DISABILITY INCOME PROTECTION

Benefit Period - Male

Issue Occupation Base Policy Waiting Period (Days)

Age Class 30 60 90 180 18-29 AAAA $2.70 $2.80 $2.90 $3.10 AAA / AA 3.00 3.10 3.20 3.40 A / B 3.30 3.50 3.60 30-34 AAAA 3.50 3.60 3.70 3.90 AAA / AA 3.90 4.00 4.10 4.30 A / B 4.20 4.40 4.50 35-39 AAAA 4.10 4.10 4.30 4.50 AAA / AA 4.50 4.60 4.80 5.00 A / B 5.00 5.10 5.20 40-44 AAAA 4.70 4.90 5.00 5.20 AAA / AA 5.20 5.40 5.50 5.80 A / B 5.80 5.90 6.00 45-49 AAAA 5.40 5.60 5.80 6.00 AAA / AA 6.00 6.20 6.40 6.70 A / B 6.70 6.80 7.00 50-54 AAAA 6.40 6.60 6.80 7.10 AAA / AA 7.10 7.30 7.50 7.90 A / B 7.80 8.00 8.20 55-60 AAAA 7.40 7.60 7.70 8.20 AAA / AA 8.20 8.40 8.60 9.10 A / B 9.00 9.30 9.50

Benefit Period - Female

Issue Occupation Base Policy Waiting Period (Days)

Age Class 30 60 90 180 18-29 AAAA $3.70 $3.80 $3.90 $4.10 AAA / AA 4.10 4.20 4.30 4.50 A / B 4.40 4.60 4.80 30-34 AAAA 4.60 4.80 5.00 5.10 AAA / AA 5.10 5.30 5.50 5.70 A / B 5.60 5.80 6.00 35-39 AAAA 5.40 5.60 5.70 6.00 AAA / AA 6.00 6.20 6.30 6.70 A / B 6.60 6.80 6.90 40-44 AAAA 6.20 6.40 6.60 6.90 AAA / AA 6.90 7.10 7.30 7.70 A / B 7.70 7.80 8.00 45-49 AAAA 7.20 7.50 7.70 8.10 AAA / AA 8.00 8.30 8.50 9.00 A / B 8.90 9.10 9.30 50-54 AAAA 8.60 8.70 8.90 9.50 AAA / AA 9.50 9.70 9.90 10.50 A / B 10.40 10.70 10.90 55-60 AAAA 9.80 10.10 10.40 10.90 AAA / AA 10.90 11.20 11.50 12.10 A / B 12.00 12.30 12.70

Male and Female

Issue Age Occupation Class Rate

18-49 AAAA $1.30 AAA 1.40 AA 1.90 A 2.30 B 3.20 50-60 AAAA $1.40 AAA 1.60 AA 2.10 A 2.70 B 3.70

2

First Day Disability Income Benefit While Hospital Confined – Item 236

Benefit amount must equal base policy’s monthly disability benefit.

Annual non-cigarette smoker premium per each $100 of monthly benefit.

3

Accidental Death and Dismemberment Benefit – Item 237

Minimum benefit, $10,000; Maximum benefit, $100,000

Annual non-cigarette smoker premium per $1,000 of coverage.

50200 (5-04)

WWW.AUTO-OWNERS.COM

Determining Monthly Benefits To Be Paid

To determine the monthly disability benefit, we will divide the monthly loss of income by the pre-loss income and

multiply the result by the Monthly Benefit purchased, as shown on the Policy Data Page.

Monthly Loss of ÷

Pre-Loss

_x

Monthly Disability

_{= Monthly Disability}

Earned Income

Earned Income

Benefit Purchased

Benefit Paid

Example: $2,000*

$3,000

$2,000

$1,333.33

*

$3,000 Pre-loss earned income minus $1,000 per month workers compensation benefit being paid = $2,000 Monthly Loss of Earned Income.

Definition of Total Disability

AAAA

-

Own occupation to age 65

AAA & AA

-

Own occupation for 5 years

A & B

-

Own occupation for 2 years

Then any occupation for which you are qualified or may become qualified by reason of education, training or experience; and with due regard to your vocation and economic status at the time total disability begins.

Earned Income

is gross income from employment less

business expenses before personal deductions.

Monthly Loss of Earned Income

is Pre-Loss Earned

Income less the amount actually received while totally

disabled from:

• Wages, salaries, bonuses, commissions, fees or

other payments for personal services; and

• Social Security, workers compensation, or other

federal or state cash sickness plans; and

• Any lump sum payments that are greater than

Pre-Loss Earned Income. These will be considered

income during future months at a rate not exceeding

Pre-Loss Earned Income until exhausted.

Pre-Loss Earned Income

is monthly Earned Income averaged for the 12 months just prior to becoming totally disabled.

