LifeScape Single Premium Whole Life Basic Illustration NARRATIVE SUMMARY

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NARRATIVE SUMMARY

Policy Description LifeScape® Single Premium Whole Life is a level-benefit, single premium, participating whole

life insurance policy with maturity at age 121. Payment of the premium, assuming no loans are made, guarantees that the policy will remain in force until age 121. Any dividends declared on this policy due to its participating status will be paid according to the dividend option selected.

This policy is a modified endowment contract (MEC) at issue. Money distributed from a modified endowment contract by cash distributions, withdrawals, loans or assignments will be considered taxable income until all gain, if any, has been distributed. The taxable income amounts will also be subject to a 10% penalty tax unless the owner is at least 59 1/2, becomes disabled or annuitizes the entire cash value. Death benefits of modified endowment contracts paid to the beneficiary continue to be treated as life insurance proceeds and therefore are not subject to income tax.

Underwriting Class: Male, Select Non-Tobacco

The premium required for the insurance coverage will depend on the outcome of the underwriting process and may vary from what is shown on this illustration. If so, you will receive a revised illustration with your policy.

Initial Base Death Benefit: $100,000

The initial base death benefit is $100,000.

Contract Premium: $57,575.00

The contract premium is $57,575.00.

Initial Dividend Option Selected: Paid-Up Additions

Policy dividends are used to purchase additional paid-up insurance. The amount of additional insurance purchased is that which the dividend, applied as net single premium, can buy at the insured's attained age. This dividend option is selected from age 60 to 121.

NUMERIC SUMMARY AND POLICY VALUES DEFINITIONS

Guaranteed Columns Illustrate the policy values that are guaranteed and established at issue. These policy values

assume no dividends are paid. Available cash values and death benefits will never be less than the values shown here assuming timely payment of the contract premium.

THIS IS AN ILLUSTRATION ONLY. AN ILLUSTRATION IS NOT INTENDED TO

PREDICT ACTUAL PERFORMANCE. INTEREST RATES, DIVIDENDS, OR VALUES

THAT ARE SET FORTH IN THE ILLUSTRATION ARE NOT GUARANTEED, EXCEPT

FOR THOSE ITEMS CLEARLY LABELED AS GUARANTEED.

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NARRATIVE SUMMARY (continued)

Non-Guaranteed Columns

Illustrate the policy values that are not guaranteed because the assumptions on which they are based are subject to change. These underlying assumptions will change as Assurity's future experience with respect to mortality, interest, expenses, taxes and other factors unfolds. The outlays, values and benefits shown in these columns are neither guarantees nor estimates of future Assurity performance. Actual outlays, values and benefits may be more or less favorable than those illustrated. The expense basis used in this illustration is the current NAIC-approved Generally Recognized Expense Table.

Illustrated Scale Columns

Illustrate the policy values that are based on the current dividend scale. The values shown in these columns assume that dividends are payable according to the current scale for the life of the policy. This is very unlikely to occur. Actual results may be more or less favorable.

Midpoint Scale Columns

Illustrate the policy values that are based on dividends payable at one-half of the current scale for the life of the policy.

Contract Premium Illustrated at the beginning of the year and represents the total premium payments required to

maintain the base policy and rider benefits shown in this illustration.

Guaranteed Cash Value

Illustrated at the end of the year and represents the cash value guaranteed to be available upon policy surrender assuming timely payment of the guaranteed contract premium(s) by the

owner/payor. Policy loans, withdrawals and partial surrenders will reduce the otherwise available death benefits and cash values.

Guaranteed Death Benefit

Illustrated at the end of the year and represents the death benefit guaranteed to be paid upon the death of the insured assuming timely payment of the guaranteed contract premium(s) by the owner/payor. Policy loans, withdrawals and partial surrenders will reduce the otherwise available death benefits and cash values.

Premium Outlay Shows the contract premium less any dividends paid in cash or used to reduce premium, any

surrenders of paid-up additions, and/or any new policy loans or loan repayments in the year. These values are meant to represent the owner/payor's out-of-pocket cost for the given year. These premium outlay amounts are not guaranteed to maintain the policy and rider benefits illustrated since these outlays assume that portions or all of the contract premium will be paid from non-guaranteed elements.

Total Annual Dividend

Illustrated at the end of year and includes dividends earned on the base policy and any paid-up additions. These values are not guaranteed. The dividends illustrated are based on 100% of Assurity's current scale and are neither guaranteed nor estimates for the future.

Total Surrender Value Illustrated at the end of year and includes the guaranteed cash value, terminal dividends and any

paid-up additions cash value. Policy loans, withdrawals and partial surrenders will reduce the otherwise available death benefits and cash values. These values are not guaranteed.

