplated (C).
lt none check, NONE
'~d Llf. Insur.nce Accldent., De.,h I. ~
Or Amount Amount or "
----.----.--..-----
/} '- t:. X. f)
- ._--~--------
COMPLETE llUfsTlliNS 27.:lf"I"--INSUREO AGE lOORGUlEii
27,i\rc-you a n1el1ibQrot~(jr-dO-YOljcontemplate Joining any
branch of the Armed Forces, the R,O.T.C., the National
Guard or any other component 01 the Armed Forces Re.
serve either on an active or Inactive status?
___{I/..::res'::E!!.~el. All/il.fy Secllon 90-5) 0 Yes 1B"N0
28, Except as a fare paying passenger on a regularly sched.
uled flight, have you flown within the past 3 years, or
do you contemplate flying In the future?
(/I "Yes," campIer. Av,.lIon Secllon 90-5) 0 Yes 0
--29."fliive you WTililn t e past 2 years part c pate n or 0
you contemplate participating In raCing (automobile,
snowmobile, motorCYCle, boat or go-kart) scuba or skin
diving, sky diving, hang gliding, mountain climbing or
rodeos?
-- - (I( "Ye,," compl.,. Avoeol/on Stellon 90-6 0 Yes 0
-jeC A~Whatls your Automobl e Dr ve s cense um er
#~l,/ State r'A-
or, 0 I do not drive an automobile.
O. In the past 3 years have you been In a motor vehicle.
accident, Charged with a moving violation of any motor
vehicle law, or had your license restricted or revoked1
(I( "Ye," upl.'n /n C" O. end/or REMARKS) 0 Yes Jlil No
C, Moving Violations within the past 3 years,
-- --Type snd Otlo .
Oote t~ptedlnl, Reckless Orlvln, Action tellallon, Accident
or/vln While 'nlorlcoled Fine) lYe. or No)
Inlurer .
-
z
Married
0, Details of any Accidents: Include date, cltat onl,
damage amounts, InJuries,)
Cil, 5 Ie lip Cod.
C. How lonll 50 employed7
REMA*~~:' ,-h.!'.!II!.e!" ~_rpl.e.'n_c"--'I~!<,AR~!L.__._
idec Iii/Billa fiTiy a n,wilrs it iids littcmcii-ls arBcorrec tlyrecorded,coniPTetli-Ond t ruolo-iliebes t oliiiYkn owl edge a nd be Hi!(:
Statemenls In this application are representations and nol warranllel,
~-) }J2
... "'. -
, . 1. ,~~,
~. -: .c_ _._____
~....-Jr:.::.- - - l=-
~- S' .h; 'UlI d , 1"'O'm~
I sd
DECLARATIONS TO PARAMEDICAL EXAMINER
NI1RTHWESTERN MUTUAL LIFE
MILWAUKEE, WISCONSIN
CHrCK
I'Ulll'osr:
Now Insurance:
I I Ufe, [I', VA
II.j1) I
I I ChanBo
I I Add 1l1'IICfit
I II'i1yor Ilonefit
I J Reconsideration
I ] Reinstatement
--._.,---_..---~.---- ~-~--~---- "--_..,,--_._-
INSURED,
j..fo.s G -f II
fin'
f A L[X 11 ~ale
MhftJlt 'Milil' l..1 Femalo
--- --_.~~-_. ~--_ ..0..___._..._..... _ --.___., 4
35, Have you ever had military service deferment, rejection
or discharge because of a physical or mental conditlon7
.... _____________.__.. _. . ___~ n Yes .Hi No
36. Have you ever requested or received a pension, benefits
or payment because of an Injury, sickness or dlsablllty7
3iJ~FamliYHrstoryl DIabetes, c;at"~er{ hlgtib~o~e~re~~~
heart or kidney disease, men a , ness or sulclde7
Ilil Yes 0 No
AU. If lIvln. CIUS. of Outh AI' .t O"lh
raltl" So
Moth"
7&"
No
ca.
No UIOlhl" 'nil 6'111" ,
40:-7I:-Have you lost we ght n the past year 0 os ~ 0
If "Ves," loss was Ibs. :k <C
B, How long have you been at your present welght7 ... ~
, Do you ave a persona p ys c an es 0 0
Name
Address
Dato last seen ~ Reason
Mo. O'V Yr.
Remarks. Give detail. 01 "Ves" enswen. Id ntl y question
number. State slllnl, symptom. .nd dlalnosl. ollllnes. and
name and addrees 01 any allendlnll hyslclan.
NOTICE OF INSURANCE INFORMATION PRACTICES . selll wilh I'ollt,
To tI1, Appllcanl and Proposed Insured: GOD1
Thank you for applying for Insurance with Northwestern Mutual Life. Some personal informallon was furnished by
you In the application and we may get information from other sources, We may call you from our Home Office In
Milwaukee to confirm or add to this Information, The questions asked during tho phono Interview will be data lied
50 you may wish to have records about your Income and health history at hand.
We need such Information 10 sea If you qualify for tho Insurance. Whon signed, the Authorization below will allow us
10 obtain this Information and to share Information with others when necessary. No unnecessary disclosures will be
made and all Information will be treated as confidential by us and by our reinsurers. However, In some cases, Informa.
lion may have to be disclosed 10 others, such as your doc lor or an Insurance regulator, without your prior consent.
You have the right to review and 10 correct Ihls Information. You have the right to get a copy of any Investigative
consumer report which Is done. If you want 10 know more about our practices and your rights, a full notice can be ob.
talned from the Director of New Business, Northwestern Mutual life, 720 East Wisconsin Avenue, MilwaUkee, WI 53202.
Medlclllnformltlen Burelu Nollce
We or our reinsurers may make a brief report to the MIB, Inc. MIB, Inc. Is a non-profit organization of life Insurance
companies. It operates as an Information exchange on behalf of Its members. MIB, Inc. will give a member company
Informallon In Its file when,
· you apply or submit a claim to that company for life or health Insurance; and
· that company has your signed authorization.
MIB, Inc. will give you Information from your file on receipt of a request from you, Medical Information will be dls.
closed only to a medical professional of your choice. Under the provisions of the Fair Credit Reporting Act, you
may question the accuracy of Information In the file and seek a correcllon by contacting the MIB, Inc. The address
of MID, Inc. Is,
MIB, Inc.
P.O. Box 105, Essex Station
Boston, Massachusetts 02112
Telephone: (617) 426.3660
'11r Credit R.portln. Act Notlc.
We may request an Investigative consumer report from a consumer reporting agency. These reports contain Infor.
matlon abeut your character, general reputation, personal characteristics, mode of living and health. The Information
may be obtained through Interviews with you, your neighbors, friends and others who know you. On request, we will
disclose to you whether or not such a report was done. We will give you the name and address of the consumer reo
porting firm so that you may request a copy of the report.
AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION
I authorize Northwestern Mutual Life, Its agents, employees, relnsurern, Insurance support organizations and their
representatives to obtain Informallon about me to evaluate this appllcallon. This Information may be aboul: (a) agel
(b) medlcel history, condition and carel (c) physical and mental health; (d) occupation; (e) Incomel (f) avocallons;
Cg) driving record; (h) other personal characteristlcsl and (I) other Insurance. It Indudes the use 0 alcohol, drugs
and tobacco.
I eutlforlze any physician, medical professional, hospital, clinic, medical facility, the Veterans Admlnlstrallon, the
MIB, Inc., employer consumer reporting agency or other Insurance company, to release Information about me to
Northwestern Mutual Life or Its representatives on receipt of this Authorization. Northwestern Mutual life or Its rep.
resentallve may also release this Informallon about me to Its relnsure!r to the MIB, Inc., or to another Insurance
company to whom I have applied or to whom a claim has been made. NO other release may be made except as al.
lowed by law or as I further authorize.
This form Is valid for 30 months from the date It Is signed, I have received caples of this form and the Medlcallnfor.
matlon Bureau and Fair Credit Reporting Act notices, I authorize Northwestern Mutual life to obtain an Investigative
consumer report on me.
t!( I request to be Interviewed If an Investigative consumer report Is done.
NemeCs) of Minor Chlld(ren) or olher Insured(s) If a parent or guardian Is providing authorization:
:~:'d:~=~.<'f.!. . S1'~d,L( ,~.t OA)J!.;;, ~
Month 0., VII' PILlpOSe IU r Guari~rent If .MInor)
SEND SIGNED FORM WITU APPLICATION - GIVE COPY TO PROP SED INSURED
90-0721 (07831
~~l'fhtt;m
1115 tl'('ollllllt'lldl'd thai you...
fll,1I1 YOIII polity.
notify YOU! Nt\ll ~lJWI11 III 1111' ("Ol1lp.IOY III 7lO I. Wi\( on\in AVPlllll'.
Mdl\,ll'~I'I', WI>, 5 J.lOl. III ~II ~ddll'\\ I h.II'II",
1~1I Y"III NMI a~I'IIllllllllflll"'alillll n pdlllllJl,uly 1111 a "'gge'lloII III
l('''''IIMIt' Of 1'),( h,IflM(llhi\ poli(-y fOf dflOllH" polil Y Of plaIt
Uelllon of lrmle...
lilt' n"'ml,,',, III JIlt' NlIIlhl""''''1Il Muluallife Imuran,,, Company al"
I" polllyhllldl''' of ImlJl~I" I' pllliri'" and d..I.."..d annuity IOnlral15.
