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Massachusetts Mutual Life P.O. Box 305002 Insurance Company Nashville TN, 37230-5002 Administrative Office: Nashville, TN Phone 844-768-6774 Fax 844-858-3913 Dear Policy Owner, Sample As a valued customer, we are notifying you of important information regarding the administration of your newly issued policy. Massachusetts Mutual Life Insurance Company has provided for Alliance-One Services, Inc., ( Alliance-One ) a licensed Third Party Administrator, to perform administrative functions, benefit payments, premium collection, and service requests. Alliance-One s servicing center located in Nashville, TN will administer your life insurance policy. Your service requests will receive the Massachusetts Mutual Life Insurance Company s high standard of service. Please use the policy number noted on your policy whenever you make a request for service on this policy. Insurance Policy Servicing Center Information Mailing Address: Insurance Services P.O. Box 305002 Nashville TN, 37230-5002 Phone Number: 844-768-6774 Facsimile: 844-768-6775 Hours of Operation: 9:00 AM to 5:00 PM EST Monday through Friday Thank you for choosing Massachusetts Mutual Life Insurance Company as your insurance company. We look forward to assisting you with your insurance needs for many years to come. Sincerely, Massachusetts Mutual Life Insurance Company
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Massachusetts Mutual Life Insurance Company Home Office: [1295 State Street] [Springfield, Massachusetts 01111-0001] Renewable Non-Convertible Term Life Insurance Policy INSURED POLICY DATE ISSUE DATE POLICY NUMBER FACE AMOUNT Dear Policy Owner: READ YOUR POLICY CAREFULLY. As you read through the policy, remember the words "we," "us," and "our" refer to Massachusetts Mutual Life Insurance Company. The words you and your refer to the Owner. We will, subject to the terms of this policy, pay the death benefit to the Beneficiary when due proof of the Insured's death is received at our Administrative Office. The terms of this policy are contained on this and the following pages. For service and information on this policy you may contact us through our third party administrator, [Alliance-One Services, Inc., toll free at: 844-768-6774]. RIGHT TO EXAMINE POLICY. If you decide not to keep this policy, contact us in writing within 10 days after you receive it. Then, the policy will be voided as though it had never been issued. We will promptly refund any premium paid for it. Signed for Massachusetts Mutual Life Insurance Company. Sincerely yours, PRESIDENT SECRETARY This Renewable Non-Convertible Term Life Insurance Policy provides that a death benefit is payable if the Insured dies while this policy is in force. Premiums are payable to a stated date or to the Insured s death, if earlier. Renewal is automatic to a stated date. Premiums after the level period are adjustable as described in the Right To Change Premiums provision. This policy is non-participating. No dividends will be paid. ICC15DTC
TABLE OF CONTENTS Policy Specifications Section Page No. Section Page No. 1. General Provisions... 1 3. Policy Ownership... 3 Policy is a legal contract... 1 Owner s rights... 3 When coverage takes effect... 1 Changing the Owner or Beneficiary 4 Termination of this policy... 1 Assigning this policy... 4 Representations and contestability 1 Decreases in the Face Amount... 4 Misstatement of age or sex... 2 Attachment of riders... 4 Death by suicide... 2 Conformity with Interstate Insurance 4. Reinstating This Policy After Lapse 4 Product Regulation Commission When policy may be reinstated... 4 standards... 2 Requirements for reinstatement... 4 Policy after reinstatement... 5 2. Premium Payments... 2 When premiums are due... 2 5. Death Benefit... 5 Premium payment options... 3 Definition... 5 Automatic Renewal... 3 Amount... 5 Right To Change Premiums... 3 Interest on death benefit... 5 Grace period... 3 6. Key Terms and Definitions... 5 Any riders and endorsements, and a copy of the application for the policy, follow page 7. ICC15DTC
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POLICY SPECIFICATIONS RENEWABLE NON-CONVERTIBLE TERM LIFE INSURANCE POLICY INSURED POLICY NUMBER POLICY DATE ISSUE DATE ISSUE AGE AND GENDER INITIAL FACE AMOUNT THE TELEPHONE NUMBER FOR THE DEPARTMENT OF INSURANCE IS 1-xxx-xxx-xxxx. BASIC POLICY INFORMATION PRODUCT Term Life 15 Subject to the terms of this policy, the Face Amount is adjustable. If the Face Amount is adjusted, then revised or additional Policy Specifications will be sent. MINIMUM FACE AMOUNT PREMIUM FREQUENCY POLICY EXPIRATION DATE $100,000 Monthly PREMIUM INFORMATION (as of January 01, 2015) Payable To Initial Monthly Policy Premium (excluding Riders)* Initial Monthly Premium for all Riders: Total Initial Monthly Premium: *All Monthly Policy Premiums include a $6 Fee. ** RENEWAL PREMIUMS ARE SHOWN ON RENEWAL TABLE. ICC15DTC POLICY SPECIFICATIONS PAGE 1 OF 6
