400 Broadway Cincinnati, OH 45202-3341 (800) 243-6631 Policy form WL-05-100 Designed for Elira Kurdina Agent/Representative CRAIG FLOYD (Agent Number 01634 ) 151 E CENTER ST LAKETOWN, UT 84038 (435) 757-1257 WL-05-100 Page: 1 of 11 State: OH
Narrative Summary Basic Life Insurance Illustration Policy Summary Policy Form Premium Information This summary provides a brief description of a life insurance policy and any riders. It also includes definitions of key terms and column headings. This summary is not intended as a substitute for a life insurance policy or any riders which may be issued with the policy. In the event of any conflict, the provisions of the policy and the riders, and NOT this summary, shall control. The Heritage (WL-05-100) is a whole life insurance policy which provides a level amount of insurance as long as the policy continues in force. Premiums are payable to age 100. If the policy is still in effect when the insured reaches age 121, the policy will mature and we will pay the net cash value to you. Premiums in this illustration are assumed to be paid on a(n) Annual basis. The policy first year modal premium is $1,000.00. First year modal premiums are: Annual: $1,000.00 Semi-annual: $504.23 Quarterly: $254.23 Monthly: $84.04 Smoker rates are illustrated. The insured may be eligible for non-smoker status at age 18. The Home Office must be contacted to make this adjustment. This illustration assumes that premiums are paid in cash, out of pocket by you, each year until the insured attains age 100 or until death of the insured, whichever comes first. Dividends Increases in future values are dependent upon dividends. Dividends are NOT guaranteed. If actual dividends are lower than assumed in this illustration, projected cash values and death benefits will be lower than shown. If actual dividends are higher than assumed, projected cash values and death benefits will be higher than shown. Policy Loans Important Tax Information You can take a loan that is secured by the policy's cash value. We will lend you an amount equal to the policy's loan value. Your loan value will be less than the policy's cash value. Loans will be charged interest payable to Lafayette Life at an adjustable loan interest rate that we may change from year to year. The minimum loan interest rate is 5.00%. The maximum loan interest rate is determined by a formula using a third-party index as set forth in the policy, and is not capped. We recommend that you pay accrued loan interest prior to the end of a policy year. Any interest that is not paid at the end of a policy year is added to the loan balance, which will also be charged interest. Interest that you pay to us is not credited to the cash value of the policy and it does not increase the cash value of the policy. A policy dividend, if any, may not be sufficient to pay loan interest. An unpaid loan balance may cause policy termination. Any references to the taxation of life insurance policies in this illustration are based on Lafayette Life's understanding of the Federal taxation of life insurance as of the date of this illustration. Lafayette Life and its agents do not provide tax advice. Please consult your tax advisor regarding your own personal situation. In order to receive favorable tax treatment of distributions (including loans) under the Internal Revenue Code, a life insurance policy must satisfy a 7-pay premium limitation. * Life insurance policy premiums must be within certain limits during the first 7 policy years and also during the 7-year period following certain policy changes. * Failure to satisfy this limitation, either at issue or later, would classify the policy as a Modified Endowment Contract (MEC) and result in distributions receiving less favorable tax treatment. WL-05-100 Page: 2 of 11 State: OH