11... nlt'mlll'" '....111'" llllllllll Ihlllugh a !Ioald of Tru,lees, [leC1lom 10
II... Illldlll all' 1",ld "al h y,'ar al Ih.. allllual meeting of m..mbl'ls,
M"mlll''' ~Il' l'nlil"'d 10 vole In pe"onlll hy p,my,
Illwblllly 'nwnw PoU, y
IlIglhl,' fill Annual Ulyldelllh
Nlln.( ,mll'lI,,"", and
Gual.lllt'l'd K"lll'wahle III Age b5
[ll/lllllllllldlly Kl'Ill'wable III Age 75
MMlil
_,t.~" ._,4.. " I lt~, t
(1lIfllll"\IIlIU.,J b)
~~ld~".'''1
I:XIIIIII'I' "II"
II
IIII' NlIftll\\'l'~lt'''l ~11lltl.lll ill' 1r'\tlI,IIH t' CWllP,lI1Y i:lgrl't'!I In flay Ilw
IW'lI'fil' plOvidt'd in Ihi\ poliry, \llbjl'{ I III il\ 11'1111\ .lIld rundiliofu.
5iglwd.1I Milw.IIl~(,t'. Wi\fOn,in un Ihl' I),lh' oll\,ul'.
1 hi!l di',lhilily i1u Will' policy h glltHJIlIl'l'd 1t'II(lw.lhle upon timely
P,lYlIll'l1t of IHC'millll1\ 10 IllP fir!ll polilY ,1I111ivl'l\,IIY ilflt" 11ll' Irl!lUIl"d's
651h hhllul,lY ,md, dwillU Ih.lI IH'';lld, 1-,111 l1l'itl1l'f hI' GHHl'lIl'd nor
h.1V1' ih h'flll' or IUI'lIIiwtl\ I h,IftHI'd hy tf1(l Company.
i'~- .u. J~ t...._/u.
PRI5/1J/NI ANIl C /.0
~py~
IICRlfARV
Dloabllity lnrnnw I'nll, y
Eligible lot Annu~1 Ulvhh'nd,
Non-Cancellable i1nd
Guaranleed Renewabl,. tll Aile 65
Conditionally Renewahle tu Aile 75
Righi To hamlne rullcy - rleale examine Ihil policy carefully. The
Owner may return Ihe policy for any realon within len daYI aher
receiving It, If returned, Ihe policy will be l:Onlidered yuld from Ihe
beginning and any pr,'miurn paid will be refunded,
.
MMlll
~~1EIte.m
'..
This policy Is ale8al ('Ontwl ""'I"l'('I1I1'l' OWllI'r al1dlll1' NUrlhwl"lern Mutual Ufl' h"uraIUl' Curn,.aIlY.
Hl'ad yuur 11l.lky ("'l'''tlly.
GuidI! To Polky Provlslolls
Pa8e
SECTION 1.
SClfEDULE OF BENEFITS AND PREMIUMS
3
SfCTION 2.
SECTION 3.
SECTION 4.
SECTION 5.
SfCTION 6.
SECTION 7.
BENEFITS
De.criptlol1 ul gel1e, alle"II>, r ullllenelil payahle lor lolal
dl.ahi/lly, ProPOftiollate lIellelil payable lor partial di.ahi/-
hy. tiow Ihe PropOftiollale !Ienelil i. dete/mlned. Trami-
tlon Benelil. Lilellme hene/II payable fOf Pre.umptlve
Disahilily. Waiver of Premlufl1l1e/1l'1i1.
5
I
I
EXCLUSIONS
CONDITIONAL RIGHT TO RENEW TO AGE 75
ClAIMS
liow to nollly Ihe Company 01 a claim. Proof of dlsahility.
tiow Ihe benefils wll' be paid, Physical examination may
he required. Limits on whell you may start a legal action.
7
8
8
OWNERSHIP
Rights of Ihe Owner. Assignment as mllateral.
8
PREMIUMS AND REINSr A TEMENT
Paymenl of premiums, Grace Period 01 31 days 10 pay
premiums, Refund of unused premium at death, How 10
relmtale Ihe policy.
9
THE CONTRACT
Changes. Inconlestahility, Mlsslatemenl of age. Dividends,
Del/nhlon 01 dates.
'.'
10
ADDITIONAL BENEFITS (II any)
APPLICATION
.
MMOl
Followlllg page 10
Allached 10 Ihe policy
.,
/.
I
I
I
i
I
I
I
I
I
I'
I
I
I
.
I
BENEFITS AND PREMIUMS
DATE OF ISSUE NOVEMBER 21, 1986
PLAN ANO ADDITIONAL BENEFITS
STEP RATE DISABILITY INCOME
FULL BENEFIT
PER MONTH
$ 1 , 000 ,
SEMIANNUAL
PREMIUM
153.20
231. 70
PAYABLE
FOR
FIRST 2 YEARS
NEXT 25 YEARS
RENEWAL OF COVERAGE BEYOND AGE 65 MAY REOUIRE AN INCREASE IN THE PREMIUM.
SEE SlCTtON 3.
A PREMIUM IS PAYABLE ON THE POLICY DATE AND EVERY 6 PDLICY MONTHS THEREAFTER.
THE FIRST PREMIUM IS $153.20.
THE PREMIUM FOR THIS POLICY IS ON A SMOKER BASIS,
BEGINNING DATE 91ST DAY Df DISABILITY IN THE FIRST 180 DAYS
AFTER THE START DF DISABILITY.
MAXIMUM BENfF I T PERIOD TO SEPTEMBER 17. 2013, BUT NOT LESS THAN
24 MONTHS OF BENEFITS.
INITIAL PERIOD TO SEPTEMBER 17, 2013, BUT NOT LESS THAN
24 MONTHS OF BENEF! TS.
OWNER
JOSEPH P ALEXA. THE INSURED
INSURED JOSEPH P ALEXA
POLICY DATE SEPTEMBER 17, 1980
EXCLUSIONS--SEE SECTION 2.
AGE AND SEX
POLICY NUMBER
:I 8 MA L E
o 499 667
MM 01
PA(lI. J
072
SECTION 1. IJENEFITS
1.1 GENERAL TERMS
1.2 FULL IIENErIl FOR TOTAL IJlsAlIlLlTY
This polic)' provides 11I'lIelits when thl' lilitHI'd i,
lotalll' or Ilalllali)' disahlen. Spellon 1 desnilll.'s Ih"
bene lis 01 Ih" polle)' .nd lell, when the)' are paYilhle.
II also gives the m".ninll 01 several 1I1Iporl.nt lerllls
Ihat are used In till' policy
InlUred and Owner, 1 he Ins wed and Owner ar"
named on page 3. The male pronouns us"d In Ihis
policy for Ihe Insured and Owner appll' 10 both m.l"s
and females,
1 he lull Il,'nelit is pill'ilhh' for paeh month 01 lotal
disabilitl' hplw,'en tl1I' Ill'ginninll Date and Ihp l'nd 01
Ih,' Maximum Ilenefit Period.
Tolal IJlsabUlly. Until Ihe pnd 01 the Initial Period
Ihe Insured Is tot all)' disabled when he Is unable I~
Ilerform Ihe Iltincl\lal dulles of his occupation, Alter
he Inlllal Pel od, t Ie Insured Is lotally disabled when
he Is unable to perform Ihe principal duties of his
necu/lallon and Is nol gainlully employed In anI' oc.
cupa lon,
Dlssbllllles Covered by Ihe I'olley. lIeneflls arc pro.
vlded for the Insuled's lolal or partial disabilitl' only fI:
· the Insured becomes disabled while this policy Is
In force;
· the Insured Is under the care 01 a licensed physl.
clan other than himsell during Ihe lime he Is
disabled;
· Ihe disability results from an accldenl or sickness;
and
· the dlsablity Is not excluded under Section 2,
Benefit Terml. The schedule of Oeneflts and Preml.
ums (page 3) has a number of fmportant terms Ihat
are used In this poliC)'. These terms are:
Full Benelll. This Is the maximum amounl of
monthly Income payable under Ihe poliey.
Beginning Date. This Is Ihe date on which benefits
begin to accrue after the Insured becomes disabled,
Oenefils are not payable for Ihe lime the Insured Is
disabled before Ihe Oeglnning Dale.
Maximum Benelll Period. This Is the longest Pl"
rlod of lime that benellts arc pa)'able for dlsabilill"
In detennlnlng the maximum length of lime for
which benefits arc payable, periods 01 lotal and
partial disability are added log ether, If page 3 pro.
vldes that the Maximum !Ienelit Period has a life.
time benefit for lolal dlsabllit)'. then see
Section 1,7,
Initial Period. This Is a period of time that starts on
the Beginning Dale and continues. while the In.
sured Is disabled, for Ihe length of time shown on
page J. The dellnitlon of lolal dlsabllill' changes
after the Initial Period,
Oenelll Amount lor Parllal Month. When a tolal
dlsabilitl' lasts for a part of a month. 1/301h of the Full
lIenefit will be payaole lor each dal' of tolal disability.
1.3 PROPORTIONATE BENEFIT FOR PARTIAL
DISABILITY
The Proportionate Benefit Is payable for each
month of partial disability between the Beginning Dale'
and Ihe end of the Maximum Oeneflt Period,
Parllal Disability. The Insured Is partially disabled
when:
a, he Is unable:
· to perform one or more of the principal duties
01 his occupation; or
· to spend a~ much time at his occupation as he
did before the disability started;
and
b, he has at leasl a 20% Loss of Eamed Income.
