Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 1 of 25

Fi LED

STt,f.IE St!~LJl:~Ul
ClfiCUIT CUHi\

J/l.Cl"\su:~ C(,(1;.;' 1Y. /\ ~.

IN THE CIRCUIT COURT OF JACKSON COUNTY, AllKANSAS

(~ DIVISION
lUI~ FEB I 7 AM II: 36

HECOROE~1AINTIFF

D.T. ALLEN & CO., INC.

vs.

CASE NO.

CV 'dO 15-:JO

800:-l_PAGE

ALLIANZ LIFE INSURANCE

COMPANY OF NORTH AMERICA

---

DEFENDANT
COMPLAINT

COMES NOW, Plaintiff, D.T. Allen & Co., Inc., by and through its attorneys, Newland &
Associates, PLLC, and for its Complaint, states as follows:
PARTIES, JUIUSDICTION, AND VENUE
1.

D.T. Allen & Co., Inc. ("D.T. Allen" or the "Company") is an Arkansas corporation

with its principal place of business in Jackson County, Arkansas.

2.

Upon information and belief, Defendant Allianz Life Insurance Company of North

America ("Allianz") is an insurance company organized under the laws of the State of Minnesota
and authorized to do business in Arkansas.
3.

Jurisdiction and venue are appropriate in this Court pursuant to Ark. Code Ann.

16-13-201 and Ark. Code Ann. 23-79-204 and 16-55213, respectively.

FACTS
4.

On or about April 17, 1991, Allianz issued life insurance policy number xxx3871,

Insuring the life of Michael W. Allen, Sr. C'Mr. Allen") in the sum of$250,000.00 (the "Policy").
Mr. Allen was designated as the owner of the Policy. A copy of the Policy is attached hereto as
Exhibit "A" and incorporated herein.
5.

At the time of the Policy's issuance, Mr. Allen was part owner ofD.T. Allen.

6.

Since the Policy's issuance. D.T. Allen has pald all premiums on the Policy.

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 2 of 25

7.

On or about May 20, 2002, Mi. Allen transferred ownership of the Policy to D.T,

Allen and designated D.T. Allen as the sole beneficiary. A copy of the Service Request signed by
Mr. Allen is attached hereto as Exhibit "B" and incorporated herein.
8.

In approximately September 2007, Mr. Allen relinquished all of his ownership in

the Company. Thereafter, the Company continued to pay all premiums on the Policy.
9.

Michael Allen Sr. passed away on or about September 4, 2014.

10.

Pursuant to the Policy and Service Request, D.T. Allen is the owner and sole

beneficiary under the Policy and the only person able to make a rightful claim. See Exhibits A-B.
11.

Despite repeated demands, Allianz has refused to pay D.T. Allen any of the

proceeds of the Policy.

COUNT I:
BREACH OF CONTRACT
12.

Plaintiff realleges and incorporates the allegations contained in the .Il'eceding

paragraphs as if set forth word for word herein.

13.

D.T. Allen sues for breach of contract for all death benefit proceeds owed to it by

Allianz under the Pol Icy.

14.

Pursuant to the insurance contract, upon Mr. Allen's death, Allianz was required to

pay all insurance proceeds to the designated beneficiary'.

15,

The Policy identifies D.T. Allen as the beneficiary of all insurance benefits.

16.

Despite demand, Allianz has refused to pay the insurance benefits due to D. T. Allen

under the Policy based on the unsubstantiated claim of a non-party to the insurance contract.
17.

Allianz has breached its contract with D.T. Allen by refusing to pay the insurance

benefits due to D.T. Allen pursuant to the Policy.

------------------------~

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 3 of 25

''

18.

As a direct and proximate result of such breach, D..T. Allen is entitled to judgment

against Allianz in the arnoimt of Two Hundred Fifty Thousand Dollars ($250,000.00), plus twelve
percent (12%) damages and its reasonable attorney's fees pursuant to Ark. Code Ann. 23-79208.
19.

Alternatively, Plaintiff is entitled to recover its costs and attorney's fees pursuant

to Ark. Code Ann. 16-22-308 for breach of contract.

RESERVATION OF RIGHTS

20.

D.T. Allen specifically reserves the right to bring any additional causes of action

against the Defendants, or additional defendants, and to amend this Complaint as necessary.
21.

D.T. Allen r~uests a jury trial on all matters to which it is entitled.

WHEREFORE, Plaintiff, D.T. Allen & Co., Inc., respectfully requests that the Court grant
the above requested relief, for its costs and attorneys' fees, and for all other just and proper relief
to which it may be entitled.

Respectfully submitted,
D.T. ALLEN & CO., INC.

By and through:

NEWLAND & ASSOCIATES, PLLC

2228 Cottondale Lane, Suite 200
Little Rock, AR 72202
(501) 221-9393 telephone
(501) 221-7058 facsimile

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 4 of 25

Allianz Life Insurance Company

of North America
PO Box59060
Mlnneapolls, MN 55459-0060
800.950.1962

. . Allianz

September 22, 2014

D T ALLEN ANDCO INC

PO BOX459
NEWPORT AR 72112

RE: Policy number

aa11

Dear D.T. Allen and CO lnc:

Per your request, please find the enclosed duplicate policy.
You can access current policy Information by going to our secure website at www.alllanzjlfe.com. If this Is your
first visit to our website, cllck on 'register here' and _follow the Instructions to aeate your own account. Do you
have feedback about a product or our service? You can submit feedback by logging In to ~ur account and
dicking on 'Contact Us'.
Thank you for the opportunity to help you reach your financial goals. If you have any questions, feel tree to ciall us
at B00.950_.1962.
Polley Administration
Allianz Life Insurance Company of North America

.a-

EXHIBIT

LPA-1390

Rev 04/08/2011

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 5 of 25

Allianz Life Insurance Company

or North Amerfca

Allianz@

POPo~seoeo

MlnnoojlOll1, MN ll545D-OOOO
TelophGno: BDOIUl!IHi&72

June S, 2002

D.T. ALLBN AND CO. INC

POBOX459

NBWPORT,AR 72112

RE: Allianz Policy Number: .3871

Insured: Michael W. Allen Sr.
Dear Policy Owner:
We have received and recorded the request to change the ownership designation on the
above-mentioned contract(s), Ph~aso keep this acknowledgment with your policy.

Please review the changes to make sure they are as desired. We appreciate the opportunity to
provide service to you. 1f you have further questions, please do not hesitate to oall your
representative or me at 800-950-1962, extension 46247.
Sincerely,

Brooke: Wood
Polley Administration
Allianz Administrative Management

C:WYNTON C NORWOOD

office #:5670

.OUPlJCATE

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 6 of 25

ACKNOWLEDGEMENT FOR CHANGB

To be attached and made part of:

Policy#: lm3s11

Insured: Micheal W. Allen Sr.

The policy is hereby changed to read: all rights, title and interest in the policy are hereby
transferred and vested in:
Primacy Ownership:
D.T. ALLEN AND CO. INC
POBOX459

NEWPORT, AR 72112

Primary Beneficiary:
D.T. ALLEN AND CO. INC
POBOX459

NEWPORT, AA 72112
Contingent Beneficiary:
ESTATE OF INSURED

In evidence thereof, t'he Company has caused the Acknowledgement to be executed at its
Home Office and put into effect this 31st day of May, 2002.

Allianz Life Insurance Company ofNorth America

Minneapolis, Minnesota

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 7 of 25

Flexible Premium Adjustable Life Policy

Death Benefit payable to the Beneficiary upon death of the

Insured before age 95. Net Cash Value, if any, paid to the Owner
at the lnsured's age 95. Nonparticipating - No annual dividends.
Signed for the Company at its Home Office on the date of Issue.

