Whole Life Policy Premiums are Guaranteed for the Life of the Contract Insurance payable at death of Insured Funeral Planning and Family Support Assistance Benefit Non-participating Non-convertible Western Life Assurance Company P O Box 3300 Winnipeg, Manitoba R3C 5S2 A Stock Company PLEASE READ YOUR POLICY CAREFULLY - This policy is a legal contract between the owner and us, Western Life Assurance Company. We agree to pay the amount of proceeds of this policy to the beneficiary upon receipt of due proof of the death of the insured and to provide the other rights and benefits in accordance with the terms of this policy. Mark Giesbrecht Vice President, Finance Dominique Gregoire President and CEO 30 - DAY RIGHT TO EXAMINE POLICY The Owner may return this policy to the Administrative Office for any reason within 30 days of the date of issue of this policy indicated in Section 1. The policy will then be void from its beginning and any premium paid will be refunded. Signed for Western Life Assurance Company at its Administrative Office in Winnipeg, Manitoba.
TABLE OF CONTENTS Section 1 Policy Schedule 3 Section 2 Policy Definitions 5 Section 3 Amount of Proceeds 6 Section 4 Payment of Amount of Proceeds 6 Section 5 Funeral Planning and Family Support Assistance Benefit 6 Section 6 Beneficiary 7 Section 7 Claims 7 Section 8 Premiums 8 Section 9 Surrender 9 Section 10 General Provisions 9 Section 11 Table of Cash Values 13 Application for Whole Life Insurance 14 PWYW08 Ed. 07-2012 Page 2
SECTION 1. POLICY SCHEDULE Amount of Insurance: Effective Date: Plan Type: Age at Issue: Paid up Date: Premium Payment Frequency: Premium: Policy loan rate: Owner Name: Relationship to Primary Beneficiary Name: Relationship to Percentage: Whole Life Monthly Pre-Authorized Payment Plan 8% per year (compounded) PWYW09 Ed. 07-2012 Page 3
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SECTION 2. POLICY DEFINITIONS Administrative Office is Western Life Assurance Company; 717 Portage Ave 4th Flr, Winnipeg, MB. Mailing Address: P.O. Box 3300, Winnipeg, MB, R3C 5S2. Administrator means Everest Canada, LP as of the effective date of this policy. Age means the age of the insured as of the last birthday. Amount of proceeds means the amount we are obligated to pay under the terms of this policy when the insured dies. Application means the application for this policy including any statements provided as proof of insurability. Contingent Beneficiary is the person designated to receive the policy proceeds if the Primary Beneficiary is deceased at the time the proceeds become payable. Effective Date means the date indicated as such in Section 1 which is the date this policy came into effect. It is the date from which policy anniversaries, policy years and premium due dates are determined. Coverage begins on this date at 12:01 A.M. standard time at the insured's residence and ends, subject to the grace period, at 12:01 A.M. The effective date is used in the definition of time periods specified in the misrepresentation and incontestability provisions. Funeral Plan means the funeral plan for the insured provided to our authorized administrator: a) by the insured during the lifetime of the insured; or b) by the administrator or executor of the estate of the insured, after the death of the insured; or c) by the authorized spouse of the insured, if living, after the death or incapacity of the insured; or d) by the authorized immediate family of the insured after the death or incapacity of the insured. Insured is the person named in Section 1 and whose life the policy insures. Owner means the insured, unless another is named as owner of this policy in Section 1. The owner is referred to as "you" in this policy and has rights and benefits in accordance with the terms of this policy. Paid up Date means the date when premium payments are no longer required. Policy anniversary is the same day and month as the effective date for each succeeding year this policy remains in force. Primary Beneficiary is the person to receive the policy proceeds in the event of the insured's death. Reinstatement is the date the insurance under this policy is put back into force if the policy terminates as a result of unpaid premiums. We, Us, Our, or the Company means the Insurer of this policy, Western Life Insurance Company. You, your means the owner of this policy. PWYW09 Ed. 07-2012 Page 5