LJnlllthe Proportionate Ilenelit has been payable for
sl. monlhs, the Insured need not have a 20% Loss of
Earned Income to be partlall)' disabled If:
· he Is unable to perform one or more erlnclpal
duties which accounted for at leasl 20,j, of the
time he spent at his occupation before the
dlsablllt)' started; or
· he has al least a 20% loss 01 time spenl at his
occupation,
If the Insured qualifies for both the Full and Prop or.
Iionate Ilenefll, the lull !Icnefit only will be paid,
Occupation. 1 he words "his ocwpatlon" mean the
occullatlon of Ihe Insured al the lime he becomes
dlsab cd, If the Insured Is regulatll' engaged In more
than one occupation, all of the occupations of Ihe
fnsured at the time he becomes disabled will he
combIned logelher tn be "his occupation",
/Ienefll Amounl lor l'artlaJ Month. When a partial
disabllit\. lasts for a part of a month, 1/30th 01 the
f'roportlonale lIeneflt will he payable lor each dal' of
partial disablllt\"
MM 111
r,
1.4 HOW TIlE PROI'ORTlONATE IIENEFIT IS
DETERMINlD
The "rorortlonale lIenefil Is Inlended 10 <:OlIIpl'n.
sale for a loss of earned Income caused by the In.
sured's disability, The amounl ul each lIIonlhl)' Ill'nellt
Is the Full lIenellt multiplied hI' Ihe InSUll'd's 100s 01
Earned Income and divided by his lIase [arned In.
come, Thus. Ihe Proportionate Ilenelll amount '!'1uals:
Full l<uLQI [arned Inrnllle
!Ienefil X IllliEart1edliiCoiile
As required by Pennsylvania law, Ihe Propurtlonale
Dene/lt will not dupllcale benellts payable under an
automobile Insurance policy Issued 10 comply with the
Motor Vehicle Financial Responsibility law, The ma.l.
mum amount payable Is 100% of the Fullllenclil.
Choice of Oeneflt Amount lor Flrsl 51. Monlhs. ror
each 01 Ihe IIrst sl. monlhs In which a Proportlooate
Deneflt Is payable. the Owner may choose:
. to receive 50% of Ihe Full !Ienelll; or
. to receive a Benellt based on the Insured's loss
01 Earned Income.
The Owner may alternate between Ihese Iwo chulces
as to each of the sl. monlhs, However. Ihe Owncr
may not change his choice alter the !Ienellt Is paid lor
thaI month.
The Choice 01 Oeneflt Amount docs not apply to a
Transition !Ienefll payable under Section 1,5,
LOll of Earned Income. This Is:
. Ihe Insured's Dase Earned Income; less
. his Earned Income lor the monlh lor which Ihe
Benellt Is claimed.
Earned Income Is credited 10 the period In which It Is
earned. not the period In which Income Is actually
received.
Euned Income. Earned Income Is:
. the sum 01 salary. wages, commissions. fees,
bonuses. and other compensation or Income
earned by the Insured lrom all sources for work
performed by him; less
. normal and cuslomary business expenses.
It Is determined before Ihe deduction 01 federal. stale
and local Income taxes,
Bue Earned Income. Durlog the first 12 lIIonlhs of a
dlsablllly. !lase Earned Income Is Illl! average 1II0nlhly
Earned Income of Ihe Insured lor a 12 cnoSl'cutlve
month period dUllnll Ihe 24 /TIonth period beflll" Ihl'
start 01 dlsabilily, The 12 lIIonth pl'rlod whir h g.'n.
erates Ih" hlgh"st aVI'ralll' land Ih,,"'fo"' thl' highl"t
benefil amounll will he ull!ll.
!\fler till' firsl 12 months 01 .. disabllily, 1I,lll' l"'''I'd
Income ili llll' .1Vt'l.lge monthly l,lHWd Illr, 111t' 01 IIU'
1\\1\\ Ilt
P"r.n,ylv.u'I,.
Imurl'dlllulliplled hI' an Indl'.lnll [.II tor. Ihe Inde.lnK
I ,\(t"r Is:
. "H~ U}fl~Ul1\er prill' Il1Ih~)( Inr lIw 'Uffcnl ye,u 01
dls"hlllty; dlvid"d h)'
. Ihl' I.Ilnsurl1l'r pllee lIuh'x for Ihe )'l'ar Ihe dlsabll.
Ity started,
Thus, alter 12 IIIllnlhs of ,I disability. lIase [allied
Income ('quills:
averaue monthly X
hUlled Income
consumer price Index
for Ihe current )'ear
__ of dlsahllllY-_ __
colllum"r price Inrl"x
for the year
disability slarlcd
111 Ihe el'enl till! Indexing 'actor Is less than one, a
value alone will he used.
COIl.umer I'rlce IlIdex. I he "consumer price Index
for the YNr the disability started" Is Ihe n e
"rice In~or All UrbalLWl\' .mers Unl e
elt" f\v"rla~e, All Items ("CPI.U') or tIC ourt monll
lie o.e t Ie start of dlsahillty' I he "consumer prlee
Index for the current year 0 disability" I. Ihe Cpf.U
for the fourth month belore the most recenl anlllver.
sary of Ihe start of disability,
The CI'I.U Is published hy Ihe Oureau 01 Labor
5tallstlcs, If the method for determining the CPI-U Is
changed. or If It I. no longer published. It will he
replaced by some olher Inde~ foulld by the Company
to selVe the same purpme,
Prouf IIf Earned IIICllme. The Cumpany may require
proof. Including Income tax relurns, of the amoullt of
Earned Income for period. before alld aller the start
01 the disability,
1.5 TRANSITION BENEFIT
The Company will pay a I'lOportlonale lIenellt lor
up to the IIrst Ihree monlh. aller Ihe Insured'. recov-
ery lrom a dlsauillty, provided:
. the Insu.ed \l'as disabled at least 12 mOllth.
during Ihe 24 mllnlh perlud after the start of
dlsablllly;
. th" Imllled has returned III full. lime employ-
ment;
. Ihe Insllled has ,.1 least a 211% tlln 01 Earned
Income lor Ihe mOllth for whll h Ihe hen"fIt Is
dalnll!d; .111d
. the mllnth for whkh Ih!! IWlleflt Is .Ialom'd I.
within till' M,lXlmull1 lIenefltl'erilld.
'h" .unllunt III Ihls II I'II"'i I wlil III! del,,"nloll!d un.
dc'r Sl'ltllln 1 ,I l'l'rllld\ Ilf tlllal ,uut parlldl dis.llIllty
"'''I'lli' addl'd logl'rlll'r 10 me"1 Ih" 1l Inlllllh reo
IIUirl'l1l1'lll
1111, ""llI'hl i, I",)'"hl" lor "l' 10 Ihft'" nllll.lhs fllr
I',IC h Ijf'fJ,1I11lt' di\,llulily. 1111 ,my IIHIIllh 1111\ nl'lll'll! I~
P,ly.lhli', (III'ltllllIJJI. \\1111)1' \V,llVf'cf
I,
1,Ii 11lANSPlAN1 1I0NOll
II till' hl!.llll'd donilh', ill \ oIgall 111I tlllll\I)I.1II1 III
illlOIIH'1 prl\\IIl. It Ih,..,I"III\' IIHJ\l'd hy tilt' l'III,llltJll
will Ill' I oll\idl'lt'd d\ ( .w\l'd br \II ~IH'''''t
1.7 IlrrllMI IIINUIT [Oil T01Al
IlISAIIIlI11'
II pall" ] p,"vld..s Ihal II", Ma,lonlll11 111'11,'111 I't'lIl1d
has a IIfelll11e 111"11'111 Itll 11IIal dl\ahilllr. 1111'11 lilt. 11I1I
Ilene III Is parault' .. lonl1' as lolal dl\ahllill' IOllllrllll'S
illlrll1g II", 1I1<'lInll' ollh,' 1I1UIl.d, p,ovlded:
. till' ImUled Is lolally di.abll'd on IIII' puli'r all-
nlversa,)' Ihal lollowI hi. 60lh hlrthda\,; alld
. 11ll' lolal disahilill' conlll111l" u"I'onrl tI\f' poliq.
annivl'lSa.)' Ihal lollow. his b~lh blolhrlay
1.0 lIfETIMI OfNHI1 fOR ['R[SUMPTlV( TOTAL
DISABILITY
(ven II the ImUll'd Is able 10 work, he will b,'
col15ldered tolalll' dlsahled II I", Incurs Ihe lolal and
Inecoverable 10" of:
. Ilghl In bolh el'I'I;
. u.e of bolh handl;
. USl' of both 'eel;
. Ule 01 one hand and one 1001;
. speerh; or
. hearing In bolh ears.
The lull Reoelll II \,ayable lor Ihll Ion provided:
the 1011 or CUll wl,lIe hi! policy Is 10 'olCe; Ihe loss
occurs bl"OIe Ihe 11111 pollry anniversary Ihal 'ollows
Ihe 651h blrthdsl' of Ihe Insured; Ihe losl II'IUItS frOI11
an accident ur slcknen; al1d the Ion I. nul e,c1uded
under Serllon 2, 1 hI' In.ured dues nol nl'ed 10 be
under the CSrl' of a ph\,slrlan.
.
1he lull lIenefll 10' Ihe lun:
. Is payable l11onthly;
. Stillts wllh II", dale ul loss, nul thl' III'gll1nll.g
lIatl';
. 'I payablr' lor a. lung u Ihe 1055 101l11rllWI dur.
