Transcription
This is only a sample policy. It is nota promise to issue coverage.You cannot buy this policy directly fromForesters Financial.It is sold only via licensed agencies such as Choice Mutual.To apply, call Choice Mutual(licensed to sell from Foresters Financial products)at 1-800-644-2926.
The Independent Order Of Foresters (‘Foresters’)Head Office: 789 Don Mills Road, Toronto, Ontario, Canada M3C 1T9U.S. Mailing Address: P.O. Box 179, Buffalo, New York 14201-01791-800-828-1540InsuredJohn DoeCertificate NumberrOwnerJane SmithIssue DateState GoverningAlaska12345671234567LEMMaarr 0202 20122012MaruummbeberrBranch Number1234123478978900123-456-7890Alaska Department of Insurance telephone numberForesters PlanRightRRighighttThis is a WHOLE LIFE INSURANCE CERTIFICATE.Pwee,, ouourr,, FFoorreesstteerrss oorr uuss)) wwillill,, ssububjeubjecctt tto the provisions ofThe Independent Order Of Foresters (referred to as wwe,our,Forestersus)will,subjectiipptt ooff pprrooooff ooff tthhee iinnssuurreedd’’ss deadeatthh. ThatTThh death must occurthis certificate, pay the death benefit upon our receiptprooftheinsured’sdeath.while this certificate is in effect.ALuurrrrendendeerr oror maturity.mmaattuurriittyy. CashCCaasshh valuesvvaalluueess areaarree guaranteed, based uponCASH SURRENDER VALUE payable at surrenderpayment of required total premiums.TUpapayyababllee areaarree shownsshhoowwnn inin thethe CertificateCCeerrttiiffiiccaatteeDData Pages.PaPaggeessPREMIUM AMOUNTS and years payableUMMeecceeiivvee dividends.ddiivviidenddends.s.PARTICIPATING, eligible to receiveOICEyyouourr meanmmeaeann thetthhee owner,oowwnenerr,, asas shownsshohowwnn above.abo . TheThe owneroIn this certificate, you and yourmay change after the issuedate as described in thishhiiss teded atat ourour head officeooffffiiccee on thethe issueiissss date.dadatteeThis certificate is executedSAPLEASECAREFULLY.PPLLEEAASSEE READRREEAADD THIST S CERTIFICATECECERRTTFRghghtt toto ExamineEExxaammiinnee – IfIf youyou areaarree notnnoott satisfiedssaattiissffwitwithh this certificate, you may return it to us within 10 daysRightwithffiirrsstt receivingrreceeceiivviinngg it.iitt. YouYYoouu cancan dodo tththishiiss by mailingiingng it to our U.S. mailing address, shown above, or byoff firstreturningourauthorizedrreettuurrnniingng iitt ttoo ononeeooff oouurr aauutthhoorriizz representatives.If tthisthhiiss certificatecceerrtrtiiffiiccaattee isis returnedrreettuurrnedned tot us during this time period, the insurance contract will be deemed to bevoid10 days after we receive it, we will refund premiums you have paidvvooiidd fromffrroomm thethe issueiissssuuee date.ddaattee WithinWtoto usus forffoorr thethe insuranceiinnssuurrananccee contract.Executive SecretaryICC12-WL-PRL-US01International Fraternal President
Foresters PlanRightThis certificate is part of a legal insurance contract between the owner and Foresters. TheThe insurancecontract sets forth, in detail, the rights and obligations for both you and us. Only the actualaaccttuauall insuranceiinncontract provisions will control. It is important that you read your insurance contractaacctt carefully.ccaarreeffuullllyy.LEThe benefit provided under each rider, if any, is described in that rider.If you have questions about this certificate or a rider, your understandingnngg ofof themtthheemm oror aboutaabbououttssee callccaallll us.uuss. OurOOuurr tollttoollll freeffrreeee numbernunummbeberrinformation that you have heard, seen or read relating to them, pleaseis 1-800-828-1540.Table of ContentsICC12-WL-PRL-US01LAUMEICOHCOMFRSAMTUPTable of Contents.2.Certificate Data