POLICY SPECIFICATIONS RENEWABLE NON-CONVERTIBLE TERM LIFE INSURANCE POLICY INSURED POLICY DATE ISSUE DATE POLICY NUMBER FACE AMOUNT ISSUE AGE AND GENDER RISK CLASS Monthly Premium Payable To WAIVER OF PREMIUM RIDER WAIVER RIDER ISSUE DATE WAIVER RIDER DATE ** RENEWAL PREMIUMS ARE SHOWN ON RENEWAL TABLE. NOTE: DIVIDENDS ARE NOT EXPECTED TO BE PAID. ICC15DTC POLICY SPECIFICATIONS PAGE 2 OF 6
POLICY SPECIFICATIONS RENEWABLE NON-CONVERTIBLE TERM LIFE INSURANCE POLICY INSURED POLICY DATE ISSUE DATE POLICY NUMBER RENEWAL TABLE Renewal Date Maximum Monthly Premium* Monthly Premium For Waiver Of Premium *These are Maximum Monthly Premiums for the Basic Policy. The Maximum Monthly Premiums shown above for the first 14 Renewal Dates are the premiums that will apply for those years. Premiums for the remaining Renewal Dates may be changed in accordance with the Right To Change Premiums provision of this Policy. However, the Monthly Premium for any Policy Year will never be more than the maximum shown. ICC15DTC POLICY SPECIFICATIONS PAGE 3 OF 6
POLICY SPECIFICATIONS RENEWABLE NON-CONVERTIBLE TERM LIFE INSURANCE POLICY INSURED POLICY DATE ISSUE DATE POLICY NUMBER RIDER INFORMATION (as of January 01, 2015) Monthly Premium Payable To Accelerated Death Benefit for Terminal Illness Rider Rider Issue Date: None ICC15DTC POLICY SPECIFICATIONS PAGE 5 OF 6
POLICY SPECIFICATIONS RENEWABLE NON-CONVERTIBLE TERM LIFE INSURANCE POLICY INSURED POLICY DATE ISSUE DATE POLICY NUMBER OWNER INFORMATION OWNER THE INSURED. BENEFICIARY INFORMATION BENEFICIARY ICC15DTC POLICY SPECIFICATIONS PAGE 6 OF 6
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For definitions of key terms used throughout this policy see Section 6, Key Terms and Definitions. 1. General Provisions Policy is a legal contract. (A) This policy is a legal contract between the Owner and us. The entire contract consists of the policy, which includes the application and any riders and endorsements the policy has. We issued this policy in return for the application and the payment of the first premium. Any changes or waiver of this policy s terms must be in writing and signed by our Secretary or an Assistant Secretary. (B) A copy of the initial application is attached and is a part of this policy. Any later applications for changes in the policy will become part of the contract if we agree to the changes. We will send copies of any later applications to the Owner for attachment to the policy. (C) The initial Policy Specifications are attached to this policy when issued. Generally, if a Policy Change is made, we will send the Owner any revised or additional Policy Specifications for attachment to the policy. When coverage takes effect. Coverage under this policy will take effect on the later of its Policy Date or the date the first premium is received, provided that the Insured is alive. Termination of this policy. (A) This policy will terminate on the Policy Expiration Date or on the earlier of the following: (1) the next premium due date following the Owner s Written Request to terminate this policy; or (2) the end of the grace period (see Section 2, Grace period). (B) If this policy terminates for any reason other than reaching the end of its grace period, it cannot be reinstated (see Section 4, Reinstating This Policy After Lapse). Representations and contestability. (A) We rely on all statements about facts made by or for the Insured in any application. Legally, those statements are representations and not warranties. (B) We may bring legal action to contest the validity of this policy, or of any Policy Change requiring evidence of insurability if we discover a material misstatement or material omission of fact in the initial application or in a later application that was attached (or sent to the Owner for attachment) to this policy. (See Section 1, Policy is a legal contract.) (C) Except for any Policy Change or reinstatement requiring evidence of insurability, we cannot, if there is no fraud, contest the validity of the policy more than two years from its Issue Date during the lifetime of the Insured, except for failure to pay premiums. ICC15DTC Page 1
(D) For any Policy Change requiring evidence of insurability, we cannot, if there is no fraud, contest the validity of the change after it has been in effect during the lifetime of the Insured for two years, except for failure to pay premiums. (E) If evidence of insurability is required to reinstate this policy (see Section 4, Reinstating This Policy After Lapse), our right to contest the validity of this policy begins again on the date of reinstatement for statements made in the reinstatement application. If there is no fraud, we cannot contest the reinstated policy after it has been in force during the lifetime of the Insured for two years after that reinstatement date, except for failure to pay premiums. (F) In the event of fraud in the procurement of a policy, Policy Change, or reinstatement, we can contest validity more than two years after the policy or Policy Change took effect if applicable state law in the state where the policy was delivered or issued for delivery permits us to do so. Misstatement of age or