Inlllhe Illellrne nf Ihl' InlUled; and
. 1\ 111 IIl'U ul olllt', hel1elil. payahl,' 111I lolal 0'
pallial dlUhilllr.
1.9 WAIVIIl 01 PIli MIUM III NI III
1111' (1111\11.111)' will \\',11\'(' PIt'IllIIlIlI" whi!" IU'tllllj('
dlll' UlI 1111, plllu Y whill' till' 111\1l1l'd I, lotallr .1I
P,lIll"lIr d".lbh'd II
. lilt. d"illlllilr 1.1'1, Ill' alh'.,,1 'III dal's; 01
. 1IIl' (lIeulhili!) 1.1\1\ h"~'IJlltl IIIl' Bt'gilllllng Dille, If
~(JlIllt'r
11,1' W.I\'l'r 01 I'It'IIl1l1l11 ""Ill'hl is nlll IlIlIlted hI' Ihe
t\1a);lInUITl IIl'rwlit P{'litHI,
II 1"..l11lul11s all' waived, Ih.. (mllpanl' will al.u
It'lulld Ihat portion 01 a premium paid which applies
III a p..rl()(' 01 dl,ahllil\, beyond the pollq' monlh In
wl1l,h till' dlSahlllty hellan. II a p,emlum Is 10 be
waived Oil a pullq' annlversa,y, an allllual premium w/II
Ill' walvl'd.
1 he Compan\' will nol waive Ihe payment 01 pre.
mluml aftN the ..nd ul the dl.abllltl' (ekcepl where
Ihe waiver conlll1Ul'I under Sertlon ,5), The Owner
mal' Ihen keep the policy 10 lorce uI' resuming Ihe
paymenl of I"l'mluml al Ihey uecome due,
1.10 RHtABllITATlON BENEFIT
Al Ihe Imllled's requesl. Ihe Companl' will comlder
JoininG In a program 10 rehabilitate the In,ured. Tne
Compsn\,'s role In Ihe program will be determined by
wrltlen agrcemenl with Ihe Imured, Deneflls will con.
tlnue during the plogram under the lerm, of Ihe
agreemenl.
I,ll DISABILITY WlTli MULTIPLE CAUSES
If Ihe Imured I. disabled from more Ihan one
cause. the amounl and duration o. benefits will nol be
more than Ihal 'or anyone of the cause,.
1.12 BENEFITS rOR SEPARATE DISABILITIES
[arh 'l'pa'ale time Ihe In,ured Is dl,abled. a new
Initial Pl'llod, lIeglnn/ng Dale and Maklmum Benefit
Period slart, A dl.ahllltl' I, sepalate. and nol a conlfnu.
atlull 01 one that Ilartl'd earlier. II:
. Ihe cause 01 Ihe laler dlsaullltl' Is nol medlcall\,
relaled 10 the rause of the earlier one and Ihe
Imured had 'elllllled on a full.tlme 6a.ls Ihe
principal dulle, of an occupation for al leall 30
rnml'rutlve dal's; or
. Ihe rallle of Ihe laler dlsahlll1y I. ,elaled 10 the
rausc 01 Ihe ea,lIl'l one. and the laiN dlsablll1l'
.la'ls al I..ast II Illonlhs altl'1 Ihe end uf Ihe
(larllt'r Olle,
SECTION 2. EXClUSIONS
2,II'Rr.IXI511NG CONIlITIONS
lI,ell' will h" Ill. 1)('n,'III, tor a di,ahilill' III 1m. tI,..1
. .ta,h wlthll' tWIl r".IS .111" 1/11' Pall' nl 1\\111'.
anrl
. III\uhr. from all iH<< Id{'llt tthll (H { lllll'd fll f!tlll! "
!lie klll'\\ Ihat \ViI' dlannolJ,{'d III tlp,llt'd wlthlll
two rl'dlll lJt'lt II (' 1111' Dill(' of 1\\Ilf' illld \Vii" IIllt
dill Ill\,'d III till' apph, atlllll
MMIII
Pt'IlII\),I.,.lllld
U 01lllR IKLUSIONS
IIwlt. will I". 110 h..lldl1. lor a rlisabllit\, or IU55 Ihat:
. i, <l11I,,'d III ('"1I,i1nlt..d 10 hy an arl or Incident
01 wal. .I,'da,erllll wll'eda,el; or
. I, .." h,,"'d frOIl1 '"Vl'lalle hI' all ^1l'l'l'nU!nl for
Itrnllatlollol ClIv,'rOlI\".
1
SECTION 3. CONDITIONAL RIGHT TO RENEW TO AGE 75
On ~ach IJOllcy annlv~rsary h~lw~en Ihe Imur~u's
65th anu 75 h hlrlhua)'s. Ihe Own~r m.1Y ren.'w Ihls
policy for on~ y~ar II th~ Insureu Is acllv~ly anu
gainfully employ~u on a full.llm~ basis, To ren~w Ihls
policy, the Owner musl senu a \Vlllten requesl to the
Company each year, This rlghl 10 renew ~nus on Ihe
IIrsl annIversary on which the Insureu Is nol so em.
ployeu or on which Ihe Owner chooses nol 10 r~new
the policy,
for a polley Ihat Is r~n~wed:
· hN1l'lils ar~ payabl~ only for lolal ulsablllly; anu
· th~ pr~mlum lor ~ach year 01 r~newal will be
based on the Insur~d'5 aile anu lhe Company's
rat~s In Use al lhe IIm~ of renewal.
SECTION 4. CLAIMS
4.1 NOTICE Of CLAIM
Wrilten notice 01 claim musl be given 10 th~ Corn.
pany wllhln 60 uays aller Ihe start 01 anI' loss cover~u
by Ihls policy. II Ihe notice cannot be g ven wilhln 60
days, II musl be given as soon as reasonably possible.
The nollce should:
· give Ihe Insured's name and policy number: anu
· be sent to Ihe Home Olllce or be given 10 an
aulhorlzed agenl 01 Ihe Company. Ihe Home
Olllce Is localed al:
720 Easl Wisconsin Avenue
Milwaukee. Wisconsin 53202.
4.2 CLAIM fORMS
The Company will furnish claim forms wllhln 15
days aller recefvlng notice of claim, II claim forms are
not lurnlshed wllhln Ihal period. \Vlllten proof of
disability may be made wllhout the use of the Com.
pany's forms.
4.3 PROOf Of DISABILITY
Wrlllen prool of dlsablllly must be given to the
Company wllhln 90 days afler Ihe end 01 each monlh.
ly period for Which beneflls are claimed, IIlhe proof Is
not given wllhln Ihe 90 days, Ihe claim will not be
allecled II Ihe prool Is given as soon as reasonably
possible.
4,4 TIME Of PAYMENT Of CLAIMS
!Ieneflls due under Ihls policy will be paid monthly.
4.5 PAYMENT Of CLAIMS
.
Ilene fils will be paid 10 the Owner or to his estate.
4.6 MEDICAL EXAMINATION
The Company, al lis own expense may have the
Insured examined as alien as reasonably necessary In
connecllon wllh a claim. This will be done by a physl.
clan of the Company's choice,
4.7 LEGAL ACTIONS
No legal aCllon may be brought for benellts under
lhls policy wllhln 60 days aller written proof of dlsabll.
Ily has heen given, No legal acllon may be brought
aller Ihree years (or a longer period Ihat Is required by
law) from Ihe lime wrlllen pronf Is required to be
given,
SECTION 5. OWNERSHIP
5.1 POLICY RIGHTS
All policy righls may he exercised hy Ihe Owner, or
his successor Of transferee.
5.2 TRANSfER Of OWNERSltIJ'
TIll! Owner may Iransl..r Ihe own.."hip III Ihis I'nll.
cy. Wrillen proof of Iransler S.lllsf.u:tllry III II", c.om.
I,any mllsl h.. ",...Ive" al ils I Inn"'. (lIlw.... I he Irans-
er WIll l.lk(1 eifel t ,Iii of the dale II was \Iglwd. lilt'
Company m.IY t('qLJirl~ lhllt lhe polk}' !JlI lj(!111 II) lis
Honw Olfkl' for PfldOf'il'l11ent 10 show Ifll' 1I,Hl',fpr.
MM [II
5.3 COLLATERAL ASSIGNMENT
The Owner may assign Ihls policy as collaleral secu.
rily" Th~ ComlJany Is nol r~sponslbl~ lor the valldlly or
ef ~(t of .1 co lal~ral assllJnment. The Company wil be
(.harg~" wilh nollc~ of th~ asslgnm~nl only If a wrllten
asslgnmenl is rccclved althe lIome Office.
A mllaleral asslgn~(! Is nol an Owner. ,\ (ollaleral
a"'gll""',,1 is nol .1 Iransl", 01 owne"hl/'. Ownership
<:Jnh~ Iramlcrr..d only hy COlllplyinll Will 5e"lIon 5,2.
