chronic illness accelerated death benefit rider sample · a stock company chronic illness...

IIC18ADBC 1

NASSAU LIFE AND ANNUITY COMPANY A Stock Company

CHRONIC ILLNESS ACCELERATED DEATH BENEFIT RIDER This rider is part of the policy to which it is attached, if it is listed on the Schedule Pages in Section 1 of the policy. This rider does not provide any policy value or loan value. Except as otherwise stated below, this rider is subject to all of the provisions contained in the policy. Coverage under this rider will begin on the Rider Issue Date as shown in the Rider Specifications of this rider.

BENEFITS PAID UNDER THIS RIDER MAY BE TAXABLE. YOU SHOULD CONSULT YOUR TAX

ADVISOR REGARDING POSSIBLE TAX CONSEQUENCES. THE POLICY’S BENEFITS AND VALUES, AS WELL AS ANY BENEFITS AND VALUES PROVIDED BY AFFECTED RIDERS, WILL BE

REDUCED IF A PAYMENT OR BENEFIT IS MADE UNDER THIS RIDER. IF APPLICABLE, PREMIUM PAYMENTS OR COST OF INSURANCE CHARGES WILL ALSO BE REDUCED IF AN ACCELERATED

DEATH BENEFIT IS PAID.

RIDER SPECIFICATIONS

Policy Number: [9730000] Insured: [John M. Doe] Rider Issue Date: [September 15, 2019] Maximum Acceleration Percentage: [95%] Maximum Accelerated Death Benefit: [$500,000] Minimum Accelerated Death Benefit: [$1,000] Administrative Charge: [$200.00] Maximum Number of Claims Permitted: [99] Maximum Number of Claims Permitted Per Calendar Year: [1]

DEFINITIONS

Acceleration Date The date on which your request for payment of the Accelerated Death Benefit under this rider is approved by us.

Activities of Daily Living Activities of Daily Living, as used in this Rider, are the following;

(a) Eating: Feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table), or by a feeding tube, or intravenously.

(b) Toileting: Getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.

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(c) Transferring: Moving into and out of a bed, chair or wheelchair.

(d) Bathing: Washing oneself by sponge bath or in either a tub or shower, including the task of getting into or out of the tub or shower.

(e) Dressing: Putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs.

(f) Continence: The ability to maintain control of bowel and bladder function; or when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene. This includes caring for a catheter or colostomy bag.

Administrative Charge The charge assessed when each payment is made under this rider. This charge will be equal to the Administrative Charge shown in the Rider Specifications section. Chronically Ill The term Chronically Ill means that the Insured has been certified, within the last 6 months, by a Physician as:

1. Being unable to perform, without substantial assistance from another person, at least two Activities of Daily Living for a period of at least 90 consecutive days due to loss of functional capacity; or

2. Requiring substantial supervision for a period of at least 90 consecutive days by another person to protect oneself from threats to health and safety due to Severe Cognitive Impairment.

Maximum Accelerated Death Benefit The amount shown in the Rider Specifications of this rider. This Maximum Accelerated Benefit applies, in aggregate, to the policy and all other accelerated death benefit riders attached hereto. This amount includes this Rider and any other Accelerated Death Benefit Rider attached to the Policy. Physician A Doctor of Medicine or Osteopathy who is legally authorized and licensed to practice medicine by the State (including District of Columbia) in which he or she currently performs such function or action. Physician does not include the Owner, the Insured, or a member of the Owner’s or the Insured’s immediate family. Immediate family includes parents, stepparents, grandparents, spouse, children, siblings, grandchildren, or in-laws.

Severe Cognitive Impairment Deterioration or loss of intellectual capacity that is measured by clinical evidence and standardized tests, which reliably measure impairment in:

1. Short-term or long-term memory; or 2. Orientation to person, place and time; or 3. Deductive or abstract reasoning; or 4. Judgment as it relates to safety awareness.