Suzanne J. Pepin
Senior Vice President, Secretary,
and Chief Legal Officer

Charles Kavltsky
President

YOUR 20 DAY RIGHT TO EXAMINE YOUR POLICY

You may return your pollcywlthln 20 days after receiVlng lt lf dissatisfied for any reason.
You may return It to the agent or our Home Office. We will void the policy and mall a refund
of any premium you paid within 10 days of receipt.
This ls a legal contract between you and the Company.
READ YOUR POLICY CAREFULLY

LifeUSA Insurance Company

5701 Golden Hiiis Drive
Minneapolis, MN 55416-1297

"A Stock Company"

P1000

--"'~-

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 8 of 25

POLICY SCHBDULB
NOTB: TIIB MATURITY DA'fB ISTHJ,nOLICY ANNIVBRSARY FOLLOWINO THB INSURBD'S
95111 BIRTHDAY. COVERAGE MAY EXPIRE PRIOR. TO Tiffi MATURITY DATB IFNO
.PREMIUMS ARE PAID A[ITEll 'fHE INITIAL PREMIUM OR [(I SUBSEQUBNT PREMIUMS
ARE INSUFFICIENT TO CONTINUE COVBitOB l'O SUCH DATE. COVERAGE MAY
ALSO BE AFFECTED BY A 0-IANOB IN CURRENT VALUES. IF THB POLICY DOES
CONTINUE IN PORCE TO THE MATURITY DA TB, IT IS POSSIBLE THA'l' "rnBltE MAY
BE U1"l'LE OR NO CASH SURRENDER VALUE AT THAT TIME.
MONTHLYEXl'ENSE CB'.An.GES:
S?.SO l'ER POLICY PER MONTH, ALL POLICY YEARS
POLICY LOAN INTEREST RA1'E:
7.40% JN ADVANCll
CONSISTENT PREMIUM BASIS:
$1,212.00.

Tim GURANTEED INTEREST RATE USBD IN CALCULATING THB ACCUMULATION VALUB IS

0.32737% PER MONTH, COMPOUNDBD MONTHLY. THIS IS EQUIVALBNT TO 4.0% PER YEAR,
COMPOUNDED YBARLY.

DlJPL!CATE:
INSURED: MICHAE!ilV ALLEN SR
POLICY NUMBER: lm31171
AGE ANDS.EX: 43 MALE
INITIAL SPECIFIED AMOUNT1 $250,000
PREMIUM RATE CLASS: NON.SMOKER
DEATH BENEFIT OPTIONr A
POLICY DATE: APRIL 17, J991
JNITV..L PREMIUM: SIOl.00
MONTHLYANNIVERSARY DAY:l7
PLANNED PREMIUM: $101.00
MATURI'N DATE1APRIL17, 2043
PLANNED EXCESS;
PAYABLE: MONTHLY
OWNER AND BENEFICJAD.Y: AS NAMBD IN APPLICATION OR AS LATBR CHANOBD

......

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 9 of 25

(POLICY SCHEDULE
POLICY

CO~TINUED>

NU1r1b!::R: .:St:71

EFFECTIVE

SP!:'.CIFIED
OTHER COVERAGES:
NO

OTHE~

COVERAGES

. TERMINATION

DATE

DATE

~,lOONT

?RESe~T

SURR:NoeR CHARGES
THE FOLLOWING

SUR~e~DER

POLICY YEAil.

~6,5il0.00

11
13
15'+

A~Y

A~E

a~seo

ON THE END OF THE POLICY YEAR:

POLICY YEAR

4\JOUNT

s6,500,JO
$61500.00
S615DO.OO

1
3

THE

CHA~~es

2
4
6
8

$0,soo.oo
ss,zoo.oo
S21600.00
so.oo

10
12
14

SURRcNDc~ CHARGE WILL SE INCRE~SEO OU~ING THE

EXCESS I~TEREST CREDITED ouql~G THE 12 MO~THS

AMOUNT
S6,S00.00
~6,500.00

S6,5QQ,OO
S6,500.00

S6,soo.oo
53,900. 00
s1,:soo.oo

FIRST 15 YEARS SY
PRECEDING THE

SURRcNiHR.

3A

DUPllCf\TE

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 10 of 25

AMENDMENT ENDORSEMENT

This endorsement Is attached to the policy as of the Polley Date and amends the policy as follows:
PAYMENT OF THE DEATH BENEFIT (added):
Interest on Life Insurance Proceeds We will pay Interest on the proceeds of any
benefit paid. under this policy more than thirty days after the Insured'& death. We will
pay interest for the period after the date of the lnsured's death the the date the beneflt Is
paid. The interest rate wlll be equal to that being used for Settlement OpUon C, or
higher If required by law.
w

In all other respects the provisions, condlUons, exceptions and llmllatlons contained ln the policy remain
unchanged and apply to this endorsement

LifeUSAe Insurance Company

Suzanne J, Pepin
Senior Vice President, Secretary
and Chief Legal Officer

--- - .. ..
:-

PE1003

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 11 of 25

AMENDMENT ENDORSEMENT
This endorsement Is attached to the policy as of the Policy Date and amends the policy as.follows:
DEFINITIONS (added):
The Preferred Annuitlzatlon Amount la equal to the Accumulation Value on the Preferred
Annultizatlon Date plus four limes the sum of the excess Interest credited to the
Accumutatlon Value since the Polley Date.
The Preferred Annultlzatlon Date Is the later of the pollcy anniversary after your age 65
or 15 years from the Policy Date.
The Preferred Annultlzatlon Elecllon Period Is the period of time between the Preferred
Annulllzallon Date and the Preferred Annultlzation Expiration Date.
The Preferred Annultlzatlon Expiration Date ls the later of the policy anniversary after
your age 70 or 15 years from the Policy Date.
Excess Interest Is the monthly accrued Interest credited In excess of the monthly accrued
Interest credited at the guaranteed minimum Interest rate.
PAYMENT OF THE DEATH BENEFIT (added):
Option A: During the Preferred Annuitlzallon Electlon Period, the Death Benefit will be the
greater of the Speclfled Amount shown on the Policy Schedule or the Death BenefK Factor
times the Preferred AnnuiUzation Amount as of the date of the lnsured's death.
Option B: During the Preferred Annuitlzallon Election Period, the Death Benefit will be the
greater of the Specified Amount shown on the Policy Schedule plus the Accumulatlon
Value as of Iha date of the lnsured's death or the Death Benefit Factor times the Preferred
Annultlzation Amount es of the dale of the lnsurecl's death.

PE1034

. l>UPllCATE

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 12 of 25

CASH VALUE (added):

Prefer~ed Annultlzatlon Electlon During the Preferred Annuitizatlon Eleotlon Period, the
Preferred Annultlzatton Amount will be paid to you If you request II to be paid over your life,
your life with a period certain or under a joint end survivor option.

To qualify for the Preferred Annultlzatlon Amount the followlng condition must be met. At
the end of each five pollcy years beginning with the fifth and at the Preferred Annultlzatlon
Date, the cumulative total to date of any renewal premiums paid must equal or exceed the
number Of renewal years since Issue times the Planned Periodic Premium.
We will tell you on your Annual Report whether the quallncallon for the Preferred
Annulllzallon Amount has been met. You wlll have 60 days from the date of the Annual
Report to pay a premium large enough to meet the qualification.
Wewlll notify you at your last known address 60 days prior to the Preferred Annultlzatlon
Expiration Date that the Preferred Annultlzatlon Election Period wlll end.
SETTLEMENT PROVISIONS (Option A and Bare deleted and replaced with the
following):
OPTION A: Installments for a Guaranteed Period - We wltl pay equal ln&tallments for a
guaranteed period of one to thirty years. If installments are paid over a minlm1.111 of ten
years, the Death Benefit will be Increased by 10%. Each Installment wlll consist of part
benefH and part Interest. We wlll pay the Installments as requested ellher monthly,
quarterly, semi-annually or annually, See Table A.
OPTION B: Installments for Life with a Guaranteed Period - We wlll pay equal monthly
Installments as long as the payee ls living, blt we wlll not make payments for less than the
guaranteed perlod the payee chooses. The Death Benefit will be Increased 10% under this
Option. We wlll pay the lnsteUments monthly. See Table 8.
In all other respects the provisions, conditions, exceptions and lfmlle!lons contained In the policy remain
unchanged and apply lo this endorsement.

LifeUSAe Insurance Company

Vice President and Secretary

PE1034

--------

~-

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 13 of 25

LifeU- Insurance
Company
Bo'!5011bfl

APPLICATlON FOR LIFE INSURAN.

1

PART1

\lmnenpolJ~

OJesianr 11hrour , 2 1n1t io

llJISl..., 11 ll1M.,. Ill relalt 10

l"OllOllO IOllJ/ld lolldll l"d'vDUll pOllCy

Pwuud 11111111~ llflOll fUYe<iilt pDli<V

CJ Spoun o11n1\lfld ( f.,l'1r "'"" IJIPl>ld 1111

0 OIMI P,opasad ln11ttdl111spo1111 llllllr DP111 111$\Sad Rid~

NAME

1a NAME

-t11<'c~ue
t
flRST

2a SOCIALSECURITYNUMBER

B.1 1.50/ I _.S:a.3

nn CS()/ 1 Se>:.