/I
SECTION 6. PREMIUMS AND REINSTATEMENT
6.1 PREMIUMS
Plymenl. All /"emiu,ns aliI" II", lil\1 ,11<' pa\,ahlt, OIl
Ihe Horne 01 ire or 10 all autho,i/I'd agellt. A I"l"
mlum musl Ill' paid Iln 0' 1)('101<' ii, ill,l' dale. A
recelpl signed h\, all Illfirl" III Ihe COlllpall\, will h.,
lurnished all lequest.
frequenC)'. Premiums ma)' he paid annuall)'. semi.
annuall)' or quarterl\, at Ihe puhlished rail'S 01 1111'
Comran)', A change In premium frequenc\, will lake
elfec on Ihe Company's acreptance 01 Ihe plemlum
for the nell' Irequenc\" Premiums mal' he paid on an\,
other frequenc)' approved b\, the Compan\"
Grue Petlod. A grace period of 31 da)'s will be
allowed for paymenl of a l"emlum that Is not paid on
Its due date. This policy w II be In lull force during this
period,
The policy will terminate at the end of the grace
period If the premium Is not paid,
Premium Refund II Dellh. The Compan)' will lefund
that portion of any premium r,ald for a period be)'ond
the date 01 the Insured's deatl,
6.2 REINSTATEMENT
Wilhln ule Paymenl Period. The late payment pe.
rlod 15 Ihe Ifrsl 31 days after the grace period, Within
the late payment period. the polic)' will be reinstated
as of Ihe dale the overdue premium Is pafd, No
evidence ollnsurabllit). will be required,
Aller Ihe Llle Plymenl Period. Aller the late pal"~
ment perlodh the cost 10 reinstate must be paid to the
Compan)'. T e Compan)' mal' also require an applica.
tlCII1 lor relnstalement and ev dence of Insurability, The
pollc\, will be reinstated as of the date the cost 10
reinstate was paid to the Compan\, If:
MMD1
l'enns\,lvanla
. Ih.. appliratloll i; apl"ovl'd h)' thl' Compan)': 01
. I1nlit (' that tlw illlplitilliOIl hill, Iwt'1l di~a\)plnv(~d
j", not givl'n willlll 41) da\'s from Ilw (ah~ the
('(Hllllilll\' 'l'[piv!'!. III(' illJIJlifalion.
011' polll)' will bl' ll'lnst.llt'd as 01 thl' dah' the Com.
pall)' arrl'pts pa)'l11ent of tl\[' rost 10 reinstate II Ihe
[ompan\, dlles not I<'qulre an appliratlan.
Coverage. If nil evidener' III Insurabllill' Is required.
till' ,einstated pallq- will cover ani\, a disabllil)' Ihat
starts after the date of reinstatement. If evidence 01
Insurablllt), Is lequlred:
. the reinstated policy will cover only a disability
that results from an accident that occurs. or lrom
a sickness that was diagnosed or treated. aller
the dale 01 reinstatement; and
. the Compan)' ma)' allach new provisions and
Iimilatlons to the paliq' at the time 01 ,eln.
statement. All other rights of the Owner and Ihe
Compan)' will remain the same.
Duty wllh Armed forces. If the pollq' terminates
while Ihe Insured Is on active dut)' wilh the armed
lorces of an)' nation or group 01 nations, the polley
ma\, be reinstated without evlaence 01 Insurability. The
poliq' will be reinstated as 01 the dale a wrlllen
lequest and the pro.rata premium lor coverage until
the next premium due date are received b)' the Com.
pan)', 1 he request musl be received:
. nu later than 90 da)'s alter the Imured's release
frOIll acllve dUI)'; and
. no latel than 5 )'ears alter the due date 01 the
unpaid premium,
9
SECTION 7. ntE CONTRACT
7.1 [NTlR[ CONTlIACT; I IIANlil ~
I hi, poli,\,' \\lIh th,' "1'1'111 allllll alld ,ll\,lIll1'd "II,
dOlsclt1cnh is lilt' rnlill' (OIlII,H t tH'h\t'I'1t till' (h\IH'1
and Ihe CompallY. NlI ,hallM" III Ihi, 1'"111 \' " ,.,lId
unless apprnYl'd 'I' an lilli, (" 1I1 IIII' (IImp"ny IIII'
Company may lI'quill' Ihal Ihl' p"ll,y Ill' "'Ill tll II III
be endorsed to shu\\' J dlJl1gl'. No iI"I~l1t has ,ltJlhOl-
III' to [hang'! Ihl' pllll< I' 01 III wai... ,illY 1I1 It, 1'",,,.
,10m,
7.2 INCONTf5TADIUn
In lUlling Ihi, polky, Ihe ClImp,IlI\,' Iii" 1I.lit.d IIn
the appllcanon. I he ClIllIpan\, may 1I.'Slll1d IIII' 1',,11< y
or den\, a claim dul' III a ml"lalt'ml'nl III Ihe appli' a.
tlon. Howe,er. aller Ihl, pollq' ha, l",,'n In 1011" Ill,
Iwo years horn Ihe Dale of I"ue. no mlsslatemenl In
the appllcalion may he u,ed 10 re,clnd Ihe 1'011,1' or
to deny a claim for a dlsablllly or 10" Ihal ,'a'h alt",
the 11'0 year petlod.
In addition. a claim may he denll'd on lite hasl, Ihal
a dlsablllly at Iou I, cau,ed by a P,e.t,I,llng ClIn-
dltlon (,ee Section 2.1). Howe,er, Ihe ClImpany ma\,.
not reduce at deny a claim on Ihal b..l, II Ihe disahil.
Ity or Ion:
. ,tarts aller Iwo years hom till' Date 01 ,,,Ut'; and
. Is not enluded I",m ,owrage b\, an Agll'''menl
for L1mllatlon 01 Co,e,age.
7.3 CItANGf Of l'IAN
The Owner may rhange Ihl, pllli' \' 10 any plan 1I1
dlsablllly InsurantI' ag,eed III hy tbe Owner and Ihe
Company, lhe change will Ill! ,ubled Ill:
. paymenl 01 required [mls: alld
. compliance wllh olhe, rondllilln, 'eqolled by Ihe
Company,
All premiums and di,ldend, aile, Ihe dalt' 01
change will be till' same a, Ihllugh. 11ll' nl'\\ plall had
been In effecl ,Ince Ihe Poli,y Dale
MM III
U MI~~lAlIll Ala
II t1IP ,tLW 01 11ll' Imowed ha.. IH'I'" lJli\~tah'd. IIw
1)I"lI'lil, will Ill' Ihlll" whit h Iht, I",'mit"", p,lid wlluld
h.w(' plllt holf.tt.tI ,tl till' {Oll..( I dgP
7.5 CONFORMITY Willi HAH 5TA1UH5
AliI' 1"'lVillolll IIllhl, plllley whl< h, lIn Ihr' flalt' 1I1
1\\0". all' III (lInlll< I with Ihl' ,talull" 01 1111' ,Ialt' In
whl< h 11ll' ()WI1l" resides '"1 Ihal Dale all' amend,'d
10 lllllfollll to \\H h slatulrs.
7.6 IlIVlOlNOS
I his poll< y will ~ha'e In the <l1,1,lble ,urplu" II an\,.
III I/ll' Company f)1,1~lhle ,urplus is delerrnllll'd an.
nuall\,. I hi, polity's ,ha,e will be crediled as an annual
<llvld"lId
Divl<l'~lIds will be:
I l"ed to reduce premiums; Of
. paid 10 Ihe Own"r when premium, a'e helng
\\alvt'd.
7.71>A1l5
Provided Ihe lil,1 plemlum Is \,al<l. this policy will
lake elletl oil Ihe Dale 01 luue. 'olley monlhl. yurs
and allnlvt'rsarles are cnmpuled from Ihe Policy Dale.
Uolh dale, a,e shown 011 palle J 01 this polley.
7,8 HHMINATlON
II p,emium, are /'ald when due, Ihl, policy will 1101
1""11fllall' unlillhe Inl policy annl,ersary lollowlns Ihe
f,~th hlrlh<lay ollhe IllIuted Of, II laIN. when Ihe tlghl
10 relll'W Ihe polity elld, (Sl'e Secllon J) However, II
tlll~ II1\UI "d Is disabled on the dale del ermined above,
the I",mlnalllln will not lake eHe( I un III l>eneflts are
rll' IUIIK'" payahle due 10 Ihal dlsabllily
111
NORTHWESl ERN MUTUAL LIFE fj,.J.~t/9<(v(. 7
INSUHANCl COMPANY
090050 MILWAUKU, WISCONSIN m01
DISABILITY INSURANCE APPLlCA nON l\J [,h' 1'01"",,1111111' 1"""""'lI'
101. INSURED
(pllnll
lrlolslfjPIHll1
Ilpj
I I I I I ~ I ,-Ie I XJA I N~::ale
h,t
Nlthtl.lnll..1
uo<
;.Icl ~c.r.~f.,!j,. r;g ~nd"~"':"'"
102, A,INSURED'S DATE OF BIRTt!
03 / /7 / If' 0, PLACE OF BIRTti
MOlllI' Oil} 'rIll
103. APPLICANT, it olher Ihan InsUled
-~--- -,;;1.- ~- p-
f1elallonshlp
10 InsUled ____~__________
M,ddlf' 11111'111 IJl'"
104, RESIDENCE OF INSURED _J/{J'?' Ii". 15 c. 14.r:.,.
This address will be used for M.. An ~
all of Ihe InsUled's poliCies J .tHo "I'IICSIVf.! rt;
Cd, J
,s;.!" ~_~ r
51'..... & No 01 ''11 ()
CfUUtJ,.,./ANa.
(,tlU'lt,
. .-- ---. ~_.- --~--_._-----_._-
___ 1'2 L jlc..!SL_
blalt' 1111 Code
105. POLICY NOTICES Send premium and olher nohces IBgard'ny 1I1Is pol,cy
10_ ~ Insured [J Appllcanl II Owner In 113 (] Olher _
at 00 InsUled'a address io 104. or
-- ------.-~--i1lJl-lth~;t'i-...