Substantial Assistance Stand-by or hands-on assistance from another person without which the Insured receiving such assistance would be unable to perform Activities of Daily Living. Stand-by assistance means the presence of another person within arm’s reach of the Insured that is necessary to prevent, by physical intervention, injury to the Insured while they are performing Activities of Daily Living. Hands-on assistance means the direct physical assistance of another person.

GENERAL Rider Description This rider allows you to elect an Accelerated Death Benefit upon the Proof of Claim as set forth below.

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The amount of the Accelerated Death Benefit is as described below and the resulting payment will be made in a lump sum. The lump sum payment will be made in lieu of a portion of any future Death Benefit payable under the policy. Any change to the policy will be listed in the Effect on Policy provision. There is no premium charge for this rider. Claim To make a claim for an Accelerated Death Benefit under this rider the Owner must complete a claim form provided by us and signed by you. We will provide such claim form upon our receipt of written notice at our Main Administrative Office. In order for the information that you provide to be considered notice of claim it must include information sufficient to identify the Insured. We must also receive proof satisfactory to us of the Chronic Illness as described in the Proof of Claim provision, as well as consent to any claim by any assignee and irrevocable beneficiary. If we have not provided the claim form within 15 days after we have received your written notice of claim, you shall be deemed to have complied with the requirement to complete such claim form. You will still be required to provide us the information required as Proof of Claim. Claims may be requested up to the Maximum Number of Claims shown in the Rider Specifications. The Owner may make up to the Maximum Number of Claims Permitted Per Calendar Year as shown in the Rider Specifications. Once you make a Claim, we will send you and any irrevocable beneficiaries under the policy a statement that discloses the effect that payment of the Accelerated Death Benefit will have on the policy. The Accelerated Death Benefit Payment is due to you immediately upon receipt of the due written proof of eligibility. Once an Accelerated Death Benefit has been paid to you, the Claim for such Accelerated Death Benefit cannot be revoked. Proof of Claim A Physician must provide us with evidence satisfactory to us, in our sole discretion, of the Insured’s Chronic Illness. Such evidence must include, at a minimum, a statement from a Physician certifying that the Insured is Chronically Ill and any documents necessary to substantiate the Insured’s eligibility for the benefit provided by this rider. At our expense, we may require an examination of the Insured by a second Physician to verify any diagnosis or certification made by the initial Physician. If your Physician and our Physician disagree, a third medical opinion may be obtained, at our expense, by a mutually acceptable Physician. Such third medical opinion will be binding on both parties. Accelerated Death Benefit The Accelerated Death Benefit will be equal to the base policy Death Benefit on the Acceleration Date multiplied by the Acceleration Percentage. There is no acceleration of any death benefit provided by a rider attached to the policy. The Acceleration Percentage is chosen by you at the time of request of an Accelerated Death Benefit Payment, subject to the following restrictions. The Acceleration Percentage chosen cannot be greater than the Maximum Acceleration Percentage or result in an Accelerated Death Benefit larger than the lesser of:

a) the Maximum Accelerated Death Benefit minus the total Death Benefit previously accelerated on the life of the Insured, and;

b) the Maximum Acceleration Percentage multiplied by the policy Death Benefit on the initial Acceleration Date, minus the total Death Benefit previously accelerated on the life of the Insured.

The Acceleration Percentage also cannot result in an Accelerated Death Benefit that is less than the Minimum Accelerated Death Benefit as specified in this rider.

Accelerated Death Benefit Payment The Accelerated Death Benefit Payment will be determined by us, as of the Acceleration Date.

The Accelerated Death Benefit Payment will equal the greater of:

A) the Net Cash Value or Net Surrender Value in the policy, if any, multiplied by the Acceleration Percentage; or

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B) the result of following:

1) the Accelerated Death Benefit multiplied by the discount factor; minus

2) the present value of any expected unpaid future premiums payable under the policy; minus

3) the Administrative Charge; minus

4) the outstanding Policy Debt, if applicable, multiplied by the Acceleration Percentage.

The discount factor will be based on our assessment of the future expected mortality of the Insured and the Accelerated Death Benefit Interest Rate.

