Heritage: Level Premium Whole Life Insurance Plan. Designed for. Agent/Representative

Transcription

1 400 Broadway Cincinnati, OH (800) Policy form WL Designed for Elira Kurdina Agent/Representative CRAIG FLOYD (Agent Number ) 151 E CENTER ST LAKETOWN, UT (435) WL Page: 1 of 11 State: OH

2 Narrative Summary Basic Life Insurance Illustration Policy Summary Policy Form Premium Information This summary provides a brief description of a life insurance policy and any riders. It also includes definitions of key terms and column headings. This summary is not intended as a substitute for a life insurance policy or any riders which may be issued with the policy. In the event of any conflict, the provisions of the policy and the riders, and NOT this summary, shall control. The Heritage (WL ) is a whole life insurance policy which provides a level amount of insurance as long as the policy continues in force. Premiums are payable to age 100. If the policy is still in effect when the insured reaches age 121, the policy will mature and we will pay the net cash value to you. Premiums in this illustration are assumed to be paid on a(n) Annual basis. The policy first year modal premium is $1, First year modal premiums are: Annual: $1, Semi-annual: $ Quarterly: $ Monthly: $84.04 Smoker rates are illustrated. The insured may be eligible for non-smoker status at age 18. The Home Office must be contacted to make this adjustment. This illustration assumes that premiums are paid in cash, out of pocket by you, each year until the insured attains age 100 or until death of the insured, whichever comes first. Dividends Increases in future values are dependent upon dividends. Dividends are NOT guaranteed. If actual dividends are lower than assumed in this illustration, projected cash values and death benefits will be lower than shown. If actual dividends are higher than assumed, projected cash values and death benefits will be higher than shown. Policy Loans Important Tax Information You can take a loan that is secured by the policy's cash value. We will lend you an amount equal to the policy's loan value. Your loan value will be less than the policy's cash value. Loans will be charged interest payable to Lafayette Life at an adjustable loan interest rate that we may change from year to year. The minimum loan interest rate is 5.00%. The maximum loan interest rate is determined by a formula using a third-party index as set forth in the policy, and is not capped. We recommend that you pay accrued loan interest prior to the end of a policy year. Any interest that is not paid at the end of a policy year is added to the loan balance, which will also be charged interest. Interest that you pay to us is not credited to the cash value of the policy and it does not increase the cash value of the policy. A policy dividend, if any, may not be sufficient to pay loan interest. An unpaid loan balance may cause policy termination. Any references to the taxation of life insurance policies in this illustration are based on Lafayette Life's understanding of the Federal taxation of life insurance as of the date of this illustration. Lafayette Life and its agents do not provide tax advice. Please consult your tax advisor regarding your own personal situation. In order to receive favorable tax treatment of distributions (including loans) under the Internal Revenue Code, a life insurance policy must satisfy a 7-pay premium limitation. * Life insurance policy premiums must be within certain limits during the first 7 policy years and also during the 7-year period following certain policy changes. * Failure to satisfy this limitation, either at issue or later, would classify the policy as a Modified Endowment Contract (MEC) and result in distributions receiving less favorable tax treatment. WL Page: 2 of 11 State: OH

