EFTA00804385

Massachusetts Mutual Life Insurance Company Home Office: 1295 State Street Springfield. Massachusetts e1111-cool Survivorship Flexible Premium Adjustable Life Insurance Policy INSURED NO. 1 JEFFREY KOGAN INSURED NO. 2 FAITH M KOGAN POLICY DATE OCTOBER 26, 2011 POLICY NUMBER 15,665,562 ISSUE DATE DECEMBER 20, 2011 INITIAL FACE AMOUNT $5,000,000 Dear Policy Owner: READ YOUR POLICY CAREFULLY. It has been written in readable language to help you understand its terms. We have used examples to explain some of its provisions. These examples do not reflect the actual amounts or status of this policy. As you read through the policy, remember the words "we," "us," and "our" refer to Massachusetts Mutual Life Insurance Company. We will, subject to the terms of this policy, pay the death benefit to the Beneficiary when due proof of the death of both Insureds has been received at our Home Office. However, due proof of the first death must be furnished when it occurs. The terms of this policy are contained on this and the following pages. For service and information on this policy, contact the agent who sold the policy, any of our agency offices, or our Home Office, toll free: 1-800- 272-2216. YOU HAVE THE RIGHT TO RETURN THIS POLICY. If you decide not to keep this policy, return it within 14 days after you receive it. It may be returned by delivering or mailing it to our Home Office, to any of our agency offices, or to the agent who sold the policy. Then, the policy will be as though it had never been issued. We will promptly refund any premium paid for it, less any amounts withdrawn and any policy debt. Signed for Massachusetts Mutual Life Insurance Company. Sincerely yours, Ootedge o Pituca- PRESIDENT SECRETARY This Policy provides that: The benefits under this policy may Increase or decrease, and are not guaranteed as to a fixed dollar amount. A death benefit is payable when both Insureds have died. Within specified limits, flexible premiums may be paid while either Insured is living. This policy is participating - Annual dividends may or may not be paid. P9-2005(FL)a (a405myfl) EFTA00804385 Policy Summary This Summary briefly describes some of the major policy provisions. Since it does not go into detail, the actual provisions will prevail. See the provisions for full information and any limits that may apply. The "Table Of Content? shows where the provisions may be found. This is a universal life insurance policy on the lives of two Insureds. We will pay a death benefit if both Insureds die while the policy is in force. "In force" means that the insurance has not terminated. "Universal life" means that, subject to the limits and conditions stated in the policy, the amount of insurance may be adjusted and flexible premium payments may be made. Premiums for this policy are flexible. After the first premium has been paid, there is no requirement that any specific amount of premium be paid on any date. Instead, within the limits stated in the policy, any amount may be paid on any date during the lifetime of either Insured. Premiums are applied to increase the value of this policy. Monthly charges are deducted from the value of this policy each month. If the value cannot cover the monthly charges for a month, the policy may terminate at the end of 62 days. There is, however, a right to reinstate the policy. Other rights available under this policy include the rights to: • Change the Owner or any Beneficiary; • Assign this policy; • Receive any dividends that may or may not be allocated to this policy; • Change the Face Amount; • Change the Death Benefit Option; • Make loans; • Make withdrawals; and • Surrender this policy. This policy also includes a number of Payment Options. They provide alternate ways for us to pay the death benefit or the amount payable upon surrender of the policy. P9-2005(FL)a (005myll) EFTA00804386 TABLE OF CONTENTS Policy Specifications Page No. Paps Na Psifit 1. - The Basics Of Thls Policy Determining Amount Of Premium The Parties Involved • Owner, Insureds, Needed To Avoid Termination 12 Beneficiary, Irrevocable Beneficiary 1 Part 4. - Guaranteed Death Benefit Safety Dates - Policy Date, Policy Anniversary Test 12 Date, Policy Year, Monthly Charge Date, Guaranteed Death Benefit Measure 12 I Issue Date 1 Guaranteed Death Benefit Measure Policy A Legal Contract 2 Interest Factors 13 Representations And Contestability 2 Maximum Guaranteed Death Benefit Misstatement Of Age Or Gender 3 Monthly Factors 13 Death By Suicide 3 Maximum Guaranteed Death Benefit Meaning Of In Force 3 Monthly Face Amount Factor 14 Meaning Of Second Death 4 Maximum Guaranteed Death Benefit Simultaneous Deaths 4 Monthly Insurance Factor 14 Face Amount 4 Safety Test Example 14 Year Of Coverage 4 Ages - Issue Age, Attained Age 4 Part 5. - Ufe Benefits 15 Written Request 4 Policy Ownership 15 Status For Federal Tax Purposes 4 Rights Of Owner 16 Currency 5 Changing The Owner Or Beneficiary 15 Home Office 6 Assigning This Policy 15 Annual Report 16 Part 2. - Premium Payments 6 This Policy's Share In Dividends 16 The First Premium 5 Policy Is Participating 15 Planned Premiums 5 How Dividends May Be Used 16 Premium Flexibility And Premium Notices 5 Dividend After Death Of Insured 16 Where To Pay Premiums 6 Right To Change The Face Amount 16 Right To Refund Premiums 6 No Increases In The Face Amount 16 Net Premium 6 Decreases In The Face Amount 16 Maximum Guaranteed Death Benefit Evidence Of Changes 17 Safety Test Premium 6 Transfers Of Values 17 Transfers From The Specified Premium Palt & Accounts, Values, And Charges 7 Premium Account 17 Values Of This Policy 7 Transfers From The GOB Premium Account Value 7 Account 17 GDB Premium Account Value 7 Borrowing Against This Policy 17 Interest On The GDB Premium Account 8 Right To Make Loans 17 Specified Premium Account Value 8 Effect Of Loan 17 Interest On The Specified Premium Maximum Loan Available 18 Account 8 Interest On Loans 18 Loaned Account Value 8 Policy Debt Limit 18 "citify Poky Charges 9 Repayment Of Policy Debt 18 Monthly Charges 9 Surrendering This Policy And Making Administrative Charge 9 Withdrawals 19 Face Amount Charge 9 Right To Surrender 19 Insurance Charge 9 Net Surrender Value 19 Rider Charge 11 Making Withdrawals 19 Grace Period And Termination 11 How We Pay 21 Grace Period 11 Reinstating This Policy 21 Grace Period Notification 11 When Policy May Be Reinstated 21 Termination 12 P9-2005(FL)a (.1105myll) EFTA00804387 TABLE OF CONTENTS (continued) Requirements To Reinstate 21 Withdrawals And Changes 24 Policy After Reinstatement 21 Income Protection 25 Reports To Owner 21 Other Payment Option Rules 25 Illustrative Report 21 Part 8. - Notes On Our Computations 25 Part 6. - The Death Benefit 22 Basis Of Computation 25 Amount Of Death Benefit 22 Method Of Computing Values 26 Changes In The Death Benefit Option 22 Minimum Death Benefit 22 Payment Option Rates Tables 27-33 When We Pay 22 Interest On Death Benefit 23 Part 7. - Payment Options 23 Availability Of Options 23 Minimum Amounts 23 Description 01 Options 23 Options 1, 2, 3 and 4 23 Options 5 and 6 24 Alternate Life Income 24 Electing A Payment Option 24 Effective Date And Payment Dates 24 My riders and endorsements, and a copy of the application for the policy, follow page 33. P9.2005(FL)a 0905rnyll) EFTA00804388 POLICY SPECIFICATIONS SURVIVORSHIP FLEXIBLE PREMIUM ADJUSTABLE LIFE INSURANCE POLICY ISSUE AGE GENDER INSURED NO. 1 JEFFREY KOGAN 58 MALE INSURED NO. 2 FAITH M KOGAN 54 FEMALE POLICY DATE OCTOBER 26, 2011 POLICY NUMBER 15,665,562 ISSUE DATE DECEMBER 20, 2011 INITIAL FACE AMOUNT $5,000,000 RISK CLASSES SEE THE TABLE(S) OF MAXIMUM MONTHLY INSURANCE CHARGES Stibject 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. DEATH BENEFIT OPTION (See Part 6 of this policy.) 1 MINIMUM FACE AMOUNT $100,000 MONTHLY CHARGE DATES 26th day of each month FIRST PREMIUM $6,000.00 PLANNED PREMIUM $6,000.00 PLANNED PREMIUM FREQUENCY Monthly MINIMUM ANNUAL INTEREST RATE 3.00% (decimal monthly equivalent 0.0024662698) (decimal daily equivalent 0.0000809863) LOAN INTEREST RATE (See Interest On Loans in Part 5.) 4% POLICY CHARGES AND FEES: MAXIMUM PREMIUM EXPENSE CHARGE 5.00% of premium payments (See Net Premium provision in Part 2.) MAXIMUM MONTHLY ADMINISTRATIVE CHARGE' $12.00 MAXIMUM MONTHLY FACE AMOUNT CHARGE BY YEAR OF COVERAGE Years 1 - 20 $0.45 (Per $1,000 of Face Amount) Years 21 and later $0.00 (Per $1,000 of Face Amount) MAXIMUM MONTHLY INSURANCE CHARGE See the Table(s) Of Maximum Monthly Insurance Charges RIDER CHARGES• See the Policy Specifications for the Rider(s), if any MAXIMUM LOAN INTEREST RATE EXPENSE CHARGE 1.00% MAXIMUM WITHDRAWAL FEE $25.00 per withdrawal SURRENDER CHARGE See the Table(s) Of Surrender Charges 'For more information, see the "Monthly Policy Charges" section in Part 3 of this policy. Monthly Charges beyond Attained Age 120 of the younger Insured are zero. Note: Unless this policy Is kept In force because the Guaranteed Death Benefit Safety Test has been met, neither the timely payment of planned premiums nor the Issuance of the policy with a planned premium of S0.00 necessarily guarantees that this policy will stay In force until the death of both Insureds. POLICY SPECIFICATIONS PAGE 1 OF 10 EFTA00804389 POLICY SPECIFICATIONS SURVIVORSHIP FLEXIBLE PREMIUM ADJUSTABLE LIFE INSURANCE POLICY INSURED NO. 1 JEFFREY KOGAN INSURED NO. 2 FAITH M KOGAN POLICY DATE OCTOBER 26, 2011 POLICY NUMBER 15,665.562 ISSUE DATE DECEMBER 20, 2011 LIMIT ON PREMIUM PAYMENTS IN ANY POLICY YEAR: The maximum limit for premium payments in any Policy Year is the largest premium that would not exceed the greatest of: • $ 95,100.00 ; • The amount of premiums paid in the preceding Policy Year; and • The largest premium that would not increase the Insurance Risk. RIDER(S) ATTACHED TO THIS POLICY: Substitute of Insureds Rider Policy Split Option Rider Accelerated Death Benefit Rider POLICY SPECIFICATIONS PAGE 2 OF 10 EFTA00804390 POLICY SPECIFICATIONS SURVIVORSHIP FLEXIBLE PREMIUM ADJUSTABLE LIFE INSURANCE POLICY INSURED NO. 1 JEFFREY KOGAN INSURED NO. 2 FAITH M KOGAN POLICY DATE OCTOBER 26,2011 POLICY NUMBER 15,665,562 ISSUE DATE DECEMBER 20, 2011 TABLE OF MAXIMUM MONTHLY INSURANCE CHARGES RATES PER THOUSAND OF INSURANCE RISK RISK CLASSES: INSURED NO.1: NON-TOBACCO INSURED NO.2: NON-TOBACCO ATTAINED ATTAINED ATTAINED AGE OF THE AGE OF THE AGE OF THE YOUNGER MONTHLY YOUNGER MONTHLY YOUNGER MONTHLY INSURED RATE INSURED RATE INSURED RATE 54 0.002600 84 5.805500 114 60.284700 55 0.008800 85 6.559400 115 63.618600 56 0.016800 86 7.278500 116 67.078800 57 0.027200 87 8.171500 117 70. 892900 58 0.040500 88 9.097900 118 75.342400 59 0.057100 89 10.069900 119 83.332500 60 0.077300 90 10.977000 120 83. 332500 61 0.101800 91 11 .509800 62 0.131000 92 12.329100 63 0.164800 93 13.494700 64 0.204500 94 14.961700 65 0.250700 95 16.783500 66 0.306300 96 18.536200 67 0.371800 97 20.327100 68 0.453000 98 20.633400 69 0.547400 99 21 .655100 70 0.656500 100 23.300300 71 0.784900 101 25.070700 72 0.934400 102 27.063300 73 1 .109600 103 29.250600 74 1 .315600 104 31.673000 75 1 .556900 105 34.304100 76 1 .832300 106 37.009900 77 2.149600 107 39.788500 78 2.502200 108 42.588400 79 2.892900 109 45.508200 80 3.331700 110 48.497300 81 3.866600 111 51.371700 82 4.472200 112 54.161200 83 5.111200 113 56.702100 The above rates are based on the following mortality tables: INSURED NO. 1 - Commissioners 2001 Standard Ordinary Nonsmoker Mortality Table • Male INSURED NO. 2 - Commissioners 2001 Standard Ordinary Nonsmoker Mortality Table - Female Maximum Monthly Insurance Charges beyond Attained Age 120 of the younger Insured are zero. POLICY SPECIFICATIONS PAGE 3 OF 10 EFTA00804391 POLICY SPECIFICATIONS SURVIVORSHIP FLEXIBLE PREMIUM ADJUSTABLE LIFE INSURANCE POLICY INSURED NO. 1 JEFFREY KOGAN INSURED NO. 2 FAITH M KOGAN POLICY DATE OCTOBER 26, 2011 POLICY NUMBER 15.665,562 ISSUE DATE DECEMBER 20, 2011 GUARANTEED DEATH BENEFIT SAFETY TEST INFORMATION MAXIMUM GUARANTEED DEATH BENEFIT SAFETY TEST PREMIUM $6,000.00 GUARANTEED DEATH BENEFIT PAY PERIOD END DATE 10/26/2027 GUARANTEED DEATH BENEFIT GUARANTEE PERIOD END DATE 10/26/2060 NOTES 1. The Maximum Guaranteed Death Benefit Safety Test Premium amount reflected above was calculated assuming the Planned Premium Frequency listed on Policy Specifications Page 1. 2. If "Not Applicable" is reflected for the Maximum Guaranteed Death Benefit Safety Test Premium, Guaranteed Death Benefit Pay Period End Date and Guaranteed Death Benefit Guarantee Period End Date, we were unable to determine premium amounts that would guarantee your policy will not lapse based on the guarantee period and payment period you requested. 3. Even if the Guaranteed Death Benefit Safety Test is met, the policy can terminate before its Guaranteed Death Benefit Guarantee Period End Date if the policy debt limit is reached. Please read the Termination, Grace Period and Policy Debt Limit provisions for more information. POLICY SPECIFICATIONS PAGE 4 OF 10 EFTA00804392 POLICY SPECIFICATIONS SURVIVORSHIP FLEXIBLE PREMIUM ADJUSTABLE LIFE INSURANCE POLICY INSURED NO. 1 JEFFREY KOGAN INSURED NO. 2 FAITH M KOGAN POLICY DATE OCTOBER 26, 2011 POLICY NUMBER 15,665,562 ISSUE DATE DECEMBER 20, 2011 GUARANTEED DEATH BENEFIT SAFETY TEST INFORMATION (Cont.) YEAR 1 GUARANTEED DEATH BENEFIT MEASURE INTEREST FACTOR 13.00% ! Decimal monthly equivalent 0.0102368444 Decimal daily equivalent 0.0003348989 YEARS 2 AND LATER GUARANTEED DEATH BENEFIT MEASURE BAND 1 INTEREST FACTOR 13.00% Decimal monthly equivalent 0.0102368444 Decimal daily equivalent GUARANTEED DEATH BENEFIT MEASURE BAND 2 INTEREST FACTOR 0.0003348989 3.08% Decimal monthly equivalent 0.0025311312 Decimal daily equivalent 0.0000831136 TABLE OF GUARANTEED DEATH BENEFIT BANDING ANNUAL THRESHOLDS PER THOUSAND OF FACE AMOUNT ATTAINED ATTAINED ATTAINED AGE OF THE ANNUAL AGE OF THE ANNUAL AGE OF THE ANNUAL YOUNGER THRESHOLD YOUNGER THRESHOLD YOUNGER THRESHOLD INSURED AMOUNT INSURED AMOUNT INSURED AMOUNT 55, 13.5100 83 340.6100 111 2,137.8900 56, 18.9700 84 352.4600 112 2,425.8500 57. 25.1400 85 363.7100 113 2,751.2600 58 31.9700 86 374.8900 114 3,118.9500 59 39.4300 87 385.3100 115 3,534.4600 60 47.6000 88 395.1100 116 4,003.9600 61' 58.8800 89 404.2900 117 4,534.5000 62 67.0000 90 414.4300 118 5,134.0200 63 77.6600 91 426.5200 119 5,811.4900 64 88.8100 92 440.0500 120 6,577.0200 65 100.3800 93 454.3600 se 112.3000 94 469.0600 67 124.4900 95 483.7400 68 136.8500 96 499.3700 69 149.4000 97 517.4900 70 162.0600 98 541.7400 71 174.7100 99 572.0900 72 187.3200 100 609.1700 73 199.7600 101 654.8800 74 214.9000 102 711.7000 75 229.8800 103 782.8700 76 244.6800 104 872.6400 77 259.2200 105 986.7600 78 273.6200 106 1,125.0500 79 287.7700 107 1,281.3400 80 301.8200 108 1,457.9500 81 315.3600 109 1,657.5300 82 328.2400 110 1,883.0500 The Annual Threshold Amount at Attained Age 120 continues beyond Attained Age 120 of the younger Insured. POLICY SPECIFICATIONS PAGE 5 OF 10 EFTA00804393 POLICY SPECIFICATIONS SURVIVORSHIP FLEXIBLE PREMIUM ADJUSTABLE LIFE INSURANCE POLICY INSURED NO. 1 JEFFREY KOGAN INSURED NO. 2 FAITH M KOGAN POLICY DATE OCTOBER 26,2011 POLICY NUMBER 15,665,562 ISSUE DATE DECEMBER 20,2011 GUARANTEED DEATH BENEFIT SAFETY TEST INFORMATION (Cons.) MAXIMUM GUARANTEED DEATH BENEFIT FACTORS MONTHLY FACE AMOUNT FACTOR Years 1 - 20 0.40 Years 21 and later 0.00 RIDER FACTORS See the Policy Specifications for the Rider(s), if any TABLE OF MAXIMUM GUARANTEED DEATH BENEFIT MONTHLY INSURANCE FACTORS PER THOUSAND OF GUARANTEED DEATH BENEFIT MEASURE RISK ATTAINED ATTAINED ATTAINED AGE OF THE AGE OF THE AGE OF THE MONTHLY YOUNGER MONTHLY YOUNGER MONTHLY YOUNGER FACTOR INSURED FACTOR INSURED FACTOR INSURED 0.001200 82 4.427700 110 11 .167600 54 55 0.005800 83 4.771100 111 11 . 237600 0.013500 84 5.118700 112 11.263000 56 0.024800 85 5.473500 113 11 . 221900 57 0.041200 86 5.763900 114 11. 325100 58 0.064700 87 6.145400 115 11.358400 59 0.096900 88 6.508300 116 11.379300 60 61 0.137800 89 6.862500 117 11 . 417900 0.186400 90 7.002100 118 11 .390500 62 0.248700 91 7.048900 119 11.349600 63 64 0.325900 92 7.229300 120 11.501600 65 0.420000 93 7.552300 66 0.526400 94 7.972200 67 0.647900 95 8.492600 68 0.785200 96 8.897800 69 0.929600 97 9. 127700 70 1 .085900 98 8.904200 71 1 . 255900 99 8.926200 72 1.437500 100 9.126800 73 1.637300 101 9.324700 74 2.068100 102 9.547600 75 2.322700 103 9.781900 76 2.589400 104 10.034800 77 2.870800 105 10.293800 78 3.144200 106 10.523800 79 3.440800 107 10. 725900 80 3.725200 108 10.890700 81 4.066000 109 11 .040900 There are no Guarantood Death Benefit Factors beyond Attained Age 120 of the younger Insured. POLICY SPECIFICATIONS PAGE 6 OF 10 EFTA00804394 POLICY SPECIFICATIONS SURVIVORSHIP FLEXIBLE PREMIUM ADJUSTABLE LIFE INSURANCE POLICY INSURED NO. 1 JEFFREY KOGAN INSURED NO. 2 FAITH M KOGAN POLICY DATE OCTOBER 26,2011 POLICY NUMBER 15,665,562 ISSUE DATE DECEMBER 20,2011 TABLE OF SURRENDER CHARGES IF SURRENDER OCCURS IN POLICY YEAR SURRENDER CHARGE 01 $ 100,400.00 02 89,356.00 03 81,324.00 04 75,300.00 05 70,280.00 06 67,268.00 07 63,252.00 08 59,236.00 09 56,224.00 10 S 52,208.00 11 50,200.00 12 5 47,188.00 13 44,176.00 14 40,160.00 15 33,132.00 16 27,108.00 17 21 ,084.00 18 14,056.00 19 7,028.00 20 and later 0.00 For more information on surrender charges, see Part 5 of this policy. POLICY SPECIFICATIONS PAGE 7 OF 10 EFTA00804395 POLICY SPECIFICATIONS SURVIVORSHIP FLEXIBLE PREMIUM ADJUSTABLE LIFE INSURANCE POLICY INSURED NO. 1 JEFFREY KOGAN INSURED NO. 2 FAITH M KOGAN POLICY DATE OCTOBER 26,2011 POLICY NUMBER 15,665,562 ISSUE DATE DECEMBER 20,2011 DEATH BENEFIT FACTORS ATTAINED ATTAINED ATTAINED AGE OF THE AGE OF THE AGE OF THE YOUNGER YOUNGER YOUNGER INSURED FACTOR INSURED FACTOR INSURED FACTOR 54 3.47 80 1 .46 106 1.00 55 3.34 81 1 .42 107 1.00 56 3.21 82 1.39 108 1.00 57 3.09 83 1 .37 109 1 .00 58 2.97 84 1.34 110 1.00 59 2.86 85 1.32 111 1.00 60 2.76 86 1 .30 112 1 .00 61 2.65 87 1.28 113 1 .00 62 2.56 88 1.26 114 1 .00 63 2.46 89 1 .24 115 1 .00 64 2.38 90 1.22 116 1 .00 65 2.29 91 1.21 117 1 .00 66 2.21 92 1.19 118 1 .00 67 2.14 93 1.17 119 1.00 68 2.06 94 1.16 120 1.00 69 2.00 95 1 .14 70 1 .93 96 1 .12 71 1 .87 97 1.10 72 1 .81 98 1 .08 73 1 .76 99 1 .04 74 1 .70 100 1 .00 75 1 .66 101 1 .00 76 1 .61 102 1 .00 77 1 .57 103 1.00 78 1 .53 104 1.00 79 1 .49 105 1.00 Death Benefit Factors beyond Attained Age 120 of the younger Insured are 1.00. These Death Benefit Factors are used to determine the amount of the minimum death benefit. For more information, see Part 6 of this policy. POLICY SPECIFICATIONS PAGE 8 OF 10 EFTA00804396 POLICY SPECIFICATIONS SURVIVORSHIP FLEXIBLE PREMIUM ADJUSTABLE LIFE INSURANCE POLICY INSURED NO. 1 JEFFREY KOGAN INSURED NO. 2 FAITH M KOGAN POLICY DATE OCTOBER 26, 2011 POLICY NUMBER 15,665,562 ISSUE DATE DECEMBER 20, 2011 OWNER INFORMATION OWNER SEE APPLICATION PAGE. POLICY SPECIFICATIONS PAGE 9 OF 10 EFTA00804397 POLICY SPECIFICATIONS SURVIVORSHIP FLEXIBLE PREMIUM ADJUSTABLE LIFE INSURANCE POLICY INSURED NO. 1 JEFFREY KOGAN INSURED NO. 2 FAITH M KOGAN POLICY DATE OCTOBER 26, 2011 POLICY NUMBER 15,665,562 ISSUE DATE DECEMBER 20, 2011 BENEFICIARY INFORMATION BENEFICIARY SEE APPLICATION PAGE. POLICY SPECIFICATIONS PAGE 10 OF 10 EFTA00804398 Part 1. The Basics Of This Policy 'n this Part, we discuss some definitions and insurance concepts necessary to understand this policy. The words "we," "us," and "our'' refer to Massachusetts Mutual Life Insurance Company. The Parties The Owner is the person who owns this policy, as shown in our records. The Owner Involved - has the right to exercise rights and privileges and to receive benefits under the terms of Owner, Insureds, this policy during the lifetime of either Insured. If the Owner designated under the terms Beneficiary, of this policy is not living and if the policy does not provide otherwise, the Owner will be Irrevocable the estate of the last Owner to die. Beneficiary For more information about the rights and benefits available to the Owner, see the "Policy Ownership" section in Part 5. The Insureds are the two persons whose lives this policy insures. An Insured may be the Owner of this policy, or someone else may be the Owner. Example: You buy a policy insuring your own life and your spouse's life, and naming yourself as Owner. In this case, you are both an Insured and the Owner. If you buy a policy insuring two other lives and naming yourself as the Owner, then the Owner is not an Insured. A Beneficiary is any person named in our records to receive the death benefit after both insureds have died. 