Pages .3.Definitions .5.Consideration .7.Entire Contract .7.When this Certificate is in Effect.7.Control of Insurance Contract.8.Assignment .8.Beneficiaries .8.Payment to Beneficiary .9.Death Benefit .9.Payment of Death Benefiteneneeffiitt .9.Amount of Death Benefit.9BBeneneeffiitt.Incontestability .10.Suicide .10.Premiums.10.Grace Period.11. .Reinstatement.11eenntt .Cash Value.uuee .12Nonforfeiture12ffeeiittuurree .OptionOOppttiionon 1 – ReducedRRedueducceded Paid-UpPPaaiidd--UUpp LifeLLiiffee InsuranceI uurranancece .12OptionCashSurrenderOOppttiionon 2 – CCaasshhSSuurrrrenenddeerr .13.BasisComputation13BBaassiiss ooff CCoommpuputtaattiionon ofof ValuesVVaallueuess .13LoanLoanss .Requested.14RReeqqueuesstteded LoaLoann .AutomaticPremiumLoan.14AAuuttoommaattiicc PPrreemmiiuumm LoMisstatementAgeSex . 15MMiissssttaatteemmeenntt ooff AAggeeoorr SConformitywithInterstateCCononffoormrmiittyy wwiitthh IInntteerrssttaa Insurance Product Regulation Commission Standards. 15LimitationAction.LLiimmiittaattiionon ooff AAccttiioonn15LaLawwAAppppliliccaabbllee .Applicable. 15LimitingEffectof our Constitution . 15mmiittiingng EEffffeecctt oSuspensionpenpenssiionon or Expulsion. 15Maintenanceenan of Reserves. 16Basis of Computation of Reserves . 16Dividends . 16Notification . 17Page 2 of 18
Certificate Data PagesJohn DoeJane SmithMarch 2, 2012 10,000.00Non-Tobacco 31.83United StatesForesters PlanRight CertificateIssue Age and Sex of Insured 50 Male12345612345677Certificate NumberMMaarrcchh22,, 20208833Maturity DateMarch208312312344Branch NumberRating ClassStandardSSttandandaarrddMMonontthhllyyPayment ModeMonthly7711Years PayableLEInsuredOwnerIssue DateFace AmountInsurance ClassTotal PremiumCurrencyProvides life insurance to the maturity date, subject to thehe provisionspprroovviissiioonnss ofof thistthhiiss certificate,cceerrtrtiiffiiccaattee,, asas longlong as the totalonon. TheTThhee firstffiirrsstt totalttoottaall premiumpprreemmiiuumm isis due onon March 2, 2012.premium is paid as described in the Premiums provision.Pssuurrrrendendeerr anandd thetthhee maturitymmaattuurriittyy date.dadattee. ThisTThhii certificate is eligible toCash surrender value is payable on the earlier of surrenderparticipate in our divisible surplus, however dividendsvviiddendendss areaarree notnot guaranteedgguauarraanntteeeedd and areaarree notn expected or anticipatedto be paid by us under this certificate.UMMTUALEach beneficiary is designated in, or indesignation mayn a formffoorrmm accompanying,aaccccoommpanpanyyiinngg,, thetthhee application.appappliliccaattiionon A beneficiarybenbeneechange as described in the Beneficiaryaarryry y ofof BenefitsBBeenneeffiittss ProvidedP vviiddeeddBeneffBenefitBeneAmountAmAm 10,000 1 20,000Expiry Date*OICCoverageAnnualPremiumHCOMFRSAForesters PlanRightRiRigghhtt FFaFaceacceeAAmAmountmouounnttMarch 2, 2083 343.80Common Carrierrrrriieerr AccidentalAAcccciiddeennttaall DeathDDeaeatthh RiderRiRidederrMarch 2, 2083 0.00 Maximummmuumm AccidentalAAcccciidedennttaall DeathDDeeaatthh AmountAAmmounountt – 30 300,000 3000 0Accidentaldendenttaall DeathDDeaeatthh RiderRiRidederr 10,000March 2, 2083 20.00* Latesteesstt ccoveragecoovveerraaggee expiryeexxppiirryy date,dadattee,, assumingaassssuummiingng allall premiumsememiiuumm are paid as due. Coverage may end earlier than theexpiryorrider, if any.ppiirryy datedadattee asas describeddedessccrriibedbed withinwiwitthhiinn thethe certificatecceerrttiiffor applicableaPremium ScheduleAAnnualAnnuannuaSemi-AnnualQuarterly 185.54 94.59TotalTToottaall PPremiumPrreemmiiuumm 363.80 363363AfterAAftfteerr tththehee iississuessuuee dadatdatetee notno all payment modes shown may be available.EachEEaacchh totalttoottaall premiumpprreemmiiuu shown above includes the applicable certificate fee.AnnualSemi-AnnualQuarterly 18.36 9.36Certificateiiccaatt Fee 36.00ICC12-WL-PRL-US01Monthly 31.83Years Payable71Monthly 3.15Page 3 of 18