PREMIUM CALCULATION

Annual Premium per each $100 of Monthly Benefit

Name _____________________________________________ Age ________ Monthly Disability Benefit $ ___________________

Male

Occupation Class:

AAAA

AAA

AA

A

B

Female

Benefit Period:

2 Year

5 Year

To Age 65

Waiting Period:

30 Day

60 Day

90 Day

180 Day

1

Item 235 Individual Disability Income: $ _____________________x __________________ = $ ______________________

Non-smoker premium Number of Units

per $100 unit

2

Item 236 Optional First Day Disability

Income Benefit While Hospital Confined: $ _____________________x __________________ = $ ______________________

Non-smoker premium Same number of

per $100 unit units as above

3

Item 237 Optional Accidental

Death and Dismemberment Benefit:

$ _____________________x $_________________ = $ ______________________

Non-smoker premium Amount

per $100 unit

Subtotal = $ ______________________

Cigarette smoker surcharge, if applicable: Add 10% of Subtotal

= $ ______________________

Add Annual Premium Adjustment Factor = $ ______________________

All States Except KY add $15.00

KY add $20.00

TOTAL ANNUAL PREMIUM = $ ______________________

$_________________________________ $ _________________________________ $ _______________________________

Semiannual Premium Quarterly Premium Monthly EFT Premium

.52 .265 .086

DISABILITY

INCOME

PROTECTION

Item 235

Waiting Period (Days)

Benefit Period - Female

2 Year 5 Year To Age 65

Issue

Age Class Waiting Period (Days)

30 60 90 30 60 90 30 60 90 180 18-29 AAAA $24 $19 $16 $35 $28 $24 $46 $39 $33 $28 AAA 27 21 18 39 31 27 51 43 37 31 AA 32 25 21 45 36 30 59 49 42 35 A 39 31 26 53 43 37 B 47 38 32 64 53 45 30-34 AAAA 26 21 17 40 32 27 55 46 41 33 AAA 29 23 19 44 35 30 61 51 45 37 AA 34 26 22 51 41 34 71 58 51 42 A 41 33 28 58 49 41 B 50 40 34 71 60 50 35-39 AAAA 28 23 19 44 36 32 62 53 46 39 AAA 31 25 21 49 40 35 69 59 51 43 AA 37 29 24 57 46 39 80 67 58 48 A 45 36 31 66 55 48 B 54 44 37 79 67 58 40-44 AAAA 30 23 20 50 40 35 68 56 50 42 AAA 33 25 22 55 44 39 76 62 56 47 AA 39 31 26 64 52 44 88 74 64 53 A 45 37 33 70 61 54 B 55 46 40 84 74 65 45-49 AAAA 32 25 23 56 45 41 70 59 52 43 AA 36 28 25 62 50 45 78 66 58 48 AA 43 34 28 72 60 51 91 77 67 54 A 49 41 37 79 69 63 B 59 50 45 95 85 76 50-54 AAAA 33 27 23 61 52 46 70 59 52 43 AAA 37 30 26 68 58 51 78 66 58 48 AA 43 35 30 79 66 57 91 77 67 54 A 52 44 39 88 78 70 B 63 54 47 106 95 84 55-60 AAAA 47 40 35 67 56 50 70 59 52 43 AAA 52 44 39 74 62 55 78 66 58 48 AA 61 51 44 86 73 63 91 77 67 54 A 73 64 58 96 85 77 B 88 78 70 116 103 93

Waiting Period (Days)

Benefit Period - Male

2 Year 5 Year To Age 65

Issue

Age Class Waiting Period (Days)

30 60 90 30 60 90 30 60 90 180 18-29 AAAA $18 $14 $13 $25 $21 $19 $32 $27 $24 $21 AAA 20 16 14 28 23 21 36 30 27 23 AA 23 19 16 32 27 23 40 34 30 26 A 28 23 20 37 31 27 B 34 28 24 45 38 33 30-34 AAAA 19 15 14 29 24 21 39 33 29 25 AAA 21 17 15 32 27 23 43 37 32 28 AA 25 20 17 36 30 26 48 41 36 31 A 29 24 20 41 35 30 B 36 30 25 50 42 36 35-39 AAAA 22 17 15 33 28 24 45 38 34 29 AAA 24 19 17 37 31 27 50 42 38 32 AA 27 22 19 41 35 30 56 48 42 36 A 32 27 23 47 40 35 B 39 33 28 57 48 42 40-44 AAAA 23 19 16 38 32 28 51 44 39 32 AAA 26 21 18 42 36 31 57 49 43 36 AA 30 24 21 48 40 35 64 55 48 41 A 35 29 25 54 45 40 B 43 36 31 65 55 49 45-49 AAAA 27 23 19 47 40 34 59 51 45 38 AAA 30 25 21 52 44 38 66 57 50 42 AA 35 28 24 59 49 43 75 64 56 47 A 41 35 30 66 56 50 B 50 42 36 79 68 61 50-54 AAAA 31 25 22 58 49 42 65 56 49 41 AAA 34 28 24 64 54 47 72 62 54 45 AA 40 32 28 73 62 54 84 71 62 51 A 47 41 34 81 69 62 B 57 49 41 97 83 75 55-60 AAAA 47 40 34 67 56 49 70 59 51 42 AAA 52 44 38 74 62 54 78 66 57 47 AA 60 50 43 86 72 62 90 76 65 52 A 72 63 55 95 82 72 B 87 77 67 114 99 87

Auto-Owners Disability Income Policy Will Provide

Money to Replace Loss of Earned Income While

Totally Disabled from Sickness or an Accident

7. Premiums are waived retroactively after

90 consecutive days of total disability.