sex. If the Insured s date of birth or sex is incorrectly stated in the application, all benefits and other amounts payable, including the Face Amount, will be adjusted. The adjustment will reflect the benefits and amount that the most recent premium paid would have bought based on the correct Issue Age and correct sex. Death by suicide. (A) If the Insured commits suicide, while sane or insane, within two years after the Issue Date and while the policy is in force, this policy will terminate and we will pay the Beneficiary an amount equal to only the premiums paid for this policy. No additional payments will be made. (B) If the Insured commits suicide, while sane or insane, within two years after this policy is reinstated and while the policy is in force, this policy will terminate and we will pay the Beneficiary an amount equal to only any amount paid to reinstate this policy and any premiums paid later. No additional payments will be made. Conformity with Interstate Insurance Product Regulation Commission standards. This policy was approved under the authority of the Interstate Insurance Product Regulation Commission and issued under the Commission standards. Any provision of this policy that on the provision s effective date is in conflict with the Interstate Insurance Product Regulation Commission Standards for this product type is hereby amended to conform to the Interstate Insurance Product Regulation Commission standards for this product type as of the provision s effective date. 2. Premium Payments When premiums are due. Premiums are payable in advance up to the Policy Expiration Date shown in the Policy Specifications or before the death of the Insured, if earlier. The first premium is due on the Policy Date. Each later premium is due when the period covered by the preceding premium ends. These premiums are due on the same day of the month as the day shown in the Policy Date. ICC15DTC Page 2
Premium payment options. Premiums are payable monthly and only under a Pre- Authorized Payment Plan. Premiums must be paid from a U.S. bank and paid in U.S. dollars and cents. Automatic Renewal. Payment of premiums will continue this policy in force to each Renewal Date. On each Renewal Date the policy will be automatically renewed (extended), without evidence of insurability, to the next Renewal Date. On the Policy Expiration Date, this policy will expire and the insurance will terminate. Right To Change Premiums. (A) The Renewal Table, shown in the Policy Specifications, shows the Maximum Monthly Premium for the basic policy that may be charged for each month during the policy year beginning on the Renewal Date. The monthly premium we charge can never be more than the Maximum Monthly Premium for the basic policy shown in the Renewal Table for that year. (B) Each year we may review the premiums for this policy to determine if any change should be made. Any change we make will be based on our expectations for future mortality, investment earnings, persistency and expense results, capital and reserve requirements, taxes, and future profits. Any change in premiums we make will: (1) Take effect on the Renewal Date on or following the date we make the change; and (2) Apply to all policies issued in the same class as this one. (C) Rider premiums will not be impacted by a change in premiums for this policy. Grace period. After the first premium has been paid, we allow a 31-day grace period to pay each following premium. Each premium after the first must be paid within 31 days after its due date. The policy will remain in force during the grace period. If a premium is not paid by the end of this grace period, the policy will Lapse as of the premium s due date. 3. Policy Ownership Owner s rights. While the Insured is living, the Owner may exercise all rights given by this policy or allowed by us. These rights include changing Beneficiaries, changing ownership, assigning this policy, and exercising all policy options. Changing the Owner or Beneficiary. (A) While the Insured is living, the Owner or any Beneficiary may be changed by Written Request. Any Irrevocable Beneficiary must consent to a change in the Beneficiary designation. (B) We do not limit the number of changes that may be made. (C) The change will take effect as of the date the request is signed unless otherwise specified by the Owner, even if the Insured dies before we receive the Written Request. Each change will be subject to any payment we made or other action we took before receiving the Written Request. ICC15DTC Page 3