Total Death Benefit Illustrated at the end of year and includes the death benefits provided by the base policy, any

riders, terminal dividends and any paid-up insurance purchased by the annual dividend on the policy or riders. Policy loans, withdrawals and partial surrenders will reduce any death benefit and cash values. These values are not guaranteed.

Form 0680 Prepared on 12/28/2011

Version 2.95.041 Page 2 of 9

This illustration is not valid without all pages.

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NARRATIVE SUMMARY (continued)

RIDER DESCRIPTIONS

Accelerated Benefits Rider (AB)

In some states, this policy may include coverage under the Accelerated Benefits Rider at no additional cost. The Accelerated Benefits Rider provides the option to accelerate a portion of policy proceeds if the insured is terminally ill or, if age 65 and over, requiring continuous confinement in a long-term care facility or under a written plan of home care expected to last until death.

Single Premium Insurance Rider (SPI)

Allows flexible additional payments to be applied to the policy. Each payment, less a premium load is applied as paid-up additions. Evidence of insurability may be required. Each payment must be at least $500.00.

DISCLOSURE

Incontestability and Suicide Provisions

Suicide, incorrect age and incontestability provisions apply. Please review the policy or ask your representative for more information.

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NUMERIC SUMMARY

---Non-Guaranteed---Illustrated Scale--- ---Mid-Point--- ---Guaranteed---Yr Age Contract Premiums Cash Value Death Benefit Premium Outlay Total Surrender Value Total Death Benefit Premium Outlay Total Surrender Value Total Death Benefit 5 65 0 58,422 100,000 0 63,235 106,783 0 68,205 113,836 10 70 0 65,326 100,000 0 74,275 112,486 0 84,135 126,366 20 80 0 78,698 100,000 0 99,844 126,124 0 126,999 159,884 61 121 0 100,000 100,000 0 203,919 203,919 0 461,083 461,083

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.

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.

ALAN N. CANTON 8041 SIERRA STREET

FAIR OAKS, California 95628-7530 Phone Number: (916) 962-9296 License Number: 0F31110

Policy Owner: Date:

Authorized Representative: Date:

Prepared for: Tom Jones Initial Death Benefit: $100,000

Issue Age: 60 Initial Annual Premium: $57,575.00

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POLICY VALUES

---Non-Guaranteed--- ---Guaranteed---Yr Age Contract Premium Cash Value Death Benefit Premium Outlay Total Annual Dividend Total Surrender Value Total Death Benefit 1 61 57,575 52,990 100,000 57,575 940 59,229 107,073 2 62 0 54,346 100,000 0 1,006 61,207 108,515 3 63 0 55,703 100,000 0 1,081 63,259 110,020 4 64 0 57,062 100,000 0 1,164 65,395 111,598 5 65 0 58,422 100,000 0 1,251 68,205 113,836 6 66 0 59,786 100,000 0 1,340 71,138 116,173 7 67 0 61,157 100,000 0 1,427 74,196 118,602 8 68 0 62,537 100,000 0 1,511 77,381 121,114 9 69 0 63,928 100,000 0 1,592 80,694 123,701 10 70 0 65,326 100,000 0 1,676 84,135 126,366 11 71 0 66,728 100,000 0 1,771 87,712 129,118 12 72 0 68,123 100,000 0 1,880 91,425 131,974 13 73 0 69,502 100,000 0 2,003 95,279 134,953 14 74 0 70,869 100,000 0 2,135 99,288 138,061 15 75 0 72,224 100,000 0 2,273 103,460 141,304 16 76 0 73,567 100,000 0 2,419 107,803 144,687 17 77 0 74,895 100,000 0 2,575 112,323 148,217 18 78 0 76,198 100,000 0 2,748 117,025 151,915 19 79 0 77,468 100,000 0 2,940 121,916 155,798 20 80 0 78,698 100,000 0 3,148 126,999 159,884 21 81 0 79,885 100,000 0 3,366 132,280 164,180 22 82 0 81,028 100,000 0 3,586 137,759 168,686 23 83 0 82,130 100,000 0 3,806 143,438 173,397 24 84 0 83,190 100,000 0 4,044 149,334 178,332 25 85 0 84,204 100,000 0 4,297 155,451 183,506 26 86 0 85,164 100,000 0 4,546 161,769 188,911 27 87 0 86,067 100,000 0 4,775 168,259 194,522 28 88 0 86,908 100,000 0 4,966 174,869 200,295 29 89 0 87,686 100,000 0 5,114 181,548 206,182 30 90 0 88,402 100,000 0 5,237 188,268 212,156 31 91 0 89,065 100,000 0 5,343 195,023 218,201 32 92 0 89,690 100,000 0 5,451 201,842 224,323 33 93 0 90,277 100,000 0 5,589 208,752 230,554 34 94 0 90,825 100,000 0 5,754 215,773 236,928 35 95 0 91,330 100,000 0 5,938 222,910 243,464