The Accelerated Death Benefit Interest Rate will be declared by us. It will not exceed the greater of:

1. the yield on 90-day U.S. Treasury Bills on the Acceleration Date; or

2. the maximum adjustable policy loan interest rate allowed by law on the Acceleration Date.

If the use of 90-day U.S. Treasury Bills is discontinued, we will use an appropriate substitute index subject to the approval of the Interstate Insurance Product Regulation Commission.

The Accelerated Death Benefit Payment will be paid to you or your estate while the Insured is living, unless otherwise designated by you. The Accelerated Death Benefit Payment will be paid in a lump sum. In no event will the Accelerated Death Benefit Payment be less than the Cash Surrender Value or Net Surrender Value (as applicable) multiplied by the Acceleration Percentage. Death of the Insured Prior to the Payment of the Accelerated Death Benefit Payment In the event that the Insured dies after the written request but before we make the Accelerated Death Benefit Payment, and we receive written notice at our Main Administrative Office of the Insured’s death, the written request to accelerate the Death Benefit will be considered void, and no payment will be made under this rider. We will pay the Death Benefit as provided in the policy when we receive due proof of death. Effect on Policy The following values will be reduced by the Acceleration Percentage at the time the Accelerated Death Benefit payment is made to you:

1. future base premium payments (excluding the Policy Fee), if permitted and payable on the policy;

2. any Cost of Insurance charges, if applicable;

3. the Face Amount of the policy;

4. any Cash Value or Policy Value in the policy to which this rider is attached, if applicable;

5. any Cash Surrender Value or Net Surrender Value in the policy to which this rider is attached, if applicable;

6. any outstanding Policy Debt, if applicable ; and

7. any Surrender Charges, if applicable.

The reduction in the Face Amount of the policy will reduce your Death Benefit in accordance with the terms of the policy. Exercise of this rider will not impact premiums on any other riders attached to this policy. Future values under the policy will be determined in a manner consistent with that under the original policy, as adjusted to reflect the above reductions. We will mail to you new policy Schedule Pages reflecting any adjusted values due to the Accelerated Death Benefit Payment made under this rider. Limitation on Payment

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If there is a surviving irrevocable beneficiary, we require the written consent of each such surviving irrevocable beneficiary and any assignee to your Claim for this Accelerated Death Benefit. No payment of an Accelerated Death Benefit under this rider will be made under any of the following conditions:

1. the Insured’s Chronic Illness is the result of a self- inflicted injury or attempted suicide, while sane or insane within two years from the Policy Date, or within two years from any reinstatement of the policy;

2. the payment is to satisfy the claims, demands, or obligations of any creditor, trustee in bankruptcy or governmental agency, or arising under any court order directed against you, to the extent that we have written notice thereof;

3. the policy to which this rider is attached has terminated.

A payment under this rider is considered made when sent from our Home Office or Main Administrative Office.

Incontestability This rider shall be incontestable after it has been in force during the Insured's lifetime for two years from the Rider Issue Date except for fraud or any provision for reinstatement. In the case of reinstatement the incontestable period shall be two years from the effective date of such reinstatement. While insurance is contestable, we may either rescind the insurance or deny a Claim on the basis of: 1. a material misstatement in the application or supplemental application for the policy; or 2. a material misstatement in the reinstatement application if there has been a reinstatement of this

rider.

Reinstatement of This Rider If the policy terminates in accordance with the Grace Period provision in the policy while this rider was in force, and the policy is reinstated in accordance with the Reinstatement provision of the policy, you may reinstate this rider at that same time if the Accelerated Death Benefit under this or any other accelerated death benefit rider attached to the policy has not been fully paid out at the time the policy is reinstated. Termination of This Rider This rider will terminate on the first of any of the following events to occur:

1. The date of lapse or termination of the policy to which it is attached; or

2. the date of our receipt of your written request to cancel coverage under this rider; or

3. the date of death of the Insured, or

4. the exercise of Terminal or Critical Illness riders, or

5. when the total accelerated amount under all accelerated death benefit riders attached to the policy equals the Maximum Accelerated Death Benefit under this rider. or

6. the date that Overloan Protection is exercised, if applicable.

