Foresters Whole Life Insurance STATEMENT OF POLICY COST AND BENEFIT INFORMATION. Life Insurance Illustration

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1 Foresters Whole Life Insurance STATEMENT OF POLICY COST AND BENEFIT INFORMATION Life Insurance Illustration Pro p o sa l o n: Pre p a re d b y: adplus Femaleage45 DCAP Producer 11 Oval Dr Islandia, NY, T info@tga4a.com The Independent Order of Foresters US Mailing Address foresters.com 789 Don Mills Rd PO Box 179 T Toronto, Ontario, Canada M3C 1T9 Buffalo, NY Foresters TM is the trade name and a trademark of The Independent Order of Foresters, a fraternal benefit society. by Foresters TM based on factors such as claims, investment earnings, expenses and overall economic environment. The actual results may Version: State: New York US (07/12) Page 1 of 10

2 BASIC INFORMAT ION Pla n Deta ils Life Insure d : adplus Femaleage45 Se x: Female Issue Ag e : 45 Rating Cla ss: Standard Fa ce Amo unt: $25,000 Insura nce Cla ss: Non-Tobacco Co ve ra g e s Be ne fit Pre miums Pre mium Amo unt Mo nthly Annua lize d Dura tio n Ba se Insura nce Co ve ra g e includ ing Sta nd a rd Fe a ture s Basic Life Insurance (Certificate) $25,000 $44.60 $ Years i Op tio na l Co ve ra g e s Se le cte d Term Rider $225,000 $66.74 $ Years i Children's Term Rider $10,000 $5.00 $ Years i Initia l Pre mium $ $1, T o ta l Initia l Pre mium $ $1, Illustration assumes premiums and payments are paid at issue and at the beginning of each certificate month. s and values are shown as at the end of each certificate year. by Foresters based on factors such as claims, investment earnings, expenses and overall economic environment. The actual results may be more or less favorable and are expected to vary from those shown. Version: State: New York US (07/12) Page 2 of 10

3 NARRATIVE SUMMARY The Narrative Summary provides a brief description of the certificate and each rider and is not intended to amend, alter, or change any of the terms and conditions of the certificate or the rider(s). Refer to the certificate and the applicable rider for variations, exclusions, terms and conditions. Pla n Descrip tio n This Foresters Whole Life certificate provides permanent individual life insurance protection with guaranteed premiums, payable to age 100, guaranteed cash values and guaranteed death benefit amount. Issue of this certificate at the rates illustrated is subject to Underwriting approval. Definitio ns (for purposes of this illustration only) Accum Pa id -up Ad d. - The accumulated additional amounts of insurance purchased using the dividends Ag e - The Issue Age of the Life Insured plus the number of certificate years elapsed since issue. Issue Ages are based upon age nearest birthday. Annua l Divid e nd - Annual Dividends are not guaranteed. The dividends are a portion of the Foresters' divisible surplus available for distribution annually to the certificate owners. Co ntra ct Pre mium - The total annualized premium required to keep in effect the base and the coverage(s) selected. Curre nt Va lue s - Certificate values and benefits based on Foresters' current dividend scale, and the current credited interest rate. This scale and rate are not guaranteed. End o f Ye a r - The end of the applicable certificate year. Gua r Ca sh Va lue - The guaranteed cash value of the certificate minus outstanding loan balance. Gua r Be ne fit - The guaranteed death benefit of the certificate minus outstanding loan balance. Insura nce Cla ss a nd Rating Cla ss - The underwriting classification assigned to the Life Insured. Mid p o int Va lue s - Certificate values and benefits based on 50% of Foresters' current dividend scale and applicable interest, which are not guaranteed. Pa id -up Ad d Ca sh Va lue - The cash equivalent of the Accum Paid-up Add amount Pre mium Outla y - The Contract Premium plus loan repayments, if any. T o ta l Ca sh Va lue - The sum of, Paid-up Add and Accum Dividends on Deposit, minus the outstanding loan balance T o ta l Be ne fit - is the sum of, Accum Paid-up Add and Accum Dividends on Deposit, minus the outstanding loan balance. Yo u - The owner of the life insurance contract. Version: State: New York US (07/12) Page 3 of 10