8. First Day Disability Income Benefit may

be added to provide a daily income while

hospital confined.

9. An optional Accidental Death and

Dismemberment Benefit may be added for

any amount from $10,000 to $100,000.

10. A Partial Disability Benefit is included

at no additional premium. Partial

disability must follow a period of total

disability for which benefits were paid.

The Partial Disability Benefit equals

one half the monthly benefit paid while

totally disabled, for up to six months

or until the end of the benefit period,

whichever is less.

Determining Maximum Disability Benefit Available

MAXIMUM MONTHLY BENEFIT

AVAILABLE

Use Net Annual Income Table

Subject to Maximum by Occupation Class $ _______

Less: Existing Disability Income Benefit

*

_{$ _______}

Less: Unearned Income

**

_{$ _______}

Equals: Maximum Monthly Benefit

Available

***

_{$ _______}

The MINIMUM Disability Benefit which can be

purchased is $300 per month.

* Other Disability policies, salary continuation or sick pay benefits likely to last more than 26 weeks.

** Unearned income includes rents, pensions, investment income, etc. Ignore unearned income less than 10% of gross income.

Use 50% of unearned income if it is 10-50% of gross income. Not eligible if unearned income is 50% or more of gross earnings. *** The maximum monthly benefit which can be purchased is the lessor of the maximum amount listed in the Net Annual Income Table or the maximum based on the Occupation Class Table below.

Net Annual Income Table

Net Maximum Net Maximum Annual Income* Mo. Benefit Annual Income* Mo. Benefit

$20,000 $1,250 $46,000 $2,650 20,500 1,280 48,000 2,760 21,500 1,310 50,000 2,830 21,500 1,340 52,000 2,950 22,000 1,380 54,000 3,060 22,500 1,410 56,000 3,170 23,000 1,440 58,000 3,240 23,500 1,470 60,000 3,300 24,000 1,480 65,000 3,520 24,500 1,510 70,000 3,790 25,000 1,540 75,000 4,000 25,500 1,570 80,000 4,200 26,000 1,600 85,000 4,390 26,500 1,630 90,000 4,500 27,000 1,670 95,000 4,670 27,500 1,700 100,000 4,750 28,000 1,730 110,000 5,040 28,500 1,740 120,000 5,200 29,000 1,760 130,000 5,530 29,500 1,790 140,000 5,720 30,000 1,830 150,000 6,000 31,000 1,890 160,000 6,270 32,000 1,950 170,000 6,520 33,000 1,980 180,000 6,900 34,000 2,040 190,000 7,130 35,000 2,100 200,000 7,330 36,000 2,160 220,000 7,880 37,000 2,220 240,000 8,000 38,000 2,250 260,000 8,450 39,000 2,310 280,000 8,870 40,000 2,330 300,000 9,500 42,000 2,420 320,000 10,000 44,000 2,530

* Net Annual Income for self employed individuals = Gross income from employment less business deductions before personal exemptions. Gross income includes wages (not overtime pay), salaries, bonuses, commissions, fees or other payments for personal services. Use 2 year average for commissioned sales personnel.

NOTE: Should the actual net annual income fall between the listed amounts, use the maximum for the next highest listed net annual income amount.

1. Worldwide, 24-hour-a-day coverage while

on or off the job.

2. Benefit periods of 2 years, 5 years, or to age

65.

3. Waiting periods (the number of days before

benefits begin) are 30, 60, 90 or 180 days.

4. Coverage is guaranteed renewable to age

65.

5. Premium rates can be changed on a class

basis only. Any change will apply to all

policies of this type and having a common

policy form number.

6. A non-smoker discount is given to those

who have not smoked cigarettes for 12

months or more.

P

eople work hard to afford what they enjoy in life, and to pay their continuing

expenses such as food, clothing, shelter, utilities, insurance premiums, and

entertainment. Their ability to earn an income is their most valuable asset.

If that ability is interrupted because of an accident or sickness, they may find it difficult

to maintain their standard of living and impossible to plan for the future. Unfortunately,

the chance of a disabling accident or sickness is greater than most people think.

• 1 out of 4 workers, age 35-65, will be disabled for 90 days.

**

• Disability is the cause of nearly 50% of all home foreclosures.

**

• Before age 65, if a disability lasts 90 days, it is expected to last an average of 2 1/2 years.

***

• 80% of U.S. workers will exhaust their savings in only two months without the ability to earn

an income.