SECTION 3. AMOUNT OF PROCEEDS 3.1 Amount of Proceeds The amount of proceeds payable at the death of the insured will be the sum of: a) the amount of insurance (See Section 1); plus less: SECTION 4. 4.1 Payment b) the portion of any premium due and unpaid which applies to a period prior to the date of death of the insured; and c) any policy loan and loan interest. PAYMENT OF AMOUNT OF PROCEEDS Any amount payable at the death of the insured or any other termination of this policy will be paid in one sum to the named beneficiary(ies). Interest will be paid on the amount of proceeds from the date of the insured's death until the date of payment. The rate will be consistent with the rate of interest then in effect and typically paid by the Company on policy proceeds left on deposit with the Company. SECTION 5. FUNERAL PLANNING AND FAMILY SUPPORT ASSISTANCE BENEFIT 5.1 Funeral Planning Assistance Benefit The Company will provide, while this policy is in effect, through our authorized administrator, funeral planning services in order to assist the insured in preparation of their funeral plan. The funeral plan may be modified, through the authorized administrator, an unlimited number of times while this policy is in effect. 5.2 Family Support Assistance Benefit Upon receipt by the Company of due proof of the death of the insured, occurring while this policy is in effect, and subject to all the terms and conditions of this policy and the exclusions, we will provide, through our authorized administrator, a family support assistance benefit at the time of death as follows: a) telephone support to respond to questions about funeral arrangements; b) review of the insured's funeral plan with their immediate family and/or executor or estate administrator; and c) communication of the insured's funeral plan to the chosen funeral home and liaison therewith. PWYW09 Ed. 07-2012 Page 6
SECTION 6. BENEFICIARY 6.1 Designation The beneficiary named in the application for this policy will receive the amount of proceeds upon the death of the insured unless the beneficiary designation has been changed by the owner. 6.2 Change The owner may change any revocable beneficiary designation during the lifetime of the insured unless otherwise provided in the previous designation. A change of beneficiary designation will automatically revoke any previous revocable designation. A change of designation shall be filed in the form of a written request in a form satisfactory to the Company at its Administrative Office. A beneficiary designated irrevocably on our records may not be changed except with written consent of that beneficiary. The Company reserves the right to require this policy for endorsement of a change of beneficiary designation. 6.3 Death of beneficiary Unless otherwise provided in the beneficiary designation: SECTION 7. a) if any beneficiary dies before the insured, that beneficiary's interest will pass to any other beneficiaries according to their respective interests; or b) if no beneficiary survives the insured, the proceeds will be paid in one sum to the owner, if living, otherwise to the owner's estate. CLAIMS The amount of proceeds will be paid within 2 business days when the Company has received written proof of claim satisfactory to the Company and has approved the claim. The Company reserves the right to not pay within 48 hours during the contestable period. 7.1 Notice and proof of claim includes: a) evidence of the death of the insured and the cause of death; b) the return of this policy; c) statement of claim completed and signed by the beneficiary; and d) any other information which the Company may reasonably require to establish the validity of the claim. PWYW09 Ed. 07-2012 Page 7
SECTION 8. PREMIUMS 8.1 Where payable Premiums are payable at the Administrative Office of the Company. 8.2 Amount and frequency Premiums are payable in advance beginning on the effective date shown in Section 1. The owner may change the frequency of premium payments on any policy anniversary subject to the Company's rules by filing a written request to the Company at its Administrative Office. 8.3 Grace period A grace period of thirty (30) days will be allowed for payment of each premium after the first. The policy will continue in force during the grace period. If any premium has not been paid at the expiry of the grace period or within such longer period as may be permitted by applicable law, insurance under this policy will immediately lapse and cease to be in force. If the amount of insurance becomes payable during the grace period, any unpaid premium will be deducted from the amount payable. 8.4 Automatic premium loan Any premium not paid before the end of its grace period will be automatically paid by charging the unpaid premium as a loan against this policy provided that the resulting policy loan and loan interest to the next premium due date or policy anniversary, whichever is earlier, do not exceed the cash value. Interest at the compounded rate of 8% per annum will be charged on the automatic premium loan from the premium due date. If the premium due cannot be paid by automatic premium loan, the policy will terminate and no coverage will be in force. An automatic premium loan can be repaid in full or in part at our Administrative Office while this policy is in force prior to the death of the insured. Cash loans are not available. 8.5 Reinstatement If this contract terminates because premiums have not been paid, it may be reinstated within two (2) years of such termination by: a) submitting a written application for reinstatement; PWYW09 Ed. 07-2012 Page 8