4 SEX

___ ---- ------.

. -- -

Bostn.. ToCa"

DATE OF BIRTH

AGE

_'ft ..k I .fB ~

F1ml1

WEIGHT

s1 ZAP

l---

HEIGHT

Ci'r

---------

em Tno Tu Call --/--'-'._.m...._._ __

CJ

7aLJ."'"'c_____

____.A~J.tj,Jj.;

J{1019

-----I

01~ No Sir"'

3a RESIDENCE ADO RESS

lulcpl~ No

lAST

MIDDlf

FIRST

2 SOCIAL SECURITY NUMBER

\hnnr,ot a :;15.1511.11Jhll

7 PLACE OF BIRTH

-Fl -.In

<4a SEX
0 Malt

------l'l11ffl
WEIGHT

Sa HEIGHT
fl

DATE OF BIRTH

6a

_,

0 ,......

In

AGE

I -

7a PLACE OF BIRTH

----Lbs

Sa OCCUPATION ll"'ut"Y U.trul

LtlllQ 11 Uos occupil1r7 _

~.,

-aritrOl&i'P'a)w'
Ai!G'CU

9 ~~FACE AMOUNT OF PLAN APPLIED F~R ~so,..ooo

10 CLASS OF RISK APPLIED FOR
0 SMDK~~
JZ( NON SMOKER
!J

9a CLASS OF AISK APPLIEO FOR

0 HDllSMOKEll
0 SllOKfN

11 ADDITIONAL BENEFITS BY RIDER l'IGflOlllinarlil

CJ W.1ver of Monl'y 1Jt1111eoon' lillotlldt 11 roeers1
CJ WilJvtr ol Pl1notd Ptl'lllrll
Q AcOldonla DH'h 5 --

0
CJ
!J

rJ

PllEFEMED

PREFEllPEO

_ - - - - - - - - - Fltt ArrOLlll

01u!>i 11y lltOGl'lt 5 - - - - - - - - - - - Monthl1 l11:111r1

Ole ln1111~1u11 S _ _ _ -1llax Paw ~'1'4111111
\;Gil ol Lvg CLnnJ Collslml 1"1~1 lllax

1Oa ADDITIONAL BENEFITS

0 Clljdl""'Tt111''1-llt

f'lnly TlllT Rdl' _ __

CJ

Ol'81 IN1rld'8pMA'

U1>ll ($1 000 Pl' U.. '1

-

Un111s1 ODO pc

JFact AlMLlll-1-

11a CHILDREN TO BE COVERED UNDER FAMILY OR CHILDREN'S RIDER

S-o~ ad o' c"< .,.., ' ""'""' Ill l!*"l rtqlltll nc1011 ol llllG' ca11oof

12 DEATH BENEFIT OPTION 1c11oo"11t1e1

NAME

1 AtC1A11w111oq value

b ~i:u."111~1111111 Y;rl"' f'lrble 11111 Spoerl1ad Arioll"I

lnch>dto 111 Sp1d1ed 11ntun1

SEX

HEIGHT

WEIGHT

BIRTHOATE

CHILD

CHILO

13 PLANNED PERIODIC PREMIUMS

CJ Aarw11
CJ m1-.\Rlll'
0
is:'." Molll')I PAC CJ loll Bid GIWI llo
!J GO'll Allo
[J 8 171 ,..mun

CHILD

_,_/"'0..._/,u.OQ~;._.------

PlllOdlC PlOlllrT1

I-

INITIAL PREMIUM h plus b I

s_

4MDUll SUSYITIEO W1111 ~Pr

IEHO PLAH~ED PERIODIC PAYMENT ~OllCfl

$--------

YES

II V.S

DUPliCATE

CHILO

11-Jrt~)

1 MODAL PAEMIUJd AMOUNTS _

b ADDITIONAL P~EMIUM lil'loLr1 t' txms al pl>Aoed

Un,,

D ftoposd '""'!
0 App11n111 I Ovrnaf
0 01111'

_.t. .O"i.........o~o"--___

CHILD
I A11 il.'t11ny th\ldr1 111'a11 """'II' " "OI boltg CGHltc

CJ~

No

b ~ U-r11nr ch1\drc shown 1bo" Who no rol 'n "11" h 1pphcr1t

D Yet
[J No
IU 'YES , .... 11J111t 1'111111sar 1n "t.MAJIKS ... l9e"11 ~"'''

AGE

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 14 of 25

14 BENEFICIARY STATE FULL NAME AND RELATIONSHIP

Pnmary lnsUfpds Benej1c1ary

_Qjiut filth

fll/.:t_n

Con11'418nt Beneficiary

YES NO
19 FOREIGN TRAVEL. AVIATION ANO MILITARY
a Except lor vacation tnps doea 1ny person to bci

'51011~

-r

Other lnsured/Spouses's Beneficiary

Conlmgent Benehc1ary
BENEFICIARY FOR CHILDREN IS THE PRIMARY INSURED

15 OWN ER (11 other than the Person to be Insured)

CJ lnd1v1dual Full Name - - - - - - - - - 0 Corporation Soc Soc , Tax or Employer ID No
D Partnership A d d r e s s - - - - - - - - - - 0 Trustee
B11!mg Address (if d1fteron11 - - - - - - - - - -

16 OWNER OF POLICY ON A JUVENILE

a II the appllcanl 1dent11Jed 111 Quest1ons !8 on page 1 rs a1uvemlo,
complele lhe owner mlormahon below
Ralat1onsh1p to Proposed Insured (Child) - - - - - 11 other than paren I or gran~arent, 01ther aparent or guardian mus I
sign this appl1callon in addition to the Applicant

b Parents name
lnsinnce mforce
rather-------- - - - - - - Mother-------- - - - - - - c Stele the total amount of hlo insurance on each brother and sister of
the child
Name
Amount _ __
Name
Amount _ __
If more space required. answer 1n REMARKS

covered Inland to travel outside the US or Canada

within lhe next two years?
0
b Does any petson to be covered intend to lly other than
as 1 passenger or has he or she flown olher thin as a
0
passenger dunno the post two years?
If "Yes' complete Avratton Ouesllonna1re
c Is any parson to be covered amember or does he or she
intend to become a member of the anned rorces
D
rnclud1ng reserves?
If Yes", give details in REMARKS

'

P.Y"
~

YES NO
20 AVOCATION AND SPORTS
Does any person to be covered part1c1pate 1n rocreatronal
acllv1t1es mvolving
a Aeronautics (including hang gliding, ultra kght. soaring,
0
sky d1vma. ballooning)?
Equipment
Frequency
Future part1cipa11on
Looa11on/area
b Powered racing or compet111ve vehicles (1nclud1ng
Cl ~
motorcycles, au1omob1les and motor boats)?
Racmg ctass1f1cation
Type of vehicle
Average
Maximum
Speeds attained
"fype ol track
I Races amually
c Recreational vehicles ovar open terrain. trails,
sand, snow or ice (including snowmobiles, dirt
0
b1kea and dune buggtes)?
Where usod?
Type of vehicle
Compet1bve tac1ng?
Frequency
II yes, specify engine sae
d Skin or SCtJba d1v1ng, mountain clmbmg, rodeos,
D fY
compebtl\le sk11ng?
Locat1onfare11
Frequency
Frequency
DIVING - Typa ol equipment
Maximum and average depths

cir,/

pr

17 COMPLETE IF APPLYING AS A NONSMOKER

YES
a Has any person to be insured smoked cigarettes in the
past year?
O
Name(s) - - - - - - - - - - b Is tobacco other than c1g1rettes used by any person to
be covered?
0
Name(s) - - - - - - - - - Type/lrequency - - - - - - - - - -

NO

p....-

2.1 OTHER INSURANCE

YES NO
a Has any company dllchnod to issue, romstate. or
renew. rated, mod111ed, postponed or canceled any hie
a
or health insurance on any person to be covered?
b Wiii insurance. mcludmo annuities, 1n any c;ompany be
discontinued or changed If the insurance applied for 1s
issued?
c Is any apphcauon for life or health insurance on any
person 10 be oovered pending in any other company? a

ool

18 DRIVINB RECORD

_ _ ,.
22 LIFE INSURANCE IN FORCE WITH ALL COMPANIES
a What is your drivers license no ~
Proposed lnsurod
Stale
rJ../S.._ _ __
ADB
l..Jle
Dis Income
Within the pas I three years, has any pe1$on to be covered been
~39()
L,
oo?>feu.1H---convicted or pleaded gu11ly to
YES MO
I
Other lnsUfed(s)
b Three or mora moving v1olat1ons an\\/ or accidents?
o 0""
c Onvmg under the Influence ol alcohol and/or drugs? Cl ~
Name

Oela1ls (give dates, type of v1olat1on) ----~--

loopuifE.

