OPTION 3

table, provided that no such commutation will be made under (3) except after the death of the payee occurring within the aforesaid twenty years.

TABLE OF INSTALLMENTS FOR EACH $1,000.

Multiply each installment by number of thousands or fractions thereof due under the policy.

Life Income for 20 Years Certain, but to Continue Thereafter During Life of
Beneficiary, Based on Age at Maturity of Policy.

2. Paid Monthly—

48

49

$

S. $
51 52

53

54

$

55

Amt. each Payment. 3.80 3.90 3.97 4.064.14 4.234.314.394.484.564.65

AGENTS ARE NOT AUTHORIZED to modify this policy or

to extend the time for paying a premium.

In Witness Whereof, the Company has caused this policy to be executed this Nineteenth day of February, Nineteen Hundred and Eleven.

H. G. EVERETT,
Secretary.

APPLICATION.

GEO. B. PEAK,
President.

I hereby agree that this application, the medical examination and the policy hereby applied for, taken together, shall constitute the entire contract between the parties hereto, and I hereby represent that all the answers made to the above questions and those that shall be made to the medical examiner are true and form the basis of an insurance contract, and that this contract shall not take effect until the first premium has been paid during my good health. I also agree to have the required medical examination made at once by a physician acceptable to the Society.

20 PREMIUMS (FIRST YEAR TERM AND 19 PREMIUMS) LIFE NONPARTICIPATING POLICY.

Agrees to Pay Ten Thousand Dollars at the Home Office of the Company as follows:

THE BENEFICIARY, to Mary Doe, wife of the insured, beneficiary by revocable designation upon receipt of due proof of the death of the insured.

THE INSURED, John Doe, of Louisville, County of Jefferson, State of Kentucky.

PREMIUMS.-This contract of insurance is issued in consideration of the application for this policy, which is hereby made a part hereof, and of the Annual Premium of Three Hundred, Twenty and 00-100 Dollars, and a like sum on the Twentyeighth day of September of every year until premiums for 20 years, including the first, have been paid, or during the continuance of the contract. The Company will accept payment of premiums at other times than as stated above as follows: $166.40, Semi-annually on each Twenty-eighth day of September and March; or $84.80, Quarter-annually on each Twenty-eighth day of September, December, March and June, provided such change is made on any anniversary of the date of this policy, upon written notice theretofore received, and provided further, that the portion of the premium for the insurance year remaining unpaid, if any, at the death of the insured, shall be deducted in any settlement under the policy.

Except as herein provided, the payment of a premium or inIstallment thereof, shall not maintain the policy in force beyond the date when the next premium or installment thereof is payable. If any note or obligation given for any premium or any part thereof shall not be paid when due, the policy shall be and become null and void, except as herein provided.

All premiums are payable in advance at the Home Office of the Company, but may be paid on or before date due to any agent of the Company producing and delivering a receipt signed by the President or Secretary of the Company and countersigned by the agent to whom payment is made.

One month (not less than thirty days) of grace during which time this policy shall be continued in force, will be allowed in payment of all premiums after the first, subject to an interest charge of five per centum per annum. If death occurs within

If the annual premium on this policy be paid in installments, allowance will be made in computing benefits from the table for that portion of a year's premium paid over and above the number of full years' premiums indicated.

The loan and surrender values under this policy shall be based upon the American Experience Table of Mortality, with 31⁄2 per cent. interest per annum, and the net value thereof is the entire reserve, less not more than 21⁄2 per cent. of the amount_insured by the policy. After the 20th year the table of loan and surrender values will be extended on request.

NON-FORFEITURE. If the insured shall fail to pay any premium or any indebtedness hereunder, when due or within the period of grace, if any, and shall not have exercised any of the foregoing options, the Company, subject to the other conditions of the policy, shall grant the continued insurance hereinbefore provided.

REINSTATEMENT.-Unless the cash value has been paid or the continued insurance has expired, this policy, upon evidence of insurability satisfactory to the Company, may be reinstated by the insured at any time within three years from date of default, by payment of arrears of premiums with interest at five per centum per annum; any loan which existed at date of default together with inte.est at the same rate to the date of reinstatement, to be, on application for such reinstatement, either repaid in cash or continued as an indebtedness against the policy.

