TABLE OF ANNUAL INSTALMENTS FOR EACH $1,000.

If so requested in writing when making the election, these in stalments will be paid in fractional parts, semi-annually, quarterly or monthly, the total of the fractional payments each year beinį equal to the annual payment provided for by this table.

Agents are not authorized to modify this Policy or to extend the tim for paying a premium.

In Witness Whereof, the Company has caused this Polic to be executed this eighteenth day of February, 1913. W. J. EASTON,

Secretary.
Countersigned..........

CHARLES A. PEABODY,

Presiden

..Registrar.

MUTUAL LIFE INS. CO., NEW YORK, N. Y.

WAIVER OF PREMIUM IN THE EVENT OF PERMANENT
TOTAL DISABILITY

The premium stated on the face of policy No. 0000000 (to which policy this agreement is attached and of which it forms a part) includes an additional premium of $2.40, payable for twenty full years. or until the prior death of the Insured, and in consideration of the payment of such addition premium THE MUTUAL LIFE INSURANCE COMPANY OF NEW YORK hereby grants the following Waiver of Premium in the Event of Permanent Total Disability.

If the Insured, after payment of premium for at least one full year and before default in the payment of any subsequent premium, and before attaining the age of sixty years, and while this policy is in full force, shall furnish proof satisfactory to the Company, at its Home Office in the City of New York, that he has become wholly and permanently disabled by bodily injury or disease so that he is and will be permanently, continuously and wholly prevented thereby from performing any work for compensation or profit or from following any gainful occupation, and that such disability has existed continuously for not less than sixty days, the Company will waive payment of premiums thereafter becoming due under this policy during the continuance of such disability. The premiums so waived shall not be deducted from the sum payable under the policy, and the values provided for in the paragraphs entitled "Loans" and "Options on Surrender or Lapse" and in the "Table of Loan and Surrender Values" shall be the same as if the premiums had continued to be paid to the Company regularly when due. Provided that, notwithstanding proof of disability may have been accepted by the Company as satisfactory, the Insured shall at any time on demand, furnish to the Company satisfactory proof of the continuance of such disability, and if the Insured shall fail to furnish such proof, or if it shall appear to the Company that the Insured is able to perform any work or to follow any occupation whatsoever for compensation, gain or profit, all premiums thereafter falling due shall be paid in conformity with the policy.

Without prejudice to any other cause of disability, the entire and irrecoverable loss of the sight of both eyes, or the severance of both hands at or above the wrists, or of both feet at or above the ankles, or of one entire hand and one entire foot, will be considered as total and permanent disability within the meaning of this provision, and the Company upon satisfactory proof of such loss or severance will waive the premiums thereafter becoming due under the policy.

After the premium stated on the face of the policy has been paid for the full number of years stated above, it will be reduced, if premiums are payable thereafter, by the amount of the above additional premium.

Dated at New York the twenty-third day of December, 1913.
W. J. EASTON,
CHARLES A. PEABODY,
President.

Secretary.

APPLICATION.

THIS APPLICATION is made to THE MUTUAL LIFE INSURANCE COMPANY OF NEW YORK. All the following statements and answers, and all those that I make to the Company's Medical Examiner, in continuation of this application, are true, and are offered to the Company as an inducement to issue the proposed policy. I expressly waive, on behalf of myself and of any person who shall have or claim any interest in any policy issued hereunder, all provisions of law forbidding any physician or other person who has attended or examined me, or who may hereafter attend or examine me, from disclosing any knowledge or information which he thereby acquired. The proposed policy shall not take effect unless and until

the first premium shall have been paid during my continuance in good health, and unless also the policy shall have been delivered t and received by me during my continuance in good health, excep in case a conditional receipt shall have been issued as hereinafte provided:

During the period of one year following the date of issue o the policy of insurance for which application is hereby made, I wi not engage in any of the following extra hazardous occupations o employments: retailing intoxicating liquors, handling electric wire or dynamos, blasting, mining, submarine labor, aeronautic ascen sions, the manufacture of highly explosive substances, service upo any railroad train or track or in switching or in coupling cars, or o any steam or other vessel, unless written permission is expressl granted by the Company. It is understood and agreed that th risk of death will not be covered by the policy if such death oceu by my own act, whether sane or insane, during the period of on year next following the date of issue.

I certify that each and all of the foregoing statements an answers were read by me and are fully and correctly recorde by the Medical Examiner.

20 PREMIUMS LIFE ANNUAL DIVIDEND POLICY WITH DISABILITY BENEFIT RIDER.

No. 99999.
AMOUNT $10,000.

AGE 35.

ANNUAL PREMIUM $359.30.

NATIONAL LIFE INSURANCE COMPANY OF THE UNITED STATES OF AMERICA,

CHICAGO, ILL.