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 15 of 25

-- ----- .
'

____ _

i~C~~PlETE WITH RESPECT TO ALL PE-NS TO BE COVERED, AS SHOWN BELOW

.' ...

NAM!; ANO ADDRESS OF YOUR FAMILY PHYSICIAN

De, Paul Her~eY1'1 (Oeb. /fJQC/q/h

st.

AJgup!t A&

COMPLETE OUESTIDllS Sl CAREFULLY, GIVE DETAILS OF ALL "YES" ANSWERS, lllCLUDIND llAME Of PEllSllH AFFECTED. All DATES. lllAONOSES,
OU RATIONS, OUTCOME AND THE llAME3 AND ADDNESSU OF ALL HOSPITALS AND ATTEHDlllB PHY&ICIAKS If ADDITIONAL SPACE REQUIRED, MTACH SHEET
Of PAPEll. SIONEO. MTED AHO WITNESSED
3 IS ANY PERSON TO BE COVERED PRESENTLY TAKING MEDICATION?
4 WITHIN THE PAST FIVE YEARS HAS ANY PERSON TO BE COVERED
a Consulted, been exa1111ned or been treated by any phys1c1an or pracl11toner?
b Had an xray. ileclrocatd1ogram or any laboratory test or 'tudy?
c Had observation or treatment al a cl1mc. hospital or sanitarium?
d Had or bean advised \o have a surgical operation?

e Had d1wness, shortness of breath. pain or pressuf"! m the chest?

f Had any in1ury requiring treatment?
5 TO THE BES TOF YOUR ICNOWLEl>GE. HAS ANY PERSON TO BE COVERED HAD
OR BEEN TOLD HE OR SHE HAD\I
a Epilepsy. fainting spells. nervous or mental condll1on, neuritis. paralysis, or any
d1smo or abnorrnahty of the brain or nervous ayatem'
b Heart allack, murmur, palp1lat10n. or tugh blood pressure. anam1a, vancose
vems. or any disease or alJlormahlY of the heart. blood or blood vessels II
c l\Jben:utosis, asthm1, pleurlb)', or any disease or abnormality ol th11 lungs,
bronchial tubes, throat or respiratory system?
Ulcer. ind1gest1on, coht1s, gall stone, hem111. or any disease orabncrmahty of the
stomacn. intestines, rectum, gall bladder or l1ver11
e Urinary 111Jgar, albumin or stone, syphilis, menslrual d1sorller, or disease or
abnormality ol the breas\s, kidneys. prostate, unnary or genital systems?
D1ab&tes. gout. or any dlS1Jas11 or abnonnahty ol Iha thyroid or other glands?
Arthritis, rheumalic fever. back trouble, or any disease or abnormality of the
1omts, muscle& or bonas?
h Any disease or abnormality of the eyus, ears or skm?
1 Cancer or tumor?
1 Any physical deformity or defect?
k AAY immune def1c1llllcy disorders, Acquired Immune Oef1c1ency Syndrome
(AIDS), or AIDS Related Complex (ARC), or test retults md1ca1ng eicposura
to the AIDS virus?
6 WITHIN THE PAST TEN YEARS, HAS ANY PERSON TO BE COVERED REGULA
a Amphotam1nes. barbiturates orsedauves, except as p11scnbed by aphysician?
b Cocaine, heroin, morphin1, LSD, mar11uana. PCP, oranyotherhalluc1nogenicor
narcotic d1Jg '>
7 a Have any close relative& of any person to be ooverad aver had cancer, diabetes,
heart disease, or a nervous or mental abnormahty\I
Has eny person to be covered everroceiv11d treatment or 101ned an organization
for alcoholism or dru11 addlc11on?
G Is any person to be covered now pregnant"
REMARKS

HOME OFFICE CHANGES IN THIS APPLICATION.

0.utd1}.

.I

DUPL~CATE

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 16 of 25

'

'

PART II OF
PROPOSED
INSURED:

'l~I

LifeU Insur~ce Company

''~.

application for Insurance to

,
(\\\f. t=?
\'f\, t_1.a e ~

First Name

ln1t1al

Bo" 69000

\ll1111cupol1~.

Date of
Birth

~Male

~L

{a

Day

Last Name

\fmnesot1t 5'54590000

ff Female

ear

a Name end address of your personal phys1c1an? _ ___;~b.\oc.

b Date and reason last co~sufled?

~ q0

d What med1ca11ons are YoU presenU taking?

2 WITHIN THE PAST FIVE YEARS HAVE YOU
a Con1:1ultecl. been examined or been treated by any phys1e1en or?
b Had an X-ray, EKG or anyJab9aloJ:I or study?
c Had obsarvahon or treatment at a clinic, hospital or san1tanum?
d Had or been advised lo have a surgical operation?
a Had dizziness, shortness of breath, pain or pre&sure in Iha chest?
3 HAVE YOU EVER BEEN TOLD YOU HAD
a Epilepsy, fainting spells, nervous or mental cond1!1on, paralysis. or
any disease or abnormality of the brain or nervous system?
b Heart attack. murmur,~. anemia, or any disease
or abnormality of the heart, blood or blood vessels?
c Tuberculosis, asthma. pleurisy, or any d1Bease or abnormality al the
lungs. or respiratory eystam?
.
d Ulcer, 1nd1gest1on, colrtis.hern1a or any disease or abnormality of the
stomach, mtestrnea, rectum, gall bladder or fiver?
e Urinary sugar, albumin or stone, syphll1a. or disease or abnormahty
of the breasts. kidneys, prostate. urinary or genital systems?
Diabetes. gout, or any disease or abnormality of the thyroid or
other glands?
g Arthnha, rheumatic fever, back trouble, or any disease or ebnormeltty
of the Joints. muscles or bones?
h Any disease or abnormality of the~aars or skin?
1 Cancer or tumor?
J Any physical deformity or delect?
k An immune de!1c1ency disorder, Acquired Immune oer1c1ency
Syndrome (AIDS), Aids Releled Complex (ARC), or test results
1nd1oating exposure to the AIDS virus?
4 a W1th1 ii the past ten yea rs. have you used amphetamines, barbiturates,
cocaine. heroin. morphine. LSD. manruana, PCP, or any other
hallucmogen1c or narcot10 drug?
b Have you ever received treatment or rorned an organizabon for
alcoholism or drug addiction?
c Has your weight changed more than 15 pounds m the past year?
5 Family History Diabetes, ~ high blood pressure, heart or
kidney disease. nervous or mental rffneas or su1c1de?
If Living
Age at
If Deceased
Stale of Health
Death
Cause of Death
Father
Mother
Brothers
& Sisters

-0 ...

I DECLARE that, to the best of my knowledge and belief. the statements end answers m Part II of this Appltcatronare lull,
complete, and true These statements and answers are to be tons1dered as the basis for any insuranc& wrttten hereon
J AUTHORIZE any licensed phys1c1an, medical prectt11oner. hospital, oltmc or other medical or medically related fac1lrty
insurance company. the Medical lnlormal1on Bureau or other organ1zalion. 1nst1tullon or person. that has any reoorda or
knowledge of me or my health, to give to the Company .any such information This authonzabon 11 good for SO months from the
apphca1lon date

To fac1htate rapid aubm1ss1on of such mformat1on. I authorize all said sources. except the Medical lnform.allon Bureau, lo
give such records or knowledge to ~ny egenoy employed by the insurance company lo collect and transmit such mformatton
A photographic copy of this authorization shall be es vahd as the ortg1nal

: ... :
..

~ed_at (C1ly&St~) ~j}A)s <'f\tl._o..~,.,)

s::s\,~;i'ks
Signature of Witness
hJR .. M'r

D ?"ltQ

l\)q..s~!Q,,
1

')~\le;)

Signature of PROPOSED INSURED

..

. On

.-/'-~ ... ,....

. ._

"

' '";

...

1~-2!:_

:.:.

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 17 of 25

. lllelJSA

("the Co(11plnt}

3fJ?/- ~ :...

= . . . . -.
~

,.,._.