Assigning this policy. (A) This policy may be assigned, but for any assignment to be binding on us, we must receive a signed copy of it at our Administrative Office. We are not responsible for the validity of any assignment. Unless the Owner specifies otherwise, the assignment will take effect as of the date the notice of assignment is signed by the Owner, subject to any payments made or actions taken by us before we receive notice. (B) Once we receive a signed copy of an assignment, the Owner s rights and any Beneficiary s or any other person s interest will be subject to the assignment. Decreases in the Face Amount. The Face Amount may be decreased by the Owner s Written Request. T he decrease must not reduce the Face Amount to an amount less than the Minimum Face Amount shown in the Policy Specifications. If the Face Amount is decreased, we will send the Owner the revised Policy Specifications. Any decrease will be effective on the next premium due date following Written Request by the Owner. Attachment of riders. Any riders that we make available for attachment to this policy after issue may be attached subject to a Written Request and evidence of insurability that is satisfactory to us. 4. Reinstating This Policy After Lapse When policy may be reinstated. After this policy has lapsed, it may be reinstated that is, put back in force. Application for reinstatement must be made during the lifetime of the Insured and before the Policy Expiration Date shown in the Policy Specifications. Reinstatement must be made within three years after the date of Lapse. Requirements for reinstatement. We require evidence of insurability that is satisfactory to us. If this policy is reinstated during the Level Premium Period, all overdue premiums must be paid. If this policy is reinstated after the Level Premium Period, only one monthly premium must be paid. All overdue premiums are payable only by electronic funds transfer. A new Pre-Authorized Payment Plan will be required. Policy after reinstatement. (A) After we approve reinstatement and receive all overdue premiums, the reinstatement will be effective. The Face Amount on the reinstatement date will be the Face Amount on the termination date. (B) Our rights to contest the validity of this policy begin again on the date of reinstatement. (See Section 1, Representations and contestability, and Death by suicide.) (C) In all other respects, we and the Owner will have the same rights under the policy as were in effect on the day before the due date of the unpaid premium. 5. Death Benefit ICC15DTC Page 4
Definition. The death benefit is the amount of money we will pay, in one sum, when we receive due proof and all other requirements at our Administrative Office that the Insured died before the Policy Expiration Date and while this policy was in force. Amount. (A) Except as otherwise provided in Section 1, Death by suicide, if the Insured dies while this policy is in force, the death benefit is the Face Amount as shown in the Policy Specifications. (B) We add the part of any premium paid for a period beyond the date of death. (C) We deduct that part of the unpaid premium to the date of death, if death occurs during the 31-day grace period. Interest on death benefit. (A) We will add interest from the date of the Insured s death to the date of a lump sum payment. The amount of interest will be computed using an effective annual rate not less than 3%. (B) We will add additional interest to the date of payment at an effective annual rate of 10% beginning 31 days from the latest of: (1) the date we receive due proof of the Insured s death; (2) the date we receive sufficient information to determine our liability, the extent of the liability, and the appropriate Beneficiary legally entitled to the proceeds; or (3) the date that legal impediments to payment of proceeds that depend on the action of parties other than us are resolved and sufficient evidence of the same is provided to us. L egal impediments to payment include the establishment of guardianships and conservatorships; the appointment and qualification of trustees, executors, and administrators; and the submission of information required to satisfy state and federal reporting requirements. 6. Key Terms and Definitions Administrative Office. Our third party Administrative Office is in [Nashville, TN. The address is Alliance-One Services, Inc., 100 Centerview Drive, Suite 100, Nashville, TN 37214]. We may designate a different address in the future. Attained Age. The Insured s Issue Age increased by the number of full Policy Years elapsed. Beneficiary. Any person named in our records to receive the death benefit after the Insured dies. There may be different classes of Beneficiaries, such as primary and secondary. These classes set the order of payment. There may be more than one Beneficiary in a class. If no Beneficiary designated under this policy survives the Insured, the Beneficiary will be the Owner unless the policy states otherwise. The ICC15DTC Page 5