b) supplying evidence of insurability satisfactory to the Company; c) paying all premiums in arrears, together with interest; and d) payment or reinstatement of any policy loans and interest due. 8.6 Default in payment of premiums Any premium which remains unpaid before the end of its grace period will result in default. The date of default is the date on which the unpaid premium was due. Default will terminate this policy except as provided under the automatic premium loan provision in Section 8.4. SECTION 9. SURRENDER This policy may be surrendered for it's net cash surrender value while the insured is alive, however, the surrender cannot be effective within the first six (6) months from the effective date. Surrender will be as of the date that we receive both the policy and a written request in a form satisfactory to us. The amount payable on surrender of this policy will be the cash value less any unpaid premium, premium loan and loan interest on the date of the surrender. We may defer payment of any cash surrender value for not more than six (6) months. If we postpone payment for more than thirty (30) days, we will also pay interest. The interest will be at the Company's current interest rate per year based on the cash surrender value for the period we postpone the payment. SECTION 10. 10.1 Assignments GENERAL PROVISIONS No assignment of this policy will be binding on the Company unless it is in writing and received by the Company at its Administrative Office. The Company will not be responsible for the validity of any assignment. Unless otherwise provided, the interest of any revocable beneficiary shall be subordinate to the interest of any assignee. The Company reserves the right to require this policy for endorsement of any assignment. 10.2 Absolute assignment An Absolute Assignment of this policy will cause the assignee to be made the Owner. 10.3 Collateral assignment This policy cannot be collaterally assigned. PWYW09 Ed. 07-2012 Page 9
10.4 Control Consistent with the terms of any beneficiary designation and any assignment, the owner may, during the lifetime of the insured: a) Assign or terminate this policy in accordance with its terms; b) Amend or modify this policy with the consent of the Company; and c) Exercise, receive, and enjoy every other right, benefit, and privilege contained in this policy. The Company reserves the right to require this policy for endorsement of any assignment or change. 10.5 Currency All payments under this policy, either to or by the Company, will be made in the lawful money of Canada. 10.6 Elections, designation, changes and requests All elections, designations, changes and requests must be made in a form satisfactory to the Company and are not effective before received by the Company at its Administrative Office. 10.7 Incontestability After this policy has been in force for two (2) years from the effective date or date of the most recent reinstatement during the lifetime of the insured, failure to disclose, or a misrepresentation of a fact that is material to this insurance, does not, in the absence of fraud, render this contract voidable. 10.8 Insurance age The insurance age of any life insured is the age attained on the last birthday. 10.9 Misstatement of age or sex If the age or sex of the life insured has been misstated, the benefits available under this policy will be those which the premium paid would have purchased for the correct age and sex. 10.10 Non-participating This policy is non-participating and it is not eligible for dividends. 10.11 Policy changes Only an Officer of the Company has the power, on behalf of the Company, to change, modify or waive any provisions of this policy. Any changes or waiver must be in writing. The Company will not be bound by any promises or representations made by any person except as specified above. 10.12 Exclusion - Suicide within two years PWYW09 Ed. 07-2012 Page 10
If the insured dies from self-inflicted injuries, while sane or insane, within two (2) years from the effective date or date of the most recent reinstatement, the amount of insurance will be limited to all premiums paid since such date. 10.13 The Contract This policy is issued in consideration of the application and payment of the first premium. The application, this policy, any document attached at issue, and any amendment to the policy agreed upon in writing after issue constitutes the entire contract. Only an officer of the company has the power, on behalf of the company, to change, modify, or waive any provisions of the policy. Any changes or waiver must be in writing. The company will not be bound by any promises or representations made by any agent or other person except as specified above. 