..--------------------S;.:..-'-'--N--;; 01 f.\1 (1---- _._--~
ell}
SlAle
lip COde
10e_ Has an applicAlion or III10rmal inqullY ever been made 10 t~or1hwes'ern Muluol Lile lor annuity, Iile or dlsablllly insUlonce
on the IIle of the Insured? ~ Yes [J No II yes, Ihe lAst policy number is ___D.!-I.:!f'_7o 2-_______ .
lor. INSURED'S OCCUPATION
A. What la the Insured.s pllmary occupellon? _llLr~s.f{~r--------
B. Llalany other occupations of Ihe InsUled _~@1ff,____ --------------- -
C. Whalare Ihe InsUled's duties and Ihe percenl 01 tllne spent Al eech duty lor each occupation? 30 r. T~.!f~.$,A<<.s
IN ~... r-i____Z,,'/IJ 'Rt.u..r_t:h_"J1J.,;N..J_____As.'/Ll1tHHr!J__J.lhTA-CI1.cMT.LJ ,Z.s-V.
-rifle. AjUJ::.*-,rilif(-- ________~___H____ ________
D. Employer: Nellle _____SICLI'.~____f_Hel!'__y.:-c.!"f--__---- ---
Address ____.!iJ___YL~1If'N _$tn~___PJ~IIf{~Il.{fr;j_-EA, 17~
, 61..., & Nu 01 RI tJ CII~ &lal. ZIp Code
E. How long hea Ihe Insurcd been employed by Ihis employer? -.--------9-1fttl~,s--
II le88Ihan 2 years, stale Ihe Insllled's prior OCcupAtion and employer - ---~----------
F. Is Ihe Inlured ectlvely el work on a lull-l1l1le basis wllhoutl1ledlcal restrictions?
IKlYel [lNo IIno,ekplein --- -----------------~
O. Doe. tho Insured Intend to change occupatlOn(s) or employer(s) Within tho nekt si. months?
o Yes ~ No II yes, e.plalll
101. Compl.l.lhls question only II enlclslng en ADDITIONAL PURCHASE BENEFIT OPTION,
A. 610le the polley lIumber(s) under which the opllon is being ekerclSed
--------:~-:::_---
/1 AdvBlleo Plllchase (Complete item c:;JJelOW)
B. This eppllcAlIon is [I nogula, Purchase
C. IIlhis Is on Advance PUlchAse, the evenl is
II Spouse
Nama 01 [-I Clllld I,,' --
MuJitIt'hllhat
Oate and place oll1la"lIIge, blllh, 01 1'"01 decree 01 adoption
[] MOlliaga
[] Illlth 01 child
[] Adoption 01 child
la,'
/
./
Month
().~
,..'
<< :Il~
('..U\lllly
__w.. --.---.' >.--6"t;--~~-.-
['1 Incrcase in Annual [atnetlll1cul1lfJ $
S
ALluol Dnu cnlt!ndar YCiH ngo (5huuhllgree Ywllh 118el
rstuHntu. CUIIOllt cAlundar year 15houldlOf8e 'Willi '18t)
'lJlCLilIJA110N810 P.\fIAMWICAL LKAMINt:n
lilt NOnlliWUill fiN MlIlUAl 1111
MllwAlIKII, WISCllt~51t1
INSUnto : (lit f i.. iI' III f
hi" I
I,,,'
elll q\
1'1 JI H', I~ d
tJI'W Ifl~IIIWll:l'
I il, II', VI,
P!
I leh""I1"
i I/\lld H"111'h' r
i : 1'4ItU1 (\, IIl'Ll [
~.:i( i. I. /1; I
1.1"
] H,,\ (l1l~,jdt'I;lli(lli
I Ht'ill~,ldh'III"'11
/..j')
, .
I,l.,,!., I"".,
IM"I.,
Ifenwle
31. ^ Hilvt, ~'tltl ''''Hlhl'd l'Udlt'th'!-> 11\ lhl' Pll!,l 10 ~'(,ill!,') :1L DUU'! 'him nlmvl', havll you within Uw past 5 yema.:
I/IVI'~' I lr~o ^ Hild nny pllY!.lclitll 01 pliHIII""H'/ (!.IIillllllltl, IIdy!!.I' III
Il All' yuu Ul.II'1J lilt"" I II III illlY Otlll" 101'"'' 111','1 you'l I I Ye~ 1'11<"
tI Y"s, Spl'clly I I y"" 1'lNo II 111'1'11 n 1Ii,I'I'II1 '" n hosp'lal, ch,"l. III l1ledlCltllaClllt'
C P'PMml ClgOfPllP fHlIOkt'f!i ..._ ! I Yus -JNo
(1) Huw l1lallY "'11"'''"1'5 du yo" SnH)~e pe' [t;lY? C 1I'''I.t~~X'IUY. 011"" II'S/? . [yVes I I Nu
(NumI1t'l or UUil11'lh'5 1101 IlLHlllIl" ollHI( lI!.l J e:/i lJ Bpell ndvls(!d to hov(l OIlV tes!. hOspltnlllEJlloll. Of
("I How many Y'''''" 'HlYe yuu "lIIu~ed'l 1'/'11"<; blll!J"'y wh,ch was nul colllploll'd'l I I Yos. (/JNu
D Pasl cignlClte smuke,s 31. Have you CVlJI flJqueslcd or rece,ved a pension, boncllls
(1) How mnny cigarelles dlCJ you smu~e po, day? 0' paymcnl bec.use 01 .nmju,y, slc~ness or dlsabihty?
(Number ul t:I01Hl'llt!t nulllumlll'l 01 pm.hl _....., ,_ [] ':'~.!'..Jd~.~
(2) How many years did you smo~e? 38. Family Hillary: ll,"bolcs, (anc~i) melllnullla, hea'1 or kidney
dls(!ase.menlllllllncss ()r SUICide? .. r~l]No
(3) When did you quit smo~lng? I I } 1
32, A,e you using any medlcnllon or drugs? [I~.es" UINo ~:.::. t.~:.; .{~J'(u.'C:~,f~~ i>t..!f}~
-33~ln ih~I;'-;tl0-yea;i,h;'~e y~Ubeen healed la~.ll; .had any -....".,; "91.~. -...... ...._-. .... ... .~__..-:..=.
Indlcallon of; / 39. A Have you losl wClghtln the pasl (j months?[J Yes [lJ~(j'
A. Disorder o.fe~ ears, nose or Ih,oal? R3Ves [] No II yes, loss was Ibs
---.- -',,::z'..~_..m.._._.._._.. ......_.._....._.._._.. '.. _'m... ..... .. .. '_'. . _.._. ...~...._.
D. DilZY Or lainllng spells, seizures 0' convulsions, re. 42. Do you have a personal PhYSIC?;?) J [j}'fes [] No
cunenl headache, paralysis or stroke, mDenlal, ne[r':',ous Nnme':J)I.'j}'b:g!!1.~(.:J c~.AL____
C. ~~~s;~;,~r~~~~;:~~~f~~~~~::~a~~~~~:~7g~rjp.fl~1. ;,~d'ess~1tf!&7AT!f;t;tJ.t7 -,:Y)-Z?dr
lung or resplrnlory dls()r~.er?_ .___.h..lJ ~~s_.IiJ-N~_ Oall' Insl seen ...3_1 0if"lAeason /A'"" flit "'~~ la s;
D. Chest pain, discomlo'l or tighlness, palpitation, high .._. ......_,,".~.'.'_....._..___... .._.____.
blood pressure. rheumatic lever, heart murmur, heart 43. Remarks, Give delalls 01 "Yes" answell.ldenllly question
a"ack or other disorde, 01 the heart or blood vessels? number. State signs, symptoms and diagnosis ollllne..
[] Yes []}-N end name and lull addre.. 01 each physlclsn consulted
anjthe dates con'!LIted;
E. Jaundice, Inlestinal bleedinll; ulcer. hernia, colllis, diver- (-:>"/1' I" 1.?'IIA'~{HSSl'.:s-.
ticulilis, recurrentlndigest,on or olher disorder 01 the ~ <./[ . - /
t'''mach, Inteslines, liver. gall bladder or"'p'ancreas? ~)/. (_ '., /\
U Yes []Jff6 'k II ) f IU( S , e /) -I.}...-
F. Su~ar. albumin, blood In urine; venereal disease; slone'- ~ /,-(':.. /<~4 ~ 'AJe .
oor other disorder 01 kidoey. bladder, prostate or r.wro-
ductive organs? 0 Yes lLJ.UO-
G. Diabetes; thyroid or othe, endocrine disorders?
DYes ~1'fcl
----~-------~--- ..-.- '"---~_._-~- ----
H Rheumatism. erth'lIis, gout, or disorder of Ihe muscles
or bones, spine, back or joints? [] Yes [lJ.No
-~~- -'--
I. Delormlly, lameness or amputation? [] Yes 1iJNo-
-'--~-"'-- ._. -------.----..---.. "---'~-.._-._--------
J. Disorder ollhe s~ln or lymph glands, unexplained lev.
ers, AIDS or Immune deliclency disense.gst, lumor or
cancer? L.J Yes [gNtr
----- -~-,. ._._._._._-~--------_._--~.-
K, Allergies; anemia Of other disorder of the blood?
------_..___._... _ . .._.__......1lY~~_l?:lN~
34. In Ihe lasllO yenrs, have you soughl or received advice
or treatment for u.s.'l.?' alc.Clh.ol or dr~.,!s?.J.:;'LYes _JL..Cl.
