paid for three full years, is not paid before the expiration of the month of grace herein allowed, this policy will, without any action of the insured, or payment of further premiums, continue as nonparticipating paid-up term insurance for the principal sum insured, but without loan or surrender values, as follows: 1. If there is no indebtedness to the Company on this policy. the insurance will be for the term specified in Column 2 of the table of surrender values herein (the net value of which is the full reserve by the Actuaries' Table of Mortality at four per cent interest, less not more than two and one-half per cent of the face of the policy), such term to be reckoned from the due date of the unpaid premium. In lieu of such term insurance, upon the insured's written request and legal surrender of this policy within one month from the due date of the unpaid premium, the Company will (a) Issue a non-participating paid-up life policy for the amount specified in Column 1 of said table (the net value of which is not less than the full reserve by the Actuaries' Table of Mortality at four per cent interest, less not more than two and one-half per cent of the face of the policy), or (b) Pay the cash value specified in Column 3 of said table (which is not less than the full reserve by the Actuaries' Table of Mortality, at four per cent interest, less not more than two and one-half per cent of the face of the policy), payment of which, however, may be deferred for not exceeding six months, at the option of the Company. 2. If there is any indebtedness to the Company on this policy, such indebtedness shall be deducted from the net value of the term insurance provided for in paragraph 1 above, and the insurance shall be for such term, reckoning from the due date of the unpaid premium, as the excess of such net value over the indebtedness will purchase at the insured's then attained age at net single premium rates by the mortality table and interest rate aforesaid. In lieu of such term insurance, upon the insured's written request and legal surrender of this policy within one month from the due date of the unpaid premium, the Company will (a) Issue a non-participating paid-up life policy for such amount as the excess referred to will purchase at the insured's then attained age at net single premium rates by the mortality table and interest rate aforesaid, or (b) Pay the cash value specified in Column 3 of said table less such indebtedness, payment of which, however, may be deferred for not exceeding six months, at the option of the Company. In case of default in the payment of a premium due at an intermediate period, the non-forfeitable values will be computed on the same basis as the corresponding values for the end of the policy year last expired. The values provided for above will be increased by the reserve, less not more than two and one-half per cent of their face amount, on all dividend additions to this policy, if any. LOANS. After three full years' premiums have been paid on this policy, the legal holder will be entitled to cash loans on the sole security of this policy, The aggregate loans hereunder, including any unpaid premiums, and interest to the end of the current policy year, shall not exceed the sum stated in the table of loan values herein (which shall be the full reserve at the end of such current policy year by the Actuaries' Table of Mortality at four per cent interest, less not more than two and one-half per cent of the face of the policy). A proper note or loan agreement and assignment of the policy must be executed by the insured on forms provided by the Company and the policy deposited with the Company. Interest shall be at the rate of six per cent per annum, payable in advance; failure to pay any loan or interest thereon shall not void this policy, unless the total indebtedness to the Company on this policy shall equal or exceed the loan value as given in the table of loan values herein, nor until one month after notice has been mailed by the Company to the last known address of the insured and of the assignee, if any, of record at the Home Office of the Company. The values above provided for will be increased by the reserve less not more than two and one-half per cent of their face amount on all dividend additions, if any, to this policy. The payment of any loan applied for under the above provisions may be deferred for not exceeding six months, at the option of the Company. 'DIVIDENDS.