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. Example: Elizabeth is named as primary (first) Beneficiary. Rachel and David are named as Beneficiaries in the secondary class. If Elizabeth is alive when the second death occurs, she receives the death benefit. If Elizabeth is not alive but Rachel and David are alive when the second death occurs, Rachel and David receive the death benefit. My Beneficiary may be named an Irrevocable Beneficiary. An Irrevocable Beneficiary is one whose consent is needed to change that Beneficiary, but has no other rights under this policy. If no Beneficiary designated under this policy survives both Insureds, the Beneficiary will be the Owner unless the policy states otherwise. The interest of any Beneficiary will be subject to any assignment of this policy that is binding on us and to any payment option in effect at the time of the time of the second death. See the "Policy Ownership" section in Part 5, and see "Part 7. Payment Options." Dates - Policy Date, The Policy Date is shown in the Policy Specifications. It is the starting point for Policy Anniversary determining Policy Anniversary Dates, Policy Years, and Monthly Charge Dates. Date, Policy Year, The first Policy Anniversary Date is one yew after the Policy Date. The period from the Monthly Charge Policy Date to the first Policy Anniversary Date, or from one Policy Anniversary Date to Date, Issue Date the next, is called a Policy Year. PS-2005(FL) Page 1 (c406m all) EFTA00804399 The Monthly Charge Dates are the dates on which monthly charges for this policy are due. The first Monthly Charge Date is the Policy Date. Subsequent Monthly Charge Dates are the same day of each month thereafter. Example: The Policy Date is June 10, 2OX4. The first Policy Anniversary Date is one year later, June 10, 20X5. The period from June 10, 20X4, through June 9, 20X5, is a Policy Year. The first Monthly Charge Date is June 10, 20X4. The next Monthly Charge Date is one month later, July 10, 20X4. The Issue Date is also shown in the Policy Specifications. The Issue Date starts the contestability and suicide periods. We discuss contestability and suicide later in this Part. Policy A Legal This policy is a legal contract between the Owner and us. The entire contract consists of Contract the policy, which includes the application and any rider(s) and endorsement(s) the policy has. We have issued this policy in return for the application and the payment of the first premium. Any changes or waiver of its terms must be in writing and signed by our Secretary or an Assistant Secretary to be valid. A copy of the initial application is attached to and made a part of this policy. Any subsequent applications requesting changes in the policy also will become part of the contract; copies of any such applications will be sent to the Owner for attachment to the policy. Representations We rely on all statements made by or for either or both Insureds in the application(s). And Legally, those statements are considered to be representations and not warranties. Contestability We can bring legal action to contest the validity of this policy, or any policy change requiring evidence of insurability, for any material misrepresentation of a fact. To do so, however, the misrepresentation must have been in the initial application or in a subsequent application, and a copy of that application must have been attached to (or sent to the Owner for attachment to) and made a part of this policy. The initial Policy Specifications are attached to this policy when issued. If a policy change is made, we will send to the Owner any revised or additional Policy Specifications for attachment to the policy. Except for any policy change or reinstatement requiring evidence of insurability, we cannot contest the validity of this policy: • With respect to any material misrepresentation in the application regarding the insurability of Insured No. 1, once the policy has been in force during the lifetime of Insured No. 1 for two years after its Issue Date; or • With respect to any material misrepresentation in the application regarding the insurability of Insured No. 2, once the policy has been in force during the lifetime of Insured No. 2 for two years after its Issue Date. P9-2005(FL) Page 2 Ic905rnall) EFTA00804400 For any policy change requiring evidence of insurability, we cannot contest the validity of the change with respect to each Insured after the change has been in effect for two years during the lifetime of that Insured. If evidence of insurability is required to reinstate this policy (see "Reinstating This Policy" in Part 5), our right to contest the validity of this policy begins again on the date of reinstatement. For each Insured living on that date, we cannot contest the reinstated policy after it has been in force during the lifetime of that Insured for two years after that reinstatement date. Misstatement Of If the date of birth or gender of either Insured as given in the application is not correct, Age Or Gender the Face Amount (discussed in this Part) will be adjusted. The adjustment will reflect the amount provided by the most recent monthly insurance charges using the correct ages and genders. If the adjustment is made while either Insured is living, monthly charges after the adjustment will be based on the correct ages and genders. Death By Suicide If either Insured commits suicide, while sane or insane, within two years after the Issue Date of this policy and while the policy is in force, this policy will terminate. In this case, we will refund to the Owner the amount of premiums accepted for this policy, less any amounts withdrawn and less any policy debt. If either 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. In this case, we will refund to the Owner any amount paid to reinstate this policy and any premiums accepted thereafter, less any amounts withdrawn and less any policy debt. Monthly charges are discussed in Part 3. Withdrawals, policy debt, and reinstatement are discussed in Part 5. Meaning Of "In force" means that the insurance provided by this policy is in effect and has not In Force terminated. This policy will be in force on the later of (a) its Issue Date or. (b) the date the first premium is received, unless: • There has been a change in the insurability of either Insured prior to the Issue Date; • The Company has issued an amendment to the application or requested additional information; or • The Company has requested a statement verifying the current insurability of either or both Insureds. If any of the above conditions apply, the policy will be considered in force on the later of (a) the date all required supplemental information is received at our Home Office, and (b) the date the first premium is received. Supplemental information may include, but is not limited to: • Evidence of policy delivery, • Evidence that there has been no material change in an Insured's health, and • Completed Application amendments. This policy will continue in force to the second death unless: P9-2005(FL) Page 3 (c906maifI) EFTA00804401 • Ether Insured commits suicide within two years after the Issue Date or the date the policy is reinstated; • The policy terminates under the terms of the Grace Period and Termination provisions in Part 3; or • The policy is surrendered. Meaning Of The "second death" under this policy means the death of the survivor of the Insureds. Second Death Simultaneous The Insureds may die at the same time, with no reasonable way to determine who died Deaths first. In this case, we will assume that Insured No. 2 died before Insured No. 1. However, the Owner may provide otherwise by written request while both Insureds are living. Face Amount The Face Amount is the amount of insurance coverage this policy provides while the policy is in face. The Initial Face Amount is the Face Amount on the Policy Date. Year Of Coverage For the Initial Face Amount, each Policy Year is a year of coverage. Ages - Issue Age, The Issue Age for each Insured (shown in the Policy Specifications) is the age of that Attained Age Insured on the birthday nearest the Policy Date. Example: Elizabeth's 32nd birthday was May 12th. The Policy Date is today, December 1. Since December 1 is closer to her 33rd birthday, her Issue Age will be 33. The Attained Age of an Insured is the Insured's Issue Age increased by the number of full Policy Years elapsed. Written Request A "written request" is a request in writing, in a form satisfactory to us, received by us at our Home Office. In the future we may also allow the telephone, Internet or other electronic media to be used for certain transactions that currently require a Written Request. We will accept such requests only after the appropriate policies, procedures and security measures have been established. Status For Federal This policy is intended to qualify as a "life insurance contract" for Federal tax Tax Purposes purposes. To maintain its status as a "life insurance contract" we will monitor the policy for compliance with the limits established by the Internal Revenue Code. In any policy year, we reserve the right to take any action we deem necessary to maintain the status of the policy, including the right to refund policy premium or to distribute to you a portion of the Account Value. We may also limit or deny any change to policy benefits (such as rider additions, or face amount decreases, rider removal or reduction, or withdrawals) to the extent required to maintain the policy's status. We will adjust the limits in any Policy Year in which there is a change to policy benefits (such as rider additions or benefit decreases resulting from the face amount reduction, rider removal or reduction or withdrawals) that alters the limits for Federal tax purposes. Following the adjustment, we reserve the right to take any action necessary to maintain the status of the policy, including the right to distribute to you a portion of the Account Value. P9-2005(FL) Page 4 (c905mall) EFTA00804402 Currency All payments made to us and by us will be in the lawful currency of the United States of America. All monetary amounts shown in this policy are in U.S. dollars. Home Our Home Office is in Springfield, Massachusetts. The address is Massachusetts Office Mutual Life Insurance Company, 1295 State Street, Springfield, Massachusetts 01111- 0001, or any other address as we may designate in the future. Part 2. Premium Payments Premiums are the payments that may be paid to us to increase the Account Value of this policy; they also may be needed to keep this policy in force. Premiums for this policy are discussed in this Part. The First Premium The first premium for this policy is shown in the Policy Specifications. It is due on the Policy Date. Planned Premiums The planned premium for this policy is shown in the Policy Specifications. The frequency of planned premiums for this policy is as elected in the application. The frequency and amount of the planned premium may be changed by written request; the frequency may be quarterly, semiannually, or annually. We also provide a pre-authorized payment plan. This plan, and any other alternate premium plans we provide, are governed by the rules we set. Timely payment of planned premiums does not guarantee that this policy will stay in force until both Insureds have died. Policy coverage may be affected by: • The amount, frequency and timing of premium payments; • Changes in the Face Amount and Death Benefit Option; • Changes in the interest credited to the Account Value; • Changes in the policy monthly charges and expense charges; • The addition of, or changes in, policy benefit riders; • Policy loans or withdrawals; and • Transfers between the GDB Premium Account and the Specified Premium Account if DBO 4 is in effect. If continued payment of the planned premium during a Policy Year would exceed the Limit On Premium Payments for the Year shown in the Policy Specifications, we may decrease the planned premium to an amount that would not exceed that limit. If premium payments are discontinued, we will continue to deduct monthly charges from the Account Value and the policy will stay in force subject to the Grace Period and Termination provisions in Part 3. Premium Flexibility Aker the first premium has been paid, there is no requirement that any amount of And Premium premium be paid on any date. Subject to the Limit On Premium Payments shown Notices in the Policy Specifications and while this policy is in force, any amount of premium may be paid at any time while either Insured is living. However, each premium paid must be at least $20 or, if greater, the amount needed to prevent termination, as P9-2005(FL) Page 5 EFTA00804403 discussed in the Determining Amount Of Premium Needed To Avoid Termination provision, in Part 3. We will send premium notices for the planned premium based on the amount and frequency in effect. We will stop sending notices for the planned premium upon receipt of the Owner's written request to do so. We do not send premium notices if you have elected a pre-authorized payment plan. Where To Pay All premiums after the first premium are payable to us at our Home Office or at the Premiums place shown for payment on the premium notice. Upon request, a receipt signed by our Secretary or an Assistant Secretary will be given for any premium payment. Right To Refund We have the right to refund any amount of premium paid in a Policy Year that exceeds Premiums the Limit On Premium Payments stated in the Policy Specifications. Net Premium A Net Premium is a premium payment we accept for this policy less the premium expense charge we deduct at that time. The Maximum Premium Expense Charge we can deduct from each premium payment is shown in the Policy Specifications. If DBO 1 is in effect, any Net Premium allocated to the GDB Premium Account will be credited as of the date we receive the premium. lt DBO 4 is in effect, any Net Premium allocated to the GDB Premium Account and the Specified Premium Account will be credited as of the date we receive the premium. For any premium payment received before the Policy Date, the Net Premium will be credited to the Account Value as of the Policy Date. If the Face Amount of this policy includes new insurance, that is, if this policy is issued as a result of a conversion or replacement, a separate "segment" for the additional face amount will be shown in the Policy Specifications. Premium payments will be allocated to each segment of the Face Amount. Maximum The Maximum Guaranteed Death Benefit Safety Test Premium ("GDB Safety Test Guaranteed Death Premium") is shown in the Policy Specifications. It is the amount of premium that Benefit Safety Teat must be paid to guarantee the policy will stay in-force until, but not including, the Premlurn Guaranteed Death Benefit Guarantee Period End Date ("GDB Guarantee Period End Date"). The GOB Safety Test Premium shown in the Policy Specifications is the amount that must be paid to satisfy the Safety Test. This premium must be fully allocated to the GDB Premium Account. Your policy's GDB Safety Test Premium, Guaranteed Death Benefit Pay Poriod End Date ("GDB Pay Period End Date") and GDB Guarantee Period End Date are set when the policy is issued based on the guarantee you requested. They are shown in the Policy Specifications. P9-2005(FL) Page 6 lc905m all) EFTA00804404 The GDB Guarantee Period End Date and GDB Pay Period End Date can be changed upon request. These changes may, however, impact the GDB Safety Test Premium. The Maximum GDB Safety Test Premium required to keep your guarantee in force may also change due to changes to your policy and certain policy transactions. These policy changes and transactions include, but are not limited to: • Face Amount changes; • Premium payment frequency changes; • Adding or eliminating Riders; • Having a sub-standard rating reduced or removed; • Withdrawals from the GDB Premium Account; • Transfers to or from the GDB Premium Account and • Taking a loan from the GDB Premium Account. If the Maximum Guaranteed Death Benefit Safety Test Premium changes, new Policy Specification pages will not be sent. The new amount will be noted in your Annual Statement. However, you should contact your agent and request an illustration before making a policy change or transaction. Part 3. Accounts, Values, And Charges This policy provides an Account Value comprised of the GDB Premium Account Value, the Specified Premium Account Value and the Loaned Account Value, all of which are part of our general account. If your elected death benefit option is Death Benefit Option 1, premiums may only be allocated to the GDB Premium Account. If your death benefit option is Death Benefit Option 4 (at issue or if changed at a later date), premiums may be allocated to both the GDB Premium Account and Specified Premium Account. Regardless of the death benefit option chosen, the amount of any policy loan is always part of the Loaned Account Value. Values Of This Policy AOlearnt Value The Account Value is equal to: • The GDB Premium Account Value; plus • The Specified Premium Account Value if DBO 4 is in effect; plus • Any Loaned Account Value. Beyond the younger Insured's Attained Age 120, the Account Value will never be less than the Face Amount on the Policy Anniversary nearest the younger Insured's Attained Age 121. GDB Premium The GDB Premium Account Value reflects: Account Value • The net premiums allocated to this account; less • Any surrender charges for this policy due to any decreases in the Face Amount; plus • My value transferred from the Specified Premium Account; less • Any value transferred to the Specified Premium Account; less • Any value deducted because of loans; less P9-2C05(FL) Page 7 (OH/Small) EFTA00804405 • Any monthly charges for this policy deducted from this account; plus • Interest credited to this account. Interest On The GDB Premium Account earns interest at an effective annual rate defined The GDB Premium in this provision. Interest is credited daily. Account For any part of the GDB Premium Account, the interest rate we use will be the daily equivalent of the greater of: • The Minimum Annual Interest Rate; and • An alternate annual rate established by us. The alternate annual rate of interest will reflect our expectations for future investment results, profits, and expenses. This rate will be declared for each calendar month in advance; once declared for a month, it cannot bo changed. Specified Premium The Specified Premium Account Value reflects: Account Value • The not premiums allocated to this account; plus • Any value transferred from the GDB Premium Account; less • Any value transferred to the GDB Premium Account; less • Any value deducted because of loans; less • Any monthly charges for this policy deducted from this account: plus • Interest credited to this account. Interest On The Specified Premium Account earns interest at an effective annual rate defined The Specified in this provision. Interest is credited daily. Premium Account For any part