Certificate Data PagesCertificate Number 1234567Table of Guaranteed Certificate Values 7,676777AAgeAggee 6060AgeAAggee 6565 1,5205205202,22,573,575733ReducedPaid-Up Amount*ounountt** 0 1144 525244 11,1,010,010100 11,1,473,474733 11,1,912,919122 2,33022,,333300 22,2,730,737300 33,3,112,111122 33,3,478,474788 33,3,827,828277 44,4,158,151588 44,4,471,474711 44,76776 5,048048048 55,5,316,313166 55,57157 5,816 6,050 6,275LATUUMEICOHCOM 141516161717181819192020Valuesueuess shownsshohowwnn areaarree asas ofof thetthhee endeenndd ofof thetthhee applicableppliliccappabb certificate year. Values shown assume that totalpremiumspprreemmiiuummss areaarree paidppaaiidd asas due andand thattthhaatt no changes are made to this certificate. Paid-up additionalinsuranceiinnssuurrananccee oror dividendsddiivviidenddendss on deposit,dedeppooss if any, will increase the reduced paid-up insurance amountsshownsshohowwnn and debtddeebbtt willwill decreasededeccrreaeassee those amounts. Paid-up additional insurance, dividends on deposit ordebt,debdebtt,, ifif any,aannyy,, willwwiillll notnot affectaafffffefecctt thetthh cash values shown. Values at the end of certificate years not shownwillSubject to the Basis of Computation of Values provision, calculationswwiillll be furnishedffuurrnniisshheded uponuuppoonn request.rreeofof cashccaasshh valuesvvaallueuess duringdduurriinngg a certificate year will be done on a consistent basis and be based upon thetotalttoottaall premiumspprreemmiiuummss paidpapaiidd and time elapsed during that certificate year.Non-Forfeiturenn--FFoorrfrfeeiittuurree Interest Rate: 4.50%t the Reduced Paid-Up Life Insurance provision.*Subject toICC12-WL-PRL-US01Page 4 of 18
DefinitionsThe following terms have specific meanings for the purposes of your certificate. Whererree thetthhee sameheherr definitionddeeffiinniittiionon forterm appears in a rider, if any, it also has that same meaning unless there is anotherthat same term in that rider.LEof completedccoommpplleetteded certificatecceerrtrtiiffiiccaatteeAge – The issue age shown in the Certificate Data Pages plus the number ofyears.iiss certificatecceerrtrtiiffiiccaattee andaanndd eacheeaacchh attachedaattttaaccheheddApplication – The application that was completed and signed for thisrider.Assignee – A person or entity indicated in an assignment ass thethe recipientrreecciippiienentt ofof thethe assignedaassssiignedned interest.inteAttached rider(s) – Each rider, if any, listed in the Certificatertirttififificcaattee DataDDaattata Pages.PagePagess.PCertificate – The cover page and each numbereded pageppaaggee thattthhaatt followsffoolllloowwss it,it, startingssttaarrtrtiinngg withwwiitthh page number 2and ending with the page that states, “This is thehe lastllaasstt pageppaaggee ofof thistthhiiss certificate”.cceerrtrtiiffiiccaattee””. TheTThhee cover pagecontains the signatures of our Executive Secretaryccrreettaarryry and InternationalIInntteerrnnaattiioonanall FraternalFFrraatteerrnanall President.ALCertificate anniversary – The same monthmmonontthh andand dayddaayy asas thetthhee issueiissssueue dateddaattee forffoo eachea calendar yearfollowing the issue date, while this certificateeerrtrtiiffiiccaattee isis inin effect.eeffffeecctt.UMMTUppaaggeess markedmmaarrkkeedd asas thetthhee CertificateCCeerrtrtitififificcaattee