|
Insured:
|
[JOHN DOE]
|
Issue Age and Sex:
|
[35] [MALE]
|
|
Rate Class:
|
[PREFERRED]
|
|
|
|
Owner:
|
[JOHN DOE]
|
|
|
|
Initial Specified Amount:
|
$[100,000]
|
Policy Date:
|
[JANUARY 1, 2026]
|
|
Minimum Specified Amount:
|
$[25,000]
|
Date of Issue:
|
[JANUARY 1, 2026]
|
|
Monthly Anniversary Day:
|
[01]
|
|
|
|
Policy Year
|
Monthly Accumulation Factor
|
Monthly No-Lapse Premium
|
|
[1 - 35
|
[1.00407413
|
$[146.15]
|
|
36] and thereafter
|
1.00486756]
|
$0.00
|
|
Long-Term Care Benefits Rider
|
|
|
Minimum LTC Duration:
|
[36] months
|
|
Initial LTC Benefit Pool:
|
$[150,000.12]
|
|
Initial Maximum Monthly LTC Benefit
|
$[4,166.67]
|
|
Benefit Payment Option Coverage
|
|
|
Maximum Monthly LTC Benefit (Reimbursement):
|
$[4,166.67]
|
|
CareFlex Plus Benefit Pool:
|
$[8,333.34]
|
|
Maximum Monthly LTC Benefit (Indemnity):
|
$[3,333.34]
|
|
Indemnity Choice Factor:
|
[80%]
|
|
Market Benefit Floor:
|
$[37,500.00]
|
|
Market Benefit Multiplier:
|
[4]
|
|
Market Benefit Divisor:
|
[20]
|
|
Market Death Benefit Divisor:
|
[36]
|
|
[Protection Factor:
|
[0.6250000000]]
|
|
International Benefit Limit
|
[36] months
|
|
Insured's
Attained Age
|
Rider
Death Benefit
|
Rider
LTC
Benefit
|
Insured's
Attained Age
|
Rider
Death Benefit
|
Rider
LTC
Benefit
|
Insured's
Attained Age
|
Rider
Death Benefit
|
Rider
LTC
Benefit
|
|
[50
|
$1,480
|
$2,220
|
81
|
$1,070
|
$1,440
|
112
|
$1,031
|
$1,547
|
|
51
|
$1,456
|
$2,177
|
82
|
$1,070
|
$1,434
|
113
|
$1,029
|
$1,544
|
|
52
|
$1,432
|
$2,134
|
83
|
$1,070
|
$1,429
|
114
|
$1,028
|
$1,542
|
|
53
|
$1,409
|
$2,093
|
84
|
$1,070
|
$1,424
|
115
|
$1,027
|
$1,541
|
|
54
|
$1,387
|
$2,053
|
85
|
$1,070
|
$1,418
|
116
|
$1,026
|
$1,539
|
|
55
|
$1,364
|
$2,012
|
86
|
$1,070
|
$1,426
|
117
|
$1,025
|
$1,538
|
|
56
|
$1,343
|
$1,975
|
87
|
$1,070
|
$1,434
|
118
|
$1,024
|
$1,536
|
|
57
|
$1,322
|
$1,937
|
88
|
$1,070
|
$1,442
|
119
|
$1,023
|
$1,535
|
|
58
|
$1,302
|
$1,901
|
89
|
$1,070
|
$1,450
|
120
|
$1,022
|
$1,533]
|
|
59
|
$1,282
|
$1,866
|
90
|
$1,070
|
$1,458
|
|
|
|
|
60
|
$1,264
|
$1,833
|
91
|
$1,070
|
$1,466
|
|
|
|
|
61
|
$1,246
|
$1,801
|
92
|
$1,070
|
$1,474
|
|
|
|
|
62
|
$1,229
|
$1,770
|
93
|
$1,070
|
$1,482
|
|
|
|
|
63
|
$1,213
|
$1,741
|
94
|
$1,070
|
$1,490
|
|
|
|
|
64
|
$1,198
|
$1,714
|
95
|
$1,070
|
$1,498
|
|
|
|
|
65
|
$1,184
|
$1,688
|
96
|
$1,068
|
$1,504
|
|
|
|
|
66
|
$1,171
|
$1,663
|
97
|
$1,065
|
$1,507
|
|
|
|
|
67
|
$1,158
|
$1,639
|
98
|
$1,061
|
$1,510
|
|
|
|
|
68
|
$1,146
|
$1,616
|
99
|
$1,057
|
$1,512
|
|
|
|
|
69
|
$1,135
|
$1,595
|
100
|
$1,054
|
$1,516
|
|
|
|
|
70
|
$1,125
|
$1,575
|
101
|
$1,051
|
$1,519
|
|
|
|
|
71
|
$1,115
|
$1,556
|
102
|
$1,048
|
$1,523
|
|
|
|
|
72
|
$1,105
|
$1,536
|
103
|
$1,046
|
$1,528
|
|
|
|
|
73
|
$1,095
|
$1,517
|
104
|
$1,045
|
$1,534
|
|
|
|
|
74
|
$1,085
|
$1,498
|
105
|
$1,043
|
$1,539
|
|
|
|
|
75
|
$1,075
|
$1,479
|
106
|
$1,041
|
$1,544
|
|
|
|
|
76
|
$1,070
|
$1,466
|
107
|
$1,039
|
$1,549
|
|
|
|
|
77
|
$1,070
|
$1,461
|
108
|
$1,038
|
$1,555
|
|
|
|
|
78
|
$1,070
|
$1,456
|
109
|
$1,036
|
$1,554
|
|
|
|
|
79
|
$1,070
|
$1,450
|
110
|
$1,034
|
$1,551
|
|
|
|
|
80
|
$1,070
|
$1,445
|
111
|
$1,033
|
$1,550
|
|
|
|
|
Minimum Rider Loan Amount:
|
$[100.00]
|
|
|
|
||
|
Minimum Rider Loan Repayment
|
$[25.00]
|
|
|
|||
|
Amount:
|
|
|
|
|
|
|
|
Rider Loan Interest Rate Charged:
|
4.00% annual effective rate in all Policy Years.
