Life Insurance Illustration
Whole Life Insurance with Long-Term Care Benefits
for Either or Both Insureds
Presented By: Valued Agent
Base Policy Long-Term Care ('LTC') Benefit Data:
Initial Base Policy Benefits $150,000.00
Minimum Base Policy LTC Benefit Period 25 months
Initial Monthly Benefit Limit for:
Assisted Living $6,000
Home Health Care / Hospice Care $6,000
Long-Term Care Facility $6,000
Adult Day Care $6,000
International Coverage (Facility Only) $3,000
Inflation Option 0%
Waiver of Premium Yes
Annual Bed Reservation Benefit 31 days per calendar year
Annual Respite Care Benefit 21 days per calendar year
Caregiver Training Benefit $12,000 Maximum Lifetime Benefit
Supportive Equipment Benefit $12,000 Maximum Lifetime Benefit
Waiting Period for:
Home Health Care Services 30 days
Other LTC Services 60 days
Optional LTC Continuation of Benefits Rider Data:
Rider Premium $1,829.76 Annual Premium
Rider Benefit Balance Lifetime
Initial Rider Monthly Benefit Limit for:
Assisted Living $6,000
Home Health Care $6,000
Long-Term Care Facility $6,000
Adult Day Care $6,000
Hospice Care (Home or Inpatient) $6,000
Annual Bed Reservation Benefit 31 days per calendar year
Annual Respite Care Benefit 21 days per calendar year
Nonforfeiture Benefit No
Inflation Option 0%
Whole Life Asset-Care Joint Policy, Form: L301 and R525
Description of Policy: Whole Life Asset-Care, also known as Current Interest Whole Life Insurance
with Long-Term Care Benefits for Either or Both Insureds, is an annual premium life insurance policy which provides an initial death benefit of $150,000. The death benefit is payable on the death of the second insured to die. The death benefit can also be used by either or both insureds prior to death to pay for long-term care expenses.When the policy is issued, the monthly amount available for the insured for long-term care expenses is as follows:
Nursing Home Care/Assisted Living: Lesser of actual charges or 4% of death benefit: $6,000 per month Home Health Care: Lesser of actual charges or 4% of death benefit: $6,000 per month Adult Day Care: Lesser of actual charges or 4% of death benefit: $6,000 per month
The death benefit and long-term care benefits may be decreased by any prior distribution (loans, partial withdrawals, or payment of long-term care benefits). Check your outline of coverage for exclusions and limitations. Payment of all benefits is subject to the terms and conditions of the policy.
Other Things You Should Know About This Policy:
Premium: The premium is due annually for the life of the policy.
Revised Illustration: This illustration assumes the life insurance policy is issued in the Class 1
underwriting class. If the policy cannot be issued as Class 1, either the premium or the amount of life insurance may change. If so, you will receive a revised illustration with your insurance contract.
Guaranteed Elements: Many elements of this contract are guaranteed, including the minimum interest
rates, and the maximum cost of insurance charges. Those elements cannot be changed.
Non-Guaranteed Elements: Certain elements of the policy cannot be predicted with absolute certainty
and can be changed from time to time by The State Life Insurance Company. These elements are non-guaranteed and usually include the current interest rate, and the current cost of insurance charges. These non-guaranteed elements will affect each policy's death benefit, long-term care benefit balance, cash value accumulation fund and cash surrender value.
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.
Premium Payment Modes: Annual, semi-annual, quarterly, and monthly pre-authorized check payment
modes are available. If you pay more frequently than annually, there is an additional charge. The modal factors are: monthly (PAC), .0858; quarterly, .265: and semi-annually, .52.
Definition of Terms Used in This Illustration: Read these to help you understand the illustration. Age: Insured's attained age as of the previous birthday.
Cash Surrender Value: The cash value accumulation fund, minus any surrender charges and any
indebtedness, which is available to the policyholder upon surrender of the policy. Surrender charges will be deducted in the first 14 years as follows:
Year Charge Year Charge Year Charge Year Charge
1 $2,465 5 $2,465 9 $1,479 13 $493
2 $2,465 6 $2,218 10 $1,232 14 $246
3 $2,465 7 $1,972 11 $986 15 $0
4 $2,465 8 $1,725 12 $739
Cash Value Accumulation Fund: The premium paid, less cost of insurance charges, plus interest. Death Benefit: The amount payable upon the death of the second insured to die.
Illustrated Basis: Policy benefits and values shown on a non-guaranteed basis.
Long-Term Care Benefit Balance: The amount payable for long-term care expenses incurred by either
or both insureds. The long-term care benefit balance can change due to interest rate, cost of insurance charges, loans taken, partial withdrawals, and long-term care benefits paid.
Policy Loan Interest Rate: The policy loan interest rate is 7.40%. Interest credited to the loan balance
is 4.00%.
Waiver of Premium: If selected, we will waive premiums if you are receiving care for which benefits
Guaranteed Non-Guaranteed Midpoint Assumptions Non-Guaranteed Illustrated Basis End of Policy Year Contract Premium Cash Value Accumulation Fund Cash Surrender Value Death Benefit / LTC Benefit Balance Cash Value Accumulation Fund Cash Surrender Value Death Benefit / LTC Benefit Balance Cash Value Accumulation Fund Cash Surrender Value Death Benefit / LTC Benefit Balance Yr. 5 $3,573 $13,694 $11,229 $150,000 $13,694 $11,229 $150,000 $13,694 $11,229 $150,000 Yr. 10 $3,573 $29,618 $28,385 $150,000 $29,618 $28,385 $150,000 $29,618 $28,385 $150,000 Yr. 20 $3,573 $66,468 $66,468 $150,000 $66,468 $66,468 $150,000 $66,468 $66,468 $150,000 Yr. 30 $3,573 $101,330 $101,330 $150,000 $101,330 $101,330 $150,000 $101,330 $101,330 $150,000 Age 70 $3,573 $43,782 $43,536 $150,000 $43,782 $43,536 $150,000 $43,782 $43,536 $150,000
Guaranteed: "Guaranteed" benefits and values are based on your contract premium of $3,573.00, assuming a guaranteed minimum interest rate of 4.00% and guaranteed maximum cost of insurance charges. The benefits and values shown are guaranteed provided the premium is paid, no policy loans or partial withdrawals are taken, and no long-term care benefits are used.
Non-Guaranteed/ Midpoint Assumptions:
All "non-guaranteed" benefits and values are not guaranteed. The interest rate and cost of insurance charges are subject to change by The State Life Insurance Company. As a result, the actual results may be more or less favorable than those illustrated. Policy benefits and values which are based on an interest rate and cost of insurance charges which are midway between the guaranteed and illustrated (non-guaranteed) interest rates and cost of insurance charges.
Non-Guaranteed/ Illustrated Basis:
"Non-guaranteed/illustrated basis" benefits and values are based on your contract premium of $3,573.00, an illustrated interest rate of 4.00%, and illustrated cost of insurance charges.
I have received a copy of this illustration and understand that any non-guaranteed elements illustrated are subject to change and could be higher or lower. The agent has told me that they are not guaranteed.
__________________________________________ ________________________
Owner Date
I certify that this illustration has been presented to the owner and that I have explained that any non-guaranteed elements are subject to change. I have not made any representations that are inconsistent with the illustration.
__________________________________________ ________________________
Agent Date
Valued Agent NANM
---Guaranteed---4.00%
End of Insureds' Cash Value Cash Death Benefit/
Policy Joint Equal Contract Accumulation Surrender LTC Benefit
Year Age Premium Fund Value Balance*
1 57 $3,573.00 $2,558 $528 $150,000 2 58 $3,573.00 $5,204 $2,739 $150,000 3 59 $3,573.00 $7,943 $5,478 $150,000 4 60 $3,573.00 $10,772 $8,307 $150,000 5 61 $3,573.00 $13,694 $11,229 $150,000 6 62 $3,573.00 $16,704 $14,486 $150,000 7 63 $3,573.00 $19,805 $17,833 $150,000 8 64 $3,573.00 $22,992 $21,267 $150,000 9 65 $3,573.00 $26,264 $24,785 $150,000 10 66 $3,573.00 $29,618 $28,385 $150,000 11 67 $3,573.00 $33,050 $32,064 $150,000 12 68 $3,573.00 $36,557 $35,817 $150,000 13 69 $3,573.00 $40,137 $39,644 $150,000 14 70 $3,573.00 $43,782 $43,536 $150,000 15 71 $3,573.00 $47,486 $47,486 $150,000 16 72 $3,573.00 $51,234 $51,234 $150,000 17 73 $3,573.00 $55,016 $55,016 $150,000 18 74 $3,573.00 $58,823 $58,823 $150,000 19 75 $3,573.00 $62,643 $62,643 $150,000 20 76 $3,573.00 $66,468 $66,468 $150,000 21 77 $3,573.00 $70,284 $70,284 $150,000 22 78 $3,573.00 $74,075 $74,075 $150,000 23 79 $3,573.00 $77,822 $77,822 $150,000 24 80 $3,573.00 $81,513 $81,513 $150,000 25 81 $3,573.00 $85,119 $85,119 $150,000 26 82 $3,573.00 $88,613 $88,613 $150,000 27 83 $3,573.00 $91,986 $91,986 $150,000
Contract Premium includes the annual charge of $358.50 for waiver of premium and $76.50 for cost of enhanced LTC monthly payout through joint equal age 100.
---Guaranteed---4.00%
End of Insureds' Cash Value Cash Death Benefit/
Policy Joint Equal Contract Accumulation Surrender LTC Benefit
Year Age Premium Fund Value Balance*
28 84 $3,573.00 $95,238 $95,238 $150,000 29 85 $3,573.00 $98,351 $98,351 $150,000 30 86 $3,573.00 $101,330 $101,330 $150,000 31 87 $3,573.00 $104,153 $104,153 $150,000 32 88 $3,573.00 $106,787 $106,787 $150,000 33 89 $3,573.00 $109,236 $109,236 $150,000 34 90 $3,573.00 $111,527 $111,527 $150,000 35 91 $3,573.00 $113,768 $113,768 $150,000 36 92 $3,573.00 $116,027 $116,027 $150,000 37 93 $3,573.00 $118,251 $118,251 $150,000 38 94 $3,573.00 $120,402 $120,402 $150,000 39 95 $3,573.00 $122,442 $122,442 $150,000 40 96 $3,573.00 $124,394 $124,394 $150,000 41 97 $3,573.00 $126,336 $126,336 $150,000 42 98 $3,573.00 $128,513 $128,513 $150,000 43 99 $3,573.00 $131,207 $131,207 $150,000 44 100 $3,573.00 $134,541 $134,541 $150,000 45 101 $0.00 $135,381 $135,381 $150,000 46 102 $0.00 $136,196 $136,196 $150,000 47 103 $0.00 $136,979 $136,979 $150,000 48 104 $0.00 $137,720 $137,720 $150,000 49 105 $0.00 $138,413 $138,413 $150,000 50 106 $0.00 $139,049 $139,049 $150,000 51 107 $0.00 $139,634 $139,634 $150,000 52 108 $0.00 $140,174 $140,174 $150,000 53 109 $0.00 $140,669 $140,669 $150,000 54 110 $0.00 $141,120 $141,120 $150,000
Contract Premium includes the annual charge of $358.50 for waiver of premium and $76.50 for cost of enhanced LTC monthly payout through joint equal age 100.
---Guaranteed---4.00%
End of Insureds' Cash Value Cash Death Benefit/
Policy Joint Equal Contract Accumulation Surrender LTC Benefit
Year Age Premium Fund Value Balance*
55 111 $0.00 $141,527 $141,527 $150,000 56 112 $0.00 $141,903 $141,903 $150,000 57 113 $0.00 $142,271 $142,271 $150,000 58 114 $0.00 $142,647 $142,647 $150,000 59 115 $0.00 $142,994 $142,994 $150,000 60 116 $0.00 $143,337 $143,337 $150,000 61 117 $0.00 $143,697 $143,697 $150,000 62 118 $0.00 $144,122 $144,122 $150,000 63 119 $0.00 $144,801 $144,801 $150,000 64 120 $0.00 $146,249 $146,249 $150,000 65 121 $0.00 $150,000 $150,000 $150,000
Contract Premium includes the annual charge of $358.50 for waiver of premium and $76.50 for cost of enhanced LTC monthly payout through joint equal age 100.
Supplemental Illustration
Long-Term Care Benefits Continuation Rider, Form R501(CO) Initial Rider Long-Term Care Monthly Benefit Limit: $6,000
Description of Rider: The Long-Term Care Benefits Continuation Rider will pay long-term care
benefits for the insured after long-term care payments under the Asset-Care policy are exhausted. Payment of the benefits under this rider are subject to the same terms and conditions as the Asset-Care policy. No death benefit is payable under this rider. The rider is noncancelable, meaning your premium cannot be increased and we can make no changes to the rider without your consent.
Optional Benefits: Inflation Protection and Nonforfeiture Benefit. For an additional premium, we
will provide an inflation protection benefit which will increase your rider monthly benefit limit, compounded annually after the first policy year. Also for an additional premium, we will pay you a nonforfeiture benefit if you lapse this rider for nonpayment of premium. The rider monthly benefit will remain at the level you choose when you purchase the rider, but will be paid for a shorter period of time. These optional benefits are not applicable to the base policy. Payment of these benefits is subject to the terms and conditions of the policy and this rider.
Effect of Base Policy on Rider Benefit: Any partial withdrawals taken from the base policy will reduce
the rider monthly benefit limit, the rider long-term care benefit balance, and the rider premium.
Single Premium Without Nonforfeiture Benefit (Guaranteed) Inflation Protection
0% 3% 5%
25 Months Coverage $16,465.86 $42,567.12 $79,344.48
Lifetime Coverage $35,480.22 $101,687.88 $191,960.16
Guaranteed Annual Premiums Without Nonforfeiture Benefit Inflation Protection
0% 3% 5%
25 Months Coverage $840.18 $2,153.58 $3,989.52
Supplemental Illustration
Long-Term Care Benefits Continuation Rider, Form R501(CO) Initial Rider Long-Term Care Monthly Benefit Limit: $6,000
Future Monthly Long-Term Care Benefit Amounts Available
Based On 0% Inflation
YEAR RIDER BENEFIT AMOUNT
10 $6,000
Asset Care Plus
Optional LTