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 Femaleage35 DCAP Producer 11 Oval Dr Islandia, NY, 11749 T. 631 870 7638 info@tga4a.com The Independent Order of Foresters US Mailing Address foresters.com 789 Don Mills Rd PO Box 179 T. 800 828 1540 Toronto, Ontario, Canada M3C 1T9 Buffalo, NY 14201-0179 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: 1.30.007 State: New York 407488 US (07/12) Page 1 of 10
BASIC INFORMAT ION Pla n Deta ils Life Insure d : adplus Femaleage35 Se x: Female Issue Ag e : 35 Rating Cla ss: Standard Fa ce Amo unt: $25,000 Insura nce Cla ss: 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 $44.54 $534.48 65 Years i Op tio na l Co ve ra g e s Se le cte d Term Rider $225,000 $61.23 $734.76 20 Years i Children's Term Rider $10,000 $5.00 $60.00 30 Years i Initia l Pre mium $110.77 $1,329.24 T o ta l Initia l Pre mium $110.77 $1,329.24 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: 1.30.007 State: New York 407488 US (07/12) Page 2 of 10
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: 1.30.007 State: New York 407488 US (07/12) Page 3 of 10
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: 1.30.007 State: New York 407488 US (07/12) Page 4 of 10
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 $857 $250,000 $980 $250,465 $1,104 $250,939 Year 10 $2,498 $250,000 $2,865 $251,182 $3,253 $252,432 Year 20 $6,203 $250,000 $7,606 $253,335 $9,196 $257,114 Age 70 (year 35) $12,345 $25,000 $16,937 $32,590 $22,806 $42,291 Age 85 (year 50) $18,241 $25,000 $27,450 $36,784 $40,936 $54,041 Age 90 (year 55) $19,662 $25,000 $30,844 $38,583 $47,850 $59,241 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 #: 551808 Version: 1.30.007 State: New York 407488 US (07/12) Page 5 of 10
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 $20.36 $18.07 $12.79 $10.50 $0.00 $57.27 Year 20 $20.36 $16.85 $13.21 $9.71 $0.00 $87.66 Term Rider Year 10 $3.11 $3.11 $3.11 $3.11 N/ A N/ A Year 20 $3.11 $3.11 $3.11 $3.11 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 $0.00 1035 Lump Sum $0.00 Se ve n Pa y Pre mium $8,934.50 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: 1.30.007 State: New York 407488 US (07/12) Page 6 of 10
TABULAR DETAILS End Ac c um o f Contrac t Annual Add. Year Age Premium Div idend Add. 1 36 $1,329.24 $0 $250,000 $0.00 $0 $0 $0 $250,000 2 37 $1,329.24 $0 $250,000 $53.33 $225 $53 $53 $250,225 3 38 $1,329.24 $255 $250,000 $53.47 $446 $109 $364 $250,446 4 39 $1,329.24 $552 $250,000 $58.91 $684 $174 $726 $250,684 5 40 $1,329.24 $857 $250,000 $64.33 $939 $247 $1,104 $250,939 6 41 $1,329.24 $1,171 $250,000 $69.57 $1,209 $329 $1,499 $251,209 7 42 $1,329.24 $1,492 $250,000 $74.53 $1,493 $419 $1,911 $251,493 8 43 $1,329.24 $1,820 $250,000 $80.63 $1,793 $521 $2,341 $251,793 9 44 $1,329.24 $2,155 $250,000 $85.74 $2,105 $632 $2,788 $252,105 10 45 $1,329.24 $2,498 $250,000 $91.47 $2,432 $754 $3,253 $252,432 11 46 $1,329.24 $2,847 $250,000 $107.67 $2,808 $900 $3,747 $252,808 12 47 $1,329.24 $3,203 $250,000 $114.33 $3,199 $1,059 $4,262 $253,199 13 48 $1,329.24 $3,563 $250,000 $123.27 $3,613 $1,235 $4,798 $253,613 14 49 $1,329.24 $3,930 $250,000 $131.38 $4,045 $1,427 $5,356 $254,045 15 50 $1,329.24 $4,300 $250,000 $140.23 $4,497 $1,636 $5,936 $254,497 16 51 $1,329.24 $4,675 $250,000 $151.12 $4,974 $1,865 $6,540 $254,974 17 52 $1,329.24 $5,053 $250,000 $161.40 $5,474 $2,114 $7,167 $255,474 18 53 $1,329.24 $5,433 $250,000 $173.37 $6,000 $2,386 $7,819 $256,000 19 54 $1,329.24 $5,816 $250,000 $183.07 $6,547 $2,679 $8,495 $256,547 20 55 $1,329.24 $6,203 $250,000 $193.27 $7,114 $2,994 $9,196 $257,114 21 56 $594.48 $6,592 $25,000 $214.12 $7,732 $3,344 $9,936 $32,732 22 57 $594.48 $6,984 $25,000 $225.43 $8,373 $3,719 $10,703 $33,373 23 58 $594.48 $7,377 $25,000 $236.28 $9,035 $4,120 $11,498 $34,035 24 59 $594.48 $7,775 $25,000 $245.73 $9,716 $4,547 $12,322 $34,716 25 60 $594.48 $8,175 $25,000 $245.98 $10,396 $4,990 $13,165 $35,396 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: 1.30.007 State: New York 407488 US (07/12) Page 7 of 10
TABULAR DETAILS End Ac c um o f Contrac t Annual Add. Year Age Premium Div idend Add. 26 61 $594.48 $8,578 $25,000 $246.23 $11,076 $5,450 $14,029 $36,076 27 62 $594.48 $8,985 $25,000 $246.48 $11,756 $5,928 $14,914 $36,756 28 63 $594.48 $9,394 $25,000 $246.73 $12,436 $6,424 $15,819 $37,436 29 64 $594.48 $9,807 $25,000 $246.98 $13,118 $6,939 $16,746 $38,118 30 65 $594.48 $10,224 $25,000 $249.36 $13,805 $7,474 $17,698 $38,805 31 66 $534.48 $10,643 $25,000 $251.23 $14,496 $8,031 $18,674 $39,496 32 67 $534.48 $11,066 $25,000 $251.67 $15,190 $8,608 $19,674 $40,190 33 68 $534.48 $11,491 $25,000 $251.99 $15,887 $9,206 $20,697 $40,887 34 69 $534.48 $11,917 $25,000 $252.24 $16,587 $9,824 $21,741 $41,587 35 70 $534.48 $12,345 $25,000 $252.49 $17,291 $10,462 $22,806 $42,291 36 71 $534.48 $12,772 $25,000 $252.74 $17,998 $11,120 $23,892 $42,998 37 72 $534.48 $13,196 $25,000 $252.99 $18,710 $11,798 $24,994 $43,710 38 73 $534.48 $13,617 $25,000 $253.24 $19,426 $12,495 $26,113 $44,426 39 74 $534.48 $14,035 $25,000 $253.49 $20,148 $13,211 $27,246 $45,148 40 75 $534.48 $14,447 $25,000 $253.93 $20,876 $13,947 $28,393 $45,876 41 76 $534.48 $14,856 $25,000 $254.18 $21,609 $14,702 $29,558 $46,609 42 77 $534.48 $15,262 $25,000 $255.51 $22,351 $15,478 $30,740 $47,351 43 78 $534.48 $15,664 $25,000 $258.76 $23,104 $16,278 $31,942 $48,104 44 79 $534.48 $16,063 $25,000 $263.45 $23,870 $17,103 $33,166 $48,870 45 80 $534.48 $16,458 $25,000 $270.19 $24,653 $17,955 $34,413 $49,653 46 81 $534.48 $16,850 $25,000 $278.41 $25,454 $18,837 $35,687 $50,454 47 82 $534.48 $17,224 $25,000 $301.51 $26,295 $19,753 $36,977 $51,295 48 83 $534.48 $17,578 $25,000 $325.93 $27,176 $20,702 $38,280 $52,176 49 84 $534.48 $17,918 $25,000 $344.28 $28,091 $21,683 $39,601 $53,091 50 85 $534.48 $18,241 $25,000 $363.53 $29,041 $22,695 $40,936 $54,041 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: 1.30.007 State: New York 407488 US (07/12) Page 8 of 10