4 NARRATIVE SUMMARY Rid e rs Child re n's T e rm Rid e r This rider provides convertible level term life insurance for each insured child, up to that child's 25th birthday. A child at least 15 days old, who has not reached their 18th birthday, is listed on the application and is not excluded by us if the rider is issued, is considered an insured child. This rider also automatically insures future children, being each child born to the Life Insured (upon reaching 15 days old) and each child who is at least 15 days old, and has not reached their 18th birthday, when either adopted by the Life Insured, becomes the Life Insured's stepchild or comes under the Life Insured's legal guardianship. Each insured child's coverage under this rider may be converted to a permanent plan then offered by Foresters, without evidence of insurability, up to the benefit amount of this rider if converted before that child's 21st birthday or up to five times the benefit amount of this rider, up to $100,000, if converted between that child's 21st and 25th birthdays. Conversion ends coverage under this rider for that child. This rider cannot be in effect after the certificate anniversary on which the Life Insured is age 65. T e rm Rid e r This rider provides convertible level term life insurance on the Life Insured, with a guaranteed level premium for the initial 20 years. After the initial term period, the rider is annually renewable, with increasing premiums, during the renewal period which is the greater of 10 years or to the certificate anniversary on which the Life Insured is age 75. This rider cannot be in effect after the end of the renewal period. During the conversion period, this rider may be converted, without evidence of insurability, to a permanent plan then offered by Foresters. The conversion period terminates on the earlier of the certificate anniversary on which the life insured is age 65 or 5 years prior to the end of the initial term period. Version: State: New York US (07/12) Page 4 of 10

5 NUMERIC SUMMARY The following table summarizes certificate values from the anteed and Current Assumptions as well as a Midpoint Assumption, based on the information displayed in the Basic Information section of the illustration. End o f Year anteed Midpoint Non anteed Current Year 5 $1,027 $250,000 $1,173 $250,487 $1,322 $250,984 Year 10 $2,901 $250,000 $3,341 $251,255 $3,807 $252,582 Year 20 $7,139 $250,000 $8,881 $253,704 $10,850 $257,888 Age 70 (year 25) $9,483 $25,000 $12,287 $30,212 $15,578 $36,333 Age 85 (year 40) $16,782 $25,000 $24,006 $34,665 $33,669 $47,594 Age 90 (year 45) $18,815 $25,000 $28,060 $36,487 $40,909 $52,452 Sta te me nt o f Owne r I 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 Producer has told me they are not guaranteed. Sta te me nt o f Pro d uce r I certify that this illustration has been presented to the owner 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. Owner (Signature) Date (mmmm/dd/yyyy) Producer (Signature) Date (mmmm/dd/yyyy) Producer #: Version: State: New York US (07/12) Page 5 of 10

6 ADDITIONAL INFORMATION Net Payment Surrender Cost Equiv alent Lev el Cost Index Index Annual Div idend anteed Current anteed Current anteed Current Basic Life Insuranc e Year 10 $20.39 $17.63 $11.60 $8.84 $0.00 $69.05 Year 20 $20.39 $16.01 $12.17 $7.78 $0.00 $ Term Rider Year 10 $3.39 $3.39 $3.39 $3.39 N/ A N/ A Year 20 $3.39 $3.39 $3.39 $3.39 N/ A N/ A Indices assume the time value of money to be 5.0%. The Net Payment Cost Index and Surrender Cost Index are measures of the relative cost of similar plans of insurance. A lower index number represents a lower cost than a higher index number. An explanation of the intended use of these indices and the Equivalent Level Annual Dividend is provided in the Life Insurance Buyer's Guide. Non-1035 Lump Sum $ Lump Sum $0.00 Se ve n Pa y Pre mium $10, annually W ithd ra wa ls, Lo a ns a nd Co ve ra g e Cha ng e s Each withdrawal, loan and non expiry coverage change illustrated, if any, must be requested, by the certificate owner, when desired, does not occur automatically based on the illustration and is subject to Foresters approval and completion of the required request forms. Version: State: New York US (07/12) Page 6 of 10