DataDPagPagee within this certificate atCertificate Data Pages – The pagesPagesto you.yyouou.the time that it was delivered toCHOICECertificate month – Thehe firstffiirrsstt dayddaayy ofof thethhee firstffirirsstt certificatecceerrtrtiiffiiccaattee monthm h isis thetthh issue date and the last day isthe day before the firstsstt monthlymmoonntthhllyy anniversary.annanniivveerrssaarryry. ForFFoorr everyeevveerryry otherherr ccehecertificateerrmonth, the first day of ammoonntthhllyy anniversaryannanniivveerrssaarryry and thethe lastllaa daydadayy isis thet day before the next monthlycertificate month iss a monthlyanniversary.OMFRSACertificatee yearyyeaearr – TheThe firstffiirrsstt dayday ofof thethe firstffiirrsstt certificateccee iiccaattee year is the issue date and the last day is theday beforeoorree thetthhee firstffiirrsstt certificatecceerrttiiffiiccaattee anniversary.aannnniivveerrssaarryry Fororr everyoevveee other certificate year, the first day of aiiccaattee yearyyeaearr isis a certificatecceerrtrtiiffiiccaattee anniversaryannanniivveerrssaa and thetthh last day is the day before the next versary.Contingentownercontingentowner named, if at all, in the application, unless changed asCCononttiingngeenntt oowwnneerr – TThehe ccoonnttiishownsshohowwnn inin ourour records.rreeccoorrddss.DDaattee wewe deliveredddeelilivveerreedd – TheThe effective date of delivery being either:Date theif hand delivered to the owner or the owner's address;the dayday ofof delivery,ddeelili thethe fifthffiiftfthh dayday after mailing, if sent by mail to the owner's address; orthe earliereaearrlili of a) the day successfully transmitted, if sent electronically to a number or theaddressaddaddrree shown for the owner in our records, and b) the day retrieved, if retrievedeelleeelectronicallyby the owner, from a site identified by us.Death benefit – The amount payable as described in the Death Benefit provision.ICC12-WL-PRL-US01Page 5 of 18
Debt – The amount owed to us under the Maintenance of Reserves, Grace Period and Loansprovisions.e notifynnoottiiffyfy youyou of,Designated office – Our head office or any other office, location or address that weor publish, as being a designated office for the identified purpose.LEssoo,, onon whatwwhahatt terms.tteerrmms.s.Evidence of insurability - Information we obtain to decide insurability and,, ifif so,he faceffaaccee amount,aammoouunnt,t, unlessununlleessssFace amount – The amount shown in the Certificate Data Pages as thechanged as shown in our records.Grace period – The period of time within which to pay an overduerrduedue totalttoottaall premiumpprreemmiiuumm asas describedddeescscrriibedbed ininthe Grace Period provision.n effect,eeffffeecct,t, ifif any.ananyy.Insurance contract – This certificate and each rider inPLapse – The termination of this certificate for non-paymentduring the--ppaayymmenentt ofof overdueoovveerrduedue totalttoottaall premiumspprreemmiiuugrace period.ATUOur records – The records at ourr headheheaadd office.oofffffiiccee.Lonontthh afteraafftf teerr thethe issueiissssuuee date,ddaattee,, on thethe samessaamm date of each monthMonthly anniversary – Occurs each monthas the date shown as the issue date.UMEMccee–TThehe aammouounntt ooff tthehe papaiidd--uupp additionalaadd iioonanall insuranceiPaid-up additional insuranceamountpaid-upbought underpprroovviissiionon.option 1 of the Dividend provision.HOICRider(s) – Each attachedcchheded rider,rriidederr,, ifif any,ananyy,, andaanndd eacheaeacchh riderrriidederr addeda eedd asas an attachment, if any, to thise issueiissssueue date,ddaattee,, asas