Narrative Summary The initial 7-pay premium for the policy as illustrated is $1,000.01 per year. This is the maximum premium * you can pay per year during the first 7 policy years, without causing the policy to be classified as a MEC. Certain changes to the policy benefits or premiums over the lifetime of the policy (whether illustrated or not) will alter the premium limitation. The policy, as illustrated, will be a MEC in policy year 49. Please review the adverse tax consequences described below regarding the MEC status. Prior to policy year 49, if changes are made to the face amount, or if certain riders are added or changed, or if the amount, duration or mode of premiums paid changes from that illustrated in the Tabular Detail, the MEC status could be affected and could cause the policy to lose its favorable tax status. If your policy is in MEC status: * You may be subject to additional taxes and penalties on any distributions from your policy during the life of the insured. * Policy distributions, such as loans, withdrawals, surrenders, cash dividends, and dividends retained by the insurer as principal or interest on a loan under the policy, will be taxed on a "gain first" basis to the full extent of such gains in the policy. * There is a penalty of 10% of taxable income for distributions from the policy prior to the policyowner's age 59 ½, with certain limited exceptions. In all cases, any gain in the policy is taxable on full surrender of the policy. The tax treatment of any death benefit provided under the policy does not change depending on whether the policy is a MEC or not. Other Important Information Premiums and surrender of additions are assumed to be beginning of the year values. Dividends, cash values, and death benefits are end of year values. This illustration has been prepared based on 100% of the company's current dividend scale. This illustration assumes that the currently illustrated, non-guaranteed elements will continue unchanged for all years shown. This is not likely to occur, and actual results may be more or less favorable than those shown. This illustration assumes that all premiums are paid in cash each year by you until the insured attains age 100. Whether future values will increase is dependent on dividends which are not guaranteed. If actual dividends are lower than assumed in this illustration, then projected, non-guaranteed net cash values and death benefits will be lower than those shown. If actual dividends are higher than assumed, the projected, non-guaranteed net cash values and death benefits will be higher than those shown. Address Please address all inquiries to The Lafayette Life Insurance Company. The Lafayette Life Insurance Company Agent: CRAIG FLOYD 400 Broadway 151 E CENTER ST Cincinnati, OH 45202-3341 LAKETOWN, UT 84038 (800) 243-6631 Riders Illustrated values include the following additional benefits: WL-05-100 Page: 3 of 11 State: OH
Narrative Summary Billed LPUA Level Premium Paid-up Additions Rider (LPUA-13): Each premium paid for this rider, less a 6% expense Premium charge, is used as a net single premium to purchase a level amount of paid-up death benefit. The minimum $577.38 annual premium for this rider is $500 in the first rider year and $120 in each rider year thereafter. If the minimum Stop Year: 70 annual premium for this rider is not paid in any rider year, no more premiums will be accepted for this rider. The maximum annual premium that may be paid for this rider during each of the first seven rider years is applied Underwritten and underwritten for at issue, but may not exceed an annual premium of $100,000. After the first seven rider years, Annual the maximum annual premium that may be paid for this rider is the average of the rider premiums paid during the Premium first seven rider years. The cumulative maximum premium that may be paid on the life of the insured under this $577.38 rider and under any other riders with a lifetime maximum premium is $1,000,000 in total. For rider years two through seven, additional premium in excess of the maximum annual premium called premium catch-ups may be paid if the cumulative rider premium paid through the prior year is less than the cumulative maximum annual premium through the prior year. The total of any premium catch-ups that may be paid in any rider year is the lesser of $25,000 or the maximum annual premium, but no premium catch-up will be accepted if it would cause the cumulative rider premiums paid to exceed the cumulative maximum annual premium. No premium catch-ups will be allowed after the seventh rider year or if we no longer accept premiums for this rider. If the premium for the base policy is not paid before the end of its grace period and this rider has sufficient net cash value, we will automatically