I-Rf PRESENT thal the statements and answers given 111 !hrs Apphcatron are lrve complete, and correctly recorded to the bes I of 1ny (our) knowledge and
bel1el
I AGREE Iha! ( 1) This Appl1cation shall consrst of Par! I and Parl II (11 apphcable) and shalt be the basrs lor any poltcy issued on this Application (2.)
Except as otherwise provided 111 the cond1t1onal receipt, 11 issued any policy issued on this Apphcat1on shall not lake e1f1ct unless all ol the follo1Vmg
cond1t1011s aro met (a) The ltrst run pramnrn is paid, (b) Tho policy 1s delivered lo tho ownor dunno tna hlohme of the person(s) to be cover11d by such
policy, and (c) AU ol tho stalements and answers given in thtS Appl1cahon to the host ol my (our) knowledge and belier conhnue Io be lrueand complete as
or the date of delivery ol lho policy. (3) No agont or medical exernmermaywa1ve or alter aprovision ol any pohty and no waiver ormod1l1cat1on ol any
po hey issued on lh1a Apphcahon shall be binding upon lhe Comp11ny unless tn wn11ng and signed by lhe Presiden\ ora Vice Pres 1denl and lhe Sucretaiy or
an Ass1stanl Secretary (4J Tlla Company may md1catechanges mIha SPlJCC for Home OH1ce Changes mtho Application foradmuwstrallve purposes only
f\rrt o1her changes rn this Appl1cauon shall be sub1ec1 to wntten consent by the owner
I AUTHORIZE any phys1c1an modrcal pract1t1oner hospital cllnrc, medically rel ate~ lacilrty. mstranoe compuny, the Medical lnforrnat1on Bureau (MIBI
or other oruamzahon uuhtutmn orpnrson that has any mlormatlon in 111 records on me or my children to give the Company us legal represenlal1vos and
its re1nsurers any such information 10 use (or underwntrno rnsurance and for delerm1nmg eltgibll11y lorbenaflls The Company may release mf 0<mat1on
obtained lo Ml 8 remsunng compa1m, oUi~r porsons or organizat1 ans performing bus1nau or legal sorvrces in conncot1on with my appl1ca11on or claim
Tho company may ruleasa 1nfonnahon as required by law. or as I may authorize

r UNDERSTAND AND AGREE to lflo fallow mg (a) This aulhonzatron 1s vehd for two and one hall year1 lfom this application date, (b) aphotocopy rs as
valid as tho ong1nal and 1c) a copy rs available to the Person to be Insured on request
I ACKNOWLEDGE recBlpl or the Notice ol Insurance lnlorrnalton Practices W11l insuranco mctudmg amu1t1111 m;my other compan'y be dlsconllnuod or
changod 1l th11 insurance applred lor IS 1s,,ued?

fl"No Name ol company replaced - - - - - - - - - Signed at _p}_etJJ.IM11,,A.._t2-_ ___._ _

, O YES

I-

1991
Year

(City and Statf)

Owner (II other than Insured)

_________ ___________
.

Spousa/Other Insured Signature

___

Child Age 15 and OIClor

_,,,,__
_...._._~----

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 18 of 25

,.

'

DEFINITIONS

We, our, us or The Company means LlfeUSA Insurance

Company.

A Polley Loan Is the Indebtedness to us for a loan secured

by this policy.

You and your means the owner of this policy named In the
application, unless later changed. The owner may be other
than the peraon(s) Insured. The owner Is solely entitled to
exercise all policy rights.

The Maturity Date Is the policy anniversary followlng the

lnsured's 95th birthday.

Insured means the person or persons whose life is Insured

lft'lderthls Policy.
Accumulation Value is the policy's total value.
describoo In the AccumulaUon Values section.

The Maximum Loan Value Is the IEM"gest amount you may

borrow under the loan provision.

The Net Cash Value Is the Cash Value less any remaining
loan balance.

It Is

Age means the lnsured's age on the last birthday.

The Beneficiary Is the person or entity to whom we will pay
the Death Benefit if the Insured dies.
Cash Value means the Accumulation Value less any
surrender penalty,
Lapse means termination of the pollcy due lo Insufficient
premium payment as described in the Grace Period section.

The Net Premium Is 100% of any premium you pay.

Reinstate means to restore coverage after the policy has
lapsed.
A Rider Is en attachment to the policy that provides an
additional benefit.
The Polley Date Is shown In the Policy Schedule and
detennlnes the monthly anniversary day, policy
anniversaries, end policy years. Insurance Is effective as
shONll on the Application.

GUIDE TO POLICY PROVISIONS

Accumulation Values .................................................. 6

Ownership Definition ..................................................2

Application ................................................................ 10

Payment of Cash Values and Loans........................... 7

Beneficiary's Rights ................................................... .4

Payment of Death Benefit... ........................................ 4

Cash Value .................................................................7

Polley Changes .......................................................... 6

Change of Beneficiary ................................................4

Polley Loans ............................................................... 7

Consistent Premium Payment Provislon ..................... 5

Polley Schedule .......................................................... 3

Death Benefit .............................................................4

Premlums ...................................................................5

Definitions .................................................................. 2

Reinstatement of Lapsed Policy ................................. 5

General Provlslons ................................................... 10

Settlement Provisions ................................................. B

Guaranteed Values ....................................................6

Surrender Option ........................................................ 7

Grace Period ..............................................................5

Table of Guaranteed Mortallty Rates ........................ 11

Misstatement of Age .................................................10

Table of Surrender Charges .................................... 3A

---

...

OUPL\Ct~fE

- --------------------------------------------'

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 19 of 25

THE BENEFICIARY
Who Receives the Death Benefit We will pay the Death
Benefit to the Beneficiary when the Insured dies. The
Beneficiary Is the person or entity named In the application
unless changed,

named beneficiaries has ended when the Insured dies, we

will pay the Death Benefit to you. If you are not living at the
time, we will ray the Death Benefit to the executor or
a<inlnlstrator o your estate.

Protection of the Death Benefit To the extent permitted

by law, the Death Benefit will not be subject to the claims of
!tie Beneficiary's creditors.

How to Chanpe a Beneficiary You may change the

named Beneficiary by sending a sallsfactoiy written notice
to us. The change will not be effective until we record II at
our Homa Office. Even ff the Insured is not living when we
record the change, the change wlll tal<e effect as of the date
signed. Any benefits we pay before we record the change
will not be affected. An irrevocable Beneficiary must give
written consent before we will change th et Beneficiary.

If the Beneficiary Dies ~If any Beneficiary dies before the

Insured, that Beneflclarv's Interest In the Death Benefit will
end. If any Beneficiary dies et the same time as the Insured,
or within 30 days after the Insured that Beneficiary's
Interest In the Death Benefit will end. If the Interest of all

PAYMENT OF THE DEATH BENEFIT

Proof of Death We will pay any benefit P.ayable at death
when we receive due proof Of the Insureds Cleath. Wa wlil
send appropriate forms to the Beneficiary upon request.
Any of our agents will help the Beneficiary fill out the forms
without charge. We will send all payments from our Home
Office.
Death Benefit The Death Benefit may be affected by the
Polley Loan or Misstatement of Age or Sex provisions.
Death Benefit Option The Death Benefit Is based on your
choice of Option A or Option B as shown in the Policy
Schedule.
Option A: The Death Benefit will be the greater d the
Specified Amount shown on the Polley Schedule or the

Death Benefit Factor times the AccumulaUon Value as of

the Date of the lnsured's death.

Option B: The Death Benefit will be the greater of the

Specified Amount shown on the Policy Schedule plus the
Accumulation Value as of the date of ttie lnsured's death or
the Death Benefit Factor times the Accumulation Value as
of the date of the lnsured's death.
In no event wlll the Death Benefit be less than the amount
needed to continue to qualify the policy as a life Insurance
contract under section 7702 of the Internal Revenue Code.
We wlll reduce the Death Benefit by any Polley Loans and
by the grace period premium necessary to provide
Insurance to the date of ttie lnsured'sdealh.