shownsshohowwnn inin ouroouurr records.rreeccoo s.certificate after theOMCrnrniingng – TheTThhee statessttaattee shownsshhoowwnn asas thetthhee statessttaa governinggogovveerrnnState governingon the cover page, which will be therree thethe applicationaappppliliccaattiionon waswwaass signedssiiggnedned byby thethe owner.owownenerrstate whereFRSAouourr,, usus aandnd ForestersForForeesstteersrs – TheTThhee IndependentIInndede enendedenntt OrderOof Foresters.We, our,YYouou,, youryour - TheThe owneroowwnenerr ofof thistthhiiss certificatecceerrttYou,as shown in the Certificate Data Pages subject to changeas describeddedescscrriibbeded inin thistthhiiss certificate.cceerrtrtiiffiiccaatteeasWhen wewe referrreeffeerr inin thistthhiiss certificatecceerrtrtiWhento a provision, unless specifically stated to be a provision in a rider,we meanmean thetthhee provisionpprroovviissiionon in this certificate with that title. When we refer in a rider to a provision,weununlleessss specificallysspepecciiffiiccaallllyy statedssttunlessto be a provision in the certificate, we mean the provision in that rider withtthahatt title.ttiittllee.thatICC12-WL-PRL-US01Page 6 of 18
Certificate ProvisionsConsiderationLEWe issue this certificate and attached rider(s) based on the application signedned byby thethe owneroowwnenerr andthe payment of premiums as described in this certificate.Entire ContractThe entire contract consists of each of the following:1.2.3.4.The insurance contract, including agreements and endorsementsnndodorrsseemmeennttss toto it.iitt.The application for this certificate and each attachedeedd rider,rriidederr,, ifif any.ananyy.Notifications we send to you confirming changess mmamadeaddee toto thistthhiiss certificatecceerrtrtiiffiiccaattee oror a rider.rriidederrand thetthhee respectiverreessppeeccttiivvee amendments.aammenenddmmeenntts.s.Our Instrument of Incorporation, Constitution,, andPdedeeemmeedd toto be representations,rreepprreesseennttaattiiononss,, notnot warranties.wAll statements in the application shall be deemedUMEMTUALNo one, including the producer who providedrroovviidedded youyou withwwiitthh thistthhiiss certificate,cceerrtrtiiffiiccaattee,, cancan makemamakk a promise orttrraacctt otheroottheherr thanthan whatwwhahatt isis describeddedescscrriibbeedd ini thehe entireentt contract. Aenrepresentation about the entire contractis notnnoott validvvaalilidd unlessuunnlleessss thetthhee changecchhananggee iiss apapprovedprropovveded by our executivechange to the insurance contractt isnn,, oror attachedaattttaacchheedd to,ttoo,, thetthhee insuranceiinnssuurrananccee contract.ccoo aacctt.secretary and it is endorsed on,OICWhen this Certificateffiiccateate iiss iinnEEfEffectffectffectHCOMFRSAThis certificatee comesccoommeess intoiinnttoo effecteefffff eecctt onon thetthhee issueiissssuuee date,da ifif bothbobotthh of the following conditions are met: Att leastlleaeasstt thetthhee firstffiirrsstt totalttoottaall premiumpprreemmiiuumm waswwaass providedvviidedded on or before the date we delivered thiscertificateinstitution from which it is to be drafted.cceerrtrtiiffiiccaattee toto youyyoouu andand isis honoredhohonnoorreded byb thehe financialffiinannan TheTThhee insurabilityiinnssuurrababiliilittyy ofof thetthhee insurediinnssuurreded didd notnot changecchhbetween the date the application wassignedssiiggnedned byby thethe insurediinnssuurreedd and thetthh issuessuessue date.daOnceOOnnccee inin effect,eeffffeecct,t, thistthhiiss certificatecceerrtrtiiffiiccaattee willwill remain in effect until the earliest of the following dates: TheTThhee dateddaattee ofof