interest of any Beneficiary will be subject to any assignment of this policy that is binding on us at the time of the Insured s death. Face Amount. The amount of insurance coverage this policy provides while the policy is in force. Insured. The person whose life this policy insures. The Insured or someone else may be the Owner of this policy. Irrevocable Beneficiary. A Beneficiary who cannot be removed from the policy or whose benefit cannot be changed without that Beneficiary s consent. An Irrevocable Beneficiary has no other rights under this policy. Any Beneficiary can be named an Irrevocable Beneficiary. Issue Age. The age of the Insured on the birthday nearest the Policy Date. The Issue Age is shown in the Policy Specifications. Issue Date. The date that this policy was issued. T he Issue Date is shown in the Policy Specifications. This date starts the contestability and suicide periods (see Section 1). Lapse. The status of the policy if a premium is not paid within 31 days after its due date. Lapse means the policy is no longer in force and the insurance has terminated on the due date. Level Premium Period. Beginning on the Policy Date, the number of years for which the maximum monthly premium is level. Owner. The person who owns this policy, as shown in our records. If the Owner designated under the terms of this policy is not living and if the policy does not provide otherwise, the Owner will be the estate of the last Owner to die. Policy Anniversary Date. One year from the previous Policy Anniversary Date. The first Policy Anniversary Date is one year after the Policy Date. Policy Changes. Face Amount decreases and changes in underwriting class requested by the Owner may be available subject to our approval and rules at the time of request. Policy Date. The starting date for determining premium due dates, Policy Anniversary Dates, and Policy Years. The Policy Date is shown in the Policy Specifications. Policy Expiration Date. The date on which the policy will expire and insurance will terminate. The Policy Expiration Date is shown in the Policy Specifications. This policy may terminate before the Policy Expiration Date. (See Section 1, Termination of this policy.) Policy Is Non-participating. This policy is "non-participating," which means that no dividends are payable on this Policy. ICC15DTC Page 6
Policy Is Non-convertible. This policy is "non-convertible," which means that it may not be converted to a different policy. Policy Year. The period from the Policy Date to the first Policy Anniversary Date, or from one Policy Anniversary Date to the next. Pre-Authorized Payment Plan. A plan by which premiums for the policy are paid through electronic withdrawals from a checking or savings account or similar account agreed to by us. This plan provides for electronic payment of the initial or automatic recurring premiums or both. Premiums. The payments needed to keep this policy in force. Renewal Date. A date on which the policy will be automatically renewed (extended) without evidence of insurability to the next Renewal Date. Payment of premiums will keep this policy in force to each Renewal Date. All Renewal Dates are shown in the Renewal Table in the Policy Specifications. Written Request. A request in writing satisfactory to us, received by us at our Administrative Office. Currently we accept only e-mail and paper to satisfy the Written Request requirement. In the future, we may also allow the telephone, Internet, or other media to be used for certain transactions that currently require a Written Request. We will accept them only after the appropriate policies, procedures, and security measures have been established. ICC15DTC Page 7
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Rider: Accelerated Death Benefit for Terminal Illness 1. Condition for Accelerated Benefits. Subject to the terms of this rider, we will pay the Owner an accelerated death benefit payment, upon request, after we receive proof that the Insured has a Terminal illness. All the provisions of the policy apply to this rider except for those that are inconsistent with this rider. Sample 2. Important Notices. Taxability. Benefits paid under this rider may be taxable. The Owner should seek tax advice before requesting an accelerated death benefit payment. Death benefit reduction. An accelerated death benefit payment made under this rider will reduce the death benefit provided by the policy. Premium reduction. After acceleration, premiums for the base policy and any accelerated riders will be based on the reduced amount of insurance and on the rates in effect for the Insured on the Acceleration Date. Compelled payment not allowed. We will not allow an accelerated death benefit payment if the Owner is being required to seek the payment: (A) by any third party (including any creditor, governmental agency, trustee in bankruptcy, or any other person); or (B) as the result of a court order. No long-term care coverage. This rider does not provide for long-term care insurance or for nursing-home care insurance. 3. Accelerated Death Benefit Payment. Eligible Amount. The Eligible Amount is the Face Amount of the policy as determined on the Acceleration Date. Amount to be accelerated. Subject to the terms of this rider, the Owner may accelerate up to 75% of the Face Amount but no more than $250,000. We reserve the right to impose a limit of not less than $25,000 on the amount to be accelerated. Amount of payment. (A) The payment under this rider will be the portion of the Eligible Amount requested for acceleration less a fee not to exceed ICC14ABR Page 1