3 Narrative Summary The initial 7-pay premium for the policy as illustrated is $1, per year. This is the maximum premium * you can pay per year during the first 7 policy years, without causing the policy to be classified as a MEC. Certain changes to the policy benefits or premiums over the lifetime of the policy (whether illustrated or not) will alter the premium limitation. The policy, as illustrated, will be a MEC in policy year 49. Please review the adverse tax consequences described below regarding the MEC status. Prior to policy year 49, if changes are made to the face amount, or if certain riders are added or changed, or if the amount, duration or mode of premiums paid changes from that illustrated in the Tabular Detail, the MEC status could be affected and could cause the policy to lose its favorable tax status. If your policy is in MEC status: * You may be subject to additional taxes and penalties on any distributions from your policy during the life of the insured. * Policy distributions, such as loans, withdrawals, surrenders, cash dividends, and dividends retained by the insurer as principal or interest on a loan under the policy, will be taxed on a "gain first" basis to the full extent of such gains in the policy. * There is a penalty of 10% of taxable income for distributions from the policy prior to the policyowner's age 59 ½, with certain limited exceptions. In all cases, any gain in the policy is taxable on full surrender of the policy. The tax treatment of any death benefit provided under the policy does not change depending on whether the policy is a MEC or not. Other Important Information Premiums and surrender of additions are assumed to be beginning of the year values. Dividends, cash values, and death benefits are end of year values. This illustration has been prepared based on 100% of the company's current dividend scale. This illustration assumes that the currently illustrated, non-guaranteed elements will continue unchanged for all years shown. This is not likely to occur, and actual results may be more or less favorable than those shown. This illustration assumes that all premiums are paid in cash each year by you until the insured attains age 100. Whether future values will increase is dependent on dividends which are not guaranteed. If actual dividends are lower than assumed in this illustration, then projected, non-guaranteed net cash values and death benefits will be lower than those shown. If actual dividends are higher than assumed, the projected, non-guaranteed net cash values and death benefits will be higher than those shown. Address Please address all inquiries to The Lafayette Life Insurance Company. The Lafayette Life Insurance Company Agent: CRAIG FLOYD 400 Broadway 151 E CENTER ST Cincinnati, OH LAKETOWN, UT (800) Riders Illustrated values include the following additional benefits: WL Page: 3 of 11 State: OH

4 Narrative Summary Billed LPUA Level Premium Paid-up Additions Rider (LPUA-13): Each premium paid for this rider, less a 6% expense Premium charge, is used as a net single premium to purchase a level amount of paid-up death benefit. The minimum $ annual premium for this rider is $500 in the first rider year and $120 in each rider year thereafter. If the minimum Stop Year: 70 annual premium for this rider is not paid in any rider year, no more premiums will be accepted for this rider. The maximum annual premium that may be paid for this rider during each of the first seven rider years is applied Underwritten and underwritten for at issue, but may not exceed an annual premium of $100,000. After the first seven rider years, Annual the maximum annual premium that may be paid for this rider is the average of the rider premiums paid during the Premium first seven rider years. The cumulative maximum premium that may be paid on the life of the insured under this $ rider and under any other riders with a lifetime maximum premium is $1,000,000 in total. For rider years two through seven, additional premium in excess of the maximum annual premium called premium catch-ups may be paid if the cumulative rider premium paid through the prior year is less than the cumulative maximum annual premium through the prior year. The total of any premium catch-ups that may be paid in any rider year is the lesser of $25,000 or the maximum annual premium, but no premium catch-up will be accepted if it would cause the cumulative rider premiums paid to exceed the cumulative maximum annual premium. No premium catch-ups will be allowed after the seventh rider year or if we no longer accept premiums for this rider. If the premium for the base policy is not paid before the end of its grace period and this rider has sufficient net cash value, we will automatically surrender a portion of the paid-up additional life insurance provided by this rider to pay the base premium to the next annual date in accordance with the Automatic Surrender Provision of this rider. These automatic surrenders, and any other surrenders, will decrease the death benefit of this rider. If the Automatic Surrender Provision is used to pay premiums, no further premiums for this rider will be accepted. The Waiver of Premium Benefit, if part of the policy, does not apply to premiums under this rider. ABR Stop Year: 121 Accelerated Benefit Rider(ABR-92): You may elect, if the insured is suffering from a terminal illness (as that term is defined in the rider), to receive a portion of the proceeds which are otherwise payable on the death of the insured. Any payment under the rider is subject to all the terms and conditions set forth in the rider. Further, the rider defines the circumstances under which an election to receive the benefit can be made and more fully describes how the benefit will be calculated. There is no premium charge for this rider. WL Page: 4 of 11 State: OH