surrender a portion of the paid-up additional life insurance provided by this rider to pay the base premium to the next annual date in accordance with the Automatic Surrender Provision of this rider. These automatic surrenders, and any other surrenders, will decrease the death benefit of this rider. If the Automatic Surrender Provision is used to pay premiums, no further premiums for this rider will be accepted. The Waiver of Premium Benefit, if part of the policy, does not apply to premiums under this rider. ABR Stop Year: 121 Accelerated Benefit Rider(ABR-92): You may elect, if the insured is suffering from a terminal illness (as that term is defined in the rider), to receive a portion of the proceeds which are otherwise payable on the death of the insured. Any payment under the rider is subject to all the terms and conditions set forth in the rider. Further, the rider defines the circumstances under which an election to receive the benefit can be made and more fully describes how the benefit will be calculated. There is no premium charge for this rider. WL-05-100 Page: 4 of 11 State: OH
Definitions of Key Terms and Column Headings "Annual Date" - Means the same date each year as the policy's Date of Issue (the Date of Issue is the effective date for the policy. However, insurance coverage only takes effect under the policy if all requirements for such coverage have been met). "Annual Dividend" - For the purposes of the non-guaranteed elements depicted in this illustration, means the dividend we anticipate will be credited annually to this policy based on the percentage of our current dividend scale stated in the Other Important Information section of this illustration. Dividends are neither estimates nor guarantees. The first dividend, if any, will be credited once the entire premium for the second policy year has been paid. "Beneficiary" - Means the person(s) named to receive the death benefit and applicable rider benefits upon the death of the insured. "Contract Premium" - Means the gross premium required for the base policy and all riders shown in this illustration. This illustration assumes that premiums are paid on a(n) Annual basis. "Cumulative Premiums" - Means the total to date of all out-of-pocket premiums paid by you. "Death Benefit" - Means the amount payable, by reason of the insured's death, under the base policy and any riders which provide insurance on the life of the insured. It does not include benefits which may be payable under an Accidental Death Benefit Rider, if applicable. The death benefit will be reduced by any outstanding loans and loan interest and any unpaid premiums due at the insured's death. The death benefit will include any in force dividend additions under the base policy and any applicable riders. The death benefit will also include a pro rata share of the dividend for the policy year of death and a refund of premiums paid for any period after the insured's death. "Guaranteed Elements" - Are the premiums, benefits and values which are guaranteed. "Illustrated Scale" - Means the scale of non-guaranteed elements currently being illustrated by us. This scale is reasonably based on our actual, recent historical experience. The non-guaranteed elements of the illustration are based on 100% of our current dividend scale. "Insured" - Means the person named on page 1 of this illustration. "Non-Guaranteed Elements" - Are the premiums, benefits, and values that are not guaranteed. The assumptions on which these are based are subject to change by us and actual results may be more or less favorable. "Net Cash Value" - Means the amount of money we will pay you on surrender of the policy. It is equal to the cash value (which includes the cash value of any paid-up additions, which are still in force) less all indebtedness (loans and loan interest). (This illustration assumes that no loans will be taken.) "Paid-Up Additions" - Means that any dividend declared on this policy shall be used to purchase paid-up additional insurance. "Premium Outlay" - This column reflects the use of non-guaranteed elements to pay premiums. This illustration assumes that premiums are paid on a(n) Annual basis. "50% Illustrated Scale" - Is a scale of the non-guaranteed dividends reduced by 50%. This reduction includes the non-guaranteed interest and charges contained in the non-guaranteed elements of this illustration. WL-05-100 Page: 5 of 11 State: OH
Definitions of Key Terms and Column Headings "We, our, or us" - Means The Lafayette Life Insurance Company "You or your" - Means the owner(s) of the policy described in this illustration. The owner is also the applicant. This illustration assumes that the currently illustrated non-guaranteed elements will continue unchanged for all years shown. This is not likely to occur, and actual results may be more or less favorable than those shown. WL-05-100 Page: 6 of 11 State: OH
Numeric Summary Guaranteed Non-Guaranteed 50% Illustrated Scale Illustrated Scale Contract Net Cash Death Contract Premium Net Cash Death Contract Premium Net Cash Death Year Premium Value Benefit Premium Outlay Value Benefit Premium Outlay Value Benefit 5 1,000 3,055 201,199 1,000 1,000 3,087 201,868 1,000 1,000 3,119 202,540 10 1,000 7,901 253,365 1,000 1,000 7,998 255,002 1,000 1,000 8,095 256,656 20 1,000 22,153 330,937 1,000 1,000 22,534 335,290 1,000 1,000 22,923 339,738 Age 70 1,000 244,323 471,504 1,000 1,000 260,027 501,380 1,000 1,000 277,106 533,870 The non-guaranteed elements are not guaranteed. The assumptions on which they are based are subject to change by the insurer. Actual results may be more or less favorable. This policy as illustrated is a Modified Endowment Contract for tax purposes. In general, this means that policy distributions will be taxed on a "gain first" basis to the full extent of such gains in the policy. Such distributions may also be subject to a 10% penalty tax. Please review the Important Tax Information Section of the Narrative Summary and consult your tax advisor. I (we) have received a copy of this illustration and understand that any non-guaranteed elements illustrated are subject to change and could be either higher or lower. The agent has told me they are not guaranteed. Your Signature (owner/applicant) Date I certify that this illustration has been presented to the applicant and that I have explained that any non-guaranteed elements illustrated are subject to change. I have made no statements that are inconsistent with the illustration. Agent Date WL-05-100 Page: 7 of 11 State: OH
Tabular Detail Guaranteed Non-Guaranteed Assumptions 100% of Current Dividend Scale Increase in Contract Net Cash Death Contract Cum Annual Net Cash Net Cash Death Age Year Premium Value Benefit Premium Premium Dividend Value Value Benefit 1 1 1,000 561 151,288 1,000 1,000 9 570 570 151,498 2 2 1,000 1,146 164,487 1,000 2,000 10 595 1,165 164,941 3 3 1,000 1,755 177,206 1,000 3,000 12 622 1,788 177,933 4 4 1,000 2,391 189,441 1,000 4,000 14 651 2,439 190,465 5 5 1,000 3,055 201,199 1,000 5,000 15 681 3,119 202,540 6 6 1,000 3,746 212,491 1,000 6,000 17 710 3,830 214,168 7 7 1,000 4,584 223,338 1,000 7,000 19 861 4,691 225,381 8 8 1,000 5,644 233,753 1,000 8,000 22 1,085 5,776 236,195 9 9 1,000 6,749 243,757 1,000 9,000 23 1,134 6,910 246,609 10 10 1,000 7,901 253,365 1,000 10,000 26 1,185 8,095 256,656 11 11 1,000 9,103 262,590 1,000 11,000 27 1,237 9,332 266,329 12 12 1,000 10,347 271,448 1,000 12,000 30 1,284 10,616 275,661 13 13 1,000 11,641 279,957 1,000 13,000 33 1,338 11,954 284,670 14 14 1,000 12,980 288,130 1,000 14,000 36 1,388 13,342 293,371 15 15 1,000 14,368 295,986 1,000 15,000 40 1,442 14,784 301,777 16 16 1,000 15,810 303,536 1,000 16,000 43 1,502 16,286 309,902 17 17 1,000 17,307 310,795 1,000 17,000 46 1,563 17,848 317,757 18 18 1,000 18,861 317,774 1,000 18,000 48 1,624 19,472 325,330 19 19 1,000 20,475 324,484 1,000 19,000 52 1,690 21,162 332,654 20 20 1,000 22,153 330,937 1,000 20,000 55 1,760 22,923 339,738 21 21 1,000 23,902 337,143 1,000 21,000 59 1,839 24,761 346,591 22 22 1,000 25,720 343,109 1,000 22,000 63 1,915 26,676 353,222 23 23 1,000 27,613 348,847 1,000 23,000 67 1,999 28,675 359,636 24 24 1,000 29,590 354,363 1,000 24,000 71 2,090 30,765 365,842 25 25 1,000 31,644 359,666 1,000 25,000 75 2,177 32,941 371,845 26 26 1,000 33,784 364,763 1,000 26,000 81 2,273 35,214 377,675 27 27 1,000 36,008 369,663 1,000 27,000 85 2,367 37,581 383,315 28 28 1,000 38,320 374,374 1,000 28,000 90 2,465 40,046 388,772 29 29 1,000 40,725 378,902 1,000 29,000 94 2,568 42,614 394,053 30 30 1,000 43,225 383,255 1,000 30,000 101 2,677 