of the Specified Premium Account, the interest rate we use will be the daily equivalent of the greater of: • The Minimum Annual Interest Rate; and • An alternate annual rate established by us. The alternate annual rate of interest will reflect our expectations for future investment results, profits, and expenses. This rate will be declared for each calendar month in advance; once declared for a month, it cannot be changed. Loaned Account Tho Loaned Account Value is equal to the amount of any outstanding loan and unpaid Value loan interest and will earn interest. The interest earned on any Loaned Account Value will be the daily equivalent of the greater of: • The annual loan interest rate in effect during the current Policy Year less the loan interest rate expense charge; and • The Minimum Annual Interest Rate. If DBO 1 is in effect, the interest will be added to the GOB Premium Account. If DBO 4 is in effect, the interest will be added to the Specified Premium Account as long as there is value in that account. If there is no value in the Specified Premium Account, the interest will be added to the GDB Premium Account. P9-2005(FL) Page 8 cesosmoio EFTA00804406 The loan interest rate is discussed in the Interest On Loans provision in Part 5. The Maximum Loan Interest Rate Expense Charge and the Minimum Annual Interest Rate are shown in the Policy Specifications. Monthly Policy Charges MOnthly Charges Monthly charges will be deducted monthly from the Account Value on each Monthly Charge Date prior to the younger Insured's Attained Age 121. No monthly charges will be deducted on or after that date. If DBO 1 is in effect, the monthly charges will be deducted from the GDB Premium Account. If DBO 4 is in effect, the monthly charges will be deducted from the GDB Premium Account until it is depleted. If the Guaranteed Death Benefit Safety Test is met, no additional charges will be deducted. If the Guaranteed Death Benefit Safety Test is not met, any remaining charges will be deducted from the Specified Premium Account. Four types of monthly charges are deducted from the Account Value: • Administrative Charge; • Face Amount Charge; • Insurance Charge; and • Rider Charges. Administrative The amount of the monthly administrative charge will be determined by us. However, it Charge will not exceed the Maximum Monthly Administrative Charge shown in the Policy Specifications. Face Amount The amount of the monthly face amount charge will be determined by us. However, it Charge will not exceed the result of: • The Face Amount divided by 1,000; then multiplied by • The Maximum Monthly Face Amount Charge for the year of coverage. These maximum charges are shown in the Policy Specifications. If the Face Amount of the policy has separate segments, the face amount charge for each month will be the sum of the charges determined separately for each segment of the Face Amount. Insurance Charge The maximum monthly insurance charge rates per $1,000 of insurance risk are shown in the Tablets) Of Maximum Monthly Insurance Charges of the Policy Specifications. Maximum monthly insurance charge rates for each segment of the Face Amount will be shown in a separate table. The insurance charge is the insurance charge rate per S1,000 of insurance risk times the insurance risk. The insurance risk is computed as of the date the charge is due. All amounts are calculated as of that date. The insurance risk is determined by the following steps. P9-2005(FL) Page 9 (csosmai) EFTA00804407 (a) We compute the Account Value of this policy after all additions and deductions other than the deduction of the insurance risk charge. (b) We determine the amount of benefit under the Death Benefit Option in effect (as discussed in Part 6). The minimum death benefit (discussed in Part 6) used here is based on the Account Value computed in (a). (c) We divide the amount of benefit determined in (b) by an amount equal to 1 plus the monthly equivalent (expressed as a decimal fraction) of the Minimum Annual Interest Rate shown in the Policy Specifications. (d) We subtract the Account Value, as computed in (a), from the amount determined in (c). The result is the monthly insurance risk. If there are two or more tables of maximum monthly insurance charges, the pro rata insurance risk allocated to each table will be based on the proportionate amount of Face Amount for the table to the total Face Amount. If the monthly insurance risk is increased due to the minimum death benefit (discussed in Part 6), the table that applies to the segment requiring evidence of insurability will be used for such increase. Example: The Initial Face Amount of your policy is $750,000. $500,000 of this amount is the result of a conversion from another policy, and $250,000 is additional new insurance. The Death Benefit Option is 1, and the benefit under Death Benefit Option 1 is $750,000. The pro rata portion of insurance risk to be allocated to the table for the first segment is $500,000 divided by $750,000, or two-thirds. The pro rata portion to be allocated to the table for the second segment is $250,000 divided by $750,000, or one-third. The monthly insurance risk is computed as $600,000. The maximum monthly insurance charge per $1,000 of insurance risk will be based on the charge for an amount equal to two-thirds of $600,000, or $400,000, from the first segment and an amount equal to one-third of $600,000, or $200,000, from the second segment. Suppose instead that the benefit under Death Benefit Option 1 is $810,000 due to the minimum death benefit and that the monthly insurance risk is $660,000. Then the maximum monthly insurance charge per $1,000 of insurance risk will be based on the charge for an amount equal to $400,000 from the first segment and an amount equal to $260,000 from the second segment ($200,000 plus the $60,000 due to the minimum death benefit). We may charge less than the maximum monthly insurance charges shown in the table(s). In this case, the monthly insurance charge rates will be based on our expectations for future mortality, investment, persistency and expense results, and future profits. The expense component of these rates is used to offset sales and issue expenses, which decrease over time. For each Insured, any change in these charges will apply to all individuals in the same class. P9-2005(FL) Page 10 (c005m all) EFTA00804408 Rider Charge The monthly rider charge is the sum of the monthly charges for any riders in effect on the Monthly Charge Date. The monthly charges for any rider are shown in the Policy Specifications for the rider. Grace Period And Termination We will determine whether this policy will remain in force on each Monthly Charge Date. If not, the policy will enter the Grace Period, which is the period of time during which you have the opportunity to send us enough premium to keep this policy in force. Grace Period The policy will enter the grace period, under the following conditions. 1. If the policy debt limit is exceeded, or 2. If there is an outstanding loan on the Monthly Charge Date, but the policy debt limit has not been reached, and a. The Net Surrender Value (Account Value less surrender charges and less Debt) is less than the monthly charges due, and b. The Guaranteed Death Benefit Safety Test is not met, or 3. If there is an outstanding loan on the Monthly Charge Date, but the policy debt limit has not been reached, and a. The Account Value minus Debt is less than the monthly charges due, and b. The Guaranteed Death Benefit Safety Test is met, or 4. If there is no outstanding loan on the Monthly Charge Date, and a. The Account Value is less than the monthly charges due, and b. The Guaranteed Death Benefit Safety Test is not met. The grace period begins on the date that monthly charges are due. It ends 31 days after that date or, if later, 31 days after we mail a written notice to the last known address(es) of the Owner and any assignee shown in our records. During the grace period, the policy will stay in force. If the second death occurs during the grace period, any unpaid premium amount needed to avoid termination will be deducted from the death benefit (see Amount Of Death Benefit provision in Part 6). The policy will terminate without value if we do not receive payment of the required amount by the end of the grace period. Grace Period We will send a written notification to you if the policy enters the Grace Period. The Notification notice will state the amount of premium needed to avoid immediate termination, which may include an amount needed to satisfy the Guaranteed Death Benefit Safety Test. If the required premium is based on an amount needed to satisfy the Guaranteed Death Benefit Safety Test, the notice will state the amount of premium that must be deposited into the GDB Premium Account. If DBO 4 is in effect, the notice may also state the amount of premium needed to keep the policy in force until a future Monthly Charge Date. This amount will depend on the P9-2005(FL) Page 11 (C905mell) EFTA00804409 planned premium frequency you have chosen. The notice will state the portion of premium, if any, that must be deposited into the GOB Premium Account. Termination The policy will terminate without value at the end of a grace period unless we receive enough premium to keep it in force. The policy will terminate if: • The policy debt limit has been reached and the required premium payment has not been paid by the end of the grace period; • The policy was surrendered for its net surrender value; or • The policy entered the grace period on any Monthly Charge Date before the younger Insured's Attained Age 121 and the required premium payment has not been paid by the end of the grace period. If we receive a premium payment that is less than the amount needed to avoid immediate termination, we will return it to you and the policy will terminate at the end of the grace period. If DBO 4 is in effect, and we receive a premium that is at least the amount needed to avoid immediate termination, but less than the amount due, we will apply the immediate amount to the GDB Premium Account. Any remaining premium will be allocated according to the current allocations. If DBO 4 is in effect, and we receive a premium that is greater than or equal to the amount due, we will apply the amount due to the GM Premium Account. Any remaining premium will be allocated according to the current allocations. Determining If the policy is at risk of terminating, and the policy debt limit has not been reached, Amount Of we may reduce the monthly charges due. Premium Needed To Avoid Termination If the GDB Premium Account Value cannot cover the monthly charges due, but the Guaranteed Death Benefit Safety Test is met, the monthly charges for that date will be reduced to an amount equal to the GDB Premium Account Value. Part 4. Guaranteed Death Benefit Safety Test On each Monthly Charge Date prior to the younger Insured's Attained Age 121, we test to determine whether the Guaranteed Death Benefit Safety Test is met. The Guaranteed Death Benefit Safety Test is met if the Guaranteed Death Benefit Measure is greater than or equal to the Guaranteed Death Benefit Monthly Factors due. We will notify you if you fail the Guaranteed Death Benefit Safety Test and this policy will lapse (see the Grace Period Notification provision in Part 3). Guaranteed Death The Guaranteed Death Benefit Measure is not used to determine this policy's Benefit Measure Account Value or death benefit. It is a reference measure that is used to determine if the Guaranteed Death Benefit Safety Test is met on each Monthly Charge Date. For the purpose of calculating the Guaranteed Death Benefit Measure, net premiums allocated to the GDB Premium Account are measured from the Monthly Charge Date that is on or precedes the date on which we receive the premium. P9-2005(FL) Page 12 (c905m all) EFTA00804410 The Guaranteed Death Benefit Measure is equal to: • Net premiums paid into the GDB Premium Account; plus • Amounts transferred into the GDB Premium Account; less • Amounts transferred or withdrawn from the GOB Premium Account; less • Any surrender charges for this policy that have been deducted from the GDB Premium Account due to any decreases in the Face Amount; less • Loans and loan interest attributed to the GDB Premium Account; less • All prior Guaranteed Death Benefit Monthly Factors taken for this policy; plus • Loans repaid to the GDB Premium Account; plus • Interest credited to the GDB Premium Account as a result of any policy loan; plus • Interest on the above amounts credited at the Guaranteed Death Benefit Measure Interest Factors shown in the Policy Specifications. The Guaranteed Death Benefit Monthly Factors are determined on each Monthly Charge Date. After the first Policy Year, the Guaranteed Death Benefit Measure can never be less than zero. Guaranteed Death In the first policy year, the interest factor we use will be the daily equivalent of the Benefit Measure Year 1 Guaranteed Death Benefit Measure Interest Factor. After the first policy year, Interest Factors interest credited to the Guaranteed Death Benefit Measure will be determined as described below. The daily equivalent of the Guaranteed Death Benefit Measure Band 1 Interest Factor will be applied to the portion of the Guaranteed Death Benefit Measure that does not exceed the Guaranteed Death Benefit Measure Annual Threshold Amount applicable for the policy year shown in the Policy Specifications. The daily equivalent of the Guaranteed Death Benefit Measure Band 2 Interest Factor will be applied to the portion of the Guaranteed Death Benefit Measure that exceeds the Guaranteed Death Benefit Measure Annual Threshold Amount applicable for the policy year shown in the Policy Specifications. The Guaranteed Death Benefit Measure Annual Threshold Amount is equal to: • The Face Amount divided by 1,000; multiplied by • The Guaranteed Death Benefit Measure Annual Threshold Amount for the policy year shown in the Table Of Guaranteed Death Benefit Banding Annual Thresholds Per $1,000 Of Face Amount. Maximum Three types of monthly factors reduce the Guaranteed Death Benefit Measure: Guaranteed Death Benefit Monthly Factors • Guaranteed Death Benefit Monthly Face Amount Factor; • Guaranteed Death Benefit Monthly Insurance Factor; and • Any applicable Guaranteed Death Benefit Rider Factors (which are described in each applicable rider). P9-2005(FL) Page 13 (c905matl) EFTA00804411 These monthly factors reduce the Guaranteed Death Benefit Measure on each Monthly Charge Date prior to the younger Insured's Attained Age 121. Monthly factors will also reduce the Guaranteed Death Benefit Measure on the date that we receive the amount of premium needed to prevent termination, as discussed in the Determining Amount Of Premium Needed To Avoid Termination provision in Part 3. The maximum Guaranteed Death Benefit factors are established on the date(s) this policy and riders are issued and can never be increased. Maximum The amount of this factor is equal to: Guaranteed Death Benefit Monthly Face Amount Factor • The Face Amount divided by 1,000; multiplied by • The Maximum Guaranteed Death Benefit Monthly Face Amount Factor shown in the Policy Specifications. Maximum The Table Of Maximum Guaranteed Death Benefit Monthly Insurance Factors per Guaranteed Death 1.000 of Guaranteed Death Benefit Measure risk is in the Policy Specifications. Benefit Monthly Insurance Factor The Guaranteed Death Benefit Measure risk is determined on each date the factor reduces the Guaranteed Death Benefit Measure. We determine the Guaranteed Death Benefit Measure of this policy after all additions and factors other than the Guaranteed Death Benefit Monthly Insurance Factor. The Guaranteed Death Benefit Measure risk is equal to: • The Face Amount divided by an amount equal to 1 plus the monthly equivalent of the Minimum Annual Interest Rate shown in the Policy Specifications; less • The Guaranteed Death Benefit Measure. If there are two or more tables of Maximum Guaranteed Death Benefit Monthly Insurance Factors, the pro rata Guaranteed Death Benefit Measure risk allocated to each table will be based on the proportionate amount of Face Amount for the table to the total Face Amount. My premiums refunded under the Right To Refund Premiums provision in Part 2 are excluded from the Guaranteed Death Benefit Safety Test calculation. Safety Teat On the 6th Monthly Charge Date, there is no policy debt and the monthly charges due Example are $100. The Guaranteed Death Benefit Measure is 75, and the Guaranteed Death Benefit Monthly Factors due are 70. The Guaranteed Death Benefit Safety Test is met and the policy remains in force because the Guaranteed Death Benefit Measure is greater than the Guaranteed Death Benefit Monthly Factors due on that Monthly Charge Date. P9-2005(FL) Page 14 (c905m all) EFTA00804412 lifirt 5. Life Benefits This life insurance policy provides a death benefit if both Insureds die while the policy is in force. Rights and benefits are also available while either Insured is living. These "Life Benefits" are discussed in this Part. Policy Ownership Rights Of Owner While either 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, enjoying all policy benefits, and exercising all policy options. Changing The While either Insured is living, the Owner or any Beneficiary may be changed by written Owner Or request. However, the consent of any Irrevocable Beneficiary is needed to change Beneficiary that Beneficiary designation. We do not limit the number of changes that may be made. The change will take effect as of the date the request is signed, even if the second death occurs before we receive it. Each change will be subject to any payment we made or other action we took before receiving the written request. Assigning This This policy may be assigned. However, for any assignment to be binding on us, we Policy must receive a signed copy of it at our Home Office. We will not be responsible for the validity of any assignment. Once we receive a signed copy of an assignment, the rights of the Owner and the interest of any Beneficiary or any other person will be subject to the assignment. An assignment is subject to any policy debt. Policy debt is discussed in the Right To Make Loans provisions in this Part. Annual Report Each year after the Policy Anniversary Date, we will mail an annual report to the Owner. There will be no charge for this report. This report will show the Account Value at the beginning of the preceding Policy Year and all premiums accepted during that Year. It also will show the additions to, and deductions from, the Account Value during that Year, and the Account Value, death benefit, net surrender value, and policy debt as of the current Policy Anniversary Date. This report will also indicate whether the Guaranteed Death Benefit Safety Test is met as of the date of the report. The annual report also will include any additional information required by applicable law or regulation. This Policy's Share In Dividends Policy Is This policy is "participating," which means it may or may not share in any dividends Participating we pay. Each year we determine how much money can be paid as dividends. This is called divisible surplus. We then determine how much of this divisible surplus is to be allocated to this policy. This determination is based on this policy's contribution to divisible surplus. P9-2005(FL) Page 15 (c905m all) EFTA00804413 Since we do not expect this policy to contribute to divisible surplus, we do not expect that any dividends will be payable on this policy. Any dividends allocated to this policy will be payable on Policy Anniversary Dates. How Dividends Dividends may be used in a number of ways. These are called dividend options. May Be Used There are four basic dividend options. Cash • Dividends will be paid in cash. Account Value Additions - Dividends will be added to the Account Value of this policy. Paid-Up Additions - Dividends will be used to buy additional level paid-up insurance. The amount of paid-up insurance will be determined by applying the dividend, on the date credited, as a net single premium at the genders and Attained Ages of the Insureds on that date. The value of the paid-up insurance will be the net single premium, on the same basis, at the Attained Ages of the Insureds. The amount of any paid-up additions will be added to the death benefit; and the value of any paid-up additions will be added to the net surrender value. However, determination of Account Value, insurance charges, and minimum death benefit ignore paid-up additions. Reduced Monthly Charges - Dividends will be used to reduce the monthly deductions we make from the Account Value to pay the monthly charges. A dividend option may be elected in the application. ft may be changed by the Owner up to 31 days after the dividend becomes payable. If no dividend option is in effect when a dividend becomes payable, we will apply any dividends payable under the paid•up additions dividend option. Dividend After If the second death occurs after the first Policy Year, the death benefit will include a Death Of Insured pro rata share of any dividend allocated to this policy for the Year that death occurs. Right To Change The Face Amount While this policy is in force, the Face Amount may be changed. We may limit the number and the size of the changes in a Policy Year. No Increases In Increases in the Face Amount will not be allowed. The Face Amount Decreases in The After the first Policy Year, the Face Amount may be decreased by the Owner's written Face Amount request while either insured is living. However, the decrease must not reduce the Face Amount to an amount less than the Minimum Face Amount shown in the Policy Specifications. A partial surrender charge may apply for each decrease in Face Amount. My decrease is effective on the Monthly Charge Date that is on, or precedes, the date we receive the written request. P9-2005(FL) Page 16 (c905ma11) EFTA00804414 Any surrender charge due upon a decrease in the Face Amount is deducted from the GDB Premium Account on the effective date of the decrease. If the GDB Premium Account has insufficient value to cover any surrender charge, the surrender charge will be capped and, after the decrease, the GDB Premium Account will be zero. Surrender charges are discussed in the Net Surrender Value provision in this Part. Evidence Of If the Face Amount is changed, we will send the Owner any revised and additional Changes Policy Specifications for attachment to this policy. However, we have the right to require that the policy be sent to us to make the change. Transfers Of Values If DBO 4 is in effect, you may make transfers between the Specified Premium Account and the GDB Premium Account. Each transfer request must be in writing and will be effective on the date we receive the written request at our Home Office. Transfers must be made in whole percentages or in dollar amounts. We reserve the right to restrict or reject any transfer. Transfers From The entire value or any portion of the Specified Premium Account may be transferred The Specified to the GDB Premium Account at any time while this policy is in force. Premium Account Transfers From Transfers may be made from the GDB Premium Account to the Specified Premium The GDB Premium Account once each policy year. My transfer may not exceed 25% of the account's Account net surrender value (the GOB Premium Account Value less surrender charges). Borrowing Against This Policy Right To Make Once the Account Value exceeds any surrender charges that apply, the Owner may Loans borrow against this policy while either Insured is living. The policy must be properly assigned to us before the loan is made. No other collateral is needed. We refer to all outstanding loans plus accrued interest as "policy debt." We may delay the granting of any loan for up to six months, except for a loan to pay premiums to us. Effect Of Loan ff DBO 1 is in effect, the amount of any loan will be deducted from the GOB Premium Account. If DBO 4 is in effect, the amount of any loan will be deducted from the Specified Premium Account to the extent possible. If there is not enough value in the Specified Premium Account, the remaining amount of any loan will be deducted from the GDB Premium Account. My loan amount deducted from the GDB Premium Account will also reduce the Guaranteed Death Benefit Measure. Any interest added to the loan will be treated as a new loan under this provision. P9-2005(FL) Page 17 (c905rnal EFTA00804415 The amount of outstanding policy loan will earn interest as described in the Loaned Account Value provision in Part 3. Maximum Loan There is a maximum amount that can be borrowed on any date. It is the amount that, Available with loan interest on it to the next Policy Anniversary Date, will equal the current Account Value less surrender charges. This maximum amount will be reduced by any outstanding policy debt. Interest On Loans Interest on loans is not due in advance. This interest accrues each day and becomes part of the policy debt Interest is due on each Policy Anniversary Date. The fixed loan interest rate is shown in the Policy Specifications. If interest is not paid when due, it will be added to the loan and will bear interest at the rate payable on the loan. Policy Debt Limit Policy debt (which includes accrued interest) may not exceed: • The Account Value less surrender charges, if the Guaranteed Death Benefit Safety Test has not been met, or • The Account Value, if the Guaranteed Death Benefit Safety Test has been met. It this limit is exceeded, the policy will enter the Grace Period and may terminate. To terminate for this reason, we must mail written notice to the Owner and any assignee shown in our records at their last known addresses. This notice will state the amount needed to bring the policy debt back within the limit. For more information, please see the Termination, Grace Period, and Grace Period Notification provisions in Part 3. Repayment Of All or part of any policy debt may be repaid at any time while either Insured is living. Policy Debt However, policy debt can be repaid only while this policy is in force. Each loan repayment will be credited on the day we receive it at our Home Office. Loan repayments made within 30 days of a policy anniversary will be used to pay loan interest due first. If DBO 1 is in effect, any other repayment of policy debt will be allocated to the GDB Premium Account up to the amount of the policy loan (not counting any loan interest). If DBO 4 is in effect, any other repayment of policy debt will be allocated to the GDB Premium Account up to the amount of the policy loan (not counting any loan interest) that was attributed to it. Any additional loan repayment will be credited to the Specified Premium Account. The amount of any loan repayment that increases the GDB Premium Account will also increase the Guaranteed Death Benefit Measure. Loan repayments must be clearly identified as such; otherwise, they will be considered premium payments. P9-2005(FL) Page 18 (c905mall) EFTA00804416 Surrendering This Policy And Making Withdrawals Right To Surrender This policy may be surrendered for its net surrender value (see the next provision) at any time while the policy is in force and either Insured is living. This policy will terminate as of the date of surrender and cannot be reinstated. The Owner has the option at any time to surrender this policy for level paid-up life insurance. The amount of level paid-up life insurance will be determined by applying the net surrender value on the date of surrender as a net single premium at the gender(s) and Attained Age(s) of the Insured(s) on that date. This net single premium will be computed on the basis of 4.0% interest and the Table(s) Of Maximum Monthly Insurance Charges shown in the Policy Specifications. On any date after this surrender, the value of the paid-up life insurance will be the net single premium, on this same basis, at the gender(s) and Attained Age(s) of the Insured(s) on that date. Monthly administrative charges will not be deducted from the paid-up life insurance. Net Surrender Value The net surrender value of this policy is equal to the Account Value less any applicable surrender charges and any policy debt. The surrender charge for this policy is the sum of the surrender charges for all segments of the Face Amount. These charges are shown in the Table(s) Of Surrender Charges of the Policy Specifications. In no event will the net surrender value be less than zero. Making Withdrawals After the first Policy Year, withdrawals may be made by written request while the policy is in force. If DBO 1 is in effect, withdrawals will be taken from the GOB Premium Account. If DBO 4 is in effect, withdrawals will be taken from the Specified Premium Account until it is depleted. Any additional amount will be taken from the GDB Premium Account. The Guaranteed Death Benefit Measure will be reduced by the amount of any withdrawal taken from the GDB Premium Account. No withdrawal from the GDB Premium Account can exceed seventy-five percent (75%) of the net surrender value of that account (the GDB Premium Account Value less any applicable surrender charge). The entire value of the Specified Premium Account may be withdrawn. On the date of a withdrawal, the Account Value will be reduced by the withdrawal amount, which includes any withdrawal fee that we may charge. The Maximum Withdrawal Fee that can be taken with each withdrawal is shown in the Policy Specifications. The minimum amount of a withdrawal (including the withdrawal fee) is S100. The Face Amount will be decreased if: • The withdrawal is taken from the GOB Premium Account; and P9-2005(FL) Page 19 (c905maft) EFTA00804417 • After the withdrawal, the Death Benefit is greater than the Minimum Death Benefit (described in Part 6); and • We have not received evidence of insurability satisfactory to us. In this case, the Face Amount will be decreased by an amount equal to the excess of (A) over (B), where: (A) is the withdrawal amount; and (B) is the lowest withdrawal amount that would reduce the Minimum Death Benefit to equal the Death Benefit just after the withdrawal. A withdrawal will not be allowed if the Face Amount after a withdrawal would be less than the Minimum Face Amount shown in the Policy Specifications. Withdrawals will be subject to the following limits: • If DBO 1 is in effect, the maximum amount of a withdrawal on any date is 75% of the Net Surrender Value. • If DBO 4 is in effect, the entire value of the Specified Premium Account may be withdrawn in addition to 75% of the net surrender value of the GDB Premium Account (the GOB Premium Account Value less any applicable surrender charges); and • The Face Amount after a withdrawal must not be less than $50,000. Example: Death Benefit Option 1 You make a withdrawal without furnishing us satisfactory evidence of insurability. Prior to your withdrawal, your policy has a Face Amount of $600,000, and an Account Value of $120,000. If you make a withdrawal of $30,000, the GDB Premium Account value will be reduced to $90,000, the Face Amount will be reduced to $570,000, and $29,975 will be paid to you. Death Benefit Option 4 You make a withdrawal without furnishing us satisfactory evidence of insurability. Prior to your withdrawal, your policy has a Face Amount of $600,000, A GDB Premium Account value of $10,000 and a Specified Premium Account value of $25,000. If you make a withdrawal of $30,000, the Specified Premium Account value will be reduced to $0, and the GDB Premium Account will be reduced to $5,000, the Face Amount will be reduced to $595,000, and $29,975 will be paid to you. If the Face Amount is reduced due to a withdrawal, we will send the Owner any revised or additional Policy Specifications for attachment to this policy. However, we have the right to require that the policy be sent to us to make the changes. P9-2005(FL) Page 20 (c905maM EFTA00804418 How We Pay Any withdrawal made will be paid in one sum. if the policy is surrendered, the net surrender value may be paid in one sum or it may be applied under any payment option elected. We may delay paying any surrender or withdrawal for up to six months from the date we receive the written request. Interest will be added if payment is delayed. The amount of interest is the same as would be paid for the same period of time under Option 3 of the payment options or, if greater, the amount using the minimum interest rate for this purpose required by the laws of the state where this policy was delivered. See Part 7 for a description of Option 3. Reinstating This Policy When Policy May Atter this policy has terminated, it may be reinstated -- that is, put back in force. Be Reinstated However, the policy may not be reinstated: • If it has been surrendered for its net surrender value; or • More than three years after the date of termination; or • If an Insured has died since the date of termination. Requirements To A written application and evidence of insurability satisfactory to us is required to Reinstate reinstate. Also, a premium is required as a cost to reinstate. This cost is the amount of premium needed to keep the policy in force for three months after reinstatement. This amount will be quoted on request. We will not apply this premium until your reinstatement application is approved. Policy After The policy will be reinstated on the Monthly Charge Date that is on, or following, the Reinstatement date we approve the application. The Face Amount on the date of reinstatement will be the Face Amount on the termination date. The reinstatement premium received will be applied according to the premium allocation in effect when the policy terminated. The amount of reinstatement premium allocated to the GDB Premium Account will be reflected in the Guaranteed Death Benefit Measure. We do not reinstate debt. Upon reinstatement of this policy, the Table(s) Of Surrender Charges (shown in the Policy Specifications) will apply as though the policy had not terminated. However, if the surrender charge was taken when this policy terminated, then the applicable surrender charges will not be reinstated. Our rights to contest the validity of, and terminate, this policy begin again on the date of reinstatement. See the Representations And Contestability and Death By Suicide provisions in Part 1. Reports To Owner Illustrative Report In addition to the annual reports, after the first Policy Year we will send an illustrative report of guaranteed and non-guaranteed values to the Owner upon written request. The illustration will be based on assumptions that the Owner may specify. We may limit the number of illustrations in any Policy Year. P9.2005(FL) Page 21 (c905matl) EFTA00804419 Part 6. The Death Benefit The death benefit is the amount of money we will pay when we receive due proof at our Home Office that both Insureds died while the policy was in force. We discuss the death benefit in this Part. When the first death occurs, we will not pay a death benefit. However, due proof of each Insured's death must be furnished to us at our Home Office when it occurs. Amount Of Death If both Insureds die while this policy is in force, the death benefit will be the amount of Benefit benefit provided by the Death Benefit Option in effect on the date of the second death, reduced by any policy debt outstanding on that date of death and any unpaid premium amount needed to avoid termination under the Grace Period and Termination provisions in Part 3. The minimum death benefit is discussed in the next provision. Death Benefit Option 1 (DBO 1) The amount of benefit is the greater of: • The Face Amount in effect on the date of the second death; or • The Minimum Death Benefit in effect on the date of the second death. Death Benefit Option 4 (DBO 4) The amount of benefit is the greater of: • The Face Amount in effect on the date of the second death plus the Account Value on that date minus the GDB Premium Account; or • The Minimum Death Benefit in effect on the date of the second death. Changes in the After the first policy year and while both Insureds are living, the Death Benefit Option Death Benefit may be changed from Death Benefit Option 1 to Death benefit Option 4 upon written Option request. If Death Benefit Option 4 is in effect, it may not be changed to Death Benefit 1 at any time. A change in the Death Benefit Option will be effective on the monthly charge date that is on or precedes, the date we receive the written request. If the Death Benefit Option is changed, we will send the owner any revised Policy Specifications for attachment to this policy. Minimum Death The Minimum Death Benefit on any date is equal to the Account Value on that date Benefit multiplied by the Death Benefit Factor for the younger Insured's Attained Age on that date. The Death Benefit Factor for each Attained Age is shown in the Policy Specifications. When We Pay The death benefit will be paid within 30 days after the date we receive due proof that both Insureds died and any other requirements necessary for us to make payment, at our Home Office. P9-2005(FL) Page 22 (C905m all) EFTA00804420 Interest On We will add interest from the date of the death of the second Insured to the date of a Death Benefit lump sum payment or the effective date of a payment option. The amount of interest will be computed using an effective annual rate not less than 3% or, if greater, the annual rate required by law. The annual interest rate used will be no less than the Moody's Corporate Bond Yield Average on the day the claim is received in good order. Part 7. Payment Options These are optional methods of settlement. These methods provide alternate ways in which payment can be made by us. Availability Of All or part of the death benefit or net surrender value may be applied under any payment Options option. If this policy is assigned, any amount due to the assignee will be paid in one sum. The balance, if any, may be applied under any payment option. Minimum Amounts If the amount to be applied under any option for any one person is less than 610,000, we may pay the amount in one sum instead. If the payments under any option come to less than $100 each, we have the right to make payments at less-frequent intervals. Description Of Our regular payment options are Options 1 through 6. They are described in terms of Options monthly payments. Annual, semiannual, or quarterly payments may be requested instead. The Payment Option Rates tables are shown after Part 8. Option 1 Installments For A Specified Period. Equal monthly payments will be made for any period selected, up to 30 years. The amount of each payment depends on the total amount applied, the period selected, and the monthly income rates we are using when the first payment is due. See the Option 1. Installments For A Specified Period table for the minimum monthly income rates. Option 2 Life Income. Equal monthly payments will be based on the life of a named person. Payments will continue for the lifetime of that person. Income with or without a minimum payment period may be elected. This benefit may be increased by the Alternate Life Income provision (in this Part). Proof of the named person's age. satisfactory to us, will be required. See the Option 2. Life Income tables for the minimum monthly income rates. Option 3 Interest. We will hold any amount applied under this option. Interest on the amount will be paid at an effective annual rate determined by us. This rate will not be less than 3%. Option 4 Installments Of Specified Amount. Each payment will be