5 Definitions of Key Terms and Column Headings "Annual Date" - Means the same date each year as the policy's Date of Issue (the Date of Issue is the effective date for the policy. However, insurance coverage only takes effect under the policy if all requirements for such coverage have been met). "Annual Dividend" - For the purposes of the non-guaranteed elements depicted in this illustration, means the dividend we anticipate will be credited annually to this policy based on the percentage of our current dividend scale stated in the Other Important Information section of this illustration. Dividends are neither estimates nor guarantees. The first dividend, if any, will be credited once the entire premium for the second policy year has been paid. "Beneficiary" - Means the person(s) named to receive the death benefit and applicable rider benefits upon the death of the insured. "Contract Premium" - Means the gross premium required for the base policy and all riders shown in this illustration. This illustration assumes that premiums are paid on a(n) Annual basis. "Cumulative Premiums" - Means the total to date of all out-of-pocket premiums paid by you. "Death Benefit" - Means the amount payable, by reason of the insured's death, under the base policy and any riders which provide insurance on the life of the insured. It does not include benefits which may be payable under an Accidental Death Benefit Rider, if applicable. The death benefit will be reduced by any outstanding loans and loan interest and any unpaid premiums due at the insured's death. The death benefit will include any in force dividend additions under the base policy and any applicable riders. The death benefit will also include a pro rata share of the dividend for the policy year of death and a refund of premiums paid for any period after the insured's death. "Guaranteed Elements" - Are the premiums, benefits and values which are guaranteed. "Illustrated Scale" - Means the scale of non-guaranteed elements currently being illustrated by us. This scale is reasonably based on our actual, recent historical experience. The non-guaranteed elements of the illustration are based on 100% of our current dividend scale. "Insured" - Means the person named on page 1 of this illustration. "Non-Guaranteed Elements" - Are the premiums, benefits, and values that are not guaranteed. The assumptions on which these are based are subject to change by us and actual results may be more or less favorable. "Net Cash Value" - Means the amount of money we will pay you on surrender of the policy. It is equal to the cash value (which includes the cash value of any paid-up additions, which are still in force) less all indebtedness (loans and loan interest). (This illustration assumes that no loans will be taken.) "Paid-Up Additions" - Means that any dividend declared on this policy shall be used to purchase paid-up additional insurance. "Premium Outlay" - This column reflects the use of non-guaranteed elements to pay premiums. This illustration assumes that premiums are paid on a(n) Annual basis. "50% Illustrated Scale" - Is a scale of the non-guaranteed dividends reduced by 50%. This reduction includes the non-guaranteed interest and charges contained in the non-guaranteed elements of this illustration. WL Page: 5 of 11 State: OH

6 Definitions of Key Terms and Column Headings "We, our, or us" - Means The Lafayette Life Insurance Company "You or your" - Means the owner(s) of the policy described in this illustration. The owner is also the applicant. This illustration assumes that the currently illustrated non-guaranteed elements will continue unchanged for all years shown. This is not likely to occur, and actual results may be more or less favorable than those shown. WL Page: 6 of 11 State: OH

7 Numeric Summary Guaranteed Non-Guaranteed 50% Illustrated Scale Illustrated Scale Contract Net Cash Death Contract Premium Net Cash Death Contract Premium Net Cash Death Year Premium Value Benefit Premium Outlay Value Benefit Premium Outlay Value Benefit 5 1,000 3, ,199 1,000 1,000 3, ,868 1,000 1,000 3, , ,000 7, ,365 1,000 1,000 7, ,002 1,000 1,000 8, , ,000 22, ,937 1,000 1,000 22, ,290 1,000 1,000 22, ,738 Age 70 1, , ,504 1,000 1, , ,380 1,000 1, , ,870 The non-guaranteed elements are not guaranteed. The assumptions on which they are based are subject to change by the insurer. Actual results may be more or less favorable. This policy as illustrated is a Modified Endowment Contract for tax purposes. In general, this means that policy distributions will be taxed on a "gain first" basis to the full extent of such gains in the policy. Such distributions may also be subject to a 10% penalty tax. Please review the Important Tax Information Section of the Narrative Summary and consult your tax advisor. I (we) have received a copy of this illustration and understand that any non-guaranteed elements illustrated are subject to change and could be either higher or lower. The agent has told me they are not guaranteed. Your Signature (owner/applicant) Date I certify that this illustration has been presented to the applicant and that I have explained that any non-guaranteed elements illustrated are subject to change. I have made no statements that are inconsistent with the illustration. Agent Date WL Page: 7 of 11 State: OH