10.14 Coordination of coverage Benefits will be paid under only one policy of this type, Series WL. In the event that any person is covered under more than one policy for coverage of this Series, such insured will be deemed to be covered only under the policy that affords that person the greatest amount of insurance. 10.15 Duty to Disclose a) The applicant for insurance and the owner must each disclose to us in the application, on a medical examination, if any, and in any written statements or answers furnished as evidence of insurability, every fact within their knowledge that is material to the insurance and is not disclosed by the other. b) Subject to sub-section (a) above, a failure to disclose, or a misrepresentation of, a fact referred to in sub-section (a) above, renders the contract voidable by us. c) A failure to disclose or misrepresentation referred to in sub-section (a) relating to evidence of insurability with respect to an application for i. additional coverage under a contract, ii. iii. 10.16 Failure to Disclose an increase in insurance under a contract, or any other change to insurance after the policy is issued renders the contract voidable by us but only in relation to the addition, increase or change. If a contract, including renewals of it, or an addition, increase or change referred to in Section 10.15 Duty to Disclose has been in effect for two (2) years with respect to a person insured, a failure to disclose, or a misrepresentation of, a fact required to be disclosed in respect of that person insured does not, in the absence of fraud, render the contract voidable. 10.17 Limitation of Actions Every action or proceeding against the Insurer for the recovery of insurance money payable under the contract is absolutely barred unless commenced within the time set out in the Insurance Act (Alberta & British Columbia). PWYW09 Ed. 07-2012 Page 11
Every action or proceeding against the Insurer for the recovery of insurance money payable under the contract is absolutely barred unless commenced within the time set out in The Insurance Act (Manitoba). Every action or proceeding against the Insurer for the recovery of insurance money payable under the contract is absolutely barred unless commenced within the time set out in the Limitations Act, 2002 (Ontario). Otherwise, in Quebec every action must be brought within three (3) years after the date evidence is furnished, and in all other provinces within one (1) year from the date of loss or such longer period as may be required under the law applicable in such province. PWYW09 Ed. 07-2012 Page 12
SECTION 11. TABLE OF CASH VALUES By written request, the owner may surrender this policy for its cash value. The written request must be in a form satisfactory to the company. This table assumes premiums have been paid when due and that there are no outstanding policy loans. Unpaid premiums, loans and loan interest will be applied to reduce the cash value of this policy. To determine the cash value of insurance, refer to the table below and then deduct any unpaid premiums, loan and loan interest. Attained Amount Attained Amount Attained Amount Age Age Age 59 0.00 73 9,480.00 87 19,950.00 60 0.00 74 10,350.00 88 20,490.00 61 0.00 75 11,220.00 89 21,000.00 62 0.00 76 12,060.00 90 21,510.00 63 810.00 77 12,900.00 91 22,020.00 64 1,650.00 78 13,710.00 92 22,530.00 65 2,490.00 79 14,520.00 93 23,040.00 66 3,330.00 80 15,300.00 94 23,610.00 67 4,200.00 81 16,050.00 95 24,210.00 68 5,070.00 82 16,770.00 96 24,900.00 69 5,970.00 83 17,460.00 97 25,710.00 70 6,840.00 84 18,120.00 98 26,730.00 71 7,710.00 85 18,750.00 99 28,080.00 72 8,610.00 86 19,350.00 100 30,000.00 PWYW09 Ed. 07-2012 Page 13
Guaranteed Issue Whole Life Policy Premiums are guaranteed for the life of the contract Insurance payable at death of insured Funeral Planning and Family Support Assistance Benefit Non-participating Non-convertible Western Life Assurance Company P O Box 3300 Winnipeg, Manitoba R3C 5S2 A Stock Company PLEASE READ YOUR POLICY CAREFULLY This policy is a legal contract between the owner and us, Western Life Assurance Company. In consideration of the payment of premiums as provided in this policy, we agree to pay the amount of proceeds of this policy to the beneficiary upon receipt of due proof of death of the insured and to provide the other rights and benefits in accordance with the terms of this policy. Mark Giesbrecht Vice President, Finance Dominique Gregoire President and CEO 30 DAY RIGHT TO EXAMINE POLICY The owner may return this policy to the Administrative Office for any reason within thirty (30) days of the date of issue of this policy indication in the Policy Schedule. The policy will then be void from its beginning and any premium paid will be refunded. Signed for Western Life Assurance Company at its Administrative Office in Winnipeg, Manitoba.