35, Are you pregnant? [] Yes [J No
(1/ iE..t) /9?;)"
~~~e:;:I~r~ ~rs :~~)~:~~~;~~1~~~7~~~~~1 nt'en;O~~:~>>~~~~fOri;PTeteo)nd(ii.U~i~ODe bOr 0:;Lt'~d90 and-belief
my prosence .----dIW((J/:.. (I-L .:-':':tVf. ' ~., ._~ _.. {....J, .-..1~.-t_b~..
paflluV"lt.1 f 8"1IIlt'f .. ., '- fi'~f\J lUlU oJ lnlu'ed (01 IflIUIII"IIl" I
Dnlo ../t!._LJllJl.G_
Month O'r '(.H'
Northwestern
~utual Lite"
Hay 8, 1995
Hr. Joseph P. Alexa
74 Drexel Place
New Cumberland, PA 17070
ReI Joseph P. Alexa
0420702-0499667
Dear Hr. Alexal
Thank you for participating in the independent medical examination
which was completed by Robert H, Davis MO on 4/11/95. The.results
of this examination have now been reviewed by our medical staff,
The examination does not support any medical evidence of a
psychiatric disorder that should impair your ability to work as an
attorney.
As we previously informed you, we have no objective evidence to
establish that you have an orthopedic disability. The Attending
Physician I s statements and medical records received from Albert
Heck HO also do not support an orthopedic disability,
Based on the medical information received to date you would not be
eligible for continued partial disability benefits under the terms
of your contract, After .careful consideration of all the
information provided, I am sorry to inform you that I am unable to
approve your request for continued disability benefits beyond
4/27/95, the date to which prior benefits are paid to. If you feel
this action has been taken without the full facts, I would be glad
to review any additonal objective medical evidence you may care to
submit,
(
I
f
i
Hr, Alexa, I would like to bring to your attention another benefit
in your disability contract called the Transition Benefit. The
Transition Benefit will help you adjust to full-time work after a
period of disability, It is payable based on your actual loss of
Earned Income during the transition period. Our Company can pay a
Transition Benefit for up to 12 months provided thatl you returned
to full-time employment and you have at least a 20\ loss of earned
income for the month for which a benefit is claimed.
'.:xJlIlll'r "c"
1111' Nllllh\-\t'\ll'lll "1ulll.IIIIII' '"\111.1111 l' ( IIrnp,lIl~ . ,..}O 1,1\1 \\1\11111\111 Afo l'lltll'. Md\\',III~I'I' \\"\11111\'11 rll.llI! . 414 171 1.f.j.t
.. '
COHHONIIIlAl.TIl 01' !'IlNNSYI,vANIA
88. :
COUNTY 01' CIIHBIlRI.AND
J08H1'Il I'. A1,I~X^, being dnly SIIOl'n a(~clll'dlng tn Iall, deposes and says that Lhll
faels set lorth In the 10l'egolng COlllplalnt are tl'lIe and coneet to the best 01 hls
knoll ledge , Inful'mallnn, and belfef.
. ~__/~~jA-_L!~J):iG.o
JOIlEPIl I'. fY'XA v
SlIorn t.o and sub~er)bed
before Ill!! Lbls/rylluiav.
of -fllLJ..l.o -.. ,199,(:J
I ). J.. jll.uJ.t--
otarv Ic
h ......-.., ..
... ",""1'" ~: II I'
WfNPY. ~l"',. I. ,.... .'.
t,morl' ....,-(:1. ( t,., b II :~. ,'I " .', ,. f I
"v (.m.,i.,l\.., r ',n , "'". .... ; \>< y I
. -~ ........,...,-.
6
..
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,
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;. ,
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..
q..~
'hklf<,- . lJt1j .
COMMONWIiAI:l'lI OF I'IiN N A I
COUNTY OF llAUI'1I1N:
HlmlllFF'H IWTlIlIN
NO. 95-2832
PAlIli 298
ANll NOW:
Hay 31, III 95 .111 3115 I' ~1.
COOPl.AltIT & NanCE
HlmVliIl TilE
IYITIIIN
lIl'ON
Northwes tern Life 1I1surance Company
II\' I'liHHONAI.J.Y
IIANDlNO TO
Barb Domchor I New Business Processor and person in charge at time
of service
A TRUE ATTESTED COpy OF Tllli OHllllNAJ. a:JMI'IAmr & NarrCE
ANI> MAI(ING I(NOWN TO
lIer
TilE CONTENTS TIIEllliOF AT 100 Pine St.,
2nd Floor, Harrisburg, Dauphin County, Penna,
SO ~H~'I1' ?(. . I) ",
. W.A \j,~~ ~":.=J
SHERIFF OF DAUPHIN COUNTY, PENNA
. . ",
II\' ."" ." I"'
/,~,,( {.'....'7''-Y.
t 11I,I'lITY sIIEIlIFf'
SWlnn and Bulmcr Iiwd I"
before me th joist d..,. nl June 1'1 95
"''''T'''~:l,/)J~
SIII\III1I"H CllST $
H IA
'In Tnl!l Court or C.:mmo:1 Ple:s or C~r..:':~H'l:nd (;,::u:-;~'Y, Pannsylvc:niQ
Jooeph P. Alexll
'is.
Northwestenl Mutual Life Ins.ur-mwe Co,
:-10. 1)5-211];> Civi I..:!:!ill!l.-..__.----, :?.__
~ow.
May ;>5, 1995
:9__ It SE:::?~::" OF C~~G~..!..A.'m COt.~,:,y. ?~ co
h=by ci:pue:: th:l SI='..ii of
lJ.luphin
ClJU::ry :0 ('-:e::".1tc =.is ',vrl:,
:h:s d..-pu~::cn b~ _!t.J_ :it ~ ::qU=1: :.:d :-:..s.k al :.::: ?!~::i.
"4'
~_( ~..., ,1 // /,:
. ~ .; :..,.-~~T',.....(. .,..;~~~
,. t" . .'~ .. ..., .#
I (
She..~ ct C::::ilu'..u:d C'U:lT. P:l.
Affidavit or Sernc=
~ow,
!9
0'
.,
o'dea
~[, I::".-d
:.:: ~t.!:in
'JpoG
11
-, '=,.;:..,,:.0
:"r -,
...
c::pr cl :.::~ o:-;~
:Uld _.r:. bowu :0
.'
::= .:::u:::::s :..~:::-::i.
So :Ll:SW'=',
Shc:'.5 .1
COWUT, !Is.
Swor.1 :Uld r~bsc:-J:d bc::'Cl'll
=::.!::s_c!.:Iyol
19_
COSTS
S!..1.v1C:Z
~ ar..::....G E
.-\.:tIDA VIT
s
---"'-------.
s
,- .-,
SCIINADIlR, IIARR I SON, SEGAL /. 1.I\W I S
BY: Saowel W. Silver
IdentificaLion No,: 56596
SuiLe 3600, 1600 Mal'kal SlleeL
Philadelphia, Peonuylvanla 1910]
215-751-2309
Attorney fm- Defendant
The Northwestenl Mutual
Li fe Inaul-ance Company
JOSEPII p, AI,IlXA,
Plaintiff,
IN '1'IIE COURT OF COMMON
PLEAS OF CUMBERLAND
COUNTY, PENNSYLVANIA
v,
CIVIL ACTION - LAW
NORTIIWESTERN MUTUAl, 1,1 FE
INSURANCE CO"
NO. 95-2832 CIVIL TERM
Defendant,
ENTRY or APPEA~CE
TO THE PROTHONOTARY:
Please enl er my appearance as counael for The
Northwestern Mutual l,it,~ InSUHlnce Company, defendant in this
matter.
/
/
,/
'/
r:ll -
,~ V ".;.-~/
~ ~'~-- , _ --: L~ ~-
~r !JamIIBl\.f. i--: jj ver .
BCIINAIJIlIi, IIA~RlIJON, SEGAL /. I,EWIS
jLOO Mark"l Street, Bulte ]600
PhililllFdl'lIla, Pennsylvania 19103
1(,:1"1 ""1 ;n09
At I. III oey f III Defendant
The 14011 hwestenl Mutual Lite
1 nBUI dOCS ('ompany
Dated: July 8, 199"
~TIPICATE OP SERVICE
I, SAMUEL W. SILVER, hereby certify that on July B,
1995, I caused to be served the foregoing ENTRY OF APPEARANCE by
depositing the same in the United States mail, postage prepaid,
and addressed as follows:
Michael L. Bangs, Esquire
ANDES, VAUGHN & BANGS
525 N. 12th Street
P. O. Box 16B
Lemoyne, PA 17043
(717) 761-5361
Attorney for Plaintiff
/.~~
.....-::::::::~ / .---e;
CMU!!l . S lver
-2-
I.
1'/(\"""(1" """"_____
,. ,," h, l,iI\' 1I,'lilwd to tik II written
1(11';,' "I1\III"CII"A"~'" "."..-H)/r'
':: "'ld,I\"ili(lI11~,l'rl'kehcrcor
, , "~ci~:;:d d:;a,iIl~,l~i1/,
__..# ____ -JV- ~V
--r. '
Attorney for Defendant
The Northwestern Mutual
I,i fe Insul-ance Company
SCHNADER, HARRISON, SEGAL I. LEWIS
BY: Samuel W, Si I vel-
Identification No,: 56596
Suit e 3600, 1600 Mal"ket Sn-eet
Philadelphia, Pennsylvania 19103
21',- '1!Jl- 2309
PlainLiff,
IN THE COURT OF COMMON
PLEAS OF CUMBERLAND
COUNTY, PENNSYLVANIA
JOSEI'll P. ALEXA,
v.