made for an agreed fixed amount. The total amount paid during the first year must be at least 6% of the total amount applied. Interest will be credited each month on the unpaid balance and added to it. This interest will be at an effective annual rate determined by us, but not less than 3%. Payments continue until the balance we hold is reduced to an amount less than the agreed fixed amount. The last payment will be for the balance only. P9-2005(FL) Page 23 (c905mall) EFTA00804421 Option 5 Life Income With Payments Guaranteed For Amount Applied. Equal monthly payments will be based on the life of a named person. Payments will be made until the total amount paid equals the amount applied, and as long thereafter as the named person lives. This benefit may be increased by the Alternate Life Income provision (in this Part). Proof of the named person's age, satisfactory to us, will be required. See the Option 5. Life Income With Payments Guaranteed For Amount Applied tables for the minimum monthly income rates. Option 6 Joint Life Income With Reduced Payments To Survivor. Monthly payments will be based on the lives of two named persons. Payments at the initial level will continue while both are living or for 10 years if longer. When one dies (but not before the 10 years has elapsed), payments are reduced by one-third and will continue at that level for the lifetime of the other. After the 10 years has elapsed, payments stop when both named persons have died. This benefit may be increased by the Alternate Life Income provision (in this Part). Proof of the named persons' ages, satisfactory to us, will be required. See the Option 6. Joint Life income With Reduced Payments To Survivor tables for the minimum monthly income rates. Alternate Life if Option 2, 5, or 6 is elected, the named person(s) can elect to receive an alternate life Income income instead of receiving income based on the rates shown in the Payment Option Rates tables. The election must be made at the time the income is to begin. The monthly alternate life income will be at least equal to the monthly income provided by a new single premium immediate annuity (first payment immediate), based on our published rates then in use when the payment option is elected. The alternate life income will not be available if we are not offering new single premium immediate annuities at the time of election. Electing A To elect any payment option, we require a written request. The Owner may elect an Payment Option option during either Insured's lifetime. If the death benefit is payable in one sum when the second death occurs, the Beneficiary may elect an option with our consent. Effective Date The effective date of a payment option is the date the amount is applied under that And Payment option. For a death benefit, this is the date that due proof of the deaths of both Insureds Dates has been received at our Home Office. For the net surrender value, it is the effective date of surrender. The first payment is due on the effective date, except the first payment under Option 3 is due one month later. A later date for the first payment may be requested in the payment option election. All payment dates will fall on the same day of the month as the first one. No payment will become due until a payment date. No part payment will be made for any period shorter than the time between payment dates. Example: Monthly payments of $100 are being made to your son on the 1st of each month. He dies on the 10th. No part payment is due your son or his estate for the period between the 1st and the 10th. Withdrawals And If provided in the payment option election, all or part of the unpaid balance under Option Changes 3 or 4 may be withdrawn or applied under any other option. P9-2005(FL) Page 24 icsosmato EFTA00804422 If the net surrender value is applied under Option 3 or 4, we may delay payment of any withdrawal for up to six months. In this case, interest at the rate in effect for Option 3 during this period will be paid on the amount withdrawn. Income Protection To the extent permitted by law, each option payment and any withdrawal shall be free from legal process and the claim of any creditor of the person entitled to them. No option payment and no amount held under an option can be taken or assigned in advance of its payment date, unless the Owner's written consent is given before the second death. This consent must be received at our Home Office. Other Payment Options for any amount payable to an association, corporation, partnership, or Option Rules fiduciary are available only with our consent. However, a corporation or partnership may apply any amount payable to it under Option 2, 5, or 6 if the option payments are based on the life or lives of an Insured, an Insured's spouse, any child of an Insured, or any other person agreed to by us. If a minimum payment period is elected under Options 1, 2, 5, and 6, the effective annual interest rate will not be less than 3%. This does not apply when an alternate life income is elected. If a minimum payment period is elected, after the first payment is made we may increase the payments to reflect any additional interest earnings determined by us. This does not apply when an alternate life income is elected. If the income that would be payable under a given payment option is the same for 2 or more periods of time at a given age, we automatically wilt pay income for the longest period. Example: You choose Option 2. You are 50 years old. The Payment Option Rate (for Option 2) is $3.64 for 5 years. The Payment Option Rate for 10 years is also $3.64. We wilt pay income for at least 10 years, which is the longest period. Part 8. Notes On Our Computations This Part covers some technical points about this policy. Basis Of The basis of computation consists of the mortality rates and interest rates we use to Computation determine: • The minimum net surrender values; • The maximum monthly insurance charges; • The minimum rate used to credit interest on the Account Value of the policy; and • The minimum payments under payment Options 2, 5. and 6. The mortality rates for the minimum net surrender values and for the maximum monthly insurance charges are shown in each Table Of Maximum Monthly Insurance Charges. The Minimum Annual Interest Rate is shown in the Policy Specifications. The mortality tables specified apply to amounts in a standard risk classification. P9-2C05(FL) Page 25 (c905m all) EFTA00804423 Appropriate modifications are made to these tables for any amount that is not in a standard risk classification. In computing the minimum payments under payment Options 2, 5, and 6, we use mortality rates from the 1983 Table "e with Projection G for 32 years. The interest rate used is an annual rate of 3%. Method Of When required by the state where this policy was delivered, we filed a detailed Computing Values statement of the method we use to compute the policy benefits and values. These benefits and values are not less than those required by the laws of that state. P9-2005(FL) Page 26 (c905mall) EFTA00804424 OPTION 1. INSTALLMENTS FOR A SPECIFIED PERIOD - PAYMENT OPTION RATES MONTHLY INCOME PER 51,000 OF AMOUNT APPLIED Years Monthly Income 1 $ 84.47 2 42.86 3 28.99 4 22.06 5 17.91 6 15.14 7 13.16 8 11.68 9 10.53 10 9.61 11 8.86 12 8.24 13 7.71 14 7.26 15 6.87 16 6.53 17 6.23 18 5.96 19 5.73 20 5.51 21 5.32 22 5.15 23 4.99 24 4.84 25 4.71 26 4.59 27 4.47 28 4.37 29 4.27 30 4.18 The first income payment is payable on the effective date of this Option. P9.2005(FL) Page 27 (c905rn all) EFTA00804425 OPTION 2. LIFE INCOME - PAYMENT OPTION RATES OPTION 5. LIFE INCOME WITH PAYMENTS GUARANTEED FOR AMOUNT APPLIED - PAYMENT OPTION RATES MONTHLY LIFE INCOME PER $1,000 OF AMOUNT APPLIED MALE 5 YEARS 10 YEARS 20 YEARS AMOUNT AGE LIFE ONLY MINIMUM MINIMUM MINIMUM APPLIED 50 $3.94 S3.93 $3.91 $3.84 $3.82 51 4.00 3.99 3.97 3.89 3.87 52 4.07 4.06 4.04 3.94 3.93 53 4.14 4.13 4.10 4.00 3.98 54 4.21 4.20 4.17 4.06 4.05 55 4.29 4.28 4.25 4.11 4.11 56 4.37 4.36 4.32 4.17 4.17 57 4.45 4.44 4.40 4.23 4.24 58 4.54 4.53 4.49 4.30 4.32 59 4.64 4.63 4.58 4.36 4.39 60 4.75 4.73 4.67 4.42 4.47 61 4.86 4.84 4.77 4.49 4.55 62 4.97 4.95 4.88 4.56 4.64 63 5.10 5.07 4.99 4.62 4.73 64 5.23 5.20 5.11 4.69 4.83 65 5.38 5.34 5.23 4.75 4.93 66 5.53 5.49 5.36 4.82 5.04 67 5.69 5.64 5.49 4.88 5.15 68 5.87 5.81 5.63 4.94 5.27 69 6.05 5.98 5.77 5.00 5.39 70 6.25 6.17 5.92 5.06 5.52 71 6.46 6.36 6.07 5.11 5.66 72 6.68 6.56 6.23 5.16 5.80 73 6.91 6.78 6.39 5.21 5.95 74 7.16 7.00 6.56 5.25 6.10 75 7.43 7.24 6.73 5.29 6.27 76 7.71 7.50 6.90 5.33 6.4-4 77 8.02 7.76 7.07 5.36 6.63 78 8.35 8.04 7.25 5.39 6.82 79 8.70 8.33 7.42 5.41 7.02 80 9.07 8.64 7.60 5.43 7.23 81 9.47 8.96 7.77 5.45 7.46 82 9.89 9.29 7.94 5.46 7.69 83 10.35 9.64 8.10 5.48 7.93 84 10.83 10.00 8.26 5.48 8.19 85 11.35 10,37 8.41 5.49 8.46 Rates for other ages are available upon request. 'Age on birthday nearest the due date of the first payment. The first income payment is payable on the effective date of this Option. P9.2005(FL) Page 28 (c 905m all) EFTA00804426 OPTION 2. LIFE INCOME - PAYMENT OPTION RATES OPTION 5. LIFE INCOME WITH PAYMENTS GUARANTEED FOR AMOUNT APPLIED - PAYMENT OPTION RATES MONTHLY LIFE INCOME PER $1,000 OF AMOUNT APPLIED FEMALE 5 YEARS 10 YEARS 20 YEARS AMOUNT AGE' LIFE ONLY MINIMUM MINIMUM MINIMUM APPLIED 50 $3.64 83.64 $3.63 83.60 $3.58 51 3.69 3.69 3.68 3.63 3.63 52 3.74 3.74 3.73 3.69 3.67 53 3.80 3.80 3.79 3.74 3.72 54 3.86 3.85 3.84 3.79 3.77 55 3.92 3.91 3.90 3.84 3.83 56 3.98 3.98 3.96 3.90 3.88 57 4.05 4.04 4.03 3.95 3.94 58 4.12 4.12 4.10 4.01 4.00 59 4.20 4.19 4.17 4.07 4.07 60 4.28 4.27 4.25 4.14 4.13 61 4.36 4.36 4.33 4.20 4.20 62 4.45 4.45 4.42 4.27 4.28 63 4.55 4.54 4.51 4.34 4.36 64 4.65 4.64 4.60 4.41 4.44 65 4.76 4.75 4.70 4.48 4.53 66 4.88 4.86 4.81 4.55 4.62 67 5.00 4.99 4.92 4.62 4.71 68 5.14 5.12 5.04 4.69 4.82 69 5.28 5.26 5.17 4.76 4.92 70 5.44 5.41 5.30 4.83 5.04 71 5.60 5.57 5.45 4.90 5.16 72 5.78 5.74 5.59 4.97 5.28 73 5.97 5.92 5.75 5.03 5.42 74 6.18 6.12 5.91 5.09 5.56 75 6.40 6.33 6.08 5.15 5.71 76 6.64 6.55 6.26 5.20 5.87 77 6.90 6.79 6.44 5.25 6.04 78 7.18 7.04 6.63 5.29 6.21 79 7.48 7.31 6.82 5.33 6.40 80 7.80 7.60 7.01 5.36 6.59 81 8.14 7.90 7.21 5.39 6.80 82 8.52 8.22 7.40 5.41 7.01 83 8.92 8.56 7.60 5.43 7.24 84 9.36 8.92 7.78 5.45 7.48 85 9.83 9.29 7.96 5.47 7.73 Rates for other ages aro available upon request. 'Age on birthday nearest the due date of the first payment. The first income payment is payable on the effective date of this Option. P9-2005(FL) Page 29 (c905m all) EFTA00804427 OPTION 6. JOINT LIFE INCOME WITH REDUCED PAYMENTS TO SURVIVOR - PAYMENT OPTION RATES MONTHLY LIFE INCOME PER $1,000 OF AMOUNT APPLIED MALE 8 FEMALE MALE FEMALE IS YOUNGER THAN MALE BY: AGE 10 Yrs. 9 Yrs. 8 Yrs. 7 Yrs. 6 Yrs. 5 Yrs. 4 Yrs. 3 Yrs. 2 Yrs. 1 Yr. 55 $3.63 $3.65 $3.68 $3.70 $3.73 $3.76 $3.79 $3.82 $3.85 $3.88 56 3.67 3.70 3.73 3.75 3.78 3.81 3.84 3.87 3.90 3.94 57 3.72 3.75 3.78 3.81 3.84 3.87 3.90 3.93 3.97 4.00 58 3.77 3.80 3.83 3.86 3.89 3.93 3.96 4.00 4.03 4.07 59 3.83 3.86 3.89 3.92 3.96 3.99 4.03 4.06 4.10 4.14 60 3.88 3.92 3.95 3.98 4.02 4.06 4.09 4.13 4.17 4.21 61 3.94 3.98 4.01 4.05 4.09 4.13 4.16 4.21 4.25 4.29 62 4.01 4.04 4.08 4.12 4.16 4.20 4.24 4.28 4.33 4.37 63 4.07 4.11 4.15 4.19 4.23 4.28 4.32 4.37 4.41 4.46 64 4.14 4.18 4.22 4.27 4.31 4.36 4.40 4.45 4.50 4.55 65 4.21 4.26 4.30 4.35 4.39 4.44 4.49 4.54 4.60 4.65 66 4.29 4.33 4.38 4.43 4.48 4.53 4.58 4.64 4.69 4.75 67 4.37 4.42 4.47 4.52 4.57 4.63 4.68 4.74 4.80 4.86 68 4.45 4.50 4.56 4.61 4.67 4.73 4.79 4.85 4.91 4.97 69 4.54 4.59 4.65 4.71 4.77 4.83 4.89 4.96 5.03 5.09 70 4.63 4.69 4.75 4.81 4.87 4.94 5.01 5.08 5.15 5.22 71 4.73 4.79 4.85 4.92 4.99 5.06 5.13 5.20 5.28 5.35 72 4.83 4.89 4.96 5.03 5.10 5.18 5.25 5.33 5.41 5.49 73 4.93 5.00 5.07 5.15 5.23 5.30 5.38 5.47 5.55 5.64 74 5.04 5.12 5.19 5.27 5.35 5.44 5.52 5.61 5.70 5.79 75 5.16 5.24 5.32 5.40 5.49 5.58 5.67 5.76 5.85 5.95 76 5.28 5.36 5.45 5.54 5.63 5.72 5.82 5.92 6.02 6.12 77 5.41 5.50 5.59 5.68 5.78 5.88 5.98 6.08 6.18 6.29 78 5.54 5.63 5.73 5.83 5.93 6.04 6.14 6.25 6.36 6.46 79 5.68 5.78 5.88 5.98 6.09 6.20 6.31 6.42 6.53 6.65 80 5.82 5.93 6.04 6.15 6.26 6.37 6.49 6.60 6.72 6.83 81 5.97 6.08 6.20 6.31 6.43 6.55 6.67 6.79 6.90 7.02 82 6.13 6.25 6.36 6.48 6.61 6.73 6.85 6.97 7.09 7.21 83 6.29 6.41 6.53 6.66 6.79 6.91 7.04 7.16 7.28 7.40 84 6.46 6.58 6.71 6.84 6.97 7.10 7.23 7.35 7.47 7.59 85 6.63 6.76 6.89 7.02 7.15 7.29 7.41 7.54 7.66 7.78 Ratos for other ages are ava table upon request. *Age on birthday nearest the due date of the first payment. The first income payment is payable on the effective date of this Option. P9-2005(FL) Page 30 (c405m all) EFTA00804428 OPTION 6. JOINT LIFE INCOME WITH REDUCED PAYMENTS TO SURVIVOR - PAYMENT OPTION RATES MONTHLY LIFE INCOME PER $1,000 OF AMOUNT APPLIED MALE & FEMALE MALE FEMALE IS OLDER THAN MALE BY: AGE' SAME AGE 1 YEAR 2 YEARS 3 YEARS 4 YEARS 5 YEARS T8 2 cr, 8 (A $3.91 $3.94 $3.97 $4.01 $4.04 $4.08 3.97 4.00 4.04 4.07 4.11 4.15 4.04 4.07 4.11 4.15 4.18 4.22 4.26 OD 0/ 03 4.10 4.14 4.18 4.22 4.30 4.18 4.22 4.26 4.30 4.34 4.39 4.25 4.30 4.34 4.38 4.43 4.47 OD co -4 0) cn 4.33 4.38 4.42 4.47 4.52 4.57 4.42 4.47 4.52 4.57 4.62 4.67 4.51 4.56 4.61 4.66 4.72 4.77 4.60 4.66 4.71 4.77 4.83 4.88 4.71 4.76 4.82 4.88 4.94 5.00 0/ CO Cf) Cbg 4.81 4.87 4.93 4.99 5.06 5.12 4.92 4.99 5.05 5.12 5.18 5.25 CD Co -4 a> 5.04 5.11 5.18 5.25 5.32 5.39 5.16 5.24 5.31 5.38 5.46 5.53 -4 5.29 5.37 5.45 5.52 5.60 5.68 V 5.43 5.51 5.59 5.67 5.76 5.84 5.58 5.66 5.74 5.83 5.91 6.00 NI /344 V 5.73 5.81 5.90 5.99 6.08 6.17 *WI° 5.88 5.97 6.07 6.16 6.25 6.34 ar .,..1-4 6.24 NI 03 CT 6.05 6.14 6.33 6.43 6.52 6.21 6.31 6.41 6.51 6.61 6.70 6.39 6.49 6.59 6.69 6.79 6.89 6.57 6.68 6.78 6.88 6.98 7.07 6.76 6.86 6.97 7.07 7.17 7.26 6.94 7.05 7.16 7.26 7.36 7.45 8 2 ?I s 7.13 7.25 7.35 7.45 7.55 7.63 7.33 7.44 7.54 7.64 7.73 7.82 7.52 7.62 7.73 7.82 7.91 7.99 Co a 7.70 7.81 7.91 8.00 8.08 8.16 OD 01 7.88 7.99 8.08 8.17 8.25 8.32 Rates for other ages are available upon request 'Age on birthday nea est the duo date of the first payment. The first income payment is payable on the effective date of this Option. P9-2005(FL) Page 31 (c905matl) EFTA00804429 OPTION 6. JOINT LIFE INCOME WITH REDUCED PAYMENTS TO SURVIVOR - PAYMENT OPTION RATES MONTHLY LIFE INCOME PER 51,000 OF AMOUNT APPLIED MALE1 8 MALE2 MALE1 MALE2 IS YOUNGER THAN MALE1 BY: AGE* 10 Yrs. 9 Yrs. 8 Yrs. 7 Yrs. 6 Yrs. 5 Yrs. 4 Yrs. 3 Yrs. 2 Yrs. 1 Yr. 60 $4.06 $4.09 $4.13 $4.17 $4.20 $4.24 $4.28 $4.33 $4.37 $4.41 61 4.12 4.16 4.20 4.24 4.28 4.32 4.36 4.41 4.45 4.50 62 4.20 4.24 4.28 4.32 4.36 4.41 4.45 4.50 4.54 4.59 63 4.27 4.31 4.36 4.40 4.45 4.49 4.54 4.59 4.64 4.69 64 4.35 4.39 4.44 4.49 4.53 4.58 4.63 4.69 4.74 4.79 65 4.43 4.48 4.53 4.58 4.63 4.68 4.73 4.79 4.84 4.90 66 4.52 4.57 4.62 4.67 4.73 4.78 4.84 4.90 4.95 5.01 67 4.61 4.66 4.72 4.77 4.83 4.89 4.95 5.01 5.07 5.13 68 4.71 4.76 4.82 4.88 4.94 5.00 5.06 5.13 5.19 5.26 69 4.81 4.87 4.93 4.99 5.05 5.12 5.19 5.25 5.32 5.39 70 4.91 4.98 5.04 5.11 5.17 5.24 5.31 5.38 5.46 5.53 71 5.02 5.09 5.16 5.23 5.30 5.37 5.45 5.52 5.59 5.67 72 5.14 5.21 5.28 5.36 5.43 5.51 5.58 5.66 5.74 5.82 73 5.26 5.33 5.41 5.49 5.57 5.65 5.73 5.81 5.89 5.97 74 5.39 5.47 5.55 5.63 5.71 5.79 5.88 5.96 6.04 6.13 75 5.52 5.60 5.69 5.77 5.86 5.95 6.03 6.12 6.21 6.29 MALE1 MALE2 IS OLDER THAN MALE1 BY: AGE* SAME AGE 1 Yr. 2 Yrs. 3 Yrs. 4 Yrs. 5 Yrs. 60 54.45 64.50 $4.54 $4.59 $4.63 $4.68 61 4.54 4.59 4.64 4.69 4.73 4.78 62 4.64 4.69 4.74 4.79 4.84 4.89 63 4.74 4.79 4.84 4.90 4.95 5.00 64 4.85 4.90 4.95 5.01 5.06 5.12 65 4.96 5.01 5.07 5.13 5.19 5.24 66 5.07 5.13 5.19 5.25 5.31 5.37 67 5.20 5.26 5.32 5.38 5.45 5.51 68 5.32 5.39 5.46 5.52 5.58 5.65 69 5.46 5.53 5.59 5.66 5.73 5.79 70 5.60 5.67 5.74 5.81 5.88 5.95 71 5.74 5.82 5.89 5.96 6.03 6.10 72 5.89 5.97 6.04 6.12 6.19 6.26 73 6.05 6.13 6.21 6.28 6.36 6.43 74 6.21 6.29 6.37 6.45 6.53 6.60 75 6.38 6.46 6.54 6.62 6.70 6.77 Rates for other ages are available upon request. 'Age on birthday nearest the due date of the first payment. The first income payment is payable on the effective date of this Option. P9-2005(FL) Page 32 (c905ma0) EFTA00804430 OPTION 6. JOINT LIFE INCOME WITH REDUCED PAYMENTS TO SURVIVOR - PAYMENT OPTION RATES MONTHLY UFE INCOME PER $1,000 OF AMOUNT APPUED FEMALE1 & FEMALE2 FEMALE1 FEMALE2 IS YOUNGER THAN FEMALE1 BY: AGE' 10 Yrs. 9 Yrs. 8 Yrs. 7 Yrs. 6 Yrs. 5 Ws. 4 Yrs. 3 Yrs. 2 Yrs. 1 Yr. 60 $3.76 $3.79 $3.82 $3.85 $3.88 $3.91 $3.95 $3.98 $4.01 $4.05 61 3.82 3.85 3.88 3.91 3.94 3.98 4.01 4.05 4.08 4.12 62 3.88 3.91 3.94 3.98 4.01 4.05 4.08 4.12 4.16 4.20 63 3.94 3.97 4.01 4.04 4.08 4.12 4.16 4.19 4.23 4.28 64 4.00 4.04 4.07 4.11 4.15 4.19 4.23 4.27 4.32 4.36 65 4.07 4.11 4.15 4.19 4.23 4.27 4.31 4.36 4.40 4.45 66 4.14 4.18 4.22 4.27 4.31 4.35 4.40 4.45 4.50 4.64 67 4.22 4.26 4.30 4.35 4.40 4.44 4.49 4.64 4.59 4.64 68 4.30 4.34 4.39 4.44 4.49 4.54 4.59 4.64 4.70 4.75 69 4.38 4.43 4.48 4.53 4.58 4.64 4.69 4.75 4.80 4.86 70 4.47 4.52 4.57 4.63 4.68 4.74 4.80 4.86 4.92 4.98 71 4.56 4.62 4.67 4.73 4.79 4.85 4.91 4.98 5.04 5.11 72 4.66 4.72 4.78 4.84 4.91 4.97 5.04 5.10 5.17 5.24 73 4.77 4.83 4.89 4.96 5.03 5.09 5.16 5.24 5.31 5.38 74 4.88 4.94 5.01 5.08 5.15 5.23 5.30 5.38 5.45 5.53 75 4.99 5.06 5.14 5.21 5.29 5.36 5.44 5.52 5.60 5.69 FEMALE1 FEMALE2 IS OLDER THAN FEMALE1 BY: AGE' SAME AGE 1 Yr. 2 Yrs. 3 Yrs. 4 Yrs. 5 Yrs. 60 $4.08 $4.12 $4.16 $4.19 $4.23 $4.27 61 4.16 4.20 4.23 4.27 4.31 4.35 62 4.24 4.28 4.32 4.36 4.40 4.44 63 4.32 4.36 4.40 4.45 4.49 4.54 64 4.40 4.45 4.50 4.54 4.59 4.64 65 4.50 4.54 4.59 4.64 4.69 4.74 66 4.59 4.64 4.70 4.75 4.80 4.85 67 4.70 4.75 4.80 4.86 4.91 4.97 68 4.81 4.88 4.92 4.98 5.04 5.09 69 4.92 4.98 5.04 5.10 5.16 5.23 70 5.04 5.11 5.17 5.24 5.30 5.36 71 5.17 5.24 5.31 5.38 5.44 5.51 72 5.31 5.38 5.45 5.52 5.59 5.66 73 5.46 5.53 5.60 5.68 5.75 5.82 74 5.61 5.69 5.76 5.84 5.92 5.99 75 5.77 5.58 5.93 6.01 6.09 6.16 Rates for other ages are available upon request. 