.1
DEATH BENEFIT FACTORS
ln1u1ed's
Attained AQ

DH th
Benefit Fa~tor

Insured'
Attained Ag

Death
Benefit Factor

Attained Ape

Ileath
81n1nt Factor

<!Oand below

2.60
2.43
2.36
2.29
2.22

60
61
62
63
64

1.30

80

1.05

41
42
43
44
46
46
47
48
49

2.16
2.09
2.03
1.97
1.91

66

50
61

Insured'

1.2~

61

1.26
1.24
1.22

B2
83
84
85
66
87
BB
89

1.06
1.06

69

1.20
1.19
1.1B
1.17
1.16

70
71
72
73
74

1.15
1.13
1.11
1.09
1.07

90
91
92
93
94

1.05

53
54

1.86
1.78
1.71
1.64
1.67

66
66
57
68
59

1.50
1.'46
1.42
1.30
1.34

76

1.05
1.05
1.06
1.05
1.05

52

66
67
66

76
78
7B
79

i(

1.05
1.05
1.06

1.05

1.05
1.05
1.05

DUPL1CATf

1.04
1.03
1.02
1.01

iI

.~ . .~-i-1

------- - ------ -- - - - ----------

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 20 of 25

PREMIUMS
Subject to the Preml1111 Limlta!lon provision and the
followlng condltlons, we wlll accept any payment you send
to us while this policy ls In force.
1. You may pay the first premium to our authorized
representative. You may send subsequent premiums
to our Home Office oryou may pay them to an agent or
cashier we authorize. We will give you a receipt If you
ask for one.
2. You may pay premiums at any time, but only If each

premium Is at least $25. Premiums paid by payroll

deduction are accepted.
3. To quallfy for the Consistent Premium Payment Pro-

vision, you must submit the Consistent Premium

Payment Basis stated In the Polley Schedule. You
must abide strictly by the conditions In the Consistent
Premium Payment Provision section.
Premium Limitation Any premium received di.ling a
policy year which Is more than three tlmes the total of the
Monthly Deductlons for the last year may be refunded. We
may also refund any unscheduled premlums that exceed
$25,000 In any twelve month period.
We will not refund any amouri lf doing so would cause your
policy to lapse before the next monthly anniversary day,

At least 30 days prior to termination, we will give you written

nollce at your laet known address that the grace period has
begun. You must then pay a premium large enough to keep
the policy In force. If you do not pay enough premium, your
policy will lapse.
We will subtract the premium necessary to provide coverage to the date of death If the Insured dies during the grace
period.
Reinstatement of Lapsed Polley Unless this policy was
surrendered, it may be reinstated after lapse. To reinstate
the policy, you must meet the following conditions.
w

1. You must request reinstatement In writing within three

years from the date of lapse and before the lnsured's
age 95.

2. The Insured must still be Insurable by our standards.

3. If any loans existed when the policy lapsed, you must

repay or reinstate them together wt th interest 'Milch

had accrued to the dale of lapse,

4. You must pay a premium large enough to cover the

two Monthly Deductions due when the policy lapsed
and three Monthly Deductions due when the poftcy le
reinstated.

We will apply any refund first toward reduction of any

outstanding loan If you give us wrllten Instructions lo apply
the refund In this manner.

The Accumulation Value of the reinstated policy will be any

loan repaid, plus 100% of any premium you pay at
reinstatement, minus the Monthly Deductions due at the
time of lapse.

We wlll remove the excess premium at the end of any policy

year If !he premiums paid exceed the amount allowable for
the Death Benefit to qualify for federal income tax exclusion.
Interest wlll be paid on the amount removed to the end of
that policy year. We will refund this excess amount
(Including Interest) within 60 days after the end of that policy
year.

Consistent Premium Payment Provision The Consistent

Premium Payment Provision Is an Increase to the
Accumulallon Value of 30% of the Consistent Premium
Payment Basis on each poBcy anniversary from the
eleventh through the twentieth.

Continuation of Insurance Subject to the Grace Period

provision, your policy will continue between premium
payments at the same face amount plus additional benefits
pro\'ided by Rider, Refer to the Monthly Deduction section
for further explanation.
Grace Period A grace period Is a period of 61 days after
which either of the following has occurred:
1. The Accumulation Value minus any loan is less than
the Monthly Deduction due.

These Increases wl!I be credited to your Accumulallon

Value if the following condition Is met:
1. Al the e!ld of each of the policy years beginning with lhe
eleventh and ending with the twentieth, the cumulallve
total to date of any renewal premiums paid must equal
or exceed the number of renewal years since Issue
times the Consistent Premium Payment Basis on the
Policy Schedule.
These Increases will terminate when the policy terminates.

2. On a monthly anniversary date there Is Insufficient Net

Cash Value to cover tile next Monthly Deductron and
the sum of the premllm paid lo date ts less than onelwelrth of the Planned Periodic Premium on an annual
basis limes the n1111ber of months since Issue.

DUPLICATE

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 21 of 25

POLICY CHANGES

Changes In Specified Amount Subject to the following

conditions, you may request a change In the lnsured's
Specified Amount after the first policy anniversary.
1. Specified Amount Decreases
Any decrease will become effective on the monthly
anniversary day that falls on or next foUows receipt of
request. Any such decrease will reduce Insurance In
the following order:
(a) Insurance provided by the most recent inaease;
(b) the next most recent inaeases successively; and
(c) Insurance provided under the original application.

No Increase Is allowed unless the Net Cash Value Is

sufficient to cover the next Monthly Deduction.
Change In Death Benefit Option You may request a
chqe In the death benefit option In effect after the first
policy anniversary. The request must be In a written form
acceptable to us. Subject to the following, !he effective date
of the change wlll be the monthly anniversary day that fells
on or next follows the date we receive your requesl
1. If the change Is from Option A to Option 8, the Specified
Amount after such change shall be equal to the
lnsured's Specified Amount before sueh change less the
Accumulation Value on the date of change.

2. Specffled Amount Increases

Any request for an Increase must be applied for on a
supplemental appllcatfon. such increase sh.all be
subject lo evidence of insurabllity satisfactory to us.

2. If the change la from Option 8 to Option A, the lnsured's

Spedfied Amount after such change shall be equ~ to
the lnsured's Death Benefit before such change.

GUARANTEED VALUES
Accumulation Values The Accumulation Value on any
specified date ls equal to:
1. The Accumula6on Value on the last monthly
an nlversary day plus accrued Interest from that
date to the specified date.
plus 2. All net premiums paid since the last monthly
anniversary day plus accrued interest from the
date of receipt to the specified date Iese any
refunds since the last monthly anniversary day.
minus 3- Any partial surrenders since the last monthly
anniversary day.
At the end of each policy month, the Monthly Deduction wRI
be subtracted from the Accumulatlon Value.
Interest Rates The guaranteed minimum Interest rate for
all polk::y years Is 4%.
We may declare a higher lnlerest rate than the guaranteed
minimum rate at any time. We may change this higher rate
at our option. We will never declare a rate lower than the
guaranteed minimum Interest rate.
We will pay Interest on any part of the Accumulatlon Value
securing a Polley Loan. The excess rate may be lower than
the rate credited to the unborrowed portion of the
Accumulatlon Value.

Monthly Mortality Charge - We will determine the Monthly

Mortality Cost Charge for each policy year at the beginning
of that year. We will use the lnsured's age as of that policy
year.
A Table of Guaranteed Maximum Monthly Mortality Cost
Charges Is shown on page 11. We may use rates lower
than these monthly deduction rates. We will never use
higher rates.
A reduction In the guaranteed Monthly Mortality Cost
Charges for this policy will also apply to all other policies
Issued on the same plan and to the same class of Insured.
The reduced rate will not be affected by any change In the
lnsured's health or occupation.
Monthly Deduction We will take the Monthly Deduction
for the prior month from the Accumulation Value at the end
of that policy month.
The Monthly Deduction is equal to

{a) the Monthly Mortallty Cost Charge times

difference between the Death Benefit and
Accumulation Value at the beglMing of
month,
plus (b) the Monthly Deduction for any Riders,
plus (c) the monthly expense charge as shown In
Polley Schedule.

,~DUPL~CATE

-- ...

the
the
the
the

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 22 of 25

BASIS OF COMPUTATION

The Cash Values of the policy will not be less than the
minimum values required by the Stale where the pafcy Is
dellvered. Tue gunnteed Monthly Deduclicn rates and the
guaranteed Interest rate are the basis fa the Cash Values.
Calcufetfon a minimum Cash Value and ncnforfelture
benefits Is based en the Commissioners 1980 Standard

Ordinary Smoker/Nonsmdcer Ultlmale Mortality Tables for

males and females, age last birthday and 4% Interest
Death Is assumed lo occur at the end of the poUcy year.
We have flied the method we used to compute minimum
Cash Values and nonforfeiture benefits with the Supervisory
Official a the Shte of policy delivery.