7 TABULAR DETAILS End Ac c um o f Contrac t Annual Add. Year Age Premium Div idend Add $1, $0 $250,000 $0.00 $0 $0 $0 $250, $1, $0 $250,000 $63.89 $236 $64 $64 $250, $1, $332 $250,000 $64.14 $470 $131 $464 $250, $1, $676 $250,000 $69.57 $717 $207 $883 $250, $1, $1,027 $250,000 $76.50 $984 $294 $1,322 $250, $1, $1,387 $250,000 $83.68 $1,270 $392 $1,779 $251, $1, $1,754 $250,000 $90.61 $1,573 $502 $2,256 $251, $1, $2,129 $250,000 $97.65 $1,893 $624 $2,752 $251, $1, $2,511 $250,000 $ $2,229 $758 $3,269 $252, $1, $2,901 $250,000 $ $2,582 $906 $3,807 $252, $1, $3,298 $250,000 $ $2,991 $1,083 $4,381 $252, $1, $3,702 $250,000 $ $3,424 $1,278 $4,980 $253, $1, $4,112 $250,000 $ $3,884 $1,494 $5,606 $253, $1, $4,528 $250,000 $ $4,372 $1,733 $6,261 $254, $1, $4,950 $250,000 $ $4,889 $1,995 $6,945 $254, $1, $5,377 $250,000 $ $5,436 $2,284 $7,661 $255, $1, $5,810 $250,000 $ $6,012 $2,599 $8,409 $256, $1, $6,248 $250,000 $ $6,616 $2,943 $9,190 $256, $1, $6,691 $250,000 $ $7,243 $3,314 $10,004 $257, $1, $7,139 $250,000 $ $7,888 $3,711 $10,850 $257, $ $7,595 $25,000 $ $8,575 $4,146 $11,741 $33, $ $8,057 $25,000 $ $9,266 $4,604 $12,661 $34, $ $8,527 $25,000 $ $9,956 $5,081 $13,608 $34, $ $9,002 $25,000 $ $10,645 $5,578 $14,580 $35, $ $9,483 $25,000 $ $11,333 $6,095 $15,578 $36,333 The amounts shown in the Tabular Detail pages apply to the certificate year for which they are shown. Contract Premium changes shown are due to the expiry of riders, ratings and benefits, or the renewal of the term rider, whenever applicable. Version: State: New York US (07/12) Page 7 of 10

8 TABULAR DETAILS End Ac c um o f Contrac t Annual Add. Year Age Premium Div idend Add $ $9,969 $25,000 $ $12,020 $6,632 $16,601 $37, $ $10,458 $25,000 $ $12,707 $7,191 $17,648 $37, $ $10,949 $25,000 $ $13,395 $7,769 $18,719 $38, $ $11,443 $25,000 $ $14,092 $8,374 $19,817 $39, $ $11,939 $25,000 $ $14,798 $9,004 $20,944 $39, $ $12,436 $25,000 $ $15,514 $9,662 $22,098 $40, $ $12,934 $25,000 $ $16,238 $10,345 $23,279 $41, $ $13,431 $25,000 $ $16,973 $11,056 $24,487 $41, $ $13,928 $25,000 $ $17,719 $11,795 $25,723 $42, $ $14,425 $25,000 $ $18,474 $12,561 $26,986 $43, $ $14,920 $25,000 $ $19,243 $13,357 $28,278 $44, $ $15,404 $25,000 $ $20,039 $14,188 $29,592 $45, $ $15,874 $25,000 $ $20,866 $15,054 $30,928 $45, $ $16,333 $25,000 $ $21,717 $15,953 $32,287 $46, $ $16,782 $25,000 $ $22,594 $16,887 $33,669 $47, $ $17,218 $25,000 $ $23,501 $17,856 $35,074 $48, $ $17,651 $25,000 $ $24,423 $18,857 $36,508 $49, $ $18,061 $25,000 $ $25,391 $19,898 $37,959 $50, $ $18,449 $25,000 $ $26,401 $20,977 $39,426 $51, $ $18,815 $25,000 $ $27,452 $22,093 $40,909 $52, $ $19,172 $25,000 $ $28,533 $23,243 $42,415 $53, $ $19,560 $25,000 $ $29,625 $24,446 $44,006 $54, $ $19,957 $25,000 $ $30,728 $25,686 $45,643 $55, $ $20,346 $25,000 $ $31,843 $26,944 $47,290 $56, $ $20,716 $25,000 $ $33,003 $28,234 $48,950 $58,003 The amounts shown in the Tabular Detail pages apply to the certificate year for which they are shown. Contract Premium changes shown are due to the expiry of riders, ratings and benefits, or the renewal of the term rider, whenever applicable. Version: State: New York US (07/12) Page 8 of 10