'Age on birthday nearest the due date of the first payment. The first income payment is payable on the effective date of this Option. P9-2005(FL) Page 33 (aerating!) EFTA00804431 Substitute Of Insureds Rider This rider provides the right to substitute a new insured in place of one of the current Insureds under this policy. We discuss this rider, and the rules that apply to it, in the provisions that follow. Rider Part Of This rider is made a part of this policy. All the provisions of this policy apply to this rider, Policy except for those that are inconsistent with this rider. This rider is in force as of the day the policy becomes in force. Rider Benefit This policy may be changed to insure the life of a substitute insured in place of one of the current Insureds. The change is subject to the provisions of this rider. Requirements To make the substitution of an insured, all of the following conditions must be met as of To Substitute the Date of Substitution: Insured 1. This policy and rider must be in force; and 2. The Owner of this policy must have an insurable interest in the life of the substitute insured and the remaining current insured; and 3. The substitute insured must have been born on or before the Policy Date; and 4. The substitute insured must not be over 90 years of age on the birthday nearest the Date of Substitution; and 5. The age of the substitute insured on the birthday nearest the Policy Date must not be less than the minimum age, or greater than the maximum age, allowed by us for this policy on the Policy Date. Before the substitution can become effective, we require: • A written application for substitution, received by us at our Home Office; • Evidence of insurability of the substitute insured that is satisfactory to us; and • Payment to us of any premium required to avoid termination under the Grace Period and Termination provisions of this policy; and • Payment of a fee of $75. Date Of The Date of Substitution will be the Monthly Charge Date that is on, or precedes, the Substitution later of: • The date we approve the application for substitution; and • The date we receive at our Home Office any premium required to avoid termination of this policy. Example: The Monthly Charge Date is the 10th of each month. We approve the application for substitution on May 5, 2021. A premium payment is required to avoid termination, and we receive it on May 15, 2021. The Date of Substitution will be May 10, 2021. The insurance under this policy on the current Insureds will continue to, but not including, the Date of Substitution. SSIR-2005(FL) Page 1 (riC6rn all) EFTA00804432 The Policy After The insurance under this poky on the substitute insured will become effective on the Substitution Date of Substitution. Any riders in force under this policy on the day before the Date of Substitution may be continued under the policy after the substitution only with our consent. Otherwise, they will be cancelled on the Date of Substitution. After the substitution, the policy will be modified to show that the contestable and suicide periods for this policy and any riders, as they apply to the substitute insured, will be measured from the Date of Substitution. Also, the contestability and suicide provisions of the policy will be modified to state that our liability in either case will be limited to: • The Account Value of this policy on the day before the Date of Substitution; plus • The amount of any premiums paid on and after the Date of Substitution; minus • Any amounts withdrawn on and after the Date of Substitution; and minus • Any policy debt. All monthly charges and other values on and after the Date of Substitution will be based on the life and risk class of the substitute insured and the remaining current Insured. After the substitution, the Face Amount of the policy cannot be less than our published minimum amount on the Date of Substitution. After the substitution, the policy will produce the same reserve as the policy on the day before the Date of Substitution. My assignment of this policy in effect just before a substitution under this rider will continue to apply on the Date of Substitution. The rights of the Owner and any Beneficiary under this policy will be subject to the assignment. Termination Of This rider will continue in force to, until the time any of the following occurs: This Rider • The Policy Anniversary Date on which the Attained Age of the current Insured becomes 75; or • The Date Of Substitution under the terms of this rider; or • Exchange of this policy under the Policy Split Option Rider; or • Death of the first Insured to die; or • Change of this policy to a different policy under which this rider is not available; or • Termination of this policy for any other reason. MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY PRESIDENT Critetbgeo ire SECRETARY SSIR-2005(FL) Page 2 (ii05matl) EFTA00804433 Policy Split Option Rider This rider provides the right to exchange this policy for two new policies, one on the life of each Insured, if certain conditions are met. We discuss this rider, and the rules that apply to it, in the provisions that follow. Rider Part Of This rider is made a part of this policy. This rider is in force as of the day the policy Policy becomes in force. NI the provisions of this policy apply to this rider, except for those that are inconsistent with this rider. Rider Benefit Subject to the provisions of this rider, this policy may be exchanged for two new life insurance policies, one on the life of each Insured. This right to exchange will be available for the six-month period beginning on: 1. The date six months after the effective date of a final decree of divorce, issued by a court of competent jurisdiction, ending the Insureds' marriage to each other, if the decree: • First becomes effective at least one year after the policy Issue Date; and • Remains in effect during the entire six-month period after it first becomes effective; or 2. The date that either: • Section 2056 of the Internal Revenue Code (I.R.C.) is nullified or amended to eliminate or reduce the Insureds' federal estate tax marital deduction; or • The maximum federal estate tax rate given in I.R.C. Section 2001 is reduced to a rate no more than one-half the rate in effect on the Issue Date of this policy; or 3. If this policy is owned by a corporation or partnership, the effective date that the corporation or partnership dissolves. For the I.R.C. changes discussed in item 2 above, the six-month period will begin on the effective date of the change or, if later, the date the change is signed into law. Policy Split The face amount of each new policy will be one-half the Face Amount of this policy at Method the time of the split. The policy date of each new policy will be the Date of Exchange (discussed later in this rider). The issue age for each new policy will be the age of that policy's Insured on their birthday nearest the policy date. For each new policy, the risk class will be the one we deem comparable to the highest risk class for that Insured under this policy. Each new policy may include benefit riders comparable to any included with this policy only with our consent. The policy split option is allowed under either of two plans, described below in this provision. Each new policy may be issued under either plan. Plan 1 - Fixed Premium Permanent Life Policy. The new policy will be a fixed premium permanent life insurance policy offered for the Insured on the Date of Exchange by us. All premiums, rates, and other values will be based on the policy date of the new policy and the life and risk class of the policy Insured. SS0R-2005(FL) Page 1 (rs05mall) EFTA00804434 Plan 2 - Flexible Premium Adjustable Life Policy. The new policy will be a flexible premium adjustable life insurance policy offered for the Insured on the Date of Exchange by us. The death benefit option will be the same as for this policy. However, if the Death Benefit Option for this policy in effect on the day before the Date of Exchange is not available on the new policy, the death benefit option on the new policy will be the available one that we determine to be closest to the one on this policy. All premiums, monthly charges, and surrender charges will be based on the policy date of the new policy and the life and risk class of the policy Insured. Payment of the first premium for each new policy is required before the exchange can be completed. If this policy has any net surrender value, it will be applied to reduce the premiums for the first year under the new policies. My net surrender value not needed for this purpose will be paid in cash when the exchange is complete. Date Of The Date of Exchange will be the Monthly Charge Date that is on, or precedes, the Exchange later of: • The date we approve both applications for exchange; and • The date we have received, at our Home Office, the first premiums due under both new policies. Example: The Monthly Charge Date is the 10th of each month. We approve the applications for exchange on May 5, 20X8. The first premiums for the new policies are paid on May 15, 20X8. The Date of Exchange will be May 10, 20X8. This policy will continue in force to, but not including, the Date of Exchange. Requirements To make an exchange, all of the following conditions must be met as of the Date of For Exchange Exchange: 1. This policy and rider are in force; and 2. Both Insureds are living; and 3. For each new policy, the Owner of that policy must have an insurable interest in the life of the Insured; and 4. The Attained Age of each Insured is lower than 85; and 5. The face amount and premium for each new policy must meet our published minimum limits; and 6. The highest risk class under this policy for each Insured must not be higher than the highest risk class available under the new policy for that Insured. If we determine that the highest risk class of any coverage under this policy for either Insured is higher than the highest risk class available under the new policy for that Insured, exchange under this rider will not be allowed. SSOR-2005(FL) Page 2 (es06mall) EFTA00804435 Before the exchange can become effective, we require: 1. For each new policy, a written application for exchange, received by us at our Home Office; and 2. Evidence, satisfactory to us. that both Insureds are living and that the Owner of each new policy has an insurable interest in the fife of the Insured under the policy; and 3. Evidence, satisfactory to us, of: • Divorce of the Insureds, if that is the reason for the exchange; or • Dissolution of the corporation or partnership owning this policy, if that is the reason for the exchange; and 4. Payment to us of the first premium due under both new policies; and 5. Payment of a fee of $100. No other evidence of insurability will be required. The New Insurance under each new policy will be effective as of the Date of Exchange. Policies After exchange, each new policy will be considered to have been issued as of its policy date. However, it will be modified to show that the contestable and suicide periods will be measured from the date(s) applicable under this policy. Each new policy for an Insured will be subject to any limitations of risk with respect to that Insured under this policy and subject to any assignments outstanding against this policy. Termination Of This rider will continue in force until the time any of the following occurs: This Rider • The Policy Anniversary Date on which the Attained Age of the older Insured becomes 85; or • Death of the first Insured to die; or • Exchange of this policy for two new policies under the terms of this rider; or • Change of this policy to a different policy under which this rider is not available; or • Termination of this policy for any other reason. MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY /41 PRESIDENT CaAW42, 0.P1W011 SECRETARY Page 3 0505mall) EFTA00804436 Accelerated Death Benefit Rider For Terminal Illness This rider provides that an accelerated death benefit payment may be made under this policy. We discuss this rider,' and the rules that apply to it, in the provisions that follow. Benefits payable under this rider may be taxable. The Owner should seek tax advice prior to requesting an accelerated death benefit payment. An accelerated death benefit payment will not be allowed If the Owner is required to request the payment by any third party (Including any creditor, governmental agency, trustee In bankruptcy, or any other person) or as the result of a court order. Rider Benefit Subject to the terms of this rider, an accelerated death benefit will be paid to the Owner upon request once we receive proof that the surviving Insured has a terminal illness. Accelerated Benefit Payment In this section, we discuss payment of the accelerated death benefit and the amounts used in determining the amount of the payment. Eligible Amount The Eligible Amount is the amount of death benefit under this policy that can be considered for acceleration. It will be determined as of the Acceleration Date. This Amount includes the following as of that Date: 1. The amount equal to the excess of: a. The death benefit payable under the base policy upon the second death: over b. The account value; and 2. The amount payable upon the second death under any survivorship life insurance rider included with this policy, if that rider provides level or increasing coverage on the lives of the policy Insureds for at least two years after the Acceleration Date. The Eligible Amount does not include: 1. The amount payable upon the second death under any survivorship life insurance rider that does not provide level or increasing coverage on the lives of the policy Insureds for at least two years after the Acceleration Date; or 2. The amount of any insurance provided under this policy on the life of someone other than the surviving Insured under the policy. SABRVL-99M(FL) Page 1 liesamall) EFTA00804437 Amount To Be Subject to the terms of this rider, the Owner may accelerate any portion of the Eligible Accelerated Amount up to the maximum limit. The maximum amount to be accelerated is equal to the lesser of: • 75% of the Eligible Amount: and • 5250,000. We reserve the right to impose a minimum limit on the amount to be accelerated; if we do so, this limit will not exceed 525,000. Amount Of Payment The amount of payment under this rider will be computed based on the amount to be accelerated less: • A fee of not more than 5100: and • The current variable loan interest rate in effect for the policy. A 12 month discount will apply to the annual interest rate. If required, a detailed statement of the method we use to compute the amount of the accelerated benefit payment has been filed with the insurance department of the state where this policy was delivered. How We Pay Payment of the accelerated benefit will be made to the Owner in a lump sum. However, we will not make the payment if we first receive due proof of the deaths of both Insureds; in this case, we will instead pay the death benefit as if no request had been received under this rider. Effect On Policy After the accelerated benefit payment is made, this policy will remain in force. Premiums and charges will continue in accordance with the policy provisions. A lien will be established against this policy. The amount of the lien will be equal to the amount to be accelerated under this rider. Interest will not be charged on the lien. The Owner may not voluntarily repay all or any portion of the lion. However, the amount of the lien will be deducted from the amount of payment under this policy upon the second death. Other Definitions And Requirements Acceleration Date The Acceleration Date is the first 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 the Proof Of TermInal Illness provision. Requirements For Before the accelerated benefit can be paid, all of the following requirements must be met: Acceleration 1. We must receive at our Administrative Office: a. The Owner's written request for payment of an accelerated death benefit under this policy; SABRVL-99M(FL) Page 2 frasmatl) EFTA00804438 b. Due proof of death of the first Insured to die: c. The surviving Insured's written authorization to release medical records to us; and d. The written consent to this request of any assignee and any Irrevocable Beneficiary under this policy. 2. We must receive proof, satisfactory to us, that the surviving Insured has a terminal illness. Terminal Illness As used in this rider, "terminal illness" is a medical condition that: • Is first diagnosed by a legally qualified physician after the Issue Date of this policy; and • With reasonable medical certainty, will result in the death of the surviving Insured within 12 months after the date the legally qualified physician certifies the diagnosis; and • Is not curable by any means available to the medical profession. Proof Of Terminal Proof of terminal illness is written certification, satisfactory to us, that a legally qualified Illness physician has diagnosed the surviving Insured as having a terminal illness. To establish this proof, we reserve the right to require that the diagnosis be confirmed with examination of the surviving Insured, at our expense, by a physician of our choice. This "confirming examination" may include any x-rays, blood tests, and other procedures that are reasonable and necessary to determine whether the surviving Insured has a terminal illness. To be acceptable to us, the confirming examination must be completed within 90 days after the date we notify the Owner of this requirement. Legally Qualified As used with this rider, a "legally qualified physician" is a person who is licensed by the Physician state in which he or she practices to give advice or treatment for the 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 surviving Insured, or a spouse, mother-in-law, father-in-law, stepparent, or natural or adoptive brother, sister, parent, grandparent, or child of the Owner or either Insured. General Provisions Rider Part Of This This rider is made a part of this policy as of its Rider Issue Date. All the provisions of Policy this policy apply to this rider, except for those that are not consistent with this rider. This rider is in force from its Rider Issue Date or, if later, the date the first premium under this policy is paid. There are no monthly charges for this rider. SABRVL-99M(FL) Page 3 itasonviii EFTA00804439 Termination Of This This rider will end automatically on the date: Rider • An accelerated benefit payment is made; or • This policy terminates for any reason; or • This policy matures; or • This policy is changed to a different policy on which this rider is not available; or • Two years before coverage under this policy is scheduled to terminate. Cancellation Of This This rider may be cancelled by the Owner's written request. Rider MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY 09(A6t4ge,o Paiszt SECRETARY PRESIDENT SABRVL-99M(FL) Page 4 (res9malI) EFTA00804440 ENDORSEMENT Adjustment To Surrender Charges Subject to the conditions set forth below, we will waive any surrender charges that apply to this policy. The surrender charges will be waived if the Owner exchanges this policy for a whole life, universal life, or variable life insurance policy that we make available for such an exchange. The policy must be offered by us or one of our affiliates and all of the following conditions must be met: 1. On the date of the exchange, the net surrender value of the new policy must be less than or equal to the value available for a surrender under this policy; 2. A written application and evidence of insurability satisfactory to us is required for the new policy: 3. The face amount of the new policy must be equal to or greater than the face (or specified) amount of this policy; 4. A variable life insurance policy may not be exchanged for another variable life insurance policy; 5. The entire value of this policy must be exchanged for the new policy; and 6. We reserve the right to require the repayment of any loans and loan interest. ff the Owner exchanges a variable life insurance policy for a non-variable life insurance policy, the entire value of this policy will first be transferred to the Money Market division of this policy. Without any interruption of coverage, we will move the entire value of this policy from the Money Market division to the new policy. If the Owner chooses to terminate the non-variable life insurance policy during the Right to Return time period, we will restore the entire value to the original variable life insurance policy. In this case, we will deposit the entire value into the Money Market division until the Owner: 1. Signs and submits a transfer form In Good Order to our Administrative Office instructing us to move the funds to other divisions of the Separate Account or the Guaranteed Principal Account; 2. Requests the surrender of this policy under its original terms; or 3. Elects to exchange this policy under the terms set forth in this endorsement again. If the Owner exchanges a non-variable life insurance policy for a variable insurance policy, the entire value of this policy will be allocated according to the terms of the new policy. If the Owner chooses to return the policy during the Right To Return time period, we will restore the entire value to this policy as if the exchange had never occurred. If the Owner exchanges a non-variable life insurance policy for another non-variable insurance policy and then chooses to return the policy during the Right To Return time period, we will restore the entire value to this policy as if the exchange had never occurred. Coverage under the current policy will terminate at midnight the night before the new policy becomes effective. At no point in time will an insured be covered under both policies at once. MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY 016tAge. C.Paae- SECRETARY Z0033MM (h0033mrs) EFTA00804441 i'\<4'cd 4. /SU S SG R To tke Canoere al Wee d beam- Application Part 1 IC MassMutual FINANCIAL GROUP' ❑ Matextusees Word Weimar* Umpurr state Sac. S7mgrdd MesiliCh4011.101111-0M1 Fen (1) New Sewell DIt We (marina Carron 0 Tern C.onverecn 1. BrIght Msadove Bo:genre. Enfield. Ceernetticut 0082 ❑ inSigibIty %ton . O Proposed Insured(*) \COWLETINIS stria,' FOE Au CASES 9r• Rtintoy Imuted — framed 1 1. Sea CP‘Ie El Female 7. Citenshipi2dCtitizen, Resident o US Citron, Non-Resider; CI Men, Resident ❑ Nien, Non-Resident idpaf: Ai 34.1) Last SuFred 2 jrc k (-)? V-IngAn Nen-US Cltitens provide: Typo al Visa Country of CtiaransMp 3. Marital Status fplaarried 0 Single 0 Divorced 13 Widowed Telephone is Rome I ) 4. DOS 141. mum, Wedt 7c0— 34O 1 ten t__t S. US Social Security Ores I Beet Wee to cal Dam Donut OH OW DC t US Drivers Lieense/ 759 a3lo Ocl (0 9. Email address State 5..).4 Expiteoon Dato 4 1,D0) I 2 la Resd anal Address2. Sontag O. Cot Steer: Coustry.100ste Cast Pa4 II rond, typo cl govarrtnetissJod photo ID Li ar r y 11. Maling Address Iel corn traM State/Country af Issue ID/ Espnution Data Ill Secondary Insured - trued 2 Far: pOirsorstép °0ther Insured Rider (Uteri ❑App5cants Waiver of Premium Rider (Faye) 12. Sas °Male peCnale It Crtiaensrlp CCICCititen. Resident CI US Given, Nen-Resident CI Men. Resident lp Men, Nan-Resident it Mini Name (srst, Kale. bal.5O5x) 1\4 KC; CA-41 Non-US Ciezerts provide: Type al Vise Cauntry of Citizenship H. Marital Status (2<terried El Single 0 Divorced 0 Widowed IS. Telephone is Home( I IS. 00B I Ffagtrthplace corgaVywf 'isAstk621.2 S— Wait i It US Social Security elTaz ID Best tirra to call DiunDpmat OWDC It US Dtiveis License tia.30 62151 Za Email address 21. R n0al Address to, Steel. A.pl. iiiilF. StniCes--.2Y.ENI/1442102.1 State i\-)1 /4/ Expirsoan Dot /•QP4ii rí I ert5b Sk" If rant type of povemmestissted photo ID •Icr (oOaa-. a Mettle Addred fd tinerect 110 Siate/Ceuntry of issue IDI Expiration08re AS3H913 EFTA00804442 JI C) Policy Monaden \CDMPtIll THIS SECTION FOR All LUIS I> Vikas Ve I. Plan 11. &Mao:unik Innance Rider (MIR) 2 Face Anisoms a Modal Pe ympat 5 1 Automatic Premium Lan O1Yes O No Pavane earpon using 103 funds Q Yes Q No b (kisel-addera brr; Sum lisen Rate Oas aksugataa s. Guidet cool ❑ Paid-up editions (PO) ❑ Cash (CS) Paying all/part uring 1035 runds ❑ Yos Ei No till Civittal d Iktian O Same as 8 asit Poky O Peichup Additions ❑ Supplementet Irisurene anider.ds/Flei(SIWFUU 12. Life Ituuren te Supplement Rider (lISR) O Reduced Pramlams (RP) O ()friland Aecurtulattms IDA, a. Fece &mount $ ❑ b. Model Neyman & Mint al Prerrdum Rader PATT G ensund i ❑ Insund 2 c. Unschatlet( Len Sum 5 Payirg all/part man 1035 (solds Q Yes ❑ No ). Applicants Wanter of Premium Rider. Mull Paltor Genfil d. Payrnem Period (7 of years) O Death or DimbIty (A00) O Olsebatty Orly IADS) e Crossman Period (I cd years) & &petit ants Weiyer at Premium ffider. luftade I osured 13. Sup plernectal Invira nto Purthase Rder (SIPRI ❑ Doch or Disatiity (POD) O Death Only (PO) a Face Amman $ 9. ❑ Rermatie Tema Mer fFITRI $ Payment 5 13. ❑ Ineurabiny Rider (GIRAPRI 14 Estate Protecten &der $ 15. Accidertel Death Benfri5 ► Variable os Universal Lifar- 15. Plan -3( it _pr- 21. V.alver el Prernitro Riders Oncicate amman il app5cable) O Wamar of Marthly Chargestleducdorts &den (VaACANMD) 17. Face Arrunt 5 O Disadity Renett Æder (OBR) $ 13. Plioned hemom $ 2-/ 7, Pro 0 Wester ol Spectie d Premium Uti (WSP) IS Non-I035 Unscheduled Premium 5 24. Other Insured Uvs (OM) 21 Ulan Rate O road Nricriustatde ❑ Soll s 21. Death flanera Option C Othar 1,5klevei ❑21rtateirg hy Attoutet Våta anat" al MfiliUtrIS 25. InsuraPlity Rider (GIR) Q 4-inci eastig tre Separata namns Mi/Spetdied Prernhim Accotn Addition! Inse:ante ({der 4J a. Deenition ol Ufo huurance 27. Estato Protocean Rder I ash Value &c CVMtillet fl Tut O Guideline Premium Test ffi Surviyershlp Term lbder 11- Tenn Ute 221 Plan 31. O Miner cal Premium Rider NYP) 31 Face Arnaunt S 72. Okt:ideala' Ornat Remin Rider1481$ 2 EFTA00804443 age a) ON COMFIER MI SECTION FOR All WHOSE In AND UNNE SAL UR CASTS, IC ) Sales Illextration CartifIcatien IL Mainclersignol, acknowledge that ONLY IF AN nwsruned PLIECAING THE POLICY UP= FOR IS NOT sicse «I ❑ sales minisauen for the proposed insured was shown to no dlustradon was used al the Q The sales ilustrabon used for Ne ›t:e i Tfrs proposed Insured does not conform ana talputer screen 11-...siEustration talfrau to the alkyls of NIS file insurance policy. • le the policy as applied lot applied for wfich no hard copy vas krMdled. I also acknodedea that a herd copy of Sustretion residing the palmy as issued must be prmnded coo later than the defirery oldie:Any. IwI O.i O D Premium Payment folannadon COWILETE MS SECTION FUR ALL CASES 1. Frequency 4. Oats PolcY to sew age for la. Second Adduce Bll 0 Arlorddy (PAC or Group only) l:IInsured 1 [) In stared 2 Fs' 0 Insured 0 Owner Ouruterty 0 Other USeml-annual 5. Has Crafted° pier-in teen paid/ .12/annual D yes ais'.. ci Sand irr°um Notices to CSIngse prernfurn (if available) a Yes. CCOIVEII Togaren OA, boon, Face ST) awed CI Owner a. Fretle Fretless Payer (grade are and marrig address adcw) 2. Oiling Typo 60 Insured ?liSwner 0 Pre-Authorized Check IPAQ 0 Other isidual OLIO« Bill 6b. Sea Pier'(i:).Necos to Grays Bal (pray:de Imc/Fran /) Ei Insured wrier Source of Prerneen (check an that apply) 0 Ottir o Me end manng address ❑ Earned Income ❑ Investment Income below) Inuestinentf5aWngs 0 OrItsAnharitance i Speedy Pal:cy Dale 1021uthen Issue On ❑ loan ica~pmpeRtgN~.177121 *Other (specify) \ 4r-', • r 0 Primary Purpose of Mantes \ COMPLETE MS SECTION FOR ALL CASES Is this poSty king secluded in ccnnsceonwirdi an employer-spewed pima I. PirroneNeeds I Business Needs GI Income ler Oe dondants 0 Key Employee 0 yes flt Yes check one cif the talloWnql 0 Stock Redemption 0 Tax-quilled employer-sponsored pir ❑ Estate Tsxes ❑ Non-c~entekecer-sconstred plan ❑Martge ttion 0 Cross Purchase i j ifter V 0 Other No In. male 2. II the pd:cy applied lor will be used in connection Path a non-qualified employer.sponscred plan involving bath and females, MI the policy be issued on a Unisex basis/ C 3. Has the pro sed insuredls) end/or the proposed ryeer(s.) been offered era economic incentive:free fil Insurance, Ro paoney, or any other consideretean es en incentive to purchase tins poxy7 (II 'Yes Bomvern Uent≤s 4. Does the proposed insured(s) and/or the proposed owner(s) have e current agreement or ccersnitm sotto sait vensfer, assign. or release this ad:ay- er any beneficial itterest of this policy wits ownership suumore • toa fife sodium ern company, viadoel company. bank, imam., or secondary =Met pronsder'l "Yas 'explain in Deeds /9) I. In connection with this porky. ha the proposed 'insureds) a neVor tho proposed ownerls) entered boo en arangement tat erm:tias a lender oram-arhce to a parten al the death beneld above and beyond the repayment of principal and interest on ben? Ill "Yes-explein in Batas^ 0 Conrete gardens 6-9 if this is a bussboss-related sale I of emoyees 6. Business is a 0 Corporation 0 LLC/UP 0 Partnership 0 Sole Proprietorship Year Esabftshed 7. Nei vaie of the business S amount ol insurance the & ll a potty is to be owned by a business or business alsocete, give names of the other officers or partners and the business new cam as cn their 'Weser has war ndyeppeed to any officers or pannen are nat insured, eepl°n in Detals Name Tele Face Arcaurn 'h Owned I Details (Please reference question en! Insured I or 2) a6eR.608 EFTA00804444 COI pia O F Owner laformailon \Catlin linStatal MY IF CMIKEUS COMDMPROW 819.21314S) 1.0 Inedeltualy Owned, a ballet estate - Cam 1 her T. Citizenship ❑ US Citizen, Resident 0 US Men. Non-Resident I. Sax 0 Mrle 0 Female 2. Fist Legal Name Mist Media, Lest Son! 0 Mien, Resident 0 Alien, Non-Resident wr Non-US Citizens piolide: Country of Citizenship 3. DC8 tra riniffnlYnY ttl 4. US Social Security /Mx ID/ & Residential Address N. Scorn. MXI. Coy, StitalCouray, ZeirPosial CcOet 5. Relationship to leaved fi. Type of Identification 0 Driver's License 0 Passport 9. Mailing Address 44 different Iran a. 0 Other ID/ State/Country of issue 10. Sat Dollar D Colateral Assirmem EreiieWn Date rrairspute Split 0 elsr Ail !WTI/Ill Icrn lor Individually Owned, or histher estate • Owner 2 (For izintcmnership,il applcatlel II. Sex 0 Male ['Female 17. Otitenship 0 US Citizen, Resident 10 US Citizen, Non-Resident 12. Ftd) Legal Name Vint Warne. Last Sulfa) 0 Alien, Resident 0 Alien, Non-Resident Non-US Citizens pant a Doe atmadlym Country of Citizenship 14. US Social Security /Mu IDI 15. Relationship to Insured it Residential Address U. St mit Apt I, CrIt StateiCiertrY, ZOPecral Coll 18 Type of Identrficatian 0 Driver's License 0 Passport 0 Other ID/ lg. hinting Address Of &IIIrunt aun a /UP State/Country of issue Exasaacn Date "Anal Entity Owned 20. Owner u0 Trust lecoaplrte Guerra= ei That Agnetnent 16134) 24. atitenshiptielS Entity 0 Men Entity 0 Incuporeted Entity, its successors of assign 1 a Owners legelAddiess K Scott AMC cry. Suregnariva ricatrrul Carel on-Incorporated Entity Isitoef fY type) H8 g Peri inn Ave. i 67 I 21. FyIttlarie of Legal Entity III Trust provide Iu0 name of That) it huef's Meg Address (rl dtherern rico" C. ns) 1drIft5b, p asepoia.hok P .P. 5 a US Tax ID/ /3 - 354 / 9 -17 a Date el Trust 27 Split Dollar 0 Endorsement (employer must be owner) 4 EFTA00804445 l r..yc 0 .0: II) Beneficiary Irtformatiod \Cowart nos swum FOR All LASES Benehclary - thins otherwise requested Sliming handl:rant:in any class steal tate °quell* Hwy bencdciary Gas before to insured. Dormant sha be made to Ma tenni/51g bieneficiants in dm class H no banafieduy is entitled to de payment at erne of ;IS. the ;concede shag be made to tha Owner. 'thine:to to (kraals estrus. I. Elena ficlary is OIrCryldualls) O Trust O HI corp.:need End% its successors or esti en-hccfaccaled tYPI)k-E- 1. Primary: Name (11Inrst provide LI name of Trusil Relationship to Insured 008/Date of Trust fr( frs P. P. 5. P 3. Contir,gent: Name (If Trust, p rovid a till name of Trust) Relationship to lammed DOH/Date of Trust 11114IVUOMA Custodian —Owing the minority c-1 the named chthenl shall be Custodian for sad Mono crhotaio Bo is Cusio418,0 eft/Oen) under the Unifcnn Tra miens/ Gifts to Motors Act Intel Canine thjessien5only for What Inured Pidn (Other, Banalictary ts O Indevidualfs) °Trust Othcorporated Enty es SUCCeSSell Ct [Non-Incorporated Entity lstheedYrypel Nome (II Trust, provide full name of Tres.) Relationship to Insured 00B/Date al Trust el Other insurance/Rept/lc 'mut Information \ COMM! TMs sicricmFOR All CASES 1. Ust tile Insurance currency applied !or, co itaropiated, or now in force on the Insured( s) with other cc nther.iss. including any policies which may have bun veld, thanslarred, or assigned. II none, cheek here 0 Insured Policy/ Company Product Issue Year Face Amount 01 02 S 'TV-1 • in‘Cin 01 02 fetw, /0 lifleh 01 02 Int err /1);r,,, 1. Writs the total face amount of tow insurance applied for Hunted' be placed in ell companies (including this Company's policies). ,003 e9g r..cP t araMO ermerliP 3. Is the insurance now being applied for in dad to roplace or change any insurance cr annuity, in whole or part issued by this Company or another company? O Yes o If "Yes" provide information bulovr. Insured Policy Company Product Issue Year Face Arritunt Replacement 103Sx ISS ND US till 01 02 O O O O 01 02 O O O O O I 02 00 00 4 II then is a 1035s. anticipated value of exchange S Inured 2 S. 131ix pros es ds ro be applied towards O Additional premium tUl. or VU ❑ALM OLIN O SIPA O Initial Premium a For Internal Tenn to Term Replacements O I wish to terminate the tern plinyfiesi/riderisl numberled) upon the issuance of the new term pa3cy applied for in this application. (Owner of the loathing term peaty regu1red ta sign this applicaEon as 'Oven, cd the Ortg:nal PIA Cy. only if ether than Proposed Insured.) MOM 5 EFTA00804446 11111 01. •OI 0 Personal HIstery Irdurnadoe COMPLETE THIS sicnom FOR ALL CASES NOW Mow is 'Yes-la any fifths fonomisp Milan; nigain in &SRIPis Insured 1 Insured 2 I. Nan yet c bhi a. smoked cigarettes during the last 12 moriltn9 b. used tobacco or products containing naofine witlin the last 12 =mho? O -er O -Cr used tobacco or products centairing nit mine withfil the last a months? O Er ❑ W Complete Until= 2-12 only when Evidence of I rucrithfilty la regain d lowed t lama 2 t-I a vow answer is l'as" to any of the following quesdans. expatin in Details ill In fix Th.S 2. 0 cos the insured anticipate ary foreign travel witan the next 24 months? O 6 O ):1 3. Wthin the last 3 years. his the Mswed been, or does s/he expect to become a pilot student 00t Tnl oruew member Marty type of aircraft within the neat 24 menthe Ulna. eacidem Linea Supplants o er o cc" t Within the lest 3 yean. has the inured taken pert in, or den s/he expect to take part in. underwater diving, hang Oda g, putt selling, pars kiting, pa rachubcg, skydiving, mountain climbrag. bugea jump:rte.helicopter skin ballooning. bob sladclin g, competitive fighting or organded racing by automobia motorcycle, motorboat or snovenotde whin the next 24 months? tft Yea COCO° Aramion Sownanal 0 e O a-- S. Within the last 5 years, has the insured been in a motor verale accident, been coronted of e moving violation, or received a driver's Oconee resuic6on or revocation? o cy O r 6. Ihittin the last 10 years, has the insured been convicted of operating a motor vehiclewhile tinder the influence of alcohal or ether drugs? O Ci 7. Has the:nunad ever been enflamedof a felony, or is A. currently on aide or orbs eon? . 0 Er 0 Ge IL Annual Earned Income • gill 000 ..jf • s Sued 1 Surd 2 9, Unearned Income It Net Worth • qotvoo loran t Koimb,coo huicred 011Proposed Insured Is not employed please inclode Honetaild Income eed Household tier Worth in Details 113 11. flown 1) Occupebon and 0 ' r / I fr pj c i f? era- - bettioyet Name & Address y el Pia 'men/ • U anured 2) Competen and Ones Oa t) R /A i Coy' p- Emplmer Name 6 Address al ferinie /1Yec ev-i- 13. Ilemin (Please reference (Nieman )orb insured 7 at 2) O Cooverthsafirrsurahilfty aglito \COMPLETE TVS SECTION FOR COPPIERSIOAS On INSLICIAMUTY OFIICNS 1. Rden MOO to the a rI4 nai paficywil be carried over lif avail able) uriess otherwise specified beta Do oat talon: O WP ❑G1CUIPR ❑D ADS hewn 1 toured 2 Ted ND la tin L Has a medical doctor or Scented medical professional concluded that you ale disabled or are you applying for or receiving any dsatefity ber.e fits? Ill las' °Wain in Details /71 0 O O O Conarsiata el Tenn fresurance Insured Pcbcycr It der Number Amount Convened Amount Continued Amount Terminated I 02 O1 O 2 1 I SS cif 4. For partial conversions of UL products avadabbal provide Banned premium and frequency for balance centnued S 5. Exercise of Insorabdity Option from PolicyI 6. type at cption O Remiar ❑ Substitute (it swag: Aga, inCtcata Masan and event date) LSOn Osa dEns 7. Pataill (Please reference quataan land insured I or 21 A60f1.133 6 EFTA00804447 Juvenile \ COMPLETE PIS SECTION ONLY 6 PROPOSED INSUREDS A JUVER011 Cl I. Total leeinsurance (Idol:n.9 group coverage vet employer) currently applied lot considered, or now in farce cn the insured's lather, mother, and sittngs in 50 sonipenes Include insured nerve, age, and amount -IInone, explain in Derails 12 Father Macher 0064 (1) Non-metHcal NMOW F DISUREDIS 4INIGETAMINEO FOR MASSfifittill41. WtotETe18 MIS MOON tS To the best of my knowledge a r. d belief, all statements made In this section are complete. lite and correctly recorded. pa Warm' I If yea weight changed by over IC (bs..n the last year, irdicate amount &reason betonr. Sleight It in. Weight 2. Personal Physician Mlomtlert Name, Address. and Phone I (if known) 1 Date tag seen end reason 4. Frrely listary Inured I Ibutieete "tmentown" whore applicable) ;idiom rrowams— inoway age or onset NO Age Relative Iespecialy for cardlovascelsr disease) if living at Death Cane of Ooath Father Mother 8rothoisUSistertsi IP binned Z Ups weight changed by over 10 lbs. in the last year, indicate amount & reason below. 5. Haight It in. Weght IDs EL Personal Physician Information: Name, Address, and Phone? (ii known) 1. Date last seen end mason & Family ilstary Insured 2 (Indicate "almewn" when applicatdel 'maim rromenu — 'nen:swage al onsei Age Age Reiman' lespoDaly for cardiovascular (sea sal it Living at Death Cause at Death Father Mother Orothet(sYSetens) If your answer is tee to angel the following questions, circle applicable medical condition and explain in DMA; 118. huured I framed 2 9. In the last 10 years have you been di/to:cud a beetled by a ficemad member el the medical profession for Til tiO Yes No a. chest pains, heart aback high blood pressure, heart ntrmut palpitations or any other illness or impairment of t a hears arteries, or veins? 0 0 O 0 b. a tumor or canter inducting skin cancer, melanoma, or colon polyps? 0 0 0 0 c. in mesa or impairment of your blood or immune system including anemia, blood clots, bleeding, immune deFctency, leukemia, or lymphoma? lexclurfng HIV) 0 0 0 0 d. an !Mass as impairment or your ore En. spinal card, or nervous system including seewes. tremors. paralysis, fainting, stroke, or TIA (transient is ctimis attack)? 0 O O e rner.tory lose, contusion. Alzheimer's disease, dementia. depression. anxiety, psychosis, suicide thoughts or attempts, anorexia or tittnia, absessive compulsive disorder, bipolar disorder, or oilier specific Sly disposed mental Mass or impairment? 0 0 O 0 ASOF1.935 EFTA00804448 I t<jc as Jr 8) 3 your answer is 'Yes' to any of the following questions, circle applicable medical condition and explain in DetailsIla to In the last 10 yews hems no WaalI leen a. used coterie, barbiturates, narcotics, stimulants, hallucinogens, or other controlled subsumesnot fra II proscribed by a physician? 0 0 0 0 b. to:eked ueatment elended a program or been counseled (or alcohol or drug abuse. or been Wad by a medical doctor or a licensed meted professional to roduto the use of alcohol? 0 0 0 0 c. tasted positive for exposure to the NW ztlecthn or been diagnosed as having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection? 0 CI 0 0 it. Is the last 5 nen have you diagnosed or tread bye liceran member of the medical piolualon foe a. an illness or impairment of your eyes, can, rase, or throat? 0 0 0 0 b. asthma. shortness of breath. bronchitis, emphysema, COPE) (chronic obstructive pulmonary diseeset rem= nia, sleep apnea, or any other einem or impairment of your respiramry system? 0 0 0 0 e. en Pass er impairment of your deosave system. 5yet princess, or gall bladder including hepatitis, Muncie , ulcers. intestinal Weeding, colitis, or Crohn's disease fl its)? 0 0 0 0 d. an l!ness or imps/num of your mascleo, bones, its or naves, indudiag anlvids, gout sciatica, or amputations? 0 0 0 0 e. clumic fatigue syndrome, lupus, or mbar rheumelotogic bets or impairment? 0 0 0 0 I. diabetes or an illness or impairment of your thyroid, phoiary, or adrenal glands? a 0 0 0 g- an anus or impairment of year kidneys, bladder, pouter& or urinaryMet or booties of sup; probilk blood in the urine? 0 0 0 0 12. la the lest 3 yews ben lee been diagnosed or treated by a licensed member of the ntadled prelude.kr a en amasser impairment of yam status. cervix, ovaries, e.r breasts? 0 0 0 0 b. an illness or impairment el your skin including eczema and psoriasis? 0 0 0 0 13. la the last 5 pars have you a. had a sickness or injury for which you made a disability claim or fa which you received payments, tea& or pension benefits? O 0 0 0 14, la the Int 3 years here you a. had en application for life, dingle or health inmance d e raid. postportect rated, or restricted? 0 0 0 0 15. in the last year, wino mimic* stated cn 11113 applicatioe, hen yea had a physical exam. checkup, or evaluation bye lx en sed member of the me al croleasion? 111 Yu. PASO ditiontisis cr firitistosl. 0 0 0 0 b. had en in.ury treated by a (tensed member of the medical profession ore medical I acikty? 0 0 0 0 c. had an electrocardiogram, way. Wood thst or other diagnostic test, excluding an HIV test? 0 0 0 0 6. had 3Jrg ery or bean a patient ins hospital, clinic, or other medical or mental health recall? 0 0 0 0 e. boon advised bye medical doom or a licensed medical professional to have surgery• medicei ersoboust,It diagnostic testing, excluding HIV testrng, that has not yet been completed? 0 0 0 0 16. Are you currently a. under treatment bye licensed member of the medical prolession or takirtg arty prescribed medication (ode than contraceptwert 0 0 0 0 b. taking any herbal or non-prescription medication at least weekly? 0 0 0 0 II. Have robe., diagnosed n pregnant bye licensed number often medical prefecien? al Yes. winds expected delivery deur 1 0 0 0 0 it Details of "Yee Answers ("lease reference question I and Insured 7 eel Give diagnosis and symptoms teas performer; dams. woes and amounts ofmedication, length of inability, degree airflows and names addresses, and phone numbers doff health professionals. A608.606 EFTA00804449 mop 01 Ull Avenues ed thparn \ Costal nos {Egon NII AU CAM ksannatiV ic. fhtiete t :n rat go warm co.'flitter "I Pa run 00703190 ad OS KWIC State dellykn=d 1 ten= see =l ar lolV ell t en a rty et dam/ al re ileac Mew a,r orbs be F41 t ag' IreenZio is ittold tc voi llig"%Par glgref fold ace um Ito Pifir tslie N7 efr irs see bit ra. c=res ir S citadri l toost ua tt s rou-,1•10 r tztg est pi c ORS nelcoitriZ . Omar an acibiodsint dzi= lo ecoettena el apt dlarrt at of be out% te Pol4 • ty4 nrs..tit, of -vaisigaitqs rad Ira=ren r toncefins =the Egi t% kolneden tor the ttnoldaa piney VSCSCIS. L nno____atain Oellonbit bpprein:iris ~a toe tort safe oolloWa r je at mi w ar" d I= MU. Tlaprig. Primkatce -,ey ra IWO bellet rearm' bit a Al t itrAtoffee tertee/415ot I—dellOodoettleaturronto -anil1 sitterbeetteolal I 'Meat* . leas lawns bow:SW this laiasorie tern. (b) ktio subettb hub" ritleoldbo nein/At hare tonprt oll fl ute ar ilvklectes, orId houesio am ITIS hoe SAS'S *sites - no imp* Reim se baba? suittboldrojitaiIlia tinIn onalonisirc us:raSteetIN4 of laPrMS irsarga WWI Wks out sod inaliall The !retinue ilbeise tuna den epoi rewire yew castle to orovilion of the document at OW. Oa ceranliab required to stop . b tend my to tend bed et tassidi Oda to Ohs Pettus rounino.int and conch sienna ride r tee al to be tent try Print Peat Na. WeeInset isettesso tome Ovaw :1Onged Petty Ltd, ftle Wax/rat/0 .1374i1of Orpime Pole! wait Feb cloak-al /Only tor than Propard Awn() ABMS% 9 Long Island - Ronnie Agency 042 EFTA00804450 ) MassMu r.,IM al 010U.- ANCtuIat Application Part 2 Massechueetts Mutual Life Insurance 255 State Siren Sp ape al d. Massa Co chosen* (1111-G201 1 Name P c.; vv, 1 2. Heigh, 5b' (Los. s.s ESL. st.c, _S-521 Weight 3 It. I/ your weight changed by over 101b in the last year. indicate amount and mason 3. Name and Addresa4Parsot Physiclin: —roci• Ns. V% ra.:1 ,1%). IA nn Phone manber Of known) 4. Date last ten end rotatles ir 1 - . • 4,......4"-; ra. e_Skil4-3'--/ ‘ • ‘," ...,„J 5. Family History: Relative Nearat Orphism% — Include Sae at onset Age if Age at Cause of lestpeiisilylor cardiovescularthessel Fatter Living Death [teeth Mother S a PC e. i ikt.—L Brother(sYSister(s) —IN C IR1 , • S t • CL St.) It your answers "as' to °twat the loilawing Question; circle linkable dem snd oralain in area provided OW 6. Have yew a. Smoked cigarettes during the last 12 loughs? Yes •••••• node.. b, used tobacco or produCtS contaln ino ni, :otine during the Iasi 1? O c. used tobacco or products containing nicotine during the last 24 months? O 1. In the lest 10 years have you O consulted a health professional regarding: a. chest98ln, man attack, high I blood pc:sure. neap murmur. palpitations anerios or veins? or any other disorder of the heart. !Lae:mar or cancer Including skin cent er metanoma or colon c. 0 disorder of your blood or Immune s)u.en intruding anomie. blued clots. bleeding, O leukemia or lymphoma? immune deficiency. • a diSOrder of your brain, spinal cord it • femurs system Including selzwes, toners, paralysis, diulnos Wilting. headaches, Stroke or TIA wpmion S. s ischemic snack)? e depression. ensie,y, nervousness. slim.. psychosis, suicide thoughts or attempts. anorexia or bulimia O traumatic stress asordet, obsessnte compul post sive disorder, bipolar disorder. or Other emotional disorde r? __...... O B. In the lest 10 years have you: a. used cocaine. barbiturates, narcotic s, stimulants. hallucinogens or other controll Substan by a physician? ed ces not proscribed o, received treatment attended a program or been counseled for alcohol or drug 6000 or bean admsed by e • O hesimprofessional to reduce the use x3iconot? " O 9. In the len 5 yeIn heirs you consulted a tienith prolartional regarding: a. a disorder of your eyes. ears, nose. them or sinuses includin g any partial or complete toss of nearing, vision or speech? b. asthma. allergin, shortness of bratoth, b onctitis. emphys ema, COPO (cnrorac obavuCtive pulmonary disease). pneumonia, sleep apnea. tuberculosis or any other disorder of your rospratoty system? . „.. . c a disorder of your digestive system Mgr penaeos or gea bladder including hepatitis. Jaundice. ulcers, intesteml bleeding, colitis, Crohn's (Ass al.e (ileitis). recurrent indigestion. diarrhea or dNerticuritis7_____„.... O a a. disorder or Overman( or your miser— bonas.jcinti, nerves, opine, nod or ben Including arthritis, gout. sciatica or amputations? — e. Epstein- Barr virus, Lyme &See* climb: fatigue syndicate, notorny alot lupus or other theuntatologic disorder? 1. diabetes or a disorder of your thyroid, taltilary or adrenal glands) g. a disorder of your kldnOyS, bladder, prc siate a urinary tract or findings of sugar. protein a blood In the wine? ASONY702 20o/goo Xvi CC -t2 2002/9Z/to EFTA00804451 EFTA00804452 “ 10. In the has 5 yearn hero you eoniult ed health professional 'Bearding! a. a disorder nt yea:: shin Including ocr.ta.a, psoriasis or latex allergy? yet b. medically diagnos ed ACcillif0 0 Immune Deficien cy Syndrome (AIDS)? a (herder of your 'acne:C ervix. ovules or breasts ? d. multiple miscarriages. cleplicated ere enemy or idereilliy evatuation? 11. In the has 5 years. have yotg a. had an apOtIcation for Mi. disability or noalin insuran 9 ce declined . postpon ed. rated or restricted? ..__..... D. had a sickness or injtrytr which ycu made a disabilit y claim or fa you received payments. Oenefits or pension bene s? . 4 12 In the len 3 0 years, unless pr 'cutely stilted on this applicalloo. have you a. had a physical exam, Che or ev<W Mon by a health professional If yes. provide diagnosis or findings li ale below. CJ b. bad an Injury treated by riesmert prole: glom, or medical Incline7 c. had an electrocardlogranl. x-ray. Mond test or other diagnostic test. excluding an HIV test? ....-----.... d. had surgery or been a pilau in a bosom, clinic 0 or other medical or mental health Nadi? e. been advised to have surgery. menace treatme EN nt or diagnostic tithing. excluding HIV testing. that has not been completed? —. 13. Are you currently: 0 ...— R a. under treaunent Cr taking sorry preset lead medication (other than contracepdves)? o tailing any herbal or nen.pre script 0 on re 1414.10011 et least weekly? c. pregnant? (fleeced delitery date: 0 14, Details of *Yes' Answers. Identify the eve-elle 0 n by le number. • Give diagnosis or syriprems,1:ests pertain:4 dares. types end amounts of medication, (engine! disability, degree of recovery, and names and addresses or all Wealth prole:slimes. Supplem ent 'A" should be inched, if necessary, ro fully explain details. ‘,Qt -;_P qkoSt-,crt..- &pa_ \ro a.cAnes ic. s ,,r,d3„ esOzd. nois y N.,. (I.. B. So. . t.ct. -Dokk-i"o Sro O e q.:N.-- Cy." , • Agreement end Signature I agree that (1) this apprication consists of P.51.. 1 aria 2 and any amendm ents end supplem ents wesch It issued: (2) no knowiedge en eh/lean shall be attached to the policy of any agent medical examiner or any other person considered as raving been mode to or brought to as to any facts pertaini ng to me shall De the knowiedga of the Compan y unless stated in wirier appticadan or any amendments orisupp Pan 1 or Pan 2 01ails iernertis . and (3) to the best of my knowledge and belief, all informa accurate, and was correctly recorded belted I signed tion is complete, true and my name below. Signed at )•--)- 1 I t-t- 7 en VP/ 20 I/ City Siam Dew Whness Proposed insurefS Signature ---S i "— j—1C -- Sgnature C S t /‘-- -7 > ,//. Printed Nz e flti k h AS0NY101 i 2 Soo/too :Cis Et tZ 1002197-1.0 .m.•-••-•y• r MassMutual ,,amectai nay. ," Application Part 2 Massachusetts Mutual Life Insu 1295 State Hreet. Sprinigala: rance Co. Masted: went (II i-aeol t. Name Se. N Cyv., DOB ti_ 1\2.7.f.5) SS 3. Haight 9`'weight no If your weight changed by over 10 lb ellail_31 in the last year. Indicate amount and reason 3. Name and Address of Perscral Physic! in,TD • —I) r t), a. Vi c C N%) e, Phone rumber (If known) `-{ W. 4, d. Oats lest seen and reaso n' 3 IV 3 7-!: o •-•-14 5. Fautifr Ristor • _ Relative Health Problems —Inc lude age at onset Age II lansaastly For c enill ow scoter Age at Couto of Father disease/ Living Dann Ocala Motion TA- 6n IT - Broth s IS\ _ • If your answer is 7es- to 6I any of the leacesiv questions. circle applicable item and 6, Haw you: eeplein in area provided (/141 . a. smoked cigarettes durin g the last 12 ineriths? 0. used tobacco or products . containing nicotine Owing tne last 0 c. used tobacco or products 12 canteNtho to :oche during trio last 0 24 months? 7, In the ran 10 years have 0 you consulted t health ptolession a. chest eatt heart attack. al regarding: nigh blood p e•SUra. bean murm aneries or veins? ur palpitations or any other disorder aline heart O. a CAW Or anCor !flaw ing skin Can( if melanoma Or colon C. a disorder of your blood or Immune s) slim including anemia. polyps?._.....__..._..__ _._....._....__.,..,__..__.._ 0 leukemia or lymphoma? blood dots. *Slag, immune 0 . deficient% d. a deputy of your twain, spina — . l cord we:runes system Inclu — 0 fainting hoodoo/las. stroke or TIA ding selzuret, tremors. parelySIS. Olnin initnslitnt kichernIC *IWO' oSt, C. depression. anxiety. nervousness. sifts traumatic stress dnorder, obsessive :. psychos's. suicide thoughts or attempts, anorexia or bulimia. post 0 cordpulsive disorder. blptir Mad er. or other emotional disorder? 13. In the last 10 years have you: ..--.. 0 a used cocaine, barbi turates. oarcOaci. SimulaMS. hallucinoge by a physICIan7 ns on other controlled substances not preecteed b. received treatment attended a progrorn abeam counseled for OlCohOl or dog 0 health professional to reclute the use )1' abuse or been advised by e ta lon 9. In the lot 5 yaw' have you cons .. . 0 ulted a health professional re/wadies: a. a disorder of your oyes, eats, nose. chi • oot or :Muses Intruding any persist or or Weal? complete lea o( Minn, Win b. asthma, allergies. shortness of breat h. Is onehiths, emphysema. COPO (chro onecmonla, sleep apnea. tuberculos nic obsuucUve pulmonary disease), is or any Other disorder of your respiratory c. a disorder of your digestive SyslOrn, systorn? — Dux. panaeas a gall weeder including 0 Intesunal bleedng, colitis. Crohn's riseEt eepatldsjetindlce, ulcers. d. a disorder or trn.poirrr.ord of yew misso (Death), recurrent indigestion es. bores. oints. nerves. spine. necadiarrhea or divalliel41437— 0 sciatica a attestations? a back inclucang atttrldS,90W. . . ... . e. Epstein-Barr virus. Ls* cisme, two se fadgue syndrome. darOillyalgia. lupus or other theur disorder? ... nalotage I. diabetes as a &sander of pus thyroS s, idt.ittary or adrenal glands? ________ g. a disorder of your ludnoys, bladder, _:________.____....—....- 0 pr: slate or urinary tract a MOW; of the urine? _ auger. protein Of bitted In ASONY702 e00/200(0 XVi LC tZ Z00Z/9Zit 0 EFTA00804453 laba0.nomplaNariMittg.S in• s -a.-.••••• te, In the tat 5 years have you consulted t. health profession e a disorder of your skin Inclu al regarding: • muscat', diagnosed ding amine, psoriasis or latex allerg y? 1m Acquired Immune kikIvey C. a ceSi0rder of your Uteru Syndrome (AIDS)? O d. multplo miscarriages, comp s. cavil. .74.floS or breasts? .. O lIcatte pregnancy or infert3lity evaluation? . — O II. In the lest 5 Thars. have you: O a. had an application far life disab ility or hearth Insurance declin b. had a sickness or Injury let whic benefits of pension benenis? 12. In the last 3 years, unles h ycir made a disability claim or s previously stated co this appli ed. postponed, raced or resulaed? for which you received payments. ..... rs a. nad a physical examt chec cation, hove you: kup or der by a health proleSsinnaf? If yes. provide diagnosis or findings it no below. O b. nad an injury treated by a healt h prole:Se:nal or medical facilit c. had an elearocardlogram. tray y7 , Met test or other diagnostic test. C) d. had surgery or been a patieru excluding en HIV tests in a hospital. clirix or other medical O cr mental health oclItty? o. been advised to have surge ry, morliell treaUnont or diagnostic toting. excluding PIN testing. to O 13. Are you currently: O • a. Under treaUnent or wag any prescnbed medication (other than • El taking any herbal or non contraceptives)? C. pregnant? (Expected delive -prescript on medication at least week ler . • O cy date: la Oxtails ol 'Yes' Answers. •• • O Identity the gunshot' by Its number. Give diagnosis of symptoms, tests • perfOrmad, dare& Types and OMPUM: of medi names and addresses of all healt cation, length of disability, dog's. of recovery h profnanalt Supplement 'A' shoul and d be artaenod.rf necessary, ro fully Itapram derails tt • (2_ D. -2-0. cicercre,_ a kccA- 3Ito • a X ‘IS0Ae. • -1.---A•rc rfleC.t.Jtc r y en-Ats."‘ , • 10— C• Ilityk.A.- • N - -t i--•(,. toitc. Agreement and SIgnettne I agree that 0) this application consists of Pols 1 and 2 and any amendments if issued: (2) no mowtedge on tre and supplements which shall tut attac pan of any agent. medical 0/AMU'S or hed to the polity considered as having been made to or any otter person as to any facts pertaining brought et the knowledge of the Comp to me snail be application or any amendments or any unless stated In tether Part 1 supplements; and (3) to the test of or Part 2 of this accurate. and was correctly recorded my knowledge and belief. all Information befee I .i.red my name Peeve is complete. Inn. and Signed at h—r—) City on 20 IL - Witness State Da Q Signature Proposed Insureds Signature n_ Printed Name ASONY702 2 800 'Coo z cc l2 ZO:2192)L; EFTA00804454 SUPPLEMENT TO APPUCATION TO: ra Massachusetts Mutual Life Insurance Co. ❑ MML Bay State Life Ins. Co. ❑ t■ Life Insurance Co. 1295 State Street. Springfield, Massachusetts 01111-0001 "Company' refers to the life insurance company indicated above. Proposed Insured(s): Policy No. Appl. Pt. 1 Dated Part 2 Dated Agcy JEFFREY KOGAN 15,665,562 Jul 11, 2011 Apr 11, 2011 042 FAITH KOGAN Apr 11, 2011 AMENDMENT OF APPLICATION El This section is Applicable ❑ This section is not Applicable The following changes and additional statements as indicated below are made with respect to the application for insurance described above. This Amendment shall be a part of the application and will be subject in all respects to the agreements contained in the application. QUESTION B20 OF THE PART 1 IS FIXED QUESTION D4 OF THE PART 1 IS INSURED 1 QUESTION El OF THE PART 1 SHOULD INCLUDE: YES, THIS POLICY IS BEING PURCHASED IN CONNECTI ON WITH A TAX QUALIFIED EMPLOYER-SPONSORED PLAN QUESTION F20 OF THE PART 1 IS TRUST QUESTION G1 OF THE PART 1 IS TRUST QUESTION H1 ON THE PART 1 IS: INSURED 1 NONE; INSURED 2 NONE. QUESTION H2 ON THE PART 1 IS: INSURED 1 $5,000,000; INSURED 2 $5,000.000. QUESTION 4 ON THE PART 2 IS 6/3/09 FOR ROUTINE CHECK-UP. QUESTION 4 ON THE PART 2 IS MAY 2007 FOR VENIPUNCTURE ONLY. STATEMENT AS TO INSURABILITY CHI This section is Applicable ❑ This section is not Applicable This Statement shall be a part of the application for insurance described above and will be subject in all respects to the agreements contained in the application. Each Proposed Insured signing below certifies that, except as may be amended above, the answers and statements given in the application for insurance referenced above are true and complete. They are true and complete to the best of the knowledge and belief of the Proposed Insured as if made when signing below. To the best of the knowledge and belief of each Proposed Insured signing below, since the date of any part of the application, the Proposed Insured has not: • Had any illness or injury; or • Sought or received treatment by a member of the medical profession; or • Been advised by a member of the medical profession to seek medical treatment or • Had any change in occupation, place of residence, or aviation status; or • Applied for, and is not now applying for or planning to apply for, life, disability, or health insurance in any other insurance company. There are no exceptions to this certification except as noted here: If there are any exceptions to this certification, the policy cannot be delivered without prior authorizatio n from the Company's office at its address shown above. H16F-99(FL) Page 1 EFTA00804455 POLICY DELIVERY RECEIPT El This section is Applicable ❑ This section is not Applicable The Owner acknowledges receiving the above-numbered policy on the date of signature shown below. AGREEMENT AND SIGNATURES Each person signing below agrees that all representations made in this Supplement To Application are true and complete to the best of that person's knowledge and belief on the date signed The policy should not be delivered until this Supplement has been completed, signed by the Owner and the Proposed Insured(s), and dated. (If this form is used only as a Policy Delivery Receipt, only the Owner must sign.) If this Supplement is not completed, signed, and dated, the policy must be returned to the Company at its address shown above. Any person who knowingly and with intent to injure, defraud, or deceive any insurer files an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Owner Proposed Insured(s), if not Owner Date Agent (if required) H16F-99(FL) Page 2 RETURN TO: Massachusetts Mutual Life Insurance Company 15,665.562 c/o Policy Delivery Requirement Unit M325 1295 State Street Springfield, MA 01111-0001 EFTA00804456 Home Office Massachusetts Mutual 1295 State Street Life Insurance Company Spring531cl, Massachusetts 01111-ooni Survivorship Flexible Premium Adjustable Life Insurance Policy This Policy provides that: A death benefit is payable when both Insureds have died. Within specified limits, flexible premiums may be paid during while either Insured is living. This policy is participating - Annual dividends may or may not be paid. Notice Of Annual Meeting The Insureds are hereby notified that by virtue of this policy they are members of Massachusetts Mutual Life Insurance Company and are entitled to vote either in person or by proxy at any and all meetings of said Company. The annual meetings are held at its Home Office, in Springfield, Massachusetts, on the second Wednesday in April of each year at 2 o'clock M. P9.2005(FL) (g905matl) EFTA00804457