Hereby Agrees to Pay Ten Thousand Dollars to Mary Doe (wife of the Insured) if living, if not living, to the Insured's Executors, Administrators or Assigns, or to any other Beneficiary designated by the Insured as hereinafter provided, at the Home Office of the Company in the City of Chicago, Illinois, less any indebtedness to the Company hereon and any unpaid portion of the current year's premium, upon receipt of due proof of the death of John Doe the Insured hereunder, during the continuance of this Contract, as hereinafter provided.

Dividends: This Policy shall participate in the surplus of the Company. The Company, beginning at the end of the second policy year, and annually thereafter, will determine and account for the portion of the surplus accruing on this Policy. The Insured shall be entitled to receive the dividends apportioned, either

(A) In Cash; or,

(B) Applied to reduce future premiums, if any; or,

(C) Applied to purchase Paid-up Participating Additions to this Policy at the Company's single premium rate for the attained age of the Insured.

If the Insured does not select one of the above options, the dividends will be paid in Cash.

BENEFITS, PRIVILEGES AND PROVISIONS.

CHANGE OF BENEFICIARY.-The Insured shall have the right, at any time when this Policy is in force and not assigned, to change the Beneficiary or Beneficiaries, in accordance with the rules of the Company, by filing with the Company a written request for the change desired and presenting the Policy for endorsement,__ such change to take effect upon endorsement of the same upon the Policy by the Company.

INCONTESTABILITY.-This Policy shall be incontestable after two years from its date, except for non-payment of premium, and except for violation of its conditions in regard to military or naval service in time of war. If, however, the age of the Insured has been misstated, the amount payable under this Policy, either within or after the contestable period, shall be such amount of insurance as the premium paid would have purchased at the rate for the correct age of the Insured. Age will be admitted on satisfactory proof.

The Insured may serve in the militia in time of peace, or for the purpose of preserving order in case of riot; but in time of war, before engaging in hostilities, a written permit must be obtained from the Company. On written request and payment of the extra premium charged therefor, a permit will be granted for military or naval service in time of war. In case of the death of the Insured from service in war, without such permit, the liability of the Company shall be limited to the reserve hereon.

GRACE IN PAYMENT OF PREMIUMS.-A grace of one month will be allowed in the payment of each premium after the first, during which month the insurance will continue in force; and if the Insured shall die within the month of grace, the unpaid premium for the current policy year will be deducted from the amount payable under this Policy.

REINSTATEMENT.-This Policy, if not previously surrendered to the Company, will be reinstated at any time within three years from date of default in payment of premium, upon written application therefor accompanied by proof of insurability satisfactory to the Company, and upon the payment of premiums to date of reinstatement, with interest at the rate of five per cent per annum, and payment or reinstatement, with interest at contract rate, of any indebtedness existing at the date of such default.

CASH LOANS.-At any time while this policy is in force under its original premium-paying condition, the Company will advance on proper assignment of the policy and on the sole security thereof, any sum not exceeding the cash surrender value of the policy at the end of the current policy year, less any outstanding indebtedness on or secured by the policy and any unpaid balance of the premium for the current policy year. Interest on any such loan will be at the rate of five per cent per annum and will be payable in advance to the end of the current policy year and annually in advance thereafter. Failure to repay any such advance or loan or to pay interest, shall not avoid the policy unless the total indebtedness thereon to the company shall equal or exceed the loan value at the time of such failure, nor until one month after notice shall have been mailed by the Company to the last known address of the Insured and of the assignee, if any.

NON-FORFEITURE PROVISIONS.

VALUES UPON SURRENDER OR LAPSE.-After premiums shall have been paid hereon for three full years, in case of default in premium payments, the Insured or the legal holder hereof shall be entitled:

CASH SURRENDER VALUE. To receive the Cash Surrender Value of this Policy, upon legal surrender thereof to the Company at its Home office within two months after date of default; or,

PAID-UP INSURANCE.-Upon written application and legal surrender of this Policy to the Company at its Home Office, within two months after default, to have this Policy reissued by endorsement as a Paid-Up Non-Participating Policy payable at the same time and on the same conditions as this Policy, for such amount as the Cash Surrender Value of this Policy, less any indebtedness thereon, will purchase, applied as a net single premium at the attained age of the Insured, according to the American Experience Table of Mortality with interest at the rate of three and one-half per cent per annum; or,

EXTENDED INSURANCE.-To have the Policy automatically extended in force from date of default, without participation and without the right to loans, for its face amount, including any dividend additions and less any indebtedness thereon, for the number of years and complete months which the Cash Surrender Value of this Policy at date of default, less any indebtedness thereon, will purchase, applied as a net single premium at the attained age of the Insured, according to the American Experience Table of Mortality with interest at the rate of three and one-half per cent per

annum.

The Cash Surrender Values of this Policy from the end of the third year to the end of the fourteenth year are the full reserve on the Policy and any dividend additions thereto, according to the American Experience Table of Mortality with interest at the rate of three and one-half per cent per annum, less a percentage (not more than one) of the face amount of the Policy. At the end of the fifteenth year and thereafter the Cash Surrender Values are the full reserve by said standard.