9 TABULAR DETAILS End Ac c um o f Contrac t Annual Add. Year Age Premium Div idend Add $ $21,055 $25,000 $ $34,231 $29,554 $50,609 $59, $ $21,379 $25,000 $ $35,511 $30,891 $52,270 $60, $ $21,698 $25,000 $ $36,835 $32,230 $53,928 $61, $ $22,117 $25,000 $ $38,177 $33,645 $55,762 $63, $ $22,641 $25,000 $ $39,538 $35,109 $57,751 $64, $0.00 $22,805 $25,000 $ $40,917 $36,598 $59,403 $65, $0.00 $22,964 $25,000 $ $42,315 $38,112 $61,076 $67, $0.00 $23,115 $25,000 $ $43,733 $39,649 $62,764 $68, $0.00 $23,259 $25,000 $ $45,172 $41,208 $64,467 $70, $0.00 $23,393 $25,000 $ $46,632 $42,784 $66,177 $71, $0.00 $23,515 $25,000 $ $48,114 $44,374 $67,889 $73, $0.00 $23,626 $25,000 $ $49,618 $45,978 $69,604 $74, $0.00 $23,728 $25,000 $ $51,146 $47,598 $71,326 $76, $0.00 $23,822 $25,000 $ $52,697 $49,236 $73,057 $77, $0.00 $23,907 $25,000 $ $54,274 $50,890 $74,797 $79, $0.00 $23,982 $25,000 $ $55,875 $52,556 $76,539 $80, $0.00 $24,050 $25,000 $ $57,503 $54,240 $78,290 $82, $0.00 $24,112 $25,000 $ $59,158 $55,945 $80,058 $84, $0.00 $24,183 $25,000 $ $60,845 $57,709 $81,892 $85, $0.00 $24,244 $25,000 $ $62,583 $59,509 $83,754 $87, $0.00 $24,303 $25,000 $ $64,365 $61,351 $85,653 $89, $0.00 $24,360 $25,000 $ $66,176 $63,225 $87,584 $91, $0.00 $24,408 $25,000 $ $68,017 $65,114 $89,522 $93, $0.00 $24,455 $25,000 $ $69,890 $67,034 $91,489 $94, $0.00 $24,516 $25,000 $ $71,792 $69,031 $93,547 $96,792 The amounts shown in the Tabular Detail pages apply to the certificate year for which they are shown. Contract Premium changes shown are due to the expiry of riders, ratings and benefits, or the renewal of the term rider, whenever applicable. Version: State: New York US (07/12) Page 9 of 10

10 TABULAR DETAILS End Ac c um o f Contrac t Annual Add. Year Age Premium Div idend Add $0.00 $25,000 $25,000 $ $73,702 $73,702 $98,702 $98,702 The amounts shown in the Tabular Detail pages apply to the certificate year for which they are shown. Contract Premium changes shown are due to the expiry of riders, ratings and benefits, or the renewal of the term rider, whenever applicable. Version: State: New York US (07/12) Page 10 of 10

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