Option (5) shall not be available (without the permission of the Company) if there be more than one beneficiary living. If settlement of this policy be made in accordance with any of the above Options at Maturity, the amount of the payments under Options (1), (2), (3) or (4) or of the instalments certain under Option (5) will be increased after one full year, by such annual dividends as may be declared by the Directors. TABLE OF LOAN AND SURRENDER VALUES. Assuming that the policy is free from indebtedness and statutory restrictions, and that the premium for the current policy year has been paid. The table below is on the basis of $1,000, and the figures given for age 35 apply to policy. As this contract is for $10,000 the values will be ten times those stated below. The term for which extended insurance will be granted remains the same without regard to the amount of the policy. AGE 30 AGE 31 AGE 32 AGE 33 34567890 Policy Loan Val. Cash or Insurance Paid-up AGE 34 586 Pol. Paid up AGE 35 69. 345678000 Loan Val. 69 130 641 Pol. Paid up 653 Pol. Paid up Any dividend additions shall operate to increase the benefits in the above schedule of values. The values in the above table are based upon the American Experience Table of Mortality with interest at three per cent less an amount not exceeding two and one-half per cent of the sum assured. The cash value in any year is at least equal to the value of the extended insurance calculated on the basis of the above mentioned table of mortality and rate of interest. After the twentieth year the minimum basis for values shall be the above mentioned table of mortality and rate of interest, less an amount not exceeding one per cent upon the sum assured. CANADA LIFE ASSURANCE COMPANY. To be attached to Policy No. 99999 on the life of John Smith. TOTAL DISABILITY BENEFIT. (a) If the assured before attaining the age of 60 years shall furnish during continuance of this contract proof satisfactory to the Company that he has become wholly and permanently disabled by bodily injury or disease, so that he shall and will be permanently, continuously and wholly prevented thereby from performing any work for compensation or profit, or from following any gainful occupation, and if premiums have been duly paid to the end of the policy year, in which such proof is approved, the Company will waive payment of the premiums thereafter falling due while such disability remains total and permanent and not otherwise, and will make endorsement hereon to that effect, which premium so waived will not be an indebtedness hereon and this policy will continue in full force. (b) Or if desired the Company will, after proof of such disability as above provided, upon payment of all indebtedness to the Company in respect of the Policy whether under the non-forfeiture provision or otherwise, endorse hereon an agreement to pay forthwith to the assured or other person entitled thereto one-twentieth of the sum assured and to make payment of a like sum yearly thereafter until Twenty such payments in all shall have been made. The agreement for such payment shall be made and accepted in satisfaction of all other benefits and privileges herein provided for. PROVIDED ALWAYS that notwithstanding proof of disability may have been accepted by the Company, the assured shall as often as required by the Company furnish satisfactory proof of the continuance of such disability. If the assured shall fail to furnish such Loan Val. Cash or Insurance Paid-up Insurance f P proof or if he shall so far recover as to be able to engage in any gainful occupation, then all premiums thereafter falling due shall be paid to the Company as originally provided in the policy; and if option (b) shall have been selected the Company's obligation to pay any further installments under it shall cease and determine, and the policy shall be restored to the amount mentioned in such endorsed agreement less the aggregate of the installments paid thereunder, which amount shall be payable according to the terms of the policy, the guaranteed values in the Table on the second page hereof being reduced in the proportion that such amount bears to the original sum mentioned in the policy, and the profits, if any, thereafter shall be in the like proportion. Without prejudice to any other cause of total and permanent disability the Company will consider 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 as total and permanent disability within the meaning of this provision. This benefit is granted in consideration of an extra annual premium of three dollars, and this extra premium is included in the amount of the premiums stated on the first page of this policy. This benefit and the extra premium therefor may be cancelled by the written request of the assured at any premium anniversary upon endorsement of such cancellation upon the Policy by the Company. If this benefit be continued in force until the assured has attained his sixtieth birthday any premiums which may fall due thereafter on this policy shall be reduced by the amount of the extra premium above stated for this benefit. Toronto, Canada, March 1, 1914. C. R. ACRES, Secretary. E. W. Cox, President. APPLICATION. I hereby declare and agree that to the best of my knowledge and belief I am at present in good health, not being afflicted with any disease or disorder, external or internal, and that the answers to the above questions are, and that those to be given to the Company's Medical Examiner shall be, full, complete and true; that I will accept and pay the first premium on the policy hereby applied for when issued by the Canada Life Assurance Company, subject to the privileges and conditions contained in said policy; and further that the said policy shall not take effect until the same C shall be issued and delivered by the said Company and the first premium paid thereon in full, and Head Office receipt therefor be received by me, while my health is in the