$250, and 12 months interest on the amount accelerated. We declare the annual interest rate as of the Acceleration Date. It will not exceed the greater of: (1) the effective annual yield on 90-day U.S. Treasury Bills as of the Acceleration Date; or (2) a variable rate determined in accordance with the NAIC Model Policy Loan Interest Rate Bill (#590). (B) A statement of the method we use to compute the amount of the accelerated death benefit payment has been filed with the Interstate Insurance Product Regulation Commission. (C) Upon request for an accelerated death benefit payment, we will give the Owner and any Irrevocable Beneficiary a statement illustrating the effect of the accelerated benefit payment on the policy. Sample How we pay. We will pay the Owner the accelerated death benefit in a lump sum. If we receive due proof of the Insured's death before we make the accelerated payment, we will pay the death benefit as if no request had been received under this rider. When we pay. (A) We will pay the accelerated benefit payment immediately on receiving all requirements for acceleration. We will add interest from the date all requirements are met to the date of payment. We will compute the amount of interest using an effective annual rate of not less than 2.5%. (B) We will add additional interest up to the date of payment at an effective annual rate of 10% beginning 31 days after we receive all requirements for acceleration. Effect on policy. (A) This policy will remain in force after we make the accelerated benefit payment. Any riders not included in determining the Eligible Amount will continue according to their terms. For any other riders and for the base policy, the amounts of insurance and all values will be reduced by the same proportion as the amount to be accelerated bears to the Eligible Amount. (B) After acceleration, premiums for the base policy and any accelerated riders will be based on the reduced amount of insurance and on the rates in effect for the Insured on the Acceleration Date. (C) When we make the accelerated benefit payment, we will send the Owner revised Policy Specifications. (D) After we make the accelerated benefit payment, our liability under the policy for the amount accelerated ends.. ICC14ABR Page 2
Statement of Effect of Payment. When the accelerated benefit payment is made, we will give the Owner and any Irrevocable Beneficiary a Statement of Effect of Payment. This statement will include the payment amount and the values in the policy both before and after the payment of the accelerated benefit 4. Definitions and Requirements. Acceleration Date. The Acceleration Date is the date on which all the requirements for acceleration, except any confirming examination that we may require, have been met. Our right to require a confirming examination is discussed below in Proof of Terminal Illness. Terminal Illness. Terminal illness is a medical condition that is first diagnosed by a legally qualified physician and that will result, with reasonable medical certainty, in the Insured s death within 12 months after the date the legally qualified physician certifies the diagnosis. Sample Proof of Terminal Illness. Proof of terminal illness is written certification, satisfactory to us, that a legally qualified physician has diagnosed the Insured as having a terminal illness. To establish this proof, we may require that the diagnosis be confirmed with an examination of the Insured by a physician of our choice at our expense. This confirming examination may include any x-rays, blood tests, and other procedures that are reasonable and necessary to determine whether the Insured has a terminal illness. If the Insured's physician and the physician of our choice have different opinions, a third opinion may be obtained from a physician acceptable to both us and the Insured. Legally Qualified Physician. A legally qualified physician is a person who is licensed by the state in which he or she practices to give advice or treatment for terminal illness and who is acting within the scope of that license. A legally qualified physician must be someone other than the Owner or the Insured, or a spouse, mother-in-law, father-in-law, stepparent, natural or adoptive brother, sister, parent, grandparent, or child of the Owner or the Insured. Requirements for Acceleration. Before we can pay the Owner the accelerated death benefit payment, we must receive, at our Administrative Office, all the following requirements for acceleration: (A) the Owner s Written Request for payment of an accelerated death benefit under this policy; (B) the Insured's written authorization to release medical records to us; ICC14ABR Page 3
(C) (D) the written consent to this request of any assignee and any Irrevocable Beneficiary under this policy; and proof of terminal illness. 5. General Provisions Rider is part of this policy. This rider is made a part of this policy as of its Rider Issue Date. There are no premiums for this rider. Sample Termination of this rider. (A) This rider will automatically end 12 months before coverage under this policy is scheduled to terminate. It will also end if this policy terminates for any reason or when we make an accelerated death benefit payment under this rider. (B) Termination of the policy does not affect the payment of benefits for Terminal Illness that occurred while this rider was in force. Cancellation of this rider. This rider may be canceled upon the Owner s Written Request. MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY PRESIDENT SECRETARY ICC14ABR Page 4