7. when the Maximum Number of Claims is reached.

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Termination of this rider will not prejudice the payment of benefits for a qualifying event that occurred while the rider was in force.

Nassau Life and Annuity Company

[ ]

[Secretary]

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IIC18ADBCI 1


CRITICAL ILLNESS ACCELERATED DEATH BENEFIT RIDER This rider is part of the policy to which it is attached, if it is listed on the Schedule Pages in Section 1 of the policy. This rider does not provide any policy value or loan value. Except as otherwise stated below, this rider is subject to all of the provisions contained in the policy. Coverage under this rider will begin on the Rider Issue Date as shown in the Rider Specifications of this rider.

BENEFITS PAID UNDER THIS RIDER MAY BE TAXABLE. THIS RIDER IS NOT COVERED BY THE

ACCELERATED DEATH BENEFITS PROVISION OF THE INTERNAL REVENUE CODE SECTION 101. YOU SHOULD CONSULT YOUR TAX ADVISOR REGARDING POSSIBLE TAX CONSEQUENCES. THE POLICY’S BENEFITS AND VALUES, AS WELL AS ANY BENEFITS AND VALUES PROVIDED BY AFFECTED RIDERS, WILL BE REDUCED IF A PAYMENT OR BENEFIT IS MADE UNDER THIS

RIDER. IF APPLICABLE, PREMIUM PAYMENTS OR COST OF INSURANCE CHARGES WILL ALSO BE REDUCED IF AN ACCELERATED DEATH BENEFIT IS PAID.


Policy Number: [9730000] Insured: [John M. Doe] Rider Issue Date: [September 15, 2019] Maximum Acceleration Percentage: [95%] Maximum Accelerated Death Benefit: [$500,000] Minimum Accelerated Death Benefit: [$5,000] Administrative Charge: [$200.00] Maximum Number of Claims Permitted: [99] Claim Period: [180 Days] from the most recent Acceleration Date

DEFINITIONS


Administrative Charge The charge assessed when each payment is made under this rider. This charge will be equal to the Administrative Charge shown in the Rider Specifications section. Maximum Accelerated Death Benefit The amount shown in the Rider Specifications of this rider. This Maximum Accelerated Benefit applies, in aggregate, to the policy and all other accelerated death benefit riders attached hereto. This amount

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includes this rider and any other Accelerated Death Benefit Rider attached to the Policy. Physician A Doctor of Medicine or Osteopathy who is legally authorized and licensed to practice medicine by the State (including District of Columbia) in which he or she currently performs such function or action. Physician does not include the Owner, the Insured, or a member of the Owner’s or the Insured’s immediate family. Immediate family includes parents, stepparents, grandparents, spouse, children, siblings, grandchildren, or in-laws.

GENERAL Rider Description This rider allows you to elect an Accelerated Death Benefit upon the occurrence of a Qualifying Event as set forth below. The amount of the Accelerated Death Benefit is as described below and the resulting payment will be made in a lump sum. The lump sum payment will be made in lieu of a portion of any future Death Benefit payable under the policy. Any change to the policy will be reflected in the Effect on Policy provision. There is no premium charge for this rider. Qualifying Event An Accelerated Death Benefit can be elected under this rider only if the Insured experiences a Qualifying Event covered under this rider while the policy and this rider are in force. The Qualifying Events covered under this rider are:

1. Heart attack (myocardial infarction) - The death of a portion of the heart muscle resulting from inadequate blood supply. Heart attack does not include angina or the chance finding of electrocardiographic (EKG) changes indicative of a previous Heart Attack. The diagnosis of heart attack must be based on the presence of all of the following:

a. Chest pain and/or dyspnea (shortness of breath);

b. Associated new EKG changes which support the diagnosis; and

c. Elevation of cardiac (heart) biomarker levels which support the diagnosis.

If the clinical or laboratory criteria used to diagnose Heart Attack (myocardial infarction) changes in the future, the generally accepted criteria at the time of the Qualifying Event must be met.