same condition as described in this application and in my answers to the Company's Medical Examiner; and further that the principles and methods or hereafter followed by the Company in determining and allotting the surplus in connection with participating policies shall be accepted by all parties; and further that the Company shall not be liable on the said policy in the event of my death by self-destruction (whether I be sane or insane) during the first policy year. now I hereby request that the Company's automatic premium loan privilege shall become operative should that privilege be available under the policy hereby applied for. MEDICAL EXAMINER'S FORM. The foregoing answers are full, complete and true, and are a continuation of and form part of my application for Assurance to and in the Canada Life Assurance Company. By this Policy of Insurance agrees to pay the sum of Ten Thousand Dollars, at its Home Office in the City of Denver, IMMEDIATELY upon receipt of due proof of the death of John Doe, of Denver, County of Denver, State of Colorado, (the Insured under this Policy,) to Mary Doe, Wife, with the right of revocation, subject to all the requirements, privileges and provisions stated on the following pages, which are conditions precedent, and are a material part of this contract as fully as if they were recited at length over the signatures hereto affixed. THIS CONTRACT is made in consideration of the written application of the above named Insured, which is made a part hereof, a copy of which is hereto attached, and the payment in advance to said Company on the delivery of this Policy of Three Hundred Eighty-one and 40-100 Dollars, being the premium for Term Insurance ending on the Thirtieth day of November, 1911, and the Legal Reserve required, and the further payment of a like sum annually thereafter upon the Thirtieth day of the month of November in every year during the life of the said Insured, until the premiums for Twenty full years shall have been duly paid to said Company. After delivery of this Policy to the Insured, it takes effect as of the Thirtieth day of November, Nineteen Hundred and Ten. In Witness Whereof, the Company has caused this Policy to be executed this Thirtieth day of November, 1910. THOS. F. DALY, Examined by President. PARTICIPATION.-This Policy shall participate in the surplus of the Company, as herein provided. DIVIDENDS.-At the end of the third year and annually thereafter as long as this Policy is maintained in full force and effect, the proportion of divisible surplus accumulated hereunder shall be ascertained and distributed, and, at the option of the Insured, shall be either (a) miums; or (c) icy; or Paid in cash; or Applied toward the payment of any premium or preApplied to the purchase of Paid-up Additions to the Pol(a) Left to accumulate to the credit of the Policy with interest at 3 per cent. per annum. Such accumulated dividends may be used for the purpose expressed in the Special Accelerating Maturity Clause, and if not so used, shall be paid at the maturity of the Policy, but in any event may be withdrawn on any anniversary. Unless the owner of the Policy shall elect otherwise within three months after the mailing by the Company of a written notice requiring the election of one of the four above options, the dividends will be applied to the purchase of Paid-up Additions, Option (c), which may be subsequently surrendered for a cash value which shall not be less than the original cash dividend. Any accumulated dividends, or the Cash Value of any dividends on this Policy, according to the American Experience Table of Mortality and interest at the rate of three and one-half per cent. per annum, shall be added to the reserve used in the calculation of the values specified in the Table of Loan anu Surrender Values herein set forth and shall increase the said values accordingly. SPECIAL ACCELERATING MATURITY CLAUSE.-When this Policy's share of apportioned surplus, together with the reserve value hereunder, shall equal the cost, according to the American Experience Table of Mortality and three and one-half per cent. interest, of paid-up Life Insurance, for the face amount of this Policy at the attained age of the Insured, premium payments may be discontinued and the Policy endorsed as a fully paid-up participating Policy for the face value. LOANS.-After three full years' premiums have been paid hereon, the Company will advance, upon proper assignment of this Policy, and upon the sole security thereof, at a rate of interest not greater than six per cent. per annum, a sum not exceeding the amount specified in the Table of Loan Values herein set forth. The Company will deduct from any loan made hereunder any existing indebtedness on the Policy, any unpaid premium for the current policy year, and interest in advance on the loan to the end of the current policy year. If the interest on any loan be not paid when due it shall be added to the principal of the loan and bear interest at the same rate, provided the total indebtedness does not exceed the total loan value. OPTIONS ON SURRENDER.-After three full years' premiums have been paid hereon, the owner, on surrender of this Policy within one month after any default, may elect, according to the Table of Surrender Values herein set forth: (a) to accept the value of this Policy in Cash; or, (b) to receive Non-Participating Paid-up Insurance, payable at the same time and on the same conditions as this Policy; or, (c) to have the Insurance continted in force from date of default, without participation and without right to loans, for its face amount, less any indebtedness to the Company hereon. Failure to repay any loan or the interest thereon, when due, shall not avoid this policy until the total indebtedness shall equal or exceed the cash value, nor until thirty-one days after notice shall have been mailed to the last known address of the Insured, and to the assignee of record, if any. |