NON-PARTICIPATION.-This policy is not entitled to participate in the profits or divisible surplus of the Company.

SELF-DESTRUCTION.-In case of self-destruction within one year from the date of this policy, whether sane or insane, the sum payable hereunder shall be one-tenth the principal sum of the policy.

OCCUPATION.-This policy is free from restriction as to any occupation except military or naval service in time of war; provided, however, a permit for such service may be procured from the Company upon the payment of an extra premum therefor, in which event the policy shall remain in force for its full amount. Otherwise, if death occur during such service, or in consequence of such service, the sum payable hereunder shall be one-tenth the principal sum named in the policy.

AUTHORITY.-Only the President or Secretary has power in behalf of the Company to make or modify this or any contract of insurance or to extend the time for paying any premium, and the Company shall not be bound by any promise or representation heretofore or hereafter given by any other person.

MISSTATEMENT OF AGE.-If the age of the insured has been misstated, the sum payable hereunder shall be such amount as the premiums paid would have purchased at the correct age.

ASSIGNMENT. No assignment of this policy shall be valid unless made in duplicate and both copies be sent with the policy to

the Home Office of the Company for endorsement, one to be retained by the Company and the other to be returned attached to the policy and endorsed with acknowledgment of notification by the Company. The Company shall assume no responsibility for the validity of any assignment.

INDEBTEDNESS.-All indebtedness to the Company on account of this policy. whether of the insured, the beneficiary or any assignee, shall be deducted from the proceeds thereof in any settlement thereunder.

TRUST FUND.-The proceeds of this policy may be paid in installments as provided on the back hereof; or may be placed in trust with the Company to pay to the beneficiary as annuitant, during the continuance of the trust, interest on such proceeds at the rate of three and one-half per centum per annum, such proceeds to be paid to the beneficiary at the termination of the trust or to the estate of the beneficiary in the event of death prior to such termination.

ENTIRE CONTRACT.-This instrument contains the entire contract between the parties hereto, and all statements made by the insured shall, in the absence of fraud, be deemed representations and not warranties, and no such statement shall be used in defense to a claim under the policy unless it be contained in the application therefor, a copy of which is endorsed hereon.

APPLICATION.

On behalf of myself and of any person who shall have or claim any interest in any policy that may be issued under this application, I hereby declare and agree that all the foregoing statements and answers, together with those contained in the declarations to the 1 Citizens National Life Insurance Company's Medical Examiner, to be full, complete and true, whether written by my own hand or not, and they are offered to the Company as a consideration for and as a basis of the contract with said Company under any policy issued under this application, which, if issued, I hereby agree to accept. I hereby agree on behalf of myself and of any person who shall have or claim any interest in any policy that may be issued under this application as follows: 1st. That such policy shall be a contract made and to be performed in the State of Kentucky. 2nd. No contract of insurance shall be deemed made and no liability on the part of said Company shall arise until a policy shall be issued and be delivered to me, and the first premium thereon be actually paid, all while I am in good health. 3d. That all premiums shall be due and payable only at the Home Office of the Company, and all payments on any policy issued under this application shall be held to have been there paid. 4th. That no statement, promise or inI formation made or given by, or to, the person soliciting or taking this application for a policy, or by or to any other person, shall be binding on the Company or in any manner affect its rights, unless such statement, promise or information be reduced to writing and presented to the officers of the Company, at the Home Office, in this application. 5th. That in case of self-destruction within one year, whether sane or insane, the sum payable under this policy shall be one-tenth the principal sum of the policy. 6th. That in the event I engage in military or naval service in time of war this policy shall be in force for its full amount, provided a permit for such service has been secured from the Company, and extra premium therefor paid in cash; otherwise, the sum payable in case I should die while engaged in such service or in consequence of having been so engaged, shall be one-tenth the principal sum named in the policy, 7th. It is hereby agreed that neither the applicant nor any one who is, or may be, interested in the policy hereby applied for, or in the person or estate of the one upon whose life such policy shall be issued, will at any time object to any physician testifying as to any fact he may know which may be material in any inquiry arising under, or in connection with said policy.