Life Illustration for:
MRS CLIENT
Phone: (###) ###-####
Presented by:
TED MILLER, MGA
, WI
Phone:
Product Description: The product illustrated is an individual life insurance certificate. This product provides permanent life insurance in just ONE premium payment. Certificates become PAID-UP Immediately. Savings are instant and grow through certificate cash value. The purchase establishes your membership in the FCSLA providing access to a variety of fraternal benefits and activities.
Eligible Issue Age: 0 through 90 Minimum purchase of $2,000 required.
Death Benefit: The Death Benefit will be paid in one lump sum payment. The Guaranteed Death Benefit is reflected under the Certificate Death Benefit columns in this illustration. The Non-Guaranteed Death Benefit is reflected under the Total Death Benefit column.
Cash Value: Cash value is immediate and grows throughout the life of the certificate. Cash value is available for loan or surrender options. The Guaranteed Cash Value is reflected under the Certificate Cash Value columns in this illustration. The Non-Guaranteed Cash Value is reflected under the Total Cash Value column.
Contract Premium: A single contract premium is due with the certificate application. See Guaranteed tabular detail for actual amounts.
Premium Class: The premium payments shown in this illustration assume that you qualify for the risk classification shown in the page header. Actual premiums will depend on the risk factors applied by our
underwriters. If this varies from what is shown on this illustration, you will receive a revised illustration with your certificate.
Non-Guaranteed Values: These benefits and values are not guaranteed. This illustration assumes that the currently illustrated non-guaranteed elements will continue unchanged for all years shown. This is not likely to occur, and actual results may be more or less favorable than those shown.
Dividends: This product is a participating whole life contract. Dividends are determined annually and will be credited, after the second year, on the Anniversary at the end of the contract year of determination. The dividend is reflected under the Annual Dividend column in this illustration. The following dividend options are available: Option 1 - Accumulate: We will hold the dividend on deposit at annual, compound, interest. The interest rate will not be less than 3.0% per year. Interest will be credited each year on the Anniversary date. This option, if
selected, is reflected under the Cash Value of Accumulated Dividends column in this illustration.
Option 2 - Cash: The dividend will be paid in cash. This option, if selected, is reflected under the Annual Dividend column in this illustration.
Option 3 - Paid Up Additions*: The dividend will be applied as a net single premium to buy participating, paid-up, whole life insurance for the Insured. The amount of paid-up insurance will be determined: (a) at the sex and then Age of the Insured; (b) at the Premium Class shown in this illustration; and (c) using Our then table of net single premium rates. The cash value of the additions, at any time, will not be less than the greater of: (a) the then net single premium for the additions; or (b) the sum of the dividends used to purchase the additions. This option, if selected, is reflected under the Paid Up Additions Death Benefit column in this illustration.
You may withdraw all or part of the cash value of any additions or accumulation at any time. Any portion of the cash value used as security for Debt may not be withdrawn; however, if You so request, it may be applied to reduce the Debt.
* Reinvesting your dividends by purchasing paid up additional insurance offers the greatest insurance value.
Fraternal Benefits: Post Mortem Benefit:
FCSLA enhances its permanent life insurance products by issuing a 25% Post Mortem Benefit (PMB). This benefit may pay an additional 25% on a member’s first $100,000 of permanent life insurance, and on any paid-up additional insurance associated with the first $100,000 of permanent life coverage. This Non-Guaranteed benefit is paid to the beneficiary at time of claim. Certificates become eligible for the PMB after the second year.
Certificate Summary Information End of Certificate Year Age Contract Premium Certificate Cash Value Certificate Death Benefit 1 71 $51,300.00 $52,900 $100,000 5 75 $0.00 $58,900 $100,000 10 80 $0.00 $66,600 $100,000 20 90 $0.00 $80,300 $100,000 51 121 $0.00 $100,000 $100,000
Cost Comparison Indexes. An explanation of the intended use of the following indexes is provided in the Life Insurance Buyer's Guide.
10 Year, Basic Contract 20 Year, Basic Contract
Net Payment Cost Index $58.16 $33.28 Surrender Cost Index $7.73 $10.15 REQUIRED SIGNATURES:
Applicant, please initial where applicable,
_____ This illustration does not fully conform to the certificate for which I am applying for. For example, I may be applying for different amounts of insurance, premium amount, or optional benefits. These changes will impact the premiums illustrated. I understand that I will receive a conforming illustration at or prior to the time of any certificate delivery. I will carefully review that illustration upon receipt.
_____ I have received a copy of this illustration and understand that any non-guaranteed elements illustrated are subject to change and could be either higher or lower. The agent has told me they are not guaranteed.