CIVIL ACTION - LAW
NORTHWESTERN MUTUAL LIFE
INSURANCE CO.,
NO. 95-2832 CIVIL TERM
Defendant.
ANSWIR AND NIW MATTIR OF DBFENDANT THI NORTHWISTBRN
MUTUAL LIFI INSURANCB COMPANY
Defendant, The Not-thweetern Mutual Life Insurance
Company ("NML"), hereby l-eaponde to plaintiff'S Complaint.
MfmfU
1. NMI, is without knowledge 01' information sufficient
Lo tln-m a bel iet all to I he Iluth of Lhe al legations contained in
thin piilil'llaph.
2. l\<lmlttl'i! in (lillI, ,lenie,1 in pan, The pI-opel' name
of ,Ielt!llllilnl 1 Ii "The. NIlI t hWl'11I '"In Mutual I,i fe II1IlUl'anCo Company,"
not "Noll hWlJutoln Mul uill Llf.. Inuulance Company." IL is denied
Ih,ll NML 1"'lUldlly C'CJllIhll'tlIIJlllliW!1l1l in the Commonwealth of
I'ennuylvillli., alii! it ill c1f'III"d Ihitl NMJ. hilll it local office located
al 100 1'111" ~:t 1",,1, 1I.111Inlllll'l, Iiauphin County, Pennsylvania.
,
NML admits that it regularly transacts business in the
Commonwealth of Pennsylvania through independent contractors.
3. NML is without knowledge or information sufficient
to fonl a bel ief as to the truth of the allegations contained in
this paragraph. Moreover, to the extent that plaintiff alleges
that he was approached by a legal agent of NML, such an
allegation is a conclusion of law to which no response is
required.
4. Admitted in part, denied in part. It is admitted
only that, in consideration of a premium paid and in reliance
upon statements made in an application for insurance, NML issued
and delivered to plaintiff disability insurance policy D420702,
effective August 1, 1985. It is denied that a "true and correct"
.
:.
:.
copy of any disability policy was attached to plaintiff's
Complaint as Exhibit A. Rather, no copy, whether "true and
correct" or otherwise, of any insurance policy was attached to
plaintiff'S CC'mplaint. NML is without knowledge or information
sufficient to form a belief as to the truth of the remaining
allegations contained in this paragraph. Moreover, to the extent
that plaintiff alleges that he had discussions with a legal agent
of NML, such an allegation is a conclusion of law to which no
response is required. Further, to the extent that this paragraph
alleges that plaintiff relied, whether justifiably or not, on
such discussions, that allegation in a conclusion of law to which
110 response is required.
- 2-
5. Denied all sLated, The teuns of the policy are as
stated therein.
6. Admitted in parL, denied in part, It is admitted
only that, in consideration of a ptemium paill Hnd in reliance
upon statements made in an application for inllut-ance, NML issued
and delivered to plaintiff disability insurance policy D499667.
However, that policy was effective Novembet- 21, 1986, not
September 17, 1986. It ill deniell that a "tnJe dnll COlt-ect" copy
of any disabil ity poli cy was at tached La plainL if f' s Complaint aa
Exhibit B. Rather, no copy, whethet- "t t-ue and correct" at"
otherwise, of any insurance policy was atLached to plaintiff's
Complaint. NML is withouL knowledge 01- information sufficient to
form a belief as to the occun-ence of any t-elevanL event at
plaintiff' a "place of el1lploymeuL, 43 Weat Main SlI-eet.
Mechanicaburg, Cumbet-Iand County, Pennsylvania,"
7 . Denied all atated. The tet ms of L he pol icy are liB
stated thet-ein.
8. Admi t ted,
9. NML ia without knowledge or infollnat1on sufficieut
to form a belief all to tit" tnah of the allegatioufl ('ontained in
tlds paragraph, Mlneovel, Ihe alle~latiou coutaiu!!ll In t.hill
pat'agt'aph that plaiuLlf1 Willi "toLally dilHtblell" If! tl coucluBiou
of law to which no reu(Joulw III require(I, To the "xl Bnl thaL a
l'eapouBe ia I-squired, Ihlll itllHljatlou 10 delllell.
10. Admitted in part, denied in pan. It is admitted
only that plaintiff fil"st notified NML of a Claim for disability
payment under the two disability policies in 1992. However, this
occurred in February 1992, not March 1992. Purther, it is denied
that NML paid the maximum benefit under each policy "from
February of 1991 and thereafter." Rather, NML paid the maximum
benefit for certain months; for other months, NML did not pay the
maximum benefit.
11. NML is without knowledge or information sufficient
to fonn a bel ief as to the truth of the allegations contained in
this paragraph.
12. Oenied, The allegations contained in this
paragraph constitute conclusions of law to which no response is
required. To the extent that a response is l"equired, NML denies
that plaintiff continues to be unable to work sufficient hours to
produce earned income that would result in payment of anything
less than the maximum benefit available under the said policies.
1]. Admitted in part, denied in part. It is admitted
that NMI, suspended benefits to plaintiff after April 1995. It is
denied Lhat NML paid the maximum benefit available under each
policy at all times prior to IIpril 1995,
14. Admitted in pan, denied in pal't, lL is admit Led
that NML intonned plaintiff by lettel" dated May 8, 1995, a true
IIn(l correct copy of which iF! attached to the Complaint, that it
wall Buspellllllll,1 difJability paymentfJ beyond Apl"il 27, 1995,
lIoWeVt3l", it if] deniml that NML "not,H ied Plaintiff that it would
.4.
cease paying any benefits under tho policies in force," Rather,
NML specifically offered in that letter to consider making
available to plaintiff a benefit known as the "Transition
Benefit." Plaintiff, however, has refused to avail himself of
the Transition Benefit.
15. Denied. The allegations contained in this
paragraph constitute conclulJions of law to which no response is
required. To the extent that a response is required, NML denies
that plaintiff continues to be partially disabled from the
injuries that he received in the motor vehicle accident in 1991,
which partial disability makes him incapable of producing earned
income that would exclude him from payment of the full benefit
under the disability insurance policies that he has with NML.
16. Admitted.
17. Denied. The allegations contained in this
paragraph constitute conclusions of law to which no response is
required. To the extent that a response is required, NML denies
that plaintiff continues to be partially disabled or unable to
produce sufficient earned income to justify the payment of
benefits under the policies. Moreover, it is denied that NML has
failed or refused to make further disability payments to
plaintiff. Rather, NML has specifically offered to consider
making available to plaintiff a benefit known as the "Transition
Benefit." Plaintiff, however, has refused to avail himself of
the Transition Benefit.
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18. The allegations contained in this paragraph
constitute conclusions of law to which no response is required.
Moreover, it is denied that NML has failed or refused to make
further disability payments to plaintiff. Rather, NML has
specifically offered to consider making available to plaintiff a
benefit known as the "Transition Benefit." Plaintiff, however,
has refused to avail himself of the Transition Benefit.
COUNT I
19. NML incorporates herein by reference paragraphs 1
through 18 of this Answer.
20. Denied. The allegations contained in this
paragraph constitute conclusions of law to which no response is
required.
21. Denied. The allegations contained in this
paragraph constitute conclusions of law to which no response is
required.
22. Denied. The allegations contained in this
paragraph constitute conclusions of law to which no response is
required.
WHEREFORE, NML requests that plaintiff'S Complaint be
dismissed in its entil-ety and judgment be entered in favor of NML
and against plaintiff, and that NML be awarded its costs,
attorneys' fees and such other relief as may be just and proper,
-6-
COUNT II
23, NMl, incoq)(natefl hen,in by I:eference paragraphs 1
Lhrough 22 of thill AnElwrn,
24. Denif'(l. The al legat. iCJIIll conLained in this
par'agraph consLiLuLe concJullionB of law to which no response is
requ iI-ed .
25, Denied, The allegatiDlIB contained in this
paragr-apl1 const.itut.e conclusions of law to which no response is
required.
WHEREFORE, NML request.s that plaintiff's Complaint be
dismisBed in !III ent.irety an'! judgment be entered in favor of NML
and against plaintiff, and that. NMI, be awarded ita costs,
attorneys' fees and Budl oLhel relief as may be just and proper.
lfU.JfATI.U
1. The Complaint fails to state a claim upon which
relief may be granted,
2, I'lainti ff ilJ nnt dillabled within the meaning of
the relevanL inBulflllcI' pol il'ir'B,
1. I'lninl ilt Iii 1101 r'1I1 !tied to benefits (other than
Ihe TI'anllil 1011 lll~n"tit, which lllay 1m available t.o plainLitf)
\11 It!eI. t.he IllleVlIll1 illllulillwe policlell,
"
WIIEREFORE, NMI, I'equl~uto that plaintiff' 0 Complaint be
dismissed in its entilcety and judgment be entel-ed in favor of NML
and against plaintiff, and thaL NMI, be awarded its costs,
attorneys' fees and such other relief as may be just and proper.
//- /'
_________=: _ ,,--'. .' -;;71/: .
~~uel W. Silver
SCIINADER, HARRISON, SEGAL & LEWIS
1600 Market Street, Suite 3600
Philadelphia, Pennsylvania 19103
(215) 751-2309
Attorney for Defendant
The Northwestern Mutual Life
Insurance Company
./
J ._.----'
~I......--~:::..
Dated. July B, 1995
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