Rider: Waiver of Premium This rider provides a benefit if the Insured becomes totally disabled. This document explains the rider s terms. 1. Rider Is Part of the Policy. In return for the application and the payment of premiums for this rider, this rider becomes part of this policy as of its Rider Issue Date. The Rider Issue Date and the premiums for this rider are shown in the Policy Specifications. All the provisions of the policy apply to this rider except for any that are inconsistent with this rider. Coverage under this rider takes effect on the day coverage under this policy takes effect. 2. Rider Benefit. If the Insured becomes totally disabled, we will waive premiums for this policy and for all riders for this policy. When benefit begins. This benefit begins after the Insured has been totally disabled for at least six continuous months and all other conditions of this rider have been met. Subject to the other provisions of this rider, we will waive: (A) any premium that becomes due after the Insured has been totally disabled for six continuous months; (B) any premium that was due during the first six continuous months of the Insured's total disability; and (C) any premium (except the first one) that was due during the 31-day period before total disability began. Sample Premium payments. Until we approve a claim, the premiums must be paid when due to avoid having this policy lapse. If we allow the waiver, we will refund any premiums paid while awaiting our approval. Effect on policy. Waiver of premiums will not reduce the amount payable in any settlement of this policy. All policy rights and values will be the same as if the premiums had been paid. 3. When Benefits End. The benefits under this rider will end when any of the following occurs: (A) the Insured is no longer disabled; (B) satisfactory proof of continued total disability is not given to us as required; (C) the Insured refuses or fails to have an examination we require; or (D) the Policy Anniversary Date nearest the Insured s Attained Age 70, if total disability began on or after the Insured s Attained Age 60. ICC14WP Page 1
4. Exclusions. This rider does not provide any benefit for: (A) total disability directly caused by any willfully and intentionally self-inflicted injury; or (B) total disability caused by war while the Insured is in the military forces of any country at war or in any civilian noncombatant unit serving with those forces. War includes undeclared war and any act of war. Country includes any international organization or group of countries. 5. Total Disability Definition. Total disability is the incapacity of the Insured that: (A) is caused by sickness or injury; (B) begins while this rider is in full force; (C) for the first 60 months of any period of total disability, prevents the Insured from performing the substantial and material duties of the Insured s occupation; and (D) after total disability has continued for 60 months, prevents the Insured from performing any of the substantial and material duties of his or her job or any other job for which the Insured may become reasonably suited by education, training or experience. Sample Insured s occupation. For the first 60 months of any period of total disability, the Insured s occupation is considered to be the Insured's usual work, employment, business, or profession when total disability began. After total disability has continued for 60 months, any occupation that the Insured is or may become qualified to perform means any work, employment, business, or profession the Insured is reasonably qualified to perform based on education, training, or experience. Example of total disability. You are a full-time surgeon. You receive an injury to your hands that prevents you from performing surgery, but you can carry on a general medical practice. For the first 60 months, your occupation is surgeon. After that time, your occupation will be any that you are reasonably qualified to do based on your education, training, or experience. Since you can carry on a general medical practice, we would no longer consider you to be totally disabled. Exceptions. For some conditions, we consider the Insured to be totally disabled even if the Insured is able to work. These conditions are the total loss of sight of both eyes, the total loss of ICC14WP Page 2