________________________________________________ Applicant's or Certificate owner's Signature
______________ Date
I certify that this illustration has been presented to the applicant and that I have explained that any non-guaranteed elements illustrated are subject to change. I have made no statements that are inconsistent with the illustration.
________________________________________________ First Catholic Slovak Ladies Association Authorized
Representative Signature
______________ Date
Guaranteed Values Yearly Detail: End of Certificate Year Age Contract Premium Certificate Cash Value Certificate Death Benefit 1 71 $51,300.00 $52,900 $100,000 2 72 $0.00 $54,300 $100,000 3 73 $0.00 $55,800 $100,000 4 74 $0.00 $57,400 $100,000 5 75 $0.00 $58,900 $100,000 $51,300.00 6 76 $0.00 $60,400 $100,000 7 77 $0.00 $62,000 $100,000 8 78 $0.00 $63,500 $100,000 9 79 $0.00 $65,000 $100,000 10 80 $0.00 $66,600 $100,000 $51,300.00 11 81 $0.00 $68,100 $100,000 12 82 $0.00 $69,600 $100,000 13 83 $0.00 $71,100 $100,000 14 84 $0.00 $72,600 $100,000 15 85 $0.00 $74,000 $100,000 $51,300.00 16 86 $0.00 $75,300 $100,000 17 87 $0.00 $76,700 $100,000 18 88 $0.00 $78,000 $100,000 19 89 $0.00 $79,200 $100,000 20 90 $0.00 $80,300 $100,000 $51,300.00 21 91 $0.00 $81,400 $100,000 22 92 $0.00 $82,500 $100,000 23 93 $0.00 $83,700 $100,000 24 94 $0.00 $84,900 $100,000 25 95 $0.00 $85,900 $100,000 $51,300.00 26 96 $0.00 $86,800 $100,000 27 97 $0.00 $87,500 $100,000 28 98 $0.00 $88,100 $100,000 29 99 $0.00 $88,800 $100,000 30 100 $0.00 $89,600 $100,000 $51,300.00 Page 5 of 8
Guaranteed Values Yearly Detail (Continued):
End of Certificate Year Age Contract Premium Certificate Cash Value Certificate Death Benefit 31 101 $0.00 $90,300 $100,000 32 102 $0.00 $91,000 $100,000 33 103 $0.00 $91,700 $100,000 34 104 $0.00 $92,300 $100,000 35 105 $0.00 $92,900 $100,000 $51,300.00 36 106 $0.00 $93,400 $100,000 37 107 $0.00 $93,900 $100,000 38 108 $0.00 $94,400 $100,000 39 109 $0.00 $94,800 $100,000 40 110 $0.00 $95,200 $100,000 $51,300.00 41 111 $0.00 $95,500 $100,000 42 112 $0.00 $95,800 $100,000 43 113 $0.00 $96,100 $100,000 44 114 $0.00 $96,400 $100,000 45 115 $0.00 $96,700 $100,000 $51,300.00 46 116 $0.00 $96,900 $100,000 47 117 $0.00 $97,200 $100,000 48 118 $0.00 $97,400 $100,000 49 119 $0.00 $97,600 $100,000 50 120 $0.00 $97,900 $100,000 $51,300.00 51 121 $0.00 $100,000 $100,000 $51,300.00 Page 6 of 8
Non-Guaranteed Values Yearly Detail: Guaranteed Non-Guaranteed* End of Certificate Year Age Contract Premium Certificate Cash Value Certificate Death Benefit Annual Dividend Paid Up Additions Death Benefit Total Cash Value Total Death Benefit 1 71 $51,300.00 $52,900 $100,000 0.00 $0 $52,900 $100,000 2 72 $0.00 $54,300 $100,000 571.00 $1,051 $54,871 $101,051 3 73 $0.00 $55,800 $100,000 591.15 $2,109 $56,978 $102,109 4 74 $0.00 $57,400 $100,000 612.65 $3,175 $59,225 $103,175 5 75 $0.00 $58,900 $100,000 633.49 $4,245 $61,412 $104,245 $51,300.00 2,408.29 6 76 $0.00 $60,400 $100,000 655.70 $5,327 $63,629 $105,327 7 77 $0.00 $62,000 $100,000 677.25 $6,418 $65,986 $106,418 8 78 $0.00 $63,500 $100,000 700.23 $7,517 $68,288 $107,517 9 79 $0.00 $65,000 $100,000 722.51 $8,622 $70,636 $108,622 10 80 $0.00 $66,600 $100,000 746.24 $9,742 $73,095 $109,742 $51,300.00 5,910.22 11 81 $0.00 $68,100 $100,000 769.29 $10,865 $75,542 $110,865 12 82 $0.00 $69,600 $100,000 793.79 $12,000 $77,992 $112,000 13 83 $0.00 $71,100 $100,000 817.60 $13,145 $80,489 $113,145 14 84 $0.00 $72,600 $100,000 840.67 $14,296 $83,035 $114,296 15 85 $0.00 $74,000 $100,000 865.22 $15,465 $85,455 $115,465 $51,300.00 9,996.79 16 86 $0.00 $75,300 $100,000 887.92 $16,637 $87,903 $116,637 17 87 $0.00 $76,700 $100,000 912.10 $17,822 $90,409 $117,822 18 88 $0.00 $78,000 $100,000 935.51 $19,020 $92,859 $119,020 19 89 $0.00 $79,200 $100,000 959.30 $20,228 $95,254 $120,228 20 90 $0.00 $80,300 $100,000 981.06 $21,445 $97,594 $121,445 $51,300.00 14,672.68 21 91 $0.00 $81,400 $100,000 1,003.14 $22,669 $99,981 $122,669 22 92 $0.00 $82,500 $100,000 1,026.74 $23,911 $102,261 $123,911 23 93 $0.00 $83,700 $100,000 1,050.77 $25,162 $104,844 $125,162 24 94 $0.00 $84,900 $100,000 1,073.89 $26,418 $107,480 $126,418 25 95 $0.00 $85,900 $100,000 1,097.31 $27,691 $109,772 $127,691 $51,300.00 19,924.53 Page 7 of 8
* These benefits and values are not guaranteed; the assumptions on which they are based are subject to change by the insurer and actual results may be more or less favorable.
Non-Guaranteed Values Yearly Detail (Continued):
Guaranteed Non-Guaranteed* End of Certificate Year Age Contract Premium Certificate Cash Value Certificate Death Benefit Annual Dividend Paid Up Additions Death Benefit Total Cash Value Total Death Benefit 26 96 $0.00 $86,800 $100,000 1,119.85 $28,979 $111,999 $128,979 27 97 $0.00 $87,500 $100,000 1,141.46 $30,280 $114,061 $130,280 28 98 $0.00 $88,100 $100,000 1,160.80 $31,592 $116,057 $131,592 29 99 $0.00 $88,800 $100,000 1,179.06 $32,912 $118,186 $132,912 30 100 $0.00 $89,600 $100,000 1,200.20 $34,245 $120,451 $134,245 $51,300.00 25,725.90 31 101 $0.00 $90,300 $100,000 1,221.62 $35,588 $122,653 $135,588 32 102 $0.00 $91,000 $100,000 1,241.99 $36,942 $124,892 $136,942 33 103 $0.00 $91,700 $100,000 1,262.61 $38,318 $126,854 $138,318 34 104 $0.00 $92,300 $100,000 1,283.59 $39,705 $129,063 $139,705 35 105 $0.00 $92,900 $100,000 1,304.84 $41,101 $131,312 $141,101 $51,300.00 32,040.55 36 106 $0.00 $93,400 $100,000 1,324.94 $42,518 $133,137 $142,518 37 107 $0.00 $93,900 $100,000 1,345.37 $43,945 $135,357 $143,945 38 108 $0.00 $94,400 $100,000 1,364.59 $45,391 $137,222 $145,391 39 109 $0.00 $94,800 $100,000 1,384.12 $46,844 $139,414 $146,844 40 110 $0.00 $95,200 $100,000 1,402.36 $48,317 $141,216 $148,317 $51,300.00 38,861.93 41 111 $0.00 $95,500 $100,000 1,422.36 $49,796 $143,381 $149,796 42 112 $0.00 $95,800 $100,000 1,439.54 $51,293 $145,120 $151,293 43 113 $0.00 $96,100 $100,000 1,458.47 $52,810 $146,879 $152,810 44 114 $0.00 $96,400 $100,000 1,477.67 $54,332 $149,150 $154,332 45 115 $0.00 $96,700 $100,000 1,495.48 $55,872 $150,945 $155,872 $51,300.00 46,155.45 46 116 $0.00 $96,900 $100,000 1,515.08 $57,433 $152,660 $157,433 47 117 $0.00 $97,200 $100,000 1,533.40 $58,997 $155,040 $158,997 48 118 $0.00 $97,400 $100,000 1,551.81 $60,580 $156,792 $160,580 49 119 $0.00 $97,600 $100,000 1,570.47 $62,182 $158,562 $162,182 50 120 $0.00 $97,900 $100,000 1,589.38 $63,803 $160,452 $163,803 $51,300.00 53,915.59 51 121 $0.00 $100,000 $100,000 1,623.29 $65,426 $165,426 $165,426 $51,300.00 55,538.88 Page 8 of 8
* These benefits and values are not guaranteed; the assumptions on which they are based are subject to change by the insurer and actual results may be more or less favorable.