|
|||||
|
|
|
Table of Rider Surrender Value Factors
|
||||
|
The Rider Surrender Value Factors below are based on the Insured's sex and Attained Age, using the Ultimate 2017
|
||||||
|
CSO, Male/Female, Composite Tobacco, Age Last Birthday mortality table. See the Benefit Transfer Rider for an
|
||||||
|
explanation of how this table will be used.
|
|
|
|
|
||
|
|
|
Rider
|
|
Rider
|
|
Rider
|
|
|
Insured’s
|
Surrender
|
Insured’s
|
Surrender
|
Insured’s
|
Surrender
|
|
|
Attained
|
Value
|
Attained
|
Value
|
Attained
|
Value
|
|
|
Age
|
Factor
|
Age
|
Factor
|
Age
|
Factor
|
|
|
[35
|
$397.76
|
64
|
$568.13
|
93
|
$898.09
|
|
|
36
|
$397.76
|
65
|
$581.34
|
94
|
$903.09
|
|
|
37
|
$397.76
|
66
|
$594.64
|
95
|
$907.95
|
|
|
38
|
$397.76
|
67
|
$608.02
|
96
|
$912.74
|
|
|
39
|
$397.76
|
68
|
$621.48
|
97
|
$917.29
|
|
|
40
|
$397.76
|
69
|
$635.03
|
98
|
$921.59
|
|
|
41
|
$397.76
|
70
|
$648.63
|
99
|
$925.54
|
|
|
42
|
$397.76
|
71
|
$662.23
|
100
|
$929.10
|
|
|
43
|
$397.76
|
72
|
$675.78
|
101
|
$932.30
|
|
|
44
|
$397.76
|
73
|
$689.22
|
102
|
$935.20
|
|
|
45
|
$397.76
|
74
|
$702.54
|
103
|
$937.82
|
|
|
46
|
$397.76
|
75
|
$715.68
|
104
|
$940.22
|
|
|
47
|
$397.76
|
76
|
$728.67
|
105
|
$942.50
|
|
|
48
|
$397.76
|
77
|
$741.51
|
106
|
$944.84
|
|
|
49
|
$397.76
|
78
|
$754.22
|
107
|
$947.30
|
|
|
50
|
$397.76
|
79
|
$766.77
|
108
|
$949.66
|
|
|
51
|
$408.62
|
80
|
$779.15
|
109
|
$951.91
|
|
|
52
|
$419.71
|
81
|
$791.32
|
110
|
$954.08
|
|
|
53
|
$431.04
|
82
|
$803.25
|
111
|
$956.15
|
|
|
54
|
$442.59
|
83
|
$814.86
|
112
|
$958.14
|
|
|
55
|
$454.36
|
84
|
$826.05
|
113
|
$960.04
|
|
|
56
|
$466.35
|
85
|
$836.74
|
114
|
$961.86
|
|
|
57
|
$478.54
|
86
|
$846.87
|
115
|
$963.60
|
|
|
58
|
$490.91
|
87
|
$856.34
|
116
|
$965.26
|
|
|
59
|
$503.46
|
88
|
$865.08
|
117
|
$966.85
|
|
|
60
|
$516.16
|
89
|
$873.07
|
118
|
$968.35
|
|
|
61
|
$529.00
|
90
|
$880.30
|
119
|
$969.70
|
|
|
62
|
$541.96
|
91
|
$886.83
|
120
|
$972.76
|
|
|
63
|
$555.00
|
92
|
$892.72
|
121 and later
|
$1,000.00]
|
|
[1
|
$[1,833.00
|
|
2
|
$1,746.00
|
|
3
|
$1,658.00
|
|
4
|
$1,568.00
|
|
5
|
$1,479.00
|
|
6
|
$1,388.00
|
|
7
|
$1,296.00
|
|
8
|
$1,203.00
|
|
9
|
$1,110.00
|
|
10
|
$1,015.00
|
|
11
|
$742.00
|
|
12
|
$498.00
|
|
13
|
$292.00
|
|
14
|
$126.00
|
|
15 and thereafter]
|
$0.00]
|
|
Policy
Year
|
Monthly
Rate
|
Policy
Year
|
Monthly
Rate
|
Policy
Year
|
Monthly
Rate
|
|
[1
|
0.11758
|
36
|
1.52184
|