8 Tabular Detail Guaranteed Non-Guaranteed Assumptions 100% of Current Dividend Scale Increase in Contract Net Cash Death Contract Cum Annual Net Cash Net Cash Death Age Year Premium Value Benefit Premium Premium Dividend Value Value Benefit 1 1 1, ,288 1,000 1, , ,000 1, ,487 1,000 2, , , ,000 1, ,206 1,000 3, , , ,000 2, ,441 1,000 4, , , ,000 3, ,199 1,000 5, , , ,000 3, ,491 1,000 6, , , ,000 4, ,338 1,000 7, , , ,000 5, ,753 1,000 8, ,085 5, , ,000 6, ,757 1,000 9, ,134 6, , ,000 7, ,365 1,000 10, ,185 8, , ,000 9, ,590 1,000 11, ,237 9, , ,000 10, ,448 1,000 12, ,284 10, , ,000 11, ,957 1,000 13, ,338 11, , ,000 12, ,130 1,000 14, ,388 13, , ,000 14, ,986 1,000 15, ,442 14, , ,000 15, ,536 1,000 16, ,502 16, , ,000 17, ,795 1,000 17, ,563 17, , ,000 18, ,774 1,000 18, ,624 19, , ,000 20, ,484 1,000 19, ,690 21, , ,000 22, ,937 1,000 20, ,760 22, , ,000 23, ,143 1,000 21, ,839 24, , ,000 25, ,109 1,000 22, ,915 26, , ,000 27, ,847 1,000 23, ,999 28, , ,000 29, ,363 1,000 24, ,090 30, , ,000 31, ,666 1,000 25, ,177 32, , ,000 33, ,763 1,000 26, ,273 35, , ,000 36, ,663 1,000 27, ,367 37, , ,000 38, ,374 1,000 28, ,465 40, , ,000 40, ,902 1,000 29, ,568 42, , ,000 43, ,255 1,000 30, ,677 45, , ,000 45, ,441 1,000 31, ,792 48, , ,000 48, ,464 1,000 32, ,903 50, , ,000 51, ,332 1,000 33, ,023 54, , ,000 54, ,051 1,000 34, ,143 57, , ,000 57, ,628 1,000 35, ,263 60, , ,000 60, ,067 1,000 36, ,388 63, , ,000 63, ,376 1,000 37, ,522 67, , ,000 66, ,559 1,000 38, ,661 70, , ,000 70, ,622 1,000 39, ,812 74, , ,000 74, ,569 1,000 40, ,968 78, , ,000 77, ,404 1,000 41, ,126 82, , ,000 81, ,132 1,000 42, ,291 87, , ,000 85, ,758 1,000 43, ,454 91, , ,000 90, ,285 1,000 44, ,628 96, , ,000 94, ,717 1,000 45, , , , ,000 98, ,059 1,000 46, , , , , , ,314 1,000 47, , , ,414 WL Page: 8 of 11 State: OH