Table of Contents Section 1 Definitions...page 5 Section 2 The insurance contract...page 5 Section 3 When the insurance contract is in effect...page 6 Section 4 Age of life insured...page 6 Section 5 Travel, residence and occupation...page 6 Section 6 Payment of premiums...page 7 Section 7 Failure to pay premiums...page 7 Section 8 Reinstatement...page 7 Section 9 Designation of beneficiary...page 8 Section 10 Assignment of policy...page 8 Section 11 Filing documents...page 8 Section 12 Options available to the owner...page 8 Section 13 Conditions for exercising the option...page 9 Section 14 When amounts are owed under this policy...page 9 Section 15 Participation in profits...page 9 Section 16 Calculation of cash surrender values...page 10 Table A basic cash surrender value...page 11 Section 17 Basic life insurance and accidental benefit conditions...page 12 Section 18 Payment of insurance amounts...page 12 Section 19 Exclusions...page 13 Section 20 Funeral Planning and Family Support Assistance Benefit...page 13 Section 21 Limitation of Actions...page 14 PGIW09 Ed. 07-2012 Page 2
Policy Schedule Policy number: Policy date: Policy years: Plan type: Policy years are computed from the policy date Guaranteed Issue Whole Life Policy Amount of Insurance: Basic Life Insurance: $ 10,000.00 Accidental death insurance: $ 10,000.00 Premium: $ Payable: Premium class: Age at issue: Owner name: Relationship to insured: Beneficiary name: Relationship to insured: Monthly Pre-Authorized Payment Plan Coverage Details Basic life Insurance coverage for the lifetime of the life insured. Within the first two (2) years from the policy date, the amount payable is 100% of the premiums you have paid. After two (2) years, the amount payable is the basic life insurance amount shown. Accidental death Total payable for death occurring as the result of an accident. Full coverage is in effect from the policy date. Terminates on your 85 th birthday. On or after your 85 th birthday, whether or not death is the result of an accident, the total benefit payable will be the basic life insurance amount shown above. PGIW10 Ed. 07-2011 Page 3
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SECTION 1. DEFINITIONS Accident is defined as a sudden, unforeseen, and fortuitous event caused purely by external, violent and accidental means that occur while the policy is in force. Administrative Office is Western Life Assurance Company; 717 Portage Ave 4 th Flr, Winnipeg, MB. Mailing Address: P.O. Box 3300, Winnipeg, MB, R3C 5S2. Administrator means Everest Canada, LP as of the effective date of this policy. Age means attained age (last birthday). Funeral Plan means the funeral plan for the insured provided to our authorized administrator. a) by the insured during the lifetime of the insured; or b) by the administrator or executor of the estate of the insured, after the death of the insured; or c) by the authorized spouse of the insured, if living, after the death or incapacity of the insured; or d) by the authorized immediate family of the insured after the death or incapacity of the insured. Insured refers to the person named in the Policy Schedule. Owner refers to the person named in the Policy Schedule. Policy Schedule refers to the page which contains specific information regarding the insurance contract. Policy Anniversary means the anniversary of the policy date from which policy years and policy months will be computed. You, Your refers to the owner of this policy. We, Us, Our or the Company means the Insurer of this policy, Western Life Assurance Company. SECTION 2. THE INSURANCE CONTRACT The insurance contract consists not only of this policy, but also certain other documents. a. the policy schedule, which is included with this policy; and b. the enrollment form and, if applicable, the recorded verbal application and its transcripts; and c. any policy endorsement and any amendment which is attached to this policy when it is delivered to you or which is added subsequently by written agreement between you and Western Life Assurance Company. The policy includes this document, the policy schedule and any policy endorsement. PGIW11 Ed. 07-2012 Page 5