45,290 399,183 31 31 1,000 45,829 387,441 1,000 31,000 105 2,792 48,082 404,149 32 32 1,000 48,529 391,464 1,000 32,000 112 2,903 50,986 408,973 33 33 1,000 51,336 395,332 1,000 33,000 117 3,023 54,008 413,642 34 34 1,000 54,248 399,051 1,000 34,000 124 3,143 57,151 418,181 35 35 1,000 57,264 402,628 1,000 35,000 132 3,263 60,414 422,593 36 36 1,000 60,388 406,067 1,000 36,000 140 3,388 63,802 426,883 37 37 1,000 63,627 409,376 1,000 37,000 147 3,522 67,324 431,056 38 38 1,000 66,988 412,559 1,000 38,000 155 3,661 70,985 435,115 39 39 1,000 70,480 415,622 1,000 39,000 163 3,812 74,797 439,064 40 40 1,000 74,106 418,569 1,000 40,000 171 3,968 78,765 442,905 41 41 1,000 77,870 421,404 1,000 41,000 179 4,126 82,891 446,642 42 42 1,000 81,773 424,132 1,000 42,000 191 4,291 87,182 450,294 43 43 1,000 85,818 426,758 1,000 43,000 199 4,454 91,636 453,847 44 44 1,000 90,007 429,285 1,000 44,000 212 4,628 96,264 457,325 45 45 1,000 94,339 431,717 1,000 45,000 228 4,802 101,066 460,742 46 46 1,000 98,808 434,059 1,000 46,000 247 4,974 106,040 464,110 47 47 1,000 103,416 436,314 1,000 47,000 262 5,145 111,185 467,414 WL-05-100 Page: 8 of 11 State: OH
Tabular Detail Guaranteed Non-Guaranteed Assumptions 100% of Current Dividend Scale Increase in Contract Net Cash Death Contract Cum Annual Net Cash Net Cash Death Age Year Premium Value Benefit Premium Premium Dividend Value Value Benefit 48 48 1,000 108,162 438,487 1,000 48,000 279 5,319 116,504 470,663 49 49& 1,000 113,042 440,580 1,000 49,000 292 5,482 121,986 473,841 50 50 1,000 118,049 442,598 1,000 50,000 309 5,646 127,632 476,967 51 51 1,000 123,190 444,545 1,000 51,000 326 5,817 133,449 480,043 52 52 1,000 128,453 446,423 1,000 52,000 346 5,977 139,427 483,075 53 53 1,000 133,840 448,235 1,000 53,000 369 6,145 145,572 486,076 54 54 1,000 139,351 449,986 1,000 54,000 387 6,308 151,881 489,032 55 55 1,000 144,984 451,677 1,000 55,000 411 6,477 158,358 491,963 56 56 1,000 150,733 453,312 1,000 56,000 436 6,641 164,999 494,869 57 57 1,000 156,594 454,893 1,000 57,000 462 6,800 171,799 497,751 58 58 1,000 162,568 456,423 1,000 58,000 491 6,967 178,766 500,620 59 59 1,000 168,663 457,904 1,000 59,000 515 7,137 185,903 503,462 60 60 1,000 174,882 459,338 1,000 60,000 540 7,313 193,216 506,278 61 61 1,000 181,236 460,727 1,000 61,000 568 7,504 200,720 509,076 62 62 1,000 187,722 462,074 1,000 62,000 599 7,697 208,418 511,864 63 63 1,000 194,343 463,380 1,000 63,000 633 7,897 216,314 514,646 64 64 1,000 201,099 464,646 1,000 64,000 662 8,092 224,407 517,412 65 65 1,000 207,989 465,875 1,000 65,000 696 8,294 232,701 520,170 66 66 1,000 215,014 467,067 1,000 66,000 731 8,497 241,198 522,921 67 67 1,000 222,165 468,225 1,000 67,000 764 8,691 249,889 525,661 68 68 1,000 229,435 469,349 1,000 68,000 801 8,881 258,770 528,398 69 69 1,000 236,826 470,442 1,000 69,000 840 9,078 267,848 531,135 70 70 1,000 244,323 471,504 1,000 70,000 880 9,257 277,106 533,870 71 71 423 251,350 471,504 423 70,423 918 8,860 285,965 535,569 72 72 423 258,435 471,504 423 70,845 963 8,995 294,960 537,303 73 73 423 265,572 471,504 423 71,268 1,004 9,121 304,081 539,064 74 74 423 272,748 471,504 423 71,690 1,051 9,239 313,320 540,860 75 75 423 279,960 471,504 423 72,113 1,099 9,356 322,676 542,692 76 76 423 287,199 471,504 423 72,536 1,147 9,461 332,138 544,556 77 77 423 294,459 471,504 423 72,958 1,194 9,562 341,699 546,450 78 78 423 301,736 471,504 423 73,381 1,249 9,664 351,363 548,385 79 79 423 309,018 471,504 423 73,804 1,299 9,750 361,113 550,351 80 80 423 316,304 471,504 423 74,226 1,357 9,842 370,955 552,358 81 81 423 323,507 471,504 423 74,649 1,417 9,836 380,791 554,409 82 82 423 330,517 471,504 423 75,071 1,483 9,705 390,496 556,511 83 83 423 337,354 471,504 423 75,494 1,550 9,600 400,097 558,664 84 84 423 344,034 471,504 423 75,917 1,611 9,506 409,603 560,860 85 85 423 350,535 471,504 423 76,339 1,674 9,388 418,991 563,100 86 86 423 356,927 471,504 423 76,762 1,735 9,349 428,340 565,381 87 87 423 363,121 471,504 423 77,185 1,799 9,206 437,546 567,706 88 88 423 368,960 471,504 423 77,607 1,873 8,884 446,429 570,089 89 89 423 374,449 471,504 423 78,030 1,948 8,566 454,996 572,533 90 90 423 379,670 471,504 423 78,452 2,009 8,329 463,324 575,018 91 91 423 385,016 471,504 423 78,875 2,044 8,543 471,867 577,513 92 92 423 390,635 471,504 423 79,298 2,062 8,921 480,788 579,994 93 93 423 396,187 471,504 423 79,720 2,098 8,904 489,693 582,484 94 94 423 401,404 471,504 423 80,143 2,152 8,572 498,265 585,006 WL-05-100 Page: 9 of 11 State: OH
