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above, or for a policy of Paid Up Insurance as provided in option. (b), the amount of insurance will be continued in force as Extended Term Insurance as provided in option (c).

All net values and net_single premiums herein mentioned shal be based on the American Experience Table of Mortality with inter est at the rate of three and one-half per centum per annum.

TABLE OF LOAN AND SURRENDER VALUES

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Extended Term In-
End of Cash or Loan
Paid Up In- surance for $10,000

Pure En
Year
Value
surance

dowmen

Years Days
3
$350
$ 880

3

339
4
550
1360

6

48
790
1910

8

275
1010
2470

11

90
1310
3050

13

182
8
1580
3600

15

140
9
1860
4150

17

72
10
2160
4710

18

250
11
2460
5250

19

358
12
2770
5790

21

47
13
3100
6330

22

60
14
3440
6880

23

47
15
3790
7410

24

78
16
4140
7920

25

130
17
4500
8430

26

242
18
4880
8940

28

105
19
5280
9470

30

258
20
5690

10000

Paid up

Paid up 25

6310 30

6940 35

7550 40

8150 The reserve under this policy shall be computed on the basis the American Experience Table of Mortality with interest at th rate of three and one-half per centum per annum. The first year insurance under this policy is term insurance, purchased by th whole or part of the premium to be received during the first polic year and the policy shall be valued according to its terms and ti laws of the State of Indiana. The net value of each benefit in ti Table is equal to the reserve less a surrender charge in no casei excess of two and one-half per centum of the amount of insurans under this policy If fractional premiums in addition to premiun for whole years be paid, due allowance will be made in the abov benefits. Values for each year after the twentieth, not shown the Table, will be equivalent to the full reserve. After the end 1 the premium paying period, if no premium be in default, the cas value hereof will be available on surrender of this policy at the er of any policy year or within thirty-one days thereafter.

The Consideration for this Policy shall be the applicatic therefor and a premium of Three Hundred Eight and 30/100 DO lars for the period terminating August 15, 1916, and a premium like amount payable on said date and annually thereafter durin: the continuance of this policy or until twenty such premiums all shall have been paid.

In Witness Whereof, AMERICAN CENTRAL LIFE INSURAN
COMPANY has caused this policy to be signed as of the fifteen
day of August, 1915.
CARROLL B. Carr,

HEBRERT M. WOOLLEN,
Secretary.

President.

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INSTALLMENT PRIVILEGE
The insured may, at any time while this polioy lo in force, eloot by written requost on the Company's form therefor that, instoad of being pay.
able in one sum, the amount payable to the beneficiary as a death olaim shall be payable in equal annual or monthly installments for any number of
years from two to twenty-five, or for twenty years and to continue so long thereafter as the beneficiary shall live. Like request may be made by the
beneficiary should the insured die without having made such request.

The installment privilege shall not be operative if the beneficiary be other than a natural person or if the amount payable as a death olaim be
less than $1000 after deduoting any indebtedness.

The amount of each installment shall be as indioated in the following tablo, which is based on $1000 insurance, but which will apply pro rata to

the amount payable under this polioy.

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In tho ovont of tho donth of the beneficiary before all tho provided installments have been paid, those remaining unpaid will be commuted me
the rate of three and one-hall por contum por annum intorout and payment of the commuted amount will bo mado in ono un to the benefioiary
ostato.

ehed.ured -videnced by endorsement
The boscaiary had voolaht to .

PREMIUMS FOR LOAN INSURANCE BASED ON 8100

and applying pro rata to other amounts

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AMERICAN CENTRAL LIFE INSURANCE COMPANY

TOTAL AND PERMANENT DISABILITY BENEFIT. Supplemental Contract attached to and part of Policy No. 99999, on the life of Abner Alston, the insured.

If, while no premium is in default, the Company shall, before the Insured shall have attained the age of sixty years nearest birthday, receive due proof of the disability of the Insured, as hereinafter defined, provided such disability has at the time of the receipt of such proof existed for not less than sixty days, the Company will, by an endorsement on the policy, waive the payment of any premium or premiums which may thereafter become payable under the policy. The premiums so waived shall not be deducted from the amount of insurance, and the loan and cash values shall increase from year to year as though the premiums were being paid in cash.

Disability of the Insured within the meaning of this supplemental contract shall exist if the Insured, as the result of accident or disease, shall have become totally, permanently and incurably disabled to such an extent that he is thereby prevented and will be permanently and continuously thereby prevented from performing any work for compensation or profit or from following any gainful occupation. Perman and complete loss of the sight of both eyes, or loss by severance of both hands at or above the wrists, or of both feet at or above the ankles, or such loss of one entire hand and one entire foot, shall be considered disability within the meaning of this supplemental contract. Provided - always that such disability shall not have been incurred while engaged in military or naval service in time of war or as the result of such service.

Even though proof of disability may have been accepted, the Company may demand of the Insured from time to time proof of the continuance of such disability; and if such proof be not furnished on the Company's demand, or if it shall appear that the Insured is able to perform any work for compensation or profit, or to follow any gainful occupation, the Insured shall resume payment of all premiums thereafter due, but the premiums already waived by the Company shall not become a policy indebtedness.

The premium for the disability benefit is $1.80 and is included in the premium for the policy stated on the third page thereof. The disability premium shall cease on the policy anniversary of the Insured nearest his age sixty years, when the amount of premium stated in the policy will be reduced by a sum equal to the premium for the disability benefit. Attest:

HERBERT M. WOOLLEN, H. W. BUTTOLPH, Actuary.

President.

APPLICATION. I hereby make application for insurance in American Central Life Insurance Company of Indianapolis, Indiana, and agree that the statements and agreements herein and the statements to the Medical Examiner in Part II of Application are made for the purpose of securing this insurance and declare that all such statements are complete and true without exception unless such exception is indicated. 7." I desire policy to be issued as of date.

..and I agree that the period to cover which the first premium is paid shall end one year after said date, and that each insurance year shall end on successive anniversaries of said date. I also agree that the insurance applied for shall not take effect until the payment of the first premium thereon, and the approval of this application by the Company.

15. I further agree that any physician may disclose to the American Central Life Insurance Company, its successors, or assigns, any facts or information communicated to, or acquired, by him as my physician, and I waive any and all provisions of law which now, or may, hereafter, exist exempting or prohibiting any physician from disclosing any facts acquired in his professional capacity or rendering such physician incompetent as a witness.

16. I have settled for the first premium on policy applied for with the Agent.

.in the following manner : Cash $. Note.. for $

due.

..on condition that, if risk is not assumed by the Company the sum paid by me shall be returned in accordance with the provisions of the binding receipt which I have accepted subject to the provisions thereof.

MEDICAL EXAMINER'S FORM. In continuation of and forming a part of my application for insurance to the American Central Life Insurance Company of Indianapolis, Indiana, dated...'.

I hereby certify that I have read the above questions and that my answers thereto are true.

..191....

Largest Amount of Insurance it will write on a Single Life. "Indefinite.' All above $10,000 reinsured. Premiums for Each $1,000 Insurance

(Nonparticipating). Adopted March 1, 1913.

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96 97 76 27 68 71 108 89

68 76 For somi-annual rates, add 4 per cent and divido by 2. For quarterly rates, add 6 per cent and divide by 4.

Por policies with Disability rider additional charge of 150 to 90c per $1.000 is made depending upon age and form of policy.

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