The insurance application refers to the document or recording described in (b) above. The insurance contract is subject to the general laws which apply to all insurance contracts from time to time. Processing of the first premium payment by us on the premium due date specified in the policy schedule, constitutes acceptance of the policy provisions. We are not bound by policy amendments or waivers unless they have been signed on our behalf at our Administrative Office by one of our authorized officials. All payments made to or by us under the policy will be in Canadian dollars. SECTION 3. WHEN THE INSURANCE CONTRACT IS IN EFFECT The insurance contract between the owner and Western Life Assurance Company takes effect on the policy date as specified in the policy schedule. SECTION 4. AGE OF THE LIFE INSURED We have prepared this policy in reliance on the statement of the age of the life insured contained in the insurance application. The age which we have used appears in the policy schedule. We will admit this age as being correct at any time before benefits become payable under this policy if we are provided, at our Administrative Office, with evidence reasonably satisfactory to us. If the age has been misstated, and this policy has not been corrected accordingly, and a. the correct age at the time of application was outside the application age range of 18-80, premiums paid plus interest will be refunded and you will not be entitled to any other benefits under this policy; or b. the correct age at the time of application was within the eligible range of 18-80, the benefits under this policy will be such as would have been provided by the same premium at the correct age. SECTION 5. TRAVEL, RESIDENCE AND OCCUPATION Once this policy has taken effect and so long as it remains in effect, the benefits provided shall not be prejudiced or affected by any travel, change of residence or change of occupation of the life insured unless otherwise stated in this policy. PGIW11 Ed. 07-2012 Page 6
SECTION 6. PAYMENT OF PREMIUMS The policy schedule sets forth the premium payable for this policy, as well as the number of full years for which the premiums are to be paid and the date or dates in each year when the premiums are to be paid. We refer to those dates as the premium due dates. If benefits have been added or changed by way of endorsement, information relating to the premiums will be found in the relevant endorsements. All premiums and any other payments to us under this policy are to be paid to us at our Administrative Office. SECTION 7. FAILURE TO PAY PREMIUMS A grace period of thirty (30) days will be allowed for payment of each premium after the first. The policy will continue in force during the grace period. If the premium has not been paid at the expiry of the grace period or within such longer period as may be permitted by applicable law, insurance under this policy will immediately lapse and cease to be in force. If the amount of insurance becomes payable during the grace period, any unpaid premium will be deducted from the amount payable. SECTION 8. REINSTATEMENT If, this policy terminates because of non-payment of premium, the owner may apply for reinstatement within two (2) years after the end of the grace period by submitting a written application for reinstatement and paying all overdue premiums, together with interest. a. reinstatement within sixty (60) days from the end of the grace period, no evidence of health or other evidence of insurability will be required from the life insured. b. for reinstatement after sixty (60) days from the end of the grace period, the life insured must provide us with evidence satisfactory to us of their insurability. The provisions of Section 19 (a) and (b) will apply for a period of two (2) years after each reinstatement date. This policy may not be reinstated if any available cash surrender value has been paid. PGIW11 Ed. 07-2012 Page 7
SECTION 9. DESIGNATION OF BENEFICIARY The owner is entitled to designate a beneficiary to receive the policy benefits described in the policy schedule. The designation may be made either in the insurance application or in a subsequent written declaration which meets the requirements of all applicable laws. The owner may alter or revoke any designation of beneficiary by a subsequent written declaration to the extent permitted by applicable laws. A beneficiary designated irrevocably on our records may not be changed except with written consent of that beneficiary. SECTION 10. ASSIGNMENT OF THE POLICY The owner is entitled to assign any rights under this policy unless otherwise expressly stated in this policy or in any document relating to this policy. Any assignment must be in writing, signed by the owner and must comply with all applicable laws. SECTION 11. FILING OF DOCUMENTS We assume no responsibility for the form, validity or effect of any election, declaration or assignment which is filed with us. We are not bound by any of the foregoing documents unless, before we have paid a benefit under this policy which would have been affected by any such document, we receive evidence of it at our Administrative Office in compliance with all applicable laws. All elections, consents and other similar documents, whether given or made by us or by you, must be in writing and, if given or made by the owner, must be in a form satisfactory to us and filed at our Administrative Office. SECTION 12. OPTIONS AVAILABLE TO THE OWNER Subject to the conditions stated in Section 13, the owner may elect to surrender the policy. The cash surrender value is calculated as set forth in Section 16. PGIW11 Ed. 07-2012 Page 8