deathdedeaatthh ofof the insured. Theas shown in our records, your signed request to end this certificate.TThhee dayddaayy wewe receive,rreecceeii Thelapses, as described in the Grace Period provision.TThhee dayddaayy thistthhiiss certificatec TheTThhee dayddaayy thistthhii certificate terminates, as described in the Loans provision. TheTThhee maturitymmaattdate, as shown in the Certificate Data Pages. TThheedTheday that option 2 applies, as described in the Nonforfeiture provision.When thistthhiiss certificate ends it is no longer in effect. This means our liability, under this certificate,ends and no death benefit would be paid.ICC12-WL-PRL-US01Page 7 of 18
Control of Insurance ContractLEThe owner of the insurance contract may exercise the options or rights provided to youou underuunndede it,the insurediinnssuurr isunless limited by statute or by the rights of an assignee or irrevocable beneficiary. Iff therreded uponuupponon theirtthheeiirryounger than 16 years old on the issue date, these rights will transfer to the insureduurrananccee contract,ccoonnttrraactct,,16th birthday. Upon this transfer, the insured will become the owner of the insuranceregardless of a prior assignment.You may request a change of owner, while the insured is alive and thiss certificatecceerrtrtiiffiiccaattee isis inin effect.eefffff eecctt. Achange of owner is not effective if prohibited by law. We are not responsibleforthevalidityssponponssiibbllee ffoorr the vvaaliliddiittyy ororeffect of a change of owner. Unless otherwise specified by you,, thetthhee changecchanhanggee ofof owneroowwnenerr willwill bebeeffective as of the date the request is signed and is subject to payment(s)papayymmenentt((ss)) mademmadadee oror action(s)aaccttiionon((ss)) takenttaakkenenby us prior to our receipt of this request.LATUAssignmentPIf the insured is not the owner and if the owner dies or ceasescceeaasseess ttooeexexist,xiisst,t, wwhwhilehililee thistthhiiss certificatecceerrtrtiiffiiccaa is intthhee insuranceiinnssuurraannccee contract,ccoonnttrraacctt,, asas ofof thetthhee datedeffect, the contingent owner becomes the owner of thethat thehe contingentccononttiinnggenentt owneroowwnenerr isis notnot effectiveeeffffeeccttiivvee if prohibited byowner died or ceased to exist. This transfer to thethe owner’soowwnenerr’’ss estateeessttaattee (if((iiff thethe owneroowwnenerr isis a natural person)law. If there is no surviving contingent owner,, theor the owner’s successor in interest (if the ownerwwnenerr isis a non-naturalnononn--nnaattuurraall person)ppeerrssonon)) willwwiillll become the sOMMYou may assign the insurancee contract.ccononttrraacct.t. An assignmentaassssiiggnnmmeenntt isis notnnoott effectivee ccttiivvee ifif prohibited by law. Unlessthe assignmentaassssiiggnnmmeenntt willwill be effectiveeeffffeeccttiivvee asa off thethe dateda the notice of assignmentotherwise specified by you,, theis signed and is subjectt toto payment(s)papayymmeenntt((ss)) mademmaadede oror action(s)aaccttiionon((ss)) takenttaa n byby usu prior to our receipt of thisnotice. Under an absoluteoolluuttee assignmentaassssiiggnnmmeenntt thethe assigneeaassssiiggneenee becomesbebecc eess thethe owner of the insurance contract.We are not bound byby an assignmentaassssiiggnnmmenentt unlessununll
Alaska Department of Insurance telephone number 123-456-7890 Foresters PlanRight This is a WHOLE LIFE INSURANCE CERTIFICATE. The Independent Order Of Foresters (referred to as we, our, Foresters or us) will, subject to the provisions of this certificate, pay the death benefit upon our receipt of proof of the insured's death.
