$1400

TABLE OF NON-FORFEITURE VALUES.

The values as herein stated, are for full paid policy years, and will be increased by outstanding additions and by payment of instalments of premiums beyond the full paid policy year, but will be decreased by any indebtedness hereon or secured hereby.

After Payment of Premiums for

Sub 3 years

$550

4

Б

6

156

26

224

338

349

262

88

177

211

203

166

116

72

56

99

248

287

20

#21"

5780

Values for additional years will be furnished upon request. NON-FORFEITURE OPTIONS.-After three full annual premiums shall have been paid hereon, then in case of default in the payment of any subsequent premium or instalment, continued after the days of grace,

OPTION A-Without action on the part of the holder, the policy will be continued for its value in participating paid-up life insurance (without disability benefits) which will have a yearly increasing surrender value; or

OPTION B-If the holder so elect, the policy will be terminated and the surrender value paid in cash; or

OPTION C-Upon written request by the holder filed at the Home Office of the Company within ninety days from the due date of the premium in default, the policy will be continued at its face amount including any outstanding additions and less any indebtedness to the Company hereon or secured hereby, for its value in participating extended term insurance (without loan privilege or disability benefits) dating from said due date. Such insurance will have a decreasing surrender value expiring with the extension term.

Upon due request of the holder filed at the Home Office of the Company while no premium is in default under this policy, extended term insurance may be made the automatic non-forfeiture option by endorsement hereon.

The surrender value due under any option will be paid upon proper surrender of the policy with the written assent of the person to whom it is made payable.

Said surrender value at date of default in payment of premium will be the full reserve on the policy and any outstanding additions,

less a sum having a maximum at the end of the third year not in excess of six-tenths of one per centum of the face amount of the policy, and thereafter decreasing, and less any indebtedness to the Company hereon or secured hereby.

The legal reserve under this policy is computed upon the American Experience Table of Mortality, with interest at three and onehalf per centum per annum.

The paid-up and extended insurance under Options A and C are such as will be purchased by the surrender value as herein defined, applied as a net single premium at the attained age of the Insured upon the mortality and interest basis adopted for the reserve computation hereunder.

SETTLEMENT OPTIONS.-In lieu of payment in one sum, the Insured, subject to the rights of any assignee, and with the right to change, or the beneficiary after the Insured's death if no election has been made by the Insured, may, subject to the terms and conditions which follow, elect, by written notice to the Company, to have the net proceeds of this policy, or any part thereof, not less than $1,000, paid as provided in any of the following options. The mode of payment elected by the Insured shall not be varied by the payee, but if payment is being made under an election by the beneficiary, such beneficiary may, except as to Option 2, revoke the election and receive the unpaid amounts in one sum; but if the stipulated instalments under Option 1 or Option 3 remaining unpaid at any time are commuted and paid in one sum they shall be discounted at the rate of three per centum per annum.

Any portion of the net sum due hereunder which may be payable to an assignee, shall be paid in one sum, and the remainder, if not less than $1,000, shall be paid according to the terms of the option elected.

The amounts of the several instalment and annuity payments for each $1,000 of the net sum so payable are shown in the table of Instalments and Annuities herein, and under Options 2 and 3 the amounts of such payments will be based on the attained age of the beneficiary at the date of death of the Insured.

The first instalment under Options 1, 2 and 3 will be payable upon due proof of death of the Insured.

If an instalment option becomes effective this policy will be exchanged by the Company for a supplementary contract which shall provide for settlement according to the option elected, and shall further provide that there will be allowed upon the funds held for the payment of the stipulated instalments under Option 1 and under Option 3 remaining unpaid from year to year such share of interest earned in excess of three per centum per annum as the Company may from year to year determine.

OPTION 1.-Payment by a stipulated number, either 5, 10, 15, 20, 25 or 30 equal annual instalments.

OPTION 2.-Payment by an annuity during the life of the beneficiary.

OPTION 3.-Payment by a stipulated number, either 10, 15, 20, 25 or 30 equal annual instalments and by an annuity for as many years thereafter as the beneficiary shall live.

OPTION 4. The net sum due under this policy, or any part thereof not less than $1,000, may be left on deposit and the Company will pay interest thereon annually at such rate not less than three per centum as may from year to year be determined by the Company, the first payment to be made one year after the death of the Insured.

The amount of said deposit may be withdrawn on any interest date if so provided when the option is elected, but if not so withdrawn, then upon the death of the person last entitled to receive interest payments under the terms hereof, the Company will pay the amount of said deposit together with any accrued interest for the then current year, in such manner as may be directed when the option is elected.

For ages under 15 amounts will be same as 15. For ages over 85 amounts will be same as 85.

NOMINATION OF PROVISIONAL PAYEE.-The Insured, with the right to change, may, by written notice to the Company at its home Office, name a provisional payee to receive in accordance with the terms of the option elected, any stipulated payments remaining unpaid under Option 1 or Option 3, or interest payments under Option 4, upon due proof of the death of the beneficiary after such beneficiary has become entitled to payments.

The privilege of nomination of a provisional payee shall not apply under Option 2, nor shall the beneficiary have the right to name a provisional payee under any option. If there be no provisional payee living at the death of the beneficiary after becoming entitled to payment under Option 1 or Option 3, or if a provisional payee shall die after becoming entitled to such payment, any stipulated payments under said Options 1 or 3 then remaining unpaid shall be commuted and paid in one sum to the executors or administrators of the one so entitled.