SECTION 13. CONDITIONS FOR EXERCISING THE OPTION All of the following conditions must be satisfied before the option provided in Section 12 is capable of being exercised: a. premiums have been paid and this policy has been in force for at least the minimum period specified in Section 16; b. we have received a signed request, from the owner, specifying the option to be elected; c. the owner made this policy available to us for cancellation; d. the owner provided us with evidence as we may reasonably require of ownership of the policy; and e. all statutory requirements which apply to the transaction have been met. SECTION 14. WHEN AMOUNTS ARE OWED UNDER THIS POLICY We will deduct from any amount which we would otherwise pay under this policy all amounts which are owed to us under this policy including unpaid premiums. If at any time the amount owed under this policy is equal to or greater than the cash surrender value calculated in accordance with Section 16, this policy will lapse as provided by Section 7. SECTION 15. PARTICIPATION IN PROFITS This policy is non-participating, which means that it does not provide for participation in the distribution of our profits, as determined from time to time by our directors. PGIW11 Ed. 07-2012 Page 9
SECTION 16. CALCULATION OF CASH SURRENDER VALUES The tables which follow will be used in calculating the values used in Section 12. The values shown in the tables assume that the basic life insurance amount shown in the policy schedule is $1,000. If the actual basic life insurance amount is more or less than $1,000, the values used in the tables will be increased or decreased proportionately. The values calculated in this Section 16 are available only if premiums for this policy have been paid for the minimum number of years shown at the top of the left-hand column of the tables and if this policy has been in force for the full number of years to which the values relate. The calculation is made as follows: a. the cash surrender values available in any policy year: i. the basic cash surrender value for that year determined from Table A, for age and sex, multiplied by the basic life insurance amount shown on the policy schedule, divided by $1,000. ii. minus any amount owed under this policy. PGIW11 Ed. 07-2012 Page 10
Table A Basic cash surrender values (per $1,000 of Basic Life Insurance) MALE Age Amount Age Amount Age Amount 57 $ 0.00 72 $ 348.00 87 $ 688.00 58 $ 0.00 73 $ 374.00 88 $ 704.00 59 $ 0.00 74 $ 400.00 89 $ 719.00 60 $ 0.00 75 $ 426.00 90 $ 734.00 61 $ 30.00 76 $ 451.00 91 $ 748.00 62 $ 60.00 77 $ 476.00 92 $ 763.00 63 $ 90.00 78 $ 501.00 93 $ 778.00 64 $ 119.00 79 $ 525.00 94 $ 795.00 65 $ 149.00 80 $ 549.00 95 $ 813.00 66 $ 178.00 81 $ 572.00 96 $ 834.00 67 $ 207.00 82 $ 594.00 97 $ 859.00 68 $ 236.00 83 $ 615.00 98 $ 890.00 69 $ 264.00 84 $ 635.00 99 $ 933.00 70 $ 293.00 85 $ 654.00 100+ $ 1,000.00 71 $ 320.00 86 $ 671.00 PGIW11 Ed. 07-2012 Page 11
SECTION 17. BASIC LIFE INSURANCE AND ACCIDENTAL BENEFIT CONDITIONS Upon the death of the life insured, the following benefit(s) will be payable, subject to policy provisions. The basic life insurance amount is payable upon the death of the life insured. The amount is specified in the policy schedule and in any subsequent endorsement. The accidental death insurance amount is payable if the life insured dies as a result of an accident. The amount is specified in the policy schedule and in any subsequent endorsement. The amount of the premium for both the basic life insurance amount and the accidental death insurance amount is shown in the policy schedule. The payment of premium(s) are required to keep this policy in force. SECTION 18. PAYMENT OF INSURANCE AMOUNTS We will pay the basic life insurance amount if this policy is in force, none of the circumstances described in Section 19 (a) and (b) applies, and we receive evidence sufficient to us