71
|
50.89244
|
|
2
|
0.12842
|
37
|
1.69912
|
72
|
53.99864
|
|
3
|
0.14094
|
38
|
1.90568
|
73
|
58.09567
|
|
4
|
0.15263
|
39
|
2.14001
|
74
|
62.62918
|
|
5
|
0.16515
|
40
|
2.40147
|
75
|
67.67469
|
|
6
|
0.17767
|
41
|
2.68599
|
76
|
73.32811
|
|
7
|
0.18936
|
42
|
2.99295
|
77
|
79.71406
|
|
8
|
0.19939
|
43
|
3.32601
|
78
|
80.11620
|
|
9
|
0.20356
|
44
|
3.69588
|
79
|
80.51834
|
|
10
|
0.20941
|
45
|
4.11521
|
80
|
80.92048
|
|
11
|
0.21442
|
46
|
4.59696
|
81
|
81.32262
|
|
12
|
0.22027
|
47
|
5.14125
|
82
|
81.72477
|
|
13
|
0.22611
|
48
|
5.78293
|
83
|
82.12691
|
|
14
|
0.23113
|
49
|
6.55095
|
84
|
82.52905
|
|
15
|
0.23948
|
50
|
7.44129
|
85
|
82.93119
|
|
16
|
0.25118
|
51
|
8.47400
|
86
|
83.33333
|
|
17
|
0.26622
|
52
|
9.66230
|
87 and
|
0.00000]
|
|
18
|
0.28294
|
53
|
11.01321
|
later
|
|
|
19
|
0.30300
|
54
|
12.50715
|
|
|
|
20
|
0.32558
|
55
|
14.11597
|
|
|
|
21
|
0.35235
|
56
|
15.80879
|
|
|
|
22
|
0.38247
|
57
|
17.53629
|
|
|
|
23
|
0.41762
|
58
|
19.27103
|
|
|
|
24
|
0.45782
|
59
|
20.96545
|
|
|
|
25
|
0.50473
|
60
|
22.53736
|
|
|
|
26
|
0.55754
|
61
|
24.21720
|
|
|
|
27
|
0.61877
|
62
|
26.25159
|
|
|
|
28
|
0.68759
|
63
|
28.51121
|
|
|
|
29
|
0.76488
|
64
|
31.02914
|
|
|
|
30
|
0.84811
|
65
|
33.77547
|
|
|
|
31
|
0.93648
|
66
|
36.61924
|
|
|
|
32
|
1.03082
|
67
|
39.44941
|
|
|
|
33
|
1.13202
|
68
|
42.34621
|
|
|
|
34
|
1.24347
|
69
|
45.25809
|
|
|
|
35
|
1.37197
|
70
|
48.12900
|
|
|
|
Insured’s
Attained Age
|
Corridor Percentage
|
Insured’s
Attained Age
|
Corridor Percentage
|
|
[35
|
361%
|
71
|
151%
|
|
36
|
351%
|
72
|
148%
|
|
37
|
342%
|
73
|
145%
|
|
38
|
334%
|
74
|
143%
|
|
39
|
325%
|
75
|
140%
|
|
40
|
317%
|
76
|
138%
|
|
41
|
309%
|
77
|
135%
|
|
42
|
302%
|
78
|
133%
|
|
43
|
294%
|
79
|
131%
|
|
44
|
287%
|
80
|
129%
|
|
45
|
280%
|
81
|
127%
|
|
46
|
273%
|
82
|
125%
|
|
47
|
266%
|
83
|
123%
|
|
48
|
260%
|
84
|
122%
|
|
49
|
253%
|
85
|
120%
|
|
50
|
247%
|
86
|
119%
|
|
51
|
241%
|
87
|
117%
|
|
52
|
235%
|
88
|
116%
|
|
53
|
229%
|
89
|
115%
|
|
54
|
223%
|
90
|
114%
|
|
55
|
218%
|
91
|
113%
|
|
56
|
212%
|
92
|
112%
|
|
57
|
207%
|
93
|
111%
|
|
58
|
202%
|
94
|
110%
|
|
59
|
197%
|
95
|
109%
|
|
60
|
193%
|
96
|
108%
|
|
61
|
188%
|
97
|
107%
|
|
62
|
184%
|
98
|
106%
|
|
63
|
180%
|
99
|
103%
|
|
64
|
176%
|
100
|
100%]
|
|
65
|
172%
|
and later
|
|
|
66
|
168%
|
|
|
|
67
|
164%
|
|
|
|
68
|
161%
|
|
|
|
69
|
158%
|
|
|
|
70
|
154%
|
|
|