***

* Society of Acturaries

** National Association of Life Underwriters *** Commissioner’s Disability Table

1

Disability Income Premium – Item 235

Annual non-cigarette smoker premium per each $100 unit of monthly benefit

See back panel for Premium Calculation Worksheet

Occupation Class Table

Occupation Subject to Monthly Maximum Class Maximum Benefit of Benefit Period

AAAA $10,000 To Age 65

AAA 8,000 To Age 65

AA 6,000 To Age 65

A 4,000 5 Years

Determining Maximum Disability Benefit Available

MAXIMUM MONTHLY BENEFIT

AVAILABLE

Use Net Annual Income Table

Subject to Maximum by Occupation Class $ _______

Less: Existing Disability Income Benefit

*

_{$ _______}

Less: Unearned Income

**

_{$ _______}

Equals: Maximum Monthly Benefit

Available

***

_{$ _______}

The MINIMUM Disability Benefit which can be

purchased is $300 per month.

* Other Disability policies, salary continuation or sick pay benefits likely to last more than 26 weeks.

** Unearned income includes rents, pensions, investment income, etc. Ignore unearned income less than 10% of gross income.

Use 50% of unearned income if it is 10-50% of gross income. Not eligible if unearned income is 50% or more of gross earnings. *** The maximum monthly benefit which can be purchased is the lessor of the maximum amount listed in the Net Annual Income Table or the maximum based on the Occupation Class Table below.

Net Annual Income Table

Net Maximum Net Maximum Annual Income* Mo. Benefit Annual Income* Mo. Benefit

$20,000 $1,250 $46,000 $2,650 20,500 1,280 48,000 2,760 21,500 1,310 50,000 2,830 21,500 1,340 52,000 2,950 22,000 1,380 54,000 3,060 22,500 1,410 56,000 3,170 23,000 1,440 58,000 3,240 23,500 1,470 60,000 3,300 24,000 1,480 65,000 3,520 24,500 1,510 70,000 3,790 25,000 1,540 75,000 4,000 25,500 1,570 80,000 4,200 26,000 1,600 85,000 4,390 26,500 1,630 90,000 4,500 27,000 1,670 95,000 4,670 27,500 1,700 100,000 4,750 28,000 1,730 110,000 5,040 28,500 1,740 120,000 5,200 29,000 1,760 130,000 5,530 29,500 1,790 140,000 5,720 30,000 1,830 150,000 6,000 31,000 1,890 160,000 6,270 32,000 1,950 170,000 6,520 33,000 1,980 180,000 6,900 34,000 2,040 190,000 7,130 35,000 2,100 200,000 7,330 36,000 2,160 220,000 7,880 37,000 2,220 240,000 8,000 38,000 2,250 260,000 8,450 39,000 2,310 280,000 8,870 40,000 2,330 300,000 9,500 42,000 2,420 320,000 10,000 44,000 2,530

* Net Annual Income for self employed individuals = Gross income from employment less business deductions before personal exemptions. Gross income includes wages (not overtime pay), salaries, bonuses, commissions, fees or other payments for personal services. Use 2 year average for commissioned sales personnel.

NOTE: Should the actual net annual income fall between the listed amounts, use the maximum for the next highest listed net annual income amount.

Occupation Class Table

Occupation Subject to Monthly Maximum Class Maximum Benefit of Benefit Period

AAAA $10,000 To Age 65

AAA 8,000 To Age 65

AA 6,000 To Age 65

A 4,000 5 Years

Waiting Period (Days)

Benefit Period - Female

2 Year 5 Year To Age 65 Issue

Age Class Waiting Period (Days)

30 60 90 30 60 90 30 60 90 180 18-29 AAAA $24 $19 $16 $35 $28 $24 $46 $39 $33 $28 AAA 27 21 18 39 31 27 51 43 37 31 AA 32 25 21 45 36 30 59 49 42 35 A 39 31 26 53 43 37 B 47 38 32 64 53 45 30-34 AAAA 26 21 17 40 32 27 55 46 41 33 AAA 29 23 19 44 35 30 61 51 45 37 AA 34 26 22 51 41 34 71 58 51 42 A 41 33 28 58 49 41 B 50 40 34 71 60 50 35-39 AAAA 28 23 19 44 36 32 62 53 46 39 AAA 31 25 21 49 40 35 69 59 51 43 AA 37 29 24 57 46 39 80 67 58 48 A 45 36 31 66 55 48 B 54 44 37 79 67 58 40-44 AAAA 30 23 20 50 40 35 68 56 50 42 AAA 33 25 22 55 44 39 76 62 56 47 AA 39 31 26 64 52 44 88 74 64 53 A 45 37 33 70 61 54 B 55 46 40 84 74 65 45-49 AAAA 32 25 23 56 45 41 70 59 52 43 AA 36 28 25 62 50 45 78 66 58 48 AA 43 34 28 72 60 51 91 77 67 54 A 49 41 37 79 69 63 B 59 50 45 95 85 76 50-54 AAAA 33 27 23 61 52 46 70 59 52 43 AAA 37 30 26 68 58 51 78 66 58 48 AA 43 35 30 79 66 57 91 77 67 54 A 52 44 39 88 78 70 B 63 54 47 106 95 84 55-60 AAAA 47 40 35 67 56 50 70 59 52 43 AAA 52 44 39 74 62 55 78 66 58 48 AA 61 51 44 86 73 63 91 77 67 54 A 73 64 58 96 85 77 B 88 78 70 116 103 93