of: a. the death of the life insured as specified in the policy schedule; and b. the age of the life insured; and c. the right of the person claiming the basic life insurance amount to receive payment of it; and d. the name and age of any beneficiary designated in accordance with the provisions of this policy. We will pay the accidental death insurance amount subject to all of the conditions above and the following conditions must also be satisfied: a. we receive proof reasonably satisfactory to us that the death of the life insured resulted directly and independently of all other causes from bodily injury and that such death was caused solely by external, violent and accidental means; and b. the death must have occurred within ninety (90) days of the date of the injury being sustained, and the injury must have occurred before the life insured's 85 th birthday; and c. both the injury and death must have occurred while this policy was in force; and d. none of the circumstances described in Section 19 is applicable. Before we pay the accidental death insurance amount, we have the right and opportunity to examine the body of the life insured and to require that an autopsy be made, unless forbidden by the law. PGIW11 Ed. 07-2012 Page 12
SECTION 19. EXCLUSIONS We will not pay the basic life insurance amount or the accidental death insurance amount if: a. the death of the life insured results either directly or indirectly from suicide within two (2) years after the policy date or the date of the most recent reinstatement, whether he or she is sane or insane at the time. In this event, we will return all premiums paid under this policy. b. the owner or the life insured signed the application knowing the information contained therein to be untrue. This condition will cease to apply (except in the case of fraud) after this policy has been in effect for two (2) consecutive years during the lifetime of the life insured or two (2) consecutive years after the most recent reinstatement. We will not pay the accidental death insurance amount if the death of the life insured results either directly or indirectly from any of the following causes: a. injury received while under the influence of an non-prescribed drug or intoxicant or while the life insured's blood contained more than 80 milligrams per 100 milliliters of blood; b. injury received during a civil disorder or war, whether declared or not, or injury received while, or as a result of, committing or attempting to commit an assault or criminal offense. SECTION 20. Funeral Planning Assistance Benefit FUNERAL PLANNING AND FAMILY SUPPORT ASSISTANCE BENEFIT The Company will provide, while this policy is in effect, through our authorized administrator, funeral planning services in order to assist the insured in preparation of their funeral plan. The funeral plan may be modified, through the authorized administrator, an unlimited number of times while this policy is in effect. Family Support Assistance Benefit Upon receipt by the Company of due proof of the death of the insured, occurring while this policy is in effect, and subject to all the terms and conditions of this policy and the exclusions, we will provide, through our authorized administrator, a family support assistance benefit at the time of death as follows: a. telephone support to respond to questions about funeral arrangements; b. review of the insured's funeral plan with their immediate family and/or executor or estate administrator ; and c. communication of the insured's funeral plan to the chosen funeral home and liaison therewith. PGIW11 Ed. 07-2012 Page 13
SECTION 21. LIMITATION OF ACTIONS Every action or proceeding against the Insurer for the recovery of insurance money payable under the contract is absolutely barred unless commenced within the time set out in the Insurance Act (Alberta & British Columbia). Every action or proceeding against the Insurer for the recovery of insurance money payable under the contract is absolutely barred unless commenced within the time set out in The Insurance Act (Manitoba). Every action or proceeding against the Insurer for the recovery of insurance money payable under the contract is absolutely barred unless commenced within the time set out in the Limitations Act, 2002 (Ontario). Otherwise, in Quebec every action must be brought within three (3) years after the date evidence is furnished, and in all other provinces within one (1) year from the date of loss or such longer period as may be required under the law applicable in such province. PGIW11 Ed. 07-2012 Page 14