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POLICY VALUES (continued)

---Non-Guaranteed--- ---Guaranteed---Yr Age Contract Premium Cash Value Death Benefit Premium Outlay Total Annual Dividend Total Surrender Value Total Death Benefit 36 96 0 91,801 100,000 0 6,124 230,184 250,168 37 97 0 92,250 100,000 0 6,306 237,615 257,035 38 98 0 92,675 100,000 0 6,523 245,233 264,103 39 99 0 93,070 100,000 0 6,786 253,064 271,422 40 100 0 93,423 100,000 0 7,085 261,109 279,031 41 101 0 93,744 100,000 0 7,356 269,362 286,900 42 102 0 94,057 100,000 0 7,543 277,804 294,942 43 103 0 94,363 100,000 0 7,673 286,381 303,094 44 104 0 94,660 100,000 0 7,749 295,032 311,301 45 105 0 94,949 100,000 0 7,794 303,726 319,530 46 106 0 95,230 100,000 0 7,837 312,462 327,779 47 107 0 95,503 100,000 0 7,913 321,271 336,084 48 108 0 95,768 100,000 0 8,040 330,203 344,498 49 109 0 96,025 100,000 0 8,216 339,305 353,073 50 110 0 96,274 100,000 0 8,406 348,591 361,821 51 111 0 96,514 100,000 0 8,551 358,011 370,698 52 112 0 96,747 100,000 0 8,656 367,531 379,661 53 113 0 96,970 100,000 0 8,766 377,144 388,717 54 114 0 97,186 100,000 0 8,887 386,872 397,876 55 115 0 97,393 100,000 0 9,025 396,721 407,158 56 116 0 97,592 100,000 0 9,177 406,709 416,575 57 117 0 97,784 100,000 0 9,412 416,921 426,214 58 118 0 97,967 100,000 0 9,653 427,354 436,080 59 119 0 98,161 100,000 0 9,899 438,098 446,176 60 120 0 98,611 100,000 0 10,674 450,760 457,012 61 121 0 100,000 100,000 0 10,951 461,083 461,083 Form 0680 Prepared on 12/28/2011 Version 2.95.041 Page 6 of 9

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MODIFIED ENDOWMENT CONTRACT DISCLOSURE STATEMENT

The Technical and Miscellaneous Revenue Act of 1988 created a new class of life insurance contracts known as Modified Endowment Contracts. The principal purpose of this law was to restrict the use of life insurance as an investment. The law limits the amount of premium that is allowed to be paid into a life insurance contract. The allowable amount of premium is dependent on the death benefit. If the calculated premium limits (defined in IRS code section 7702A) for the life insurance contract are exceeded, the life insurance contract becomes a Modified Endowment Contract.

The plan of insurance exceeds the calculated allowable premium limits and would therefore be considered a Modified Endowment Contract. A policy that is a Modified Endowment Contract has the following implications:

Death benefits of Modified Endowment Contracts paid to the beneficiary continue to be treated as life insurance proceeds and therefore are not subject to income tax.

I acknowledge that I have read this disclosure statement and understand that the plan of insurance illustrated is a Modified Endowment Contract and therefore subject to special tax treatment as outlined above.

1) Money distributed from a Modified Endowment Contract by cash distributions, withdrawals, loans, or assignments, will be considered taxable income until all gain, if any, has been distributed.

2) The taxable income amounts will also be subject to a 10% penalty tax unless the Owner is at least 59 1/2, becomes disabled, or annuitizes the entire cash value. (If the Owner is a corporation, such proceeds are subject to the 10% penalty tax at any time).

/ /

Date (MM/DD/YYYY) Signature of Owner/Proposed Owner Printed Name

Printed Insured/Proposed Insured’s Name (First, Middle, Last) Policy Number (if applicable)

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INDICES AND PREMIUM

Life Insurance Indices at 5.00%

Premium

10 Year 20 Year

Surrender Cost 10.92 9.20

Net Payment Cost 60.38 31.86

Equivalent Level Annual Dividend 10.63 12.14

Benefits Included

Base policy $57,575.00

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HOME OFFICE INFORMATION

New Business-ID Units

LS SPWL 100.000

ACCDB121 SPIR 0112

State: CA