SETILEMENT PROVISIONS
When the Insured dies, we will pay the Death Benefit In a
lump sum unless you or the Beneficiary choose a
settlement option. You may choose a settlement option
while the Insured Is llvlng. The Benellclary may choose a
settlement option after the Insured has died.
You may also choose one of these opllons as a method d
receiving the surrender or maturity proceeds if any ll'e
available under this policy. if the BeneHciary Is no! an
Individual, Home Office approval ts required.
When we receive a satisfactory wrlllen reques~ we will
apply the benefit according to one of these options:
OPTION A: Installments for a Guaranteed Period We
wfll i:>ay equal Installments for a guaranteed period of one
to thirty years. Each Installment will consist of part benefit
and part Interest. We win pay the Installments as
requested either monthly, quarterly, semi-annually or
ainually. See Table A.
OPTION B: Installments for Life with a Guaranteed
Period We will pay equal monthly installments as long
as the payee Is living, but we Will not make payments for
less than the guaranteed period the payee chooses. The
guaranteed period may be either ten or twenty years. We
will pay the Installments monthly. See Table B.
OPTION C: Benefit Deposited with Interest We wlll
hold the benefit on deposll. It will earn Interest at such
Interest rates as we declare, but not less than 4%
annually. We will pay the earned interest as requested
either monthly, quarterly, semi-annually or annually. The
payee may withdraw part or all of the benefit and earned
Interest at any time.
.

OPTION D: Installments of a Selected Amount. We will

pay Installments of a selected amount untll we have paid
the entire benefit and accumulated Interest.
OPTION E: Annuity - We wlll use the benefit as a single
premium to buy an annuity. The annuity may be payable
to one or two payees. It may be payable as requested for
life with or wltliout a guaranteed period. The annully
payment wlll not be less than our current amulty contracts
are then paying.
The payee may arrange af1Y other method of settlement
as long as we agree to It. The payee must be an Individual
receiving payment In his or her own right. There must be
at least $1,000 avallable for an optlon and each
installment to each payee must be Et least $26. If the
benefit ls not enough to meet these requirements, we will
pay the benefit In a lump sum.
We will pay the ftrst lnstaHment under any option as of the
date of death, maturity, or surrender. Any unpaid balance
we hold under Option A, 8 or D will earn Interest at the
rate we are 1>aying at the time of the settle1mr1l We wlll
not pay less than 4% annual Interest.
If the payee does not live to receive all guaranteed
payments under Oi:>tlon A, B, D or E or any amount
deposited under Option C, plus any accumulated interest,
we will pay the remaining benefit to the payee's estate.
The payee may name and change a successor payee for
any amount we would otherwise pay the payee's estate.

. DUPl~CATE

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 23 of 25

TABLE A
INSTALLMENTS FOR EACH $1000 PAYABLE UNDER OPTION A
GuaranlH
Porlod

Monthly
1n1lallm1nt1

Gueranloa
Period

Monthly
lntallm111t1

Guarantee
Period

Monlhly
lnmlallm1nla

1
2
3
4
5

$84.84
<13.25
29,.tlO
22.47
18.32

11
12
13
14
15

$1.31
8.17
7,72
7.34

21
22
23
24
21i

$11.111
5.84
11.49
1.36
11.22

16.611
13.&9
12.12
10.97
10.os

11
17
18
19
20

7,00
1.71
8.44
6.21
11.00

28
27
28
29
30

6,10
IS.DO
4.90
4.80
4,12

7
8

9
10
M~tiply

8,69

Monthly Installment by 11.78696 for Annual, by 5.95127 for Semi-Annual, or by 2.99022 for Quarterly lnslallments.

TABLE 8
MONTHLY INSTALLMENTS FOR EACH $1000 PAYABLE UNDER OPTION B
Mal Payee
Guarntee Period
jO Year.
20 )'.ears

M11leP1y11
Period

F1m1le P1ye1
Guarant1e Period

GUll'HIH

F1mal1 PaylO
Guaranlff Pt11od

10 Year1

20 Years

Ag1

jOY11r1

20'.J'.H[!

10 Yl!lll

2Q)'.H!!

2.83

2.83

2.84
2.88
2.117

2.14

61
62
63
54

4.4.4
4.63

4.10
4.17

65

4.11

4.'21
4.32
U9
4.46
4.12

4.33
4.42

4.02
4.011
4.14
4.21
4.21

&6
67
li8
68
80

4.92
6.03
1.11
6.'0
11.40

4.69
......
4.73

us

2.91
2.93
2.94
2,88

4.61
4.11
4.71
4.82
4.84

4.as
4.42
4.60
U7
4.115

2.811
2.99
3.01
3,03
3,Dli

51
82
83
84
llli

6.113

04
a.OD
11.07
li.13
6.111

a.01
li.11

4.72

a.1e

2.98
3.00
3.02
3.04
3.06

:J.20
3.22
3.28
3.211
3.31

3.18

3.08

3,07

3.21

3.10

3.24
3.27
3.30

3.16

3.10
3.12
3.14
3.17

86
67
68
69
70

31
32
33
34
36

3.34

3.33

3.20

3.36

3.19
3.22

71
72

'3.26

7S
74
75

38

Asl!
11

2.90
2.91
2.93
2.94
2.98

2.88
2.91
:z.92
2.94
2.98

15
17
18
19
20

2,98
S.00
S.01
3.03

2.97
2.99
3.01
3.03

21
23
24

3.011
3.10
3.12
3.14

26

3.17

26

12

13
14
15

22

27
21
29
30

3.05

ua

a.oa

3,07

3.09
3.11
3.14

2.88

2.90
2.91
2,93

2.96

3.12
3.17

2.8&
2.117
2.18

2.10

3.41

3.38

3.23
3.26

3.45
3.411

3.43
3,441

3.29
3.32

3.28

3.63
3.67
3.82
3.67
3.72

3.50
3.&4
3.68

3.35

3.39

3.34
3.17

3.42
3.48
3.50

3.41
3.44
3.48

3.71
3.7&
3.81
3,88
3.81

3.64

46

3.77
3.12
3.88
3.14
4.00

3.li2
3.66
3.10
3,1!
U8

46

4.0'1

3.97

3.78

1.7

4.14
4.21

4.02

3.84

4.08
4.14
"20

3.90
3.98
4.03

37
38
39
40
41
42
43

44

48

411
60

4.28

01

U2
3.67

U9
3.113
3.88
3.73

3.31

76
77
71

79
80
111
112
83
84
115

U2

4.71

S.88
5.83

li.98
11.1&
8.32

uo
a.sa
6.118
T.07

1.21
7.411
7.611
7,118
a.oa
8.27
8,46
8.83
a.79
8.114

4.80
4.87

5.24
Ull
6.33
6.36
S.40

.ua

8.33

5.47

us

5,79

S.16
9,14
6.33

8.53

11.09
5.11!
1.21
5.27
6.32

5.73
8.84
7.18
7.38
7,BD

&.38

7.82
7.112
B.211
11.46
8.64

1.48
li.411
11.60
5.51

5.&1

11.82
a.97

&.61
&.111
IS.111
8.91
G.61

S.42
IU&

S.46

6,46
6.49
&.50
&.60
11.61

s.a1
&.51

9,07
8.18
9.28

6.51

6.61

9.11

9.38

&.61
11.&1

9.23
9,32

9.42

4.110
4.118
4,95
5.02

11.40
1.43
li.4&
6.47

6.61

Ag ... youngrlhan 11 ro lh 11m1 a1 for age 11, and

llH old1r than II are tho same 1111 sho~n foe 8&.

3.74
3.79
3.86
3.90
3,99

DUPLHCAf~

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 24 of 25

'

GENERAL PROVISIONS

Annual Report We wHI send you a report at least once

a year which shows the premium payments, expense
charges, Interest credited, mortality charges, and partial
surrenders since lhe last report. It will also show any
a.itstand(ng loans, the current Accumulation Value, and
current Net Cash Value.
Projection of Benefits If you send us a written request,
we wll furnish you a report which shows future benefits
and values, The report will assume your S peclrled
Amount, type of Death Benefit option, Interest rate and
future premium payments. We may specify other
assumptions a& necessary. You may request one report
free each year. Addltlonal reports will not cost more than
$25 each.
lncontcstablllty of the Polley This policy wlll be
lncontes!able after It has been In force during the
lnsured's nfetime for two years from the Policy Date. This
provision does not apply to any Rider providing benents
speclflcally for disability or death by accident.
Amount We Pay Is limited In the Event of Suicide We wlll be Hable only for the premiums paid, less any
particular surrenders, if the Insured dies by suicide whlle
sane or Insane within one year from the Polley Dale.
Misstatement of Age or Sex In the Appllcation - If
there Is a misstatement of the lnsured's age or sex In the
pol!cy, we will adjust the excess of the Death Benefit ova."
the Accumulatlon Value to that which the most recent
Monthly Deduction would purchase at the correct age or
sex.
The Contract Consists of the Polley and the
Appllcatlon We have Issued this pollcy In consideration
of the application and Initial premium. A copy of the
application Is attached and Is a part of this policy. The
policy and the

application together are the entire contract. All statements

made by or for the Insured are considered representations
md not warranties. No statements other than those
contained In the application wlll be used lo void the pollcy
or defend a clalm.
Who Can Make Changes In the Polley Only our
Presldent or a Vice President together with our Secretary
have the authority to make any changes ln this pollcy. Any
change must be In writing.
Assignment of the Polley - You may assign or transfer all
or specific rights of your poUcy. No assignment wlll be
effective unlll you notify us In writing. We will record your
assignment. We wlll not be responsible for Its valldlty or
effect.
Death of the Owner - If you die before the Insured, your
rights will pass to the executor of your estate unless
ownership has been otherwise assigned.
Termination of Insurance This policy Will terminate
l he earliest of:

a the date of surrender;

b. the poOcy anniversary following the lnsured's age 95;
or
c. the date of lapse.
No Dividends are Payable - This Is nonparticipating
Insurance. It does not participate In our profits or surplus.
We do not distribute past surplus or recover past losses by
changing the Monthly Deduction rates.
Notice Any notice given under the provisions of this pollcy
will be sent to your last knCM'n address and to any assignee
of record