Waiting Period (Days)

Benefit Period - Male

2 Year 5 Year To Age 65 Issue

Age Class Waiting Period (Days)

30 60 90 30 60 90 30 60 90 180 18-29 AAAA $18 $14 $13 $25 $21 $19 $32 $27 $24 $21 AAA 20 16 14 28 23 21 36 30 27 23 AA 23 19 16 32 27 23 40 34 30 26 A 28 23 20 37 31 27 B 34 28 24 45 38 33 30-34 AAAA 19 15 14 29 24 21 39 33 29 25 AAA 21 17 15 32 27 23 43 37 32 28 AA 25 20 17 36 30 26 48 41 36 31 A 29 24 20 41 35 30 B 36 30 25 50 42 36 35-39 AAAA 22 17 15 33 28 24 45 38 34 29 AAA 24 19 17 37 31 27 50 42 38 32 AA 27 22 19 41 35 30 56 48 42 36 A 32 27 23 47 40 35 B 39 33 28 57 48 42 40-44 AAAA 23 19 16 38 32 28 51 44 39 32 AAA 26 21 18 42 36 31 57 49 43 36 AA 30 24 21 48 40 35 64 55 48 41 A 35 29 25 54 45 40 B 43 36 31 65 55 49 45-49 AAAA 27 23 19 47 40 34 59 51 45 38 AAA 30 25 21 52 44 38 66 57 50 42 AA 35 28 24 59 49 43 75 64 56 47 A 41 35 30 66 56 50 B 50 42 36 79 68 61 50-54 AAAA 31 25 22 58 49 42 65 56 49 41 AAA 34 28 24 64 54 47 72 62 54 45 AA 40 32 28 73 62 54 84 71 62 51 A 47 41 34 81 69 62 B 57 49 41 97 83 75 55-60 AAAA 47 40 34 67 56 49 70 59 51 42 AAA 52 44 38 74 62 54 78 66 57 47 AA 60 50 43 86 72 62 90 76 65 52 A 72 63 55 95 82 72 B 87 77 67 114 99 87

Auto-Owners Disability Income Policy Will Provide

Money to Replace Loss of Earned Income While

Totally Disabled from Sickness or an Accident

7. Premiums are waived retroactively after

90 consecutive days of total disability.

8. First Day Disability Income Benefit may

be added to provide a daily income while

hospital confined.

9. An optional Accidental Death and

Dismemberment Benefit may be added for

any amount from $10,000 to $100,000.

10. A Partial Disability Benefit is included

at no additional premium. Partial

disability must follow a period of total

disability for which benefits were paid.

The Partial Disability Benefit equals

one half the monthly benefit paid while

totally disabled, for up to six months

or until the end of the benefit period,

whichever is less.

Determining Maximum Disability Benefit Available

MAXIMUM MONTHLY BENEFIT

AVAILABLE

Use Net Annual Income Table

Subject to Maximum by Occupation Class $ _______

Less: Existing Disability Income Benefit

*

_{$ _______}

Less: Unearned Income

**

_{$ _______}

Equals: Maximum Monthly Benefit

Available

***

_{$ _______}

The MINIMUM Disability Benefit

which can be

purchased is $300 per month.

* Other Disability policies, salary continuation or sick pay benefits likely to last more than 26 weeks.

** Unearned income includes rents, pensions, investment income, etc. Ignore unearned income less than 10% of gross income.

Use 50% of unearned income if it is 10-50% of gross income. Not eligible if unearned income is 50% or more of gross earnings. *** The maximum monthly benefit which can be purchased is the lessor of the maximum amount listed in the Net Annual Income Table or the maximum based on the Occupation Class Table below.

Net Annual Income Table

Net Maximum Net Maximum

Annual Income* Mo. Benefit Annual Income* Mo. Benefit

$20,000 $1,250 $46,000 $2,650 20,500 1,280 48,000 2,760 21,500 1,310 50,000 2,830 21,500 1,340 52,000 2,950 22,000 1,380 54,000 3,060 22,500 1,410 56,000 3,170 23,000 1,440 58,000 3,240 23,500 1,470 60,000 3,300 24,000 1,480 65,000 3,520 24,500 1,510 70,000 3,790 25,000 1,540 75,000 4,000 25,500 1,570 80,000 4,200 26,000 1,600 85,000 4,390 26,500 1,630 90,000 4,500 27,000 1,670 95,000 4,670 27,500 1,700 100,000 4,750 28,000 1,730 110,000 5,040 28,500 1,740 120,000 5,200 29,000 1,760 130,000 5,530 29,500 1,790 140,000 5,720 30,000 1,830 150,000 6,000 31,000 1,890 160,000 6,270 32,000 1,950 170,000 6,520 33,000 1,980 180,000 6,900 34,000 2,040 190,000 7,130 35,000 2,100 200,000 7,330 36,000 2,160 220,000 7,880 37,000 2,220 240,000 8,000 38,000 2,250 260,000 8,450 39,000 2,310 280,000 8,870 40,000 2,330 300,000 9,500 42,000 2,420 320,000 10,000 44,000 2,530