2. Stroke - A cerebrovascular accident or infarction (death) of brain tissue caused by hemorrhage, embolism, or thrombosis lasting more than 24 hours and producing measurable neurological deficit which persists for at least 30 consecutive days following the occurrence of the Stroke. Stroke does not include transient ischemic attacks.

3. Diagnosis of Cancer. Cancer means a disease manifested by the presence of one or more malignant tumors and characterized by the uncontrolled growth and spread of malignant cells and the invasion of normal tissue. Cancer does not include:

a. Any skin cancer, except invasive malignant melanoma into the dermis or deeper;

b. Pre-malignant lesions, benign tumors, or polyps; and

c. Carcinoma in-situ.

4. Diagnosis of End Stage Renal Failure. End Stage Renal Failure means an irreversible and total failure of both kidneys which requires the undergoing of renal transplantation or regular renal dialysis.

5. Major Organ Transplant - The receipt by transplant of any of the following organs or tissues: heart, lungs, liver, kidney, pancreas, or bone marrow.

6. Diagnosis of ALS (Amyotrophic Lateral Sclerosis) by a qualified Physician. Proof of Qualifying Event

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Upon each Claim, a Physician must provide us with evidence satisfactory to us, in our sole discretion, of the Insured’s Qualifying Event. Such evidence must include, at a minimum, a statement from a Physician certifying that the Insured has experienced a Qualifying Event and any documents necessary to substantiate the Insured’s eligibility for the benefit provided by this rider. At our expense, we may require an examination of the Insured by a second Physician to verify any diagnosis or certification made by the initial Physician. If your Physician and our Physician disagree, a third medical opinion may be obtained, at our expense, by a mutually acceptable Physician. Such third medical opinion will be binding on both parties. Claim To make a Claim for an Accelerated Death Benefit under this rider the Owner must complete a claim form provided by us and signed by you. We will provide such claim form upon our receipt of written notice at our Main Administrative Office. In order for the information that you provide to be considered notice of claim it must include information sufficient to identify the Insured. We must also receive proof satisfactory to us of the Qualifying Event as described in the Proof of Qualifying Event provision, as well as consent to any claim by any assignee and irrevocable beneficiary. If we have not provided the claim form within 15 days after we have received your written notice of claim, you shall be deemed to have complied with the requirement to complete such claim form. You will still be required to provide us the information required as Proof of Qualifying Event. Any Claim for an Accelerated Death Benefit under this rider must be made within 365 days following the occurrence of the Qualifying Event. The Owner may make up to the Maximum Number of Claims Permitted as shown in the Rider Specifications. After payment of an Accelerated Death Benefit, no subsequent requests for an Accelerated Death Benefit may be made until after the Claim Period expires. Once you make a Claim, we will send you and any irrevocable beneficiaries under the policy a statement that discloses the effect that payment of the Accelerated Death Benefit will have on the policy. The Accelerated Death Benefit Payment is due to you immediately upon receipt of the due written proof of eligibility. Once an Accelerated Death Benefit has been paid to you, the Claim for such Accelerated Death Benefit cannot be revoked. Accelerated Death Benefit The Accelerated Death Benefit will be equal to the base policy Death Benefit on the Acceleration Date multiplied by the Acceleration Percentage. There is no acceleration of any death benefit provided by a rider attached to the policy. The Acceleration Percentage is chosen by you at the time of request of an Accelerated Death Benefit Payment, subject to the following restrictions. The Acceleration Percentage requested cannot be greater than the Maximum Acceleration Percentage or result in an Accelerated Death Benefit larger than the lesser of:

a) the Maximum Accelerated Death Benefit minus the total Death Benefit previously accelerated on the life of the Insured, and;

b) the Maximum Acceleration Percentage multiplied by the policy Death Benefit on the initial Acceleration Date, minus the total Death Benefit previously accelerated on the life of the Insured.

The Acceleration Percentage also cannot result in an Accelerated Death Benefit that is less than the Minimum Accelerated Death Benefit as specified in this rider. Accelerated Death Benefit Payment The Accelerated Death Benefit Payment will be determined by us, as of the Acceleration Date.