10

Case 1:15-cv-00040-BRW Document 2 Filed 03/27/15 Page 25 of 25

GUARANTEED MAXIMUM MONTHLY MORTALITY COST CHARGES

PER DOLLAR NET AMOUNT AT RISK
NONSMOKER

AGE

MALE

0.000219215
o.ooooao641
0.000092507
2
0.0000110040
3
4
0.000077606
0.000073339
G
G
0.0000611171
O.OOOOBB004
7
II
0.000082604
0.000061670
9
10
o.ooooe2s<lo4
0.000087506
11
12
0.000076873
13
0.0000119176
14
0.0001011177
Hi
0.000113346
0.000124182
111
0.000130850
17
0.000135852
18
19
O.D0013918G
0.000140020
20
21
0.0001311362
0.00013Sllll2
22
23
0.000132818
2'4
0.000129163
25
0.0001215016
0.000122515
28
0.0001208'48
27
0.000120014
211
211
0.00120014
30
0,000120848
31
0.000123349
32
0.000126883
33
0.000131884
34
D.00013111185
0.000143354
35
0.0001a1690
36
0.00016161l3
37
38
0.000172530
39
0.000184201
'40
0.000198373
0.00021337D
41
'42
0.000229219
43
0.00024 7561
0.000266738
44
0.000287683
45
46
0.000311764
47
0,0003311780
48
0.0003114299
0

FEMALE

0.00011i6691
0.000010005
0.000006611
0.000065004
0.000064171
0.000062604
0.0000601137
0.0000811170
0.000068337
0.000057503
0.000056670
0.000068337
0.0000130837
0.000084171
O.OOOOG8338
0.000071672
0.000076008
0.0000776011
0.0000800011
0,000082507
0.000094174
0.000085641
0.000086074
0.000088341
0.000090008
0.000091678
0.000094178
0.000095&13
o.ooooee343
0.000101677
0.000104178
0.000107612
0.000110846
0.000116013
0.000120014
0.000126849
0.000134185
0,0001107
0.000156024
0.000161569'4
0.0001110666
0.0001U5872
0.000210878
0.000221!81lo4
0.000240891
0.000267666
0.000276076
0,000294253
0.000314266

SMOKER
MALE

0.000219216
0.000085041
0.000082507
0.000000040
0,000077500
0.000073339
0.000060171
o. 000086004
0.000082604
0.00011111870
0.0000821104
0.0000&7ll05
0.000071!1573
0.000089'176
0.000116680
o.0001.caee8
0.0001833150
0.000176884
0. 000184201
0.000190038
0.000193371
0.0001113371
0,0001110870
0,000186702
0.000181700
0.00017158154
0.000172630
o. 00 017 0863
0.00017011C3
0.000173363
0.000177632
0.0001113367
0.0001110870
0.000200874
o. 000212545
0.000226718
0.000244 228
0 .000214238
0.000287583
0.000314286
0.0003415119
0,000378477
0.000415172
0.0004500"41
0.000499416
0.000646131
0.000594620
0,000847085
0.000702994

FEMALE

0.000166691
0.000070005
0.000086671
0,000005004
0.0000&4171
0.0000112504
0.000060637
0.000059170
0.000058337
0,000067608
O.OOOOD6670
0.0000511337
0.000080637
0.000064171
0.000098338

o.ooooaooos
0.000084174
0.000088341
0.0000112609
0.000098009
0.000097610
0.000099177
0.000101677
0.000104178
0.000106678
0.000109178
0.000113346
0.000110080
0.0001201148
0.000125849
0.000131684
0.0001386115
0.000142520
0.000150023
0.0001!183611
0.0001117628
0.000181700
0.000198373
o.oom17547
0.0002303110
0.0Do263403
0.000290084
0.0003167117
0.000343461
0.00037013 7
0.0003984112
0.000427883
0.000457709
0.0004Q024D

NON SMOKER

AGE
49
50

51
52
53

04
65
e6

67
68

59
eo
111
62
113
114
65
66
67

68
69
70
71

72
73
74
76
78
77
78
79
80
111
82
83
84
85
811
87

118

ea
90
91
92
93
IM

MALE

FEMALE

0.000393488
0,0003367110
0.00042711113
0.0003617110
0.000889310
0.0004156886
0,000421011
0.000312763
0,000466041
0.000585319
o.0004u1 uoe
0.000626391
0.000630281
0.000693814
0.0007118090 0.000568657
0.000860723
0.000&011201
0.000940884
o.oooe4:m1
0.0()1039413
o.oooeosaiM
0.00'1148810
0.0007363715
0.000798137
0.001270779
0.001409484
0.000874932
0.000969272
0.001585781
0.001739888
0.0010715322
0.001920049
0.00111111747
0,002134547
o.oo 13083 76
o.oot 4291541
0.002354698
0.001554914
0.0025 90862
0,0018D4633
0.002860603
0.001868447
0.003143182
0.0034757211
0.00205113915
0.002303828
o. 003 864880
0.002887563
0.004302800
0,0021138095
0.004 785290
0.003314262
0.0015300447
0.005840581
0.0037231115
0.0041ea093
0.006403241
0.00415311920
0.0089113670
0.0061661558
0.007820434
0. 0067 87237
0.006331338
0.008458850
0.009118224
o.01oooea.u 0.00726721111
0.010986289
0.008169370
0.012062093
o.oog1 s5564
0.01 023531111
0.013184058
0.0143415380
D.01t391Cl41
0.0155360011
0.012623192
0.013767003
o.01s9a1.11 e
o.018013753
0.015327210
0.018822481
0.01D316039
0.020694683
0.01845288 6
D.020211116211
0.022217035
0.0240431193
0.022438280
0.02615034 64
0.025223060

SMOKER
MALE

0.0007116586
0.00083428
0.000911664
0.000908406
0.0010953115
0.00119836
o.001307M1
0.001421184
0.001536624
0.0016615907
0.0017 89028
0.001U37078
0.002102746
0.002291907
0.002!106428
0.002737473
0.002903039
0.003237U50
0.003600544
0.003782687
0.0040915034
0.004412145
0.0048~1181

0.006279392
0.005773981
0.0083015342
0.00118778115
0. 007 4113061
0.0 0110 956~ 0
0.0087220114
0.009363057
0.0101018110
0.010697'4 76
0.011787322
0.012759076
0.0137849'41
0.014835199
0.01118871138
0.0169310615
0,017961038
o.0111887992
0.0200915022
0.021343526
0.022717104
0.024366882
0.026629926

DUPl~CATE
11

FEMALE

0.000526110
0.000564485
0,0008011380
0.000852092
0.000703620
0.000756405
0.000010067
0.000864079
O.ODOU14168
0.000963427
0.001016031
0.0010786112
0.001157171
0.001268248
0.001381071
0.0011118130
0.001t!t!27t!O
0.001809987
0.00181521 S7
0.002098051
0.002262683
0.002437&84
0.0021172121
0.00296!1567
O.OOS30161l9
0.0035111913
0.004118560
0.004572479
0.0011047011
0.00554896'1
O.OOG09e104
0.0087 097 20
0.007406UllO
0.008200874
0.008119073
0.010118315
0.011177727
0,0122951118
0.0134678711
0.0146721 CSG
0.0111937520
0.01734~020

0.0168626'12
0.020552221
0.022643680
0.026223050