* Net Annual Income for self employed individuals = Gross income from employment less business deductions before personal exemptions. Gross income includes wages (not overtime pay), salaries, bonuses, commissions, fees or other payments for personal services. Use 2 year average for commissioned sales personnel.

NOTE: Should the actual net annual income fall between the listed amounts, use the maximum for the next highest listed net annual income amount.

1. Worldwide, 24-hour-a-day coverage while

on or off the job.

2. Benefit periods of 2 years, 5 years, or to age

65.

3. Waiting periods (the number of days before

benefits begin) are 30, 60, 90 or 180 days.

4. Coverage is guaranteed renewable to age

65.

5. Premium rates can be changed on a class

basis only. Any change will apply to all

policies of this type and having a common

policy form number.

6. A non-smoker discount is given to those

who have not smoked cigarettes for 12

months or more.

P

eople work hard to afford what they enjoy in life, and to pay their continuing

expenses such as food, clothing, shelter, utilities, insurance premiums, and

entertainment. Their ability to earn an income is their most valuable asset.

If that ability is interrupted because of an accident or sickness, they may find it difficult

to maintain their standard of living and impossible to plan for the future. Unfortunately,

the chance of a disabling accident or sickness is greater than most people think.

• 1 out of 4 workers, age 35-65, will be disabled for 90 days.

**

• Disability is the cause of nearly 50% of all home foreclosures.

**

• Before age 65, if a disability lasts 90 days, it is expected to last an average of 2 1/2 years.

***

• 80% of U.S. workers will exhaust their savings in only two months without the ability to earn

an income.

***

* Society of Acturaries

** National Association of Life Underwriters *** Commissioner’s Disability Table

1

Disability Income Premium – Item 235

Annual non-cigarette smoker premium per each $100 unit of monthly benefit

See back panel for Premium Calculation Worksheet

Occupation Class Table

Occupation Subject to Monthly Maximum Class Maximum Benefit of Benefit Period

AAAA $10,000 To Age 65

AAA 8,000 To Age 65

AA 6,000 To Age 65

A 4,000 5 Years

Benefit Period - Male

Issue Occupation Base Policy Waiting Period (Days) Age Class 30 60 90 180 18-29 AAAA $2.70 $2.80 $2.90 $3.10 AAA / AA 3.00 3.10 3.20 3.40 A / B 3.30 3.50 3.60 30-34 AAAA 3.50 3.60 3.70 3.90 AAA / AA 3.90 4.00 4.10 4.30 A / B 4.20 4.40 4.50 35-39 AAAA 4.10 4.10 4.30 4.50 AAA / AA 4.50 4.60 4.80 5.00 A / B 5.00 5.10 5.20 40-44 AAAA 4.70 4.90 5.00 5.20 AAA / AA 5.20 5.40 5.50 5.80 A / B 5.80 5.90 6.00 45-49 AAAA 5.40 5.60 5.80 6.00 AAA / AA 6.00 6.20 6.40 6.70 A / B 6.70 6.80 7.00 50-54 AAAA 6.40 6.60 6.80 7.10 AAA / AA 7.10 7.30 7.50 7.90 A / B 7.80 8.00 8.20 55-60 AAAA 7.40 7.60 7.70 8.20 AAA / AA 8.20 8.40 8.60 9.10 A / B 9.00 9.30 9.50

Benefit Period - Female

Issue Occupation Base Policy Waiting Period (Days) Age Class 30 60 90 180 18-29 AAAA $3.70 $3.80 $3.90 $4.10 AAA / AA 4.10 4.20 4.30 4.50 A / B 4.40 4.60 4.80 30-34 AAAA 4.60 4.80 5.00 5.10 AAA / AA 5.10 5.30 5.50 5.70 A / B 5.60 5.80 6.00 35-39 AAAA 5.40 5.60 5.70 6.00 AAA / AA 6.00 6.20 6.30 6.70 A / B 6.60 6.80 6.90 40-44 AAAA 6.20 6.40 6.60 6.90 AAA / AA 6.90 7.10 7.30 7.70 A / B 7.70 7.80 8.00 45-49 AAAA 7.20 7.50 7.70 8.10 AAA / AA 8.00 8.30 8.50 9.00 A / B 8.90 9.10 9.30 50-54 AAAA 8.60 8.70 8.90 9.50 AAA / AA 9.50 9.70 9.90 10.50 A / B 10.40 10.70 10.90 55-60 AAAA 9.80 10.10 10.40 10.90 AAA / AA 10.90 11.20 11.50 12.10 A / B 12.00 12.30 12.70

Male and Female

Issue Age Occupation Class Rate 18-49 AAAA $1.30 AAA 1.40 AA 1.90 A 2.30 B 3.20 50-60 AAAA $1.40 AAA 1.60 AA 2.10 A 2.70 B 3.70

2

First Day Disability Income Benefit While Hospital Confined – Item 236

Benefit amount must equal base policy’s monthly disability benefit.