If there be no named beneficiary or provisional payee entitled to receive payment under this policy at the death of the Insured the net sum payable hereunder will be paid in one sum.

Annual payments of $100 and over, under the terms of any option or under the Disability Provision herein, may be taken in equivalent semi-annual, quarterly or monthly payments.

The equivalent of each $100 of annual payment is $50.40 paid semi-annually; $25.30 paid quarterly; or $8.45 paid monthly.

TOTAL AND PERMANENT DISABILITY BENEFIT

PROVISION.

1. PAYMENT BY INSTALMENTS.-After one full year's premium shall have been paid upon this policy, then if at any time, while no premium is in default, the Company shall receive due proof that the Insured, prior to attaining the age of 60 years, has become wholly and permanently disabled by bodily injury or by disease sustained or contracted after the date hereof, and that thereby he will be wholly, continuously and permanently prevented from the pursuit of any form of mental or manual labor for compensation, gain or profit whatsoever, and has been so disabled for not less than sixty days, the Company will waive, after the then current policy year, payment of further premiums during the continuance of the disability, and, at the end of one year from the date on which said disability is proved, provided the disability then exists, will pay to the Insured, with the written consent of the assignee, if any, one-tenth of the face amount of this policy, and one-tenth annually thereafter during the continuance of the disability, until the said face amount, less any indebtedness, shall have been paid in full, or until the maturity of the policy when any unpaid remainder of the sum insured, less any indebtedness, will be paid as provided in the policy. In case there are any accumulations or policy additions from surplus distributions then outstanding they shall be payable with the final payment.

The sum insured shall be reduced by each annual instalment so paid and the cash surrender and loan values from year to year will be those shown by the table of non-forfeiture values in the policy, reduced proportionately to the reduced insurance, less any existing indebtedness.

Whenever the existing indebtedness shall exceed the cash surrender value of the reduced insurance, the succeeding instalment shall be reduced by the amount of such excess, and the indebtedness correspondingly reduced.

Whenever the instalments paid and credited together with the indebtedness shall equal the face amount of the policy and of any accumulations or additions from surplus distributions, the liability of the Company shall cease.

The policy must be forwarded to the Home Office for endorsement of the payment of each disability instalment.

2. WAIVER OF PREMIUMS AFTER AGE 60.-If the Company, while no premium is in default, shall receive due proof that the Insur

after attaining the age of 60 years, has become disabled as aforesaid and has been so disabled for not less than sixty days, the policy will be maintained in force, without payment of further premiums during the continuance of the disability, for a decreasing sum, which shall be the face amount of the policy less the premiums waived, and less any existing indebtedness. The amount of the premium waived yearly will decrease in proportion to the decreasing sum insured, and the cash surrender and loan values from year to year will be those shown by the table of non-forfeiture values in the policy, reduced proportionately to the reduced insurance, less any existing indebtedness.

3. RECOVERY FROM DISABILITY.-The Company shall have the right to require at any time, but not oftener than once a year, due proof of the continuance of the disability. If the Insured shall fail to furnish such proof when required to do so, or shall so far recover as to be able to perform work of any kind for compensation, gain or profit, no further premiums will be waived, and no further disability instalments will be paid. In such case the insurance will be the face of the policy less the instalments paid (Sec. 1) or the premiums waived after age 60 (Sec. 2) as the case may be, and the non-forfeiture values, as well as the premiums payable, will be in proportion to the reduced insurance.

(4. DISABILITY PREMIUM.-The disability benefits set forth in this provision are granted in consideration of the statements and representations in the application for this policy and of a special yearly premium of Five dollars and Twenty cents payable in addition to and as a part of the regular premium of the policy during its premium paying period, or until the Insured reaches the age of sixty years. The special premium may be discontinued at any policy anniversary upon request by the Insured, and the presentation of the policy to the Company for cancellation of the disability benefit provision.

5. RECOGNIZED DISABILITIES.-Without prejudice to any other cause of disability, the following will be recognized as disability within the meaning of this provision, namely, the total and irrecoverable loss of the use of both eyes or of both hands or of both feet, by removal or disease; or such loss of the use of one hand and one foot.

In Witness Whereof, the JOHN HANCOCK MUTUAL LIFE INSURANCE COMPANY has, by its President and Secretary, executed and delivered this contract and caused the same to be duly countersigned, at Boston, Massachusetts, on this First day of March, A. D., 1915.

WALTON L. CROCKER,

ROLAND O. LAMB,
President.

The Assured is hereby notifled that by virtue of this policy he is a member of the JOHN HANCOCK MUTUAL LIFE INSURANCE COMPANY, and is entitled to vote either in person or by proxy at any and all meetings of said Company. The annual meetings are held at its Home Office on the second Monday of February in each year, at twelve o'clock noon.

APPLICATION.

I hereby declare that I have never made an application to insure my life to any company or agent upon which a policy has not been issued in the exact form and amount originally applied for and that there is none now pending, unless so stated above; and further, I declare that all the statements herein made are complete and true, and that they are correctly recorded.

MEDICAL EXAMINER'S FORM.

I certify that the statements and answers which I have made in this application as a basis for the contract of insurance are complete, true and correctly recorded, and I agree that any policy which may be issued hereon shall take effect only in case it shall be delivered and the first premium or instalment thereof actually paid during my lifetime, and that such delivery and payment shall constitute an acceptance of the policy and of all its conditions.