9 Tabular Detail Guaranteed Non-Guaranteed Assumptions 100% of Current Dividend Scale Increase in Contract Net Cash Death Contract Cum Annual Net Cash Net Cash Death Age Year Premium Value Benefit Premium Premium Dividend Value Value Benefit , , ,487 1,000 48, , , , & 1, , ,580 1,000 49, , , , , , ,598 1,000 50, , , , , , ,545 1,000 51, , , , , , ,423 1,000 52, , , , , , ,235 1,000 53, , , , , , ,986 1,000 54, , , , , , ,677 1,000 55, , , , , , ,312 1,000 56, , , , , , ,893 1,000 57, , , , , , ,423 1,000 58, , , , , , ,904 1,000 59, , , , , , ,338 1,000 60, , , , , , ,727 1,000 61, , , , , , ,074 1,000 62, , , , , , ,380 1,000 63, , , , , , ,646 1,000 64, , , , , , ,875 1,000 65, , , , , , ,067 1,000 66, , , , , , ,225 1,000 67, , , , , , ,349 1,000 68, , , , , , ,442 1,000 69, , , , , , ,504 1,000 70, , , , , , , , , , , , , , , , , , ,268 1,004 9, , , , , ,690 1,051 9, , , , , ,113 1,099 9, , , , , ,536 1,147 9, , , , , ,958 1,194 9, , , , , ,381 1,249 9, , , , , ,804 1,299 9, , , , , ,226 1,357 9, , , , , ,649 1,417 9, , , , , ,071 1,483 9, , , , , ,494 1,550 9, , , , , ,917 1,611 9, , , , , ,339 1,674 9, , , , , ,762 1,735 9, , , , , ,185 1,799 9, , , , , ,607 1,873 8, , , , , ,030 1,948 8, , , , , ,452 2,009 8, , , , , ,875 2,044 8, , , , , ,298 2,062 8, , , , , ,720 2,098 8, , , , , ,143 2,152 8, , ,006 WL Page: 9 of 11 State: OH

10 Tabular Detail Guaranteed Non-Guaranteed Assumptions 100% of Current Dividend Scale Increase in Contract Net Cash Death Contract Cum Annual Net Cash Net Cash Death Age Year Premium Value Benefit Premium Premium Dividend Value Value Benefit , , ,566 2,220 7, , , , , ,988 2,295 7, , , , , ,411 2,367 6, , , , , ,833 2,398 6, , , , , ,256 2,379 6, , , , , ,679 2,385 7, , , , , ,679 2,644 6, , , , , ,679 2,675 6, , , , , ,679 2,700 6, , , , , ,679 2,726 6, , , , , ,679 2,751 6, , , , , ,679 2,777 5, , , , , ,679 2,796 5, , , , , ,679 2,810 5, , , , , ,679 2,817 5, , , , , ,679 2,824 5, , , , , ,679 2,831 4, , , , , ,679 2,838 4, , , , , ,679 2,826 4, , , , , ,679 2,807 4, , , , , ,679 2,800 4, , , , , ,679 2,787 4, , , , , ,679 2,767 4, , , , , ,679 2,753 4, , , , , ,679 2,726 4, , , , , ,679 2,672 4, , , , , ,679 1,615 15, , ,864 WL Page: 10 of 11 State: OH

11 Additional Information Life Insurance Cost Information Net Payment Cost Index Surrender Cost Index Guaranteed Projected Guaranteed Projected Year Year These indices are computed by the formulae as prescribed by the National Association of Insurance Commissioners, and reflect the time value of money at 5%. These indices do not include the cost of additional benefits. First Year Premiums Premium Information Premiums in this illustration are assumed to be paid on a(n) Annual basis. Regularly Billed Premiums Paid Annual Base Policy $ Accelerated Benefit Rider(ABR-92) $0.00 Level Premium Paid-up Additions Rider $ Underwritten Annual LPUA Premium $ Max LPUA Premium: Years 8+ $ & $1, The initial 7-pay premium for the policy as illustrated is $1, per year. The policy, as illustrated, will become a MODIFIED ENDOWMENT CONTRACT (MEC) in year 49. Please review the adverse tax consequences described above in Important Tax Information regarding this MEC status. Underwriting Requirements Primary Insured Underwriting Requirements Level A ($219,045): o Nonmedical Underwriting Additional Information The above underwriting requirements are based solely on age and death benefit of the proposed insured. They do not take into account other factors which may affect underwriting, such as adverse medical history and/or total life insurance applied for and/or inforce with this and all other companies. Under these circumstances please contact The Lafayette Life Insurance Company Underwriting Department to determine if any additional requirements are necessary. If the insured has had a complete favorable physical within the last 12 months which is available for us to review, Nonmedical underwriting may apply. These Expanded Nonmedical Limits depend on age and death benefit amount, according to the following schedule: ages 0-30 up to $500,000; ages up to $400,000; ages up to $200,000, and ages up to $100,000. Refer to Agents Reference Manual page B-16 for further details. WL Page: 11 of 11 State: OH