-This policy, while in force, shall participate in the surplus of the Company, and, beginning not later than the end of the third policy year, and annually thereafter, the Company will determine and account for the portion of divisible surplus accruing on this policy, and the dividends awarded hereon shall, at the option of the insured, as elected at time of making application be, (1) payable in cash, or (2) be used to purchase additional paid-up insurance, payable according to the terms of this policy, or (3) be applied in reduction of premiums, or (4) be allowed to accumulate to the credit of the policy holder with interest at three per cent per annum. If no election is made, as provided above, the dividends will be payable in cash. Any indebtedness to the Company on this policy, including any balance of the current year's premium remaining unpaid, will be deducted in any settlement of this policy. APPLICATION. It is hereby expressly stipulated and agreed: 1st. That the above application, together with the statement made to the examining physician, and the report of the examining physician and this declaration, and the policy that may be issued to me, shall be the contract between me and THE BANKERS LIFE INSURANCE COMPANY OF NEBRASKA; and I hereby represent the same to be full, complete and true, whether written by my own hand or not; this representation being a condition precedent to, and a consideration for, the policy which may be issued hereon. And it is fully understood and agreed, that if any fraudulent answers shall be or shall have been made, or if I should neglect or refuse to pay any premium on or before the dates when they shall become due, then, and in that event, the said policy shall become null and void, and ali money which shall have been paid shall be forfeited to the Company, except as provided in the policy. 2d. That said Company shall not be liable, during the first two years under the policy hereby applied for, if my death shall be the result or consequence of violation of law, or while I am resisting or attempting to escape arrest therefor. It is also understood and agreed, that if I shall engage in blasting, submarine labor, aeronautic travel, the manufacture or handling of highly inflammable or explosive substances, or service upon any vessel or railroad during the first two years under this policy, or in any military or naval service in the time of war, without first obtaining the consent of said Company in writing, then the policy shall be null and void and of no effect, except as provided in the policy. 3d. That inasmuch as only the officers at the Home Office of said Company, in the City of Lincoln, Nebraska, have authority to determine whether or not a policy shall issue on any application, and as they act on the written statements and representations referred to, no statements, representations, promises or information 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 said Company, or in any manner affect its rights, unless such statements, representations, promises, or information be reduced to writing, and presented to the officers of said Company, at the Home Office of this Company. 4th. That in any distribution of surplus or profits, the principles and methods which may be adopted by said Company for such distribution, and its determinination of the amount equitably belonging to any policy which may be issued under this applica tion, shall be and are hereby ratified and accepted by and for every person who shall have or claim any interest under such policy. 5th. And it is agreed that there shall be no contract of insurance until a policy shall have been issued and delivered by the said Company, and the first premium thereon paid while the person proposed for insurance is living and in good health. 6th. That no suit shall be brought against said Company under said contract after the lapse of six years from the time when the cause of action accrues. I also understand that no person is authorized to erase, waive, or change in any manner any of the blanks or printed matter used or furnished by the Company, or to promise any other terms or conditions than those published by the Company in its printed matter. MEDICAL EXAMINER'S FORM I HEREBY DECLARE that I have read the above questions, and written answers, and that the answers as written are true. 888°F 77 70 104 20 83 122 50 92 00. . . . . . . . . . . . . .. 253 00 90 78 65......124 85 94 45...............280 10 Ages 15 to 25 the rate is the same as at age 25 when no rate is given under age 25. ..... ..... ..... ..... 25 12 52 12 68 13 14 13 65 35 15 13 94 15 14 28 15 14 74 15 52 43 50 17 09 17 Life, 50 per cent Return. *10-Year Bond. 100% Return. 20-Year Settlem't 20-Year Bond. 100% Return. Largest Amount of Insurance it will write on a Single Life, $10,000. Prem iums for Each $1,000 Insurance (Participating). Adopted Jan. 1, 1893. LIFE. ENDOWMENT. Annual Premiums. Life with Return Premiums. Largest Amount of Insurance it will write on one life, $10,000. Prem iums for Each $1,000 Insurance (Nonparticipating). For semi-annual premiums add 4 per cent. Surrender Values same as under Participating forms. 81 00 90 32 88 90 72 0978 65 65 02 124 85109 4094 45 79 900. 91 118 05 103 87 85 90 72 69.......... 69 30 57 15 119 40105 0787 76 74 26 94 72 20 59 55 120 95106 88 89 80 75 99.......... 69 44 75 30 62 26 122 50 107 82 92 00 77 84.......... 8888 0892 56 68 40857 Premiums After First Premiums First Year. Premiums After First Premiums First Year. After First Premiums After First |