TABULAR DETAILS End Ac c um o f Contrac t Annual Add. Year Age Premium Div idend Add. 51 86 $534.48 $18,551 $25,000 $378.95 $30,021 $23,737 $42,289 $55,021 52 87 $534.48 $18,862 $25,000 $380.93 $31,015 $24,808 $43,670 $56,015 53 88 $534.48 $19,149 $25,000 $407.27 $32,054 $25,910 $45,059 $57,054 54 89 $534.48 $19,415 $25,000 $427.84 $33,131 $27,038 $46,453 $58,131 55 90 $534.48 $19,662 $25,000 $443.36 $34,241 $28,188 $47,850 $59,241 56 91 $534.48 $19,906 $25,000 $444.32 $35,367 $29,360 $49,266 $60,367 57 92 $534.48 $20,193 $25,000 $444.57 $36,507 $30,604 $50,797 $61,507 58 93 $534.48 $20,501 $25,000 $444.82 $37,662 $31,897 $52,398 $62,662 59 94 $534.48 $20,814 $25,000 $445.07 $38,832 $33,221 $54,035 $63,832 60 95 $534.48 $21,124 $25,000 $445.32 $40,018 $34,563 $55,687 $65,018 61 96 $534.48 $21,401 $25,000 $480.27 $41,260 $35,912 $57,313 $66,260 62 97 $534.48 $21,662 $25,000 $515.05 $42,560 $37,272 $58,934 $67,560 63 98 $534.48 $21,913 $25,000 $543.53 $43,912 $38,626 $60,538 $68,912 64 99 $534.48 $22,260 $25,000 $543.78 $45,284 $40,070 $62,331 $70,284 65 100 $534.48 $22,709 $25,000 $544.03 $46,676 $41,572 $64,280 $71,676 66 101 $0.00 $22,852 $25,000 $544.28 $48,088 $43,100 $65,952 $73,088 67 102 $0.00 $22,992 $25,000 $544.53 $49,521 $44,657 $67,649 $74,521 68 103 $0.00 $23,128 $25,000 $544.78 $50,976 $46,241 $69,370 $75,976 69 104 $0.00 $23,262 $25,000 $545.03 $52,453 $47,856 $71,118 $77,453 70 105 $0.00 $23,396 $25,000 $545.28 $53,952 $49,506 $72,902 $78,952 71 106 $0.00 $23,517 $25,000 $545.53 $55,474 $51,167 $74,684 $80,474 72 107 $0.00 $23,628 $25,000 $545.78 $57,020 $52,842 $76,470 $82,020 73 108 $0.00 $23,730 $25,000 $546.03 $58,590 $54,529 $78,259 $83,590 74 109 $0.00 $23,823 $25,000 $546.28 $60,186 $56,235 $80,058 $85,186 75 110 $0.00 $23,908 $25,000 $546.53 $61,807 $57,956 $81,864 $86,807 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: 1.30.007 State: New York 407488 US (07/12) Page 9 of 10
TABULAR DETAILS End Ac c um o f Contrac t Annual Add. Year Age Premium Div idend Add. 76 111 $0.00 $23,983 $25,000 $567.06 $63,476 $59,708 $83,691 $88,476 77 112 $0.00 $24,051 $25,000 $595.78 $65,202 $61,505 $85,555 $90,202 78 113 $0.00 $24,113 $25,000 $619.15 $66,982 $63,347 $87,460 $91,982 79 114 $0.00 $24,183 $25,000 $632.59 $68,804 $65,260 $89,443 $93,804 80 115 $0.00 $24,245 $25,000 $654.85 $70,680 $67,209 $91,454 $95,680 81 116 $0.00 $24,303 $25,000 $669.62 $72,601 $69,202 $93,505 $97,601 82 117 $0.00 $24,360 $25,000 $669.87 $74,555 $71,230 $95,590 $99,555 83 118 $0.00 $24,408 $25,000 $670.12 $76,541 $73,274 $97,683 $101,541 84 119 $0.00 $24,455 $25,000 $670.37 $78,560 $75,350 $99,805 $103,560 85 120 $0.00 $24,516 $25,000 $670.62 $80,613 $77,512 $102,029 $105,613 86 121 $0.00 $25,000 $25,000 $670.87 $82,674 $82,674 $107,674 $107,674 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: 1.30.007 State: New York 407488 US (07/12) Page 10 of 10