B) the result of the following:

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2) the present value of any expected unpaid future premiums payable under the policy; minus



The discount factor will be based on our assessment of the future expected mortality of the Insured and the Accelerated Death Benefit Interest Rate. The Accelerated Death Benefit Interest Rate will be declared by us. It will not exceed the greater of:




The Accelerated Death Benefit Payment will be paid to you or your estate while the Insured is living, unless otherwise designated by you. The Accelerated Death Benefit Payment will be paid in a lump sum. In no event will the Accelerated Death Benefit Payment be less than the Cash Surrender Value or Net Surrender Value (as applicable) multiplied by the Acceleration Percentage. Death of the Insured Prior to the Payment of the Accelerated Death Benefit Payment In the event that the Insured dies after the written request but before we make the Accelerated Death Benefit Payment, and we receive written notice at our Main Administrative Office of the Insured’s death, the written request to accelerate the Death Benefit will be considered void, and no payment will be made under this rider. We will pay the Death Benefit as provided in the policy when we receive due proof of death. Effect on Policy The following values will be reduced by the Acceleration Percentage at the time the Accelerated Death Benefit payment is made to you:






6. any outstanding Policy Debt, if applicable; and


The reduction in the Face Amount of the policy will reduce your Death Benefit in accordance with the terms of the policy. Exercise of this rider will not impact premiums on any other riders attached to this policy. Future values under the policy will be determined in a manner consistent with that under the original policy, as adjusted to reflect the above reductions. We will mail to you new policy Schedule Pages reflecting any adjusted values due to the Accelerated Death Benefit Payment made under this rider. Limitation on Payment If there is a surviving irrevocable beneficiary, we require the written consent of each such surviving irrevocable beneficiary and any assignee to your Claim for this Accelerated Death Benefit. No payment of an Accelerated Death Benefit under this rider will be made under any of the following conditions:

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1. the Insured’s Qualifying Event is the result of a self-inflicted injury or attempted suicide, while sane or insane within two years from the Policy Date, or within two years from any reinstatement of the policy;

2. the payment is to satisfy the claims, demands, or obligations of any creditor, trustee in bankruptcy or governmental agency, or arising under any court order directed against you, to the extent that we have written notice thereof;


A payment under this rider is considered made when sent from our Home Office or Main Administrative Office.

Incontestability This rider shall be incontestable after it has been in force during the Insured's lifetime for two years from the Rider Issue Date except for fraud or any provision for reinstatement. In the case of reinstatement the incontestable period shall be two years from the effective date of such reinstatement. While insurance is contestable, we may either rescind the insurance or deny a Claim on the basis of: 1. a material misstatement in the application or supplemental application for the policy; or 2. a material misstatement in the reinstatement application if there has been a reinstatement of this

rider.


1. the date of lapse or termination of the policy to which it is attached; or


4. the date of death of the Insured, or

5. the exercise of Terminal or Chronic Illness riders, or

6. when the total accelerated amount under all accelerated death benefit riders attached to the policy equals the Maximum Accelerated Death Benefit under this rider, or

7. the date Overloan Protection is exercised, if applicable.

8. when the Maximum Number of Claims is reached.

Termination of this rider will not prejudice the payment of benefits for a qualifying event that occurred while the rider was in force.


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[ ]

[Secretary]

SAMPLE

ICC18ADBT 1


TERMINAL ILLNESS ACCELERATED DEATH BENEFIT RIDER This rider is part of the policy to which it is attached, if it is listed on the Schedule Pages in Section 1 of the policy. This rider does not provide any policy value or loan value. Except as otherwise stated below, this rider is subject to all of the provisions contained in the policy. Coverage under this rider will begin on the Rider Issue Date as shown in the Rider Specifications of this rider.