Tabular Detail Guaranteed Non-Guaranteed Assumptions 100% of Current Dividend Scale Increase in Contract Net Cash Death Contract Cum Annual Net Cash Net Cash Death Age Year Premium Value Benefit Premium Premium Dividend Value Value Benefit 95 95 423 406,023 471,504 423 80,566 2,220 7,925 506,189 587,579 96 96 423 409,922 471,504 423 80,988 2,295 7,128 513,318 590,214 97 97 423 413,111 471,504 423 81,411 2,367 6,329 519,646 592,911 98 98 423 416,188 471,504 423 81,833 2,398 6,227 525,873 595,625 99 99 423 419,785 471,504 423 82,256 2,379 6,869 532,743 598,295 100 100 423 423,519 471,504 423 82,679 2,385 7,049 539,791 600,950 101 101 0 426,852 471,504 0 82,679 2,644 6,893 546,684 603,871 102 102 0 430,054 471,504 0 82,679 2,675 6,775 553,460 606,804 103 103 0 433,114 471,504 0 82,679 2,700 6,638 560,098 609,743 104 104 0 436,000 471,504 0 82,679 2,726 6,457 566,555 612,691 105 105 0 438,668 471,504 0 82,679 2,751 6,219 572,774 615,648 106 106 0 441,106 471,504 0 82,679 2,777 5,959 578,734 618,616 107 107 0 443,331 471,504 0 82,679 2,796 5,716 584,450 621,590 108 108 0 445,373 471,504 0 82,679 2,810 5,501 589,951 624,564 109 109 0 447,250 471,504 0 82,679 2,817 5,303 595,253 627,534 110 110 0 448,947 471,504 0 82,679 2,824 5,083 600,336 630,499 111 111 0 450,451 471,504 0 82,679 2,831 4,842 605,178 633,463 112 112 0 451,814 471,504 0 82,679 2,838 4,669 609,847 636,424 113 113 0 453,143 471,504 0 82,679 2,826 4,620 614,468 639,364 114 114 0 454,549 471,504 0 82,679 2,807 4,712 619,180 642,276 115 115 0 455,798 471,504 0 82,679 2,800 4,502 623,682 645,173 116 116 0 456,981 471,504 0 82,679 2,787 4,407 628,089 648,049 117 117 0 458,113 471,504 0 82,679 2,767 4,322 632,411 650,897 118 118 0 459,103 471,504 0 82,679 2,753 4,120 636,531 653,724 119 119 0 460,065 471,504 0 82,679 2,726 4,060 640,591 656,518 120 120 0 461,277 471,504 0 82,679 2,672 4,359 644,950 659,249 121 121 0 471,504 471,504 0 82,679 1,615 15,914 660,864 660,864 WL-05-100 Page: 10 of 11 State: OH
Additional Information Life Insurance Cost Information Net Payment Cost Index Surrender Cost Index Guaranteed Projected Guaranteed Projected Year 10 3.07 3.02 2.47 2.42 Year 20 3.07 3.02 1.97 1.93 These indices are computed by the formulae as prescribed by the National Association of Insurance Commissioners, and reflect the time value of money at 5%. These indices do not include the cost of additional benefits. First Year Premiums Premium Information Premiums in this illustration are assumed to be paid on a(n) Annual basis. Regularly Billed Premiums Paid Annual Base Policy $422.62 Accelerated Benefit Rider(ABR-92) $0.00 Level Premium Paid-up Additions Rider $577.38 Underwritten Annual LPUA Premium $577.38 Max LPUA Premium: Years 8+ $577.38 & $1,000.00 The initial 7-pay premium for the policy as illustrated is $1,000.01 per year. The policy, as illustrated, will become a MODIFIED ENDOWMENT CONTRACT (MEC) in year 49. Please review the adverse tax consequences described above in Important Tax Information regarding this MEC status. Underwriting Requirements Primary Insured Underwriting Requirements Level A ($219,045): o Nonmedical Underwriting Additional Information The above underwriting requirements are based solely on age and death benefit of the proposed insured. They do not take into account other factors which may affect underwriting, such as adverse medical history and/or total life insurance applied for and/or inforce with this and all other companies. Under these circumstances please contact The Lafayette Life Insurance Company Underwriting Department to determine if any additional requirements are necessary. If the insured has had a complete favorable physical within the last 12 months which is available for us to review, Nonmedical underwriting may apply. These Expanded Nonmedical Limits depend on age and death benefit amount, according to the following schedule: ages 0-30 up to $500,000; ages 31-35 up to $400,000; ages 36-45 up to $200,000, and ages 46-50 up to $100,000. Refer to Agents Reference Manual page B-16 for further details. WL-05-100 Page: 11 of 11 State: OH