Annual non-cigarette smoker premium per each $100 of monthly benefit.

3

Accidental Death and Dismemberment Benefit – Item 237

Minimum benefit, $10,000; Maximum benefit, $100,000

Annual non-cigarette smoker premium per $1,000 of coverage.

50200 (5-04)

WWW.AUTO-OWNERS.COM

Determining Monthly Benefits To Be Paid

To determine the monthly disability benefit, we will divide the monthly loss of income by the pre-loss income and

multiply the result by the Monthly Benefit purchased, as shown on the Policy Data Page.

Monthly Loss of ÷

Pre-Loss

_x

Monthly Disability

_{= Monthly Disability}

Earned Income

Earned Income

Benefit Purchased

Benefit Paid

Example: $2,000*

$3,000

$2,000

$1,333.33

*

$3,000 Pre-loss earned income minus $1,000 per month workers compensation benefit being paid = $2,000 Monthly Loss of Earned Income.

Definition of Total Disability

AAAA

-

Own occupation to age 65

AAA & AA

-

Own occupation for 5 years

A & B

-

Own occupation for 2 years

Then any occupation for which you are qualified or may become qualified by reason of education, training or experience; and with due regard to your vocation and economic status at the time total disability begins.

Earned Income

is gross income from employment less

business expenses before personal deductions.

Monthly Loss of Earned Income

is Pre-Loss Earned

Income less the amount actually received while totally

disabled from:

• Wages, salaries, bonuses, commissions, fees or

other payments for personal services; and

• Social Security, workers compensation, or other

federal or state cash sickness plans; and

• Any lump sum payments that are greater than

Pre-Loss Earned Income. These will be considered

income during future months at a rate not exceeding

Pre-Loss Earned Income until exhausted.

Pre-Loss Earned Income

is monthly Earned Income averaged for the 12 months just prior to becoming totally disabled.

PREMIUM CALCULATION

Annual Premium per each $100 of Monthly Benefit

Name _____________________________________________ Age ________ Monthly Disability Benefit $ ___________________

Male

Occupation Class:

AAAA

AAA

AA

A

B

Female

Benefit Period:

2 Year

5 Year

To Age 65

Waiting Period:

30 Day

60 Day

90 Day

180 Day

1

Item 235 Individual Disability Income: $ _____________________x __________________ = $ ______________________

Non-smoker premium Number of Units

per $100 unit

2

Item 236 Optional First Day Disability

Income Benefit While Hospital Confined: $ _____________________x __________________ = $ ______________________

Non-smoker premium Same number of

per $100 unit units as above

3

Item 237 Optional Accidental

Death and Dismemberment Benefit:

$ _____________________x $_________________ = $ ______________________

Non-smoker premium Amount

per $100 unit

Subtotal = $ ______________________

Cigarette smoker surcharge, if applicable: Add 10% of Subtotal

= $ ______________________

Add Annual Premium Adjustment Factor = $ ______________________

All States Except KY add $15.00

KY add $20.00

TOTAL ANNUAL PREMIUM = $ ______________________

$_________________________________ $ _________________________________ $ _______________________________

Semiannual Premium Quarterly Premium Monthly EFT Premium .52 .265 .086

DISABILITY

INCOME

PROTECTION

Item 235

Benefit Period - Male

Issue Occupation Base Policy Waiting Period (Days) Age Class 30 60 90 180 18-29 AAAA $2.70 $2.80 $2.90 $3.10 AAA / AA 3.00 3.10 3.20 3.40 A / B 3.30 3.50 3.60 30-34 AAAA 3.50 3.60 3.70 3.90 AAA / AA 3.90 4.00 4.10 4.30 A / B 4.20 4.40 4.50 35-39 AAAA 4.10 4.10 4.30 4.50 AAA / AA 4.50 4.60 4.80 5.00 A / B 5.00 5.10 5.20 40-44 AAAA 4.70 4.90 5.00 5.20 AAA / AA 5.20 5.40 5.50 5.80 A / B 5.80 5.90 6.00 45-49 AAAA 5.40 5.60 5.80 6.00 AAA / AA 6.00 6.20 6.40 6.70 A / B 6.70 6.80 7.00 50-54 AAAA 6.40 6.60 6.80 7.10 AAA / AA 7.10 7.30 7.50 7.90 A / B 7.80 8.00 8.20 55-60 AAAA 7.40 7.60 7.70 8.20 AAA / AA 8.20 8.40 8.60 9.10 A / B 9.00 9.30 9.50