THE BENEFIT PAID UNDER THIS RIDER MAY BE TAXABLE. YOU SHOULD CONSULT

YOUR TAX ADVISOR REGARDING POSSIBLE TAX CONSEQUENCES. THE POLICY’S BENEFITS AND VALUES, AS WELL AS ANY BENEFITS AND VALUES PROVIDED BY AFFECTED RIDERS,

WILL BE REDUCED IF AN ACCELERATED DEATH BENEFIT IS PAID. IF APPLICABLE, PREMIUM PAYMENTS OR COST OF INSURANCE CHARGES WILL ALSO BE REDUCED IF AN ACCELERATED

DEATH BENEFIT IS PAID.


Policy Number: [9730000] Insured: [John M. Doe] Rider Issue Date: [September 15, 2019] Maximum Acceleration Percentage: [95%] Maximum Accelerated Death Benefit: [$500,000] Minimum Accelerated Death Benefit: [$5,000] Terminal Illness Life Expectancy Period: 12 months Administrative Charge: [$150.00]

DEFINITIONS


Administrative Charge The charge assessed when payment is made under this rider. This charge will be equal to the Administrative Charge shown in the Rider Specifications section. Maximum Accelerated Death Benefit The amount shown in the Rider Specifications of this rider. This Maximum Accelerated Benefit applies, in aggregate, to the policy and all other accelerated death benefit riders attached hereto. This amount includes this Rider and any other Accelerated Death Benefit Rider attached to the Policy. Physician A Doctor of Medicine or Osteopathy who is legally authorized and licensed to practice medicine by the State (including District of Columbia) in which he or she currently performs such function or action. Physician does not include the Owner, the Insured, or a member of the Owner’s or the Insured’s

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immediate family. Immediate family includes parents, stepparents, grandparents, spouse, children, siblings, grandchildren, or in-laws.

GENERAL Rider Description This rider allows you to elect an Accelerated Death Benefit upon Terminal Illness of the Insured. Only one benefit Claim is allowed under this rider. The amount of the Accelerated Death Benefit Payment is as described below and the resulting payment will be made in a lump sum. The lump sum payment will be made in lieu of a portion of any future Death Benefit payable under the policy. Any change to the Policy will be reflected in the Effect on Policy provision. There is no premium charge for this rider. Terminal Illness An Accelerated Death Benefit can be elected under this rider only if the Insured is diagnosed with a Terminal Illness while the policy and this rider are in force. A Terminal Illness under this rider is an illness or condition which has been diagnosed by a Physician, with such diagnosis being supported by clinical, radiological, laboratory or other evidence satisfactory to us and that is reasonably expected to result in the Insured’s death within the Terminal Illness Life Expectancy Period shown in the Rider Specifications based on evidence required under the Proof of Terminal Illness section below. Proof of Terminal Illness A Physician must provide us with evidence satisfactory to us, in our sole discretion, of the Insured’s Terminal Illness. Such evidence must include, at a minimum, a statement from a Physician certifying that the Insured is Terminally Ill and any documents necessary to substantiate the Insured’s eligibility for the benefit provided by this rider. At our expense, we may require an examination of the Insured by a second Physician to verify any diagnosis or certification made by the initial Physician. If your Physician and our Physician disagree, a third medical opinion may be obtained, at our expense, by a mutually acceptable Physician. Such third medical opinion will be binding on both parties. Claim To make a Claim for an Accelerated Death Benefit under this rider the Owner must complete a claim form provided by us and signed by you. We will provide such claim form upon our receipt of written notice at our Main Administrative Office. In order for the information that you provide to be considered notice of claim it must include information sufficient to identify the Insured. We must also receive proof satisfactory to us of the Insured’s Terminal Illness as described in the Proof of Terminal Illness provision, as well as consent to any claim by any assignee and irrevocable beneficiaries. If we have not provided the claim form within 15 days after we have received your written notice of claim, you shall be deemed to have complied with the requirement to complete such claim form. You will still be required to provide us the information required as Proof of Terminal Illness. Once you make a Claim, we will send you and any irrevocable beneficiaries under the policy a statement that discloses the effect that payment of the Accelerated Death Benefit will have on the policy. The Accelerated Death Benefit Payment is due to you immediately upon receipt of the due written proof of eligibility. Once an Accelerated Death Benefit has been paid to you, the Claim for such Accelerated Death Benefit cannot be revoked. Accelerated Death Benefit The Accelerated Death Benefit will be equal to the base policy Death Benefit on the Acceleration Date multiplied by the Acceleration Percentage. There is no acceleration of any death benefit provided by a rider attached to the policy. The Acceleration Percentage is chosen by you at the time of request of an Accelerated Death Benefit Payment, subject to the following restrictions. The Acceleration Percentage chosen cannot be greater than the Maximum Acceleration Percentage or result in an Accelerated Death Benefit larger than the Maximum Accelerated Death Benefit minus the total Death Benefit previously accelerated. The Acceleration Percentage also cannot result in an Accelerated Death Benefit that is less than the Minimum Accelerated Death Benefit as specified in this rider.