use of both hands or both feet, or the total loss of one hand and one foot. Any of these will be total disability as long as the loss continues. 6. Recurrent Disabilities Period of disability. A period of total disability due to the same condition or related conditions as that of an earlier period of total disability may be considered a continuation of the earlier period, depending on how much time has passed from the end of the earlier period to the date the current total disability began. If less than six months have passed, it is a continuation of the earlier period. If six months or more have passed, it is a new period of total disability. Example of a recurrent disability. You were totally disabled for 10 months because of a severe knee injury. Two weeks after you recover, your knee fails and you are totally disabled again. This is a continuation of the earlier period of total disability. Sample 7. Notice of Claim 8. Proof of Claim Definition. Notice of claim means Written Notice that the Insured is totally disabled and that a claim may be made under this rider. This notice must identify the Insured. Notice given by or for the Owner is notice of claim. Time limits. There are two time limits for giving notice of claim. First, we will not consider any benefit unless notice is given to us while the Insured is living and while total disability continues. Second, we will not waive a premium if its due date was more than one year before we were given the notice. Exception to time limit. If it was not reasonably possible to give us notice of claim while the Insured was living and within the specified time limits, the delay will not reduce the benefit if notice is given as soon as reasonably possible. This exception applies to each time limit. Requirements. Before any benefit is allowed, proof of claim must be given to us at our Administrative Office by or for the Owner. Proof of claim includes written proof from a licensed medical practitioner, other than the Insured or an Insured's family member, satisfactory to us, that: ICC14WP Page 3
(A) (B) (C) (D) the Insured is totally disabled total disability began while this rider was in full force; total disability began before the Insured's Attained Age 65; and total disability has continued for six continuous months. Claim forms. Our forms must be used to make a claim, and we will send them promptly upon request. As part of the proof of claim, we have the right to require an examination of the Insured at our expense by a physician we choose. 9. When Proof of Claim Must Be Given. Written proof of claim must be given to us at our Administrative Office while the Insured is living and during the continuance of total disability. Also, it must be received within one year after the earliest of the Policy Anniversary Date nearest the Insured's Attained Age 65; the maturity, expiration, or termination of the policy; or the due date of an unpaid premium. Sample 10. Proof of Continued Disability 11. Contestability When we require proof. During the first 24 months after we receive proof of claim, we may require satisfactory proof of continued disability every 30 days. After 24 months, we may require proof not more than once a year. As part of this proof, we may require an examination of the Insured at our expense by a physician chosen by us. When we will not require proof. If total disability begins before the Insured has Attained Age 60, we will not require proof of continued disability once the Insured has Attained Age 65. Misrepresentation. We may bring legal action to contest this rider s validity because of any material misrepresentation of a fact made in the application for this rider. Fraud. In the event of fraud in the procurement of this rider, we can contest validity more than two years after the rider took effect if applicable state law in the state where this rider and the policy was delivered or issued for delivery permits us to do so. ICC14WP Page 4
12. Termination of This Rider At Attained Age 65. While premiums for this rider are being paid, this rider will continue in full force until, but not including, the Policy Anniversary Date on which the Insured's Attained Age becomes 65. Any benefits under this rider for which the Insured qualified before termination may be claimed after termination as specified in Section 7, Notice of Claim. Sample Earlier termination. This rider will terminate before the Insured reaches Attained Age 65 if this policy is terminated for any reason or if the 31-day grace period for any unpaid policy premium ends. 13. Cancellation of This Rider. This rider may be canceled by the Owner s Written Request. The cancellation will take effect on the date we receive the Written Request. MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY PRESIDENT SECRETARY ICC14WP Page 5
Massachusetts Mutual Life Insurance Company Home Office: 1295 State Street Springfield, Massachusetts 01111-0001 Renewable Non-Convertible Term Life Insurance Policy This Renewable Non-Convertible Term Life Insurance Policy provides that a death benefit is payable if the Insured dies while this policy is in force. Premiums are payable to a stated date or to the Insured s death, if earlier. Renewal is automatic to a stated date. Premiums after the level period are adjustable as described in the Right To Change Premiums provision. This policy is non-participating. No dividends will be paid. ICC15DTC