Benefit Period - Female

Issue Occupation Base Policy Waiting Period (Days) Age Class 30 60 90 180 18-29 AAAA $3.70 $3.80 $3.90 $4.10 AAA / AA 4.10 4.20 4.30 4.50 A / B 4.40 4.60 4.80 30-34 AAAA 4.60 4.80 5.00 5.10 AAA / AA 5.10 5.30 5.50 5.70 A / B 5.60 5.80 6.00 35-39 AAAA 5.40 5.60 5.70 6.00 AAA / AA 6.00 6.20 6.30 6.70 A / B 6.60 6.80 6.90 40-44 AAAA 6.20 6.40 6.60 6.90 AAA / AA 6.90 7.10 7.30 7.70 A / B 7.70 7.80 8.00 45-49 AAAA 7.20 7.50 7.70 8.10 AAA / AA 8.00 8.30 8.50 9.00 A / B 8.90 9.10 9.30 50-54 AAAA 8.60 8.70 8.90 9.50 AAA / AA 9.50 9.70 9.90 10.50 A / B 10.40 10.70 10.90 55-60 AAAA 9.80 10.10 10.40 10.90 AAA / AA 10.90 11.20 11.50 12.10 A / B 12.00 12.30 12.70

Male and Female

Issue Age Occupation Class Rate

18-49 AAAA $1.30 AAA 1.40 AA 1.90 A 2.30 B 3.20 50-60 AAAA $1.40 AAA 1.60 AA 2.10 A 2.70 B 3.70

2 First Day Disability Income Benefit While Hospital Confined – Item 236

Benefit amount must equal base policy’s monthly disability benefit.

Annual non-cigarette smoker premium per each $100 of monthly benefit.

3 Accidental Death and Dismemberment Benefit – Item 237

Minimum benefit, $10,000; Maximum benefit, $100,000

Annual non-cigarette smoker premium per $1,000 of coverage.

50200 (5-04)

WWW.AUTO-OWNERS.COM

Determining Monthly Benefits To Be Paid

To determine the monthly disability benefit, we will divide the monthly loss of income by the pre-loss income and

multiply the result by the Monthly Benefit purchased, as shown on the Policy Data Page.

Monthly Loss of ÷

Pre-Loss

_x

Monthly Disability

_{= Monthly Disability}

Earned Income

Earned Income

Benefit Purchased

Benefit Paid

Example: $2,000*

$3,000

$2,000

$1,333.33

*

$3,000 Pre-loss earned income minus $1,000 per month workers compensation benefit being paid = $2,000 Monthly Loss of Earned Income.

Definition of Total Disability

AAAA

-

Own occupation to age 65

AAA & AA

-

Own occupation for 5 years

A & B

-

Own occupation for 2 years

Then any occupation for which you are qualified or may become qualified by reason of education, training or experience; and with due regard to your vocation and economic status at the time total disability begins.

Earned Income

is gross income from employment less

business expenses before personal deductions.

Monthly Loss of Earned Income

is Pre-Loss Earned

Income less the amount actually received while totally

disabled from:

• Wages, salaries, bonuses, commissions, fees or

other payments for personal services; and

• Social Security, workers compensation, or other

federal or state cash sickness plans; and

• Any lump sum payments that are greater than

Pre-Loss Earned Income. These will be considered

income during future months at a rate not exceeding

Pre-Loss Earned Income until exhausted.

Pre-Loss Earned Income

is monthly Earned Income averaged for the 12 months just prior to becoming totally disabled.

PREMIUM CALCULATION

Annual Premium per each $100 of Monthly Benefit

Name _____________________________________________ Age ________ Monthly Disability Benefit $ ___________________

Male

Occupation Class:

AAAA

AAA

AA

A

B

Female

Benefit Period:

2 Year

5 Year

To Age 65

Waiting Period:

30 Day

60 Day

90 Day

180 Day

1

Item 235 Individual Disability Income: $ _____________________x __________________ = $ ______________________

Non-smoker premium Number of Units

per $100 unit

2

Item 236 Optional First Day Disability

Income Benefit While Hospital Confined: $ _____________________x __________________ = $ ______________________

Non-smoker premium Same number of

per $100 unit units as above

3

Item 237 Optional Accidental

Death and Dismemberment Benefit:

$ _____________________x $_________________ = $ ______________________

Non-smoker premium Amount

per $100 unit

Subtotal = $ ______________________

Cigarette smoker surcharge, if applicable: Add 10% of Subtotal

= $ ______________________

Add Annual Premium Adjustment Factor = $ ______________________

All States Except KY add $15.00

KY add $20.00

TOTAL ANNUAL PREMIUM = $ ______________________

$_________________________________ $ _________________________________ $ _______________________________

Semiannual Premium Quarterly Premium Monthly EFT Premium .52 .265 .086

DISABILITY

INCOME

PROTECTION

Item 235