Accelerated Death Benefit Payment The Accelerated Death Benefit Payment will be determined by us, as of the Acceleration Date.

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B) the result of the following:




The discount factor will be based on the Terminal Illness Life Expectancy Period and the Accelerated Death Benefit Interest Rate. The Accelerated Death Benefit Interest Rate will be declared by us. It will not exceed the greater of:




The Accelerated Death Benefit Payment will be paid to you or your estate while the Insured is living, unless otherwise designated by you. The Accelerated Death Benefit Payment will be paid in a lump sum. In no event will the Accelerated Death Benefit Payment be less than the Cash Surrender Value or Net Surrender Value (as applicable) multiplied by the Acceleration Percentage. Death of the Insured Prior to the Payment of the Accelerated Death Benefit Payment In the event that the Insured dies after the written request but before we make the Accelerated Death Benefit Payment, and we receive written notice at our Main Administrative Office of the Insured’s death, the written request to accelerate the Death Benefit will be considered void, and no payment will be made under this rider. We will pay the Death Benefit as provided in the policy when we receive due proof of death. Effect on Policy The following values will be reduced by the Acceleration Percentage at the time the Accelerated Death Benefit Payment is made to you:






6. any outstanding Policy Debt, if applicable; and


The reduction in the Face Amount of the policy will reduce your Death Benefit in accordance with the terms of the policy. Exercise of this rider will not impact premiums on any other riders attached to the policy. Future values under the policy will be determined in a manner consistent with that under the original policy, as adjusted to reflect the above reductions. We will mail to you new policy Schedule Pages reflecting any adjusted values due to the Accelerated Death Benefit Payment made under this rider. Limitation on Payment

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If there is a surviving irrevocable beneficiary, we require the written consent of each such surviving irrevocable beneficiary and any assignee to your Claim for this Accelerated Death Benefit. No payment of an Accelerated Death Benefit under this rider will be made under any of the following conditions:

1. the Insured’s Terminal Illness is the result of a self- inflicted injury or attempted suicide, while sane or insane within two years from the Policy Date, or within two years from any reinstatement of the policy;

2. the payment is to satisfy the claims, demands, or obligations of any creditor, trustee in bankruptcy or governmental agency, or arising under any court order directed against you, to the extent that we have written notice thereof; and


A payment under this rider is considered made when sent from our Home Office or Main Administrative Office. Incontestability This rider shall be incontestable after it has been in force during the Insured's lifetime for two years from the Rider Issue Date except for fraud or any provision for reinstatement. In the case of reinstatement the incontestable period shall be two years from the effective date of such reinstatement. While insurance is contestable, we may either rescind the insurance or deny a Claim on the basis of:

1. a material misstatement in the application or supplemental application for the policy; or 2. a material misstatement in the reinstatement application if there has been a reinstatement of this

rider.


1. the date of any payment under this rider; or

2. the date of lapse or termination of the policy to which it is attached; or


4. the date of death of the Insured: or

5. when the total accelerated amount under all accelerated death benefit riders attached to the policy equals the Maximum Accelerated Death Benefit, or

6. the date Overloan Protection is exercised, if applicable. Termination of this rider will not prejudice the payment of benefits for a qualifying event that occurred while the rider was in force.


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[Secretary]

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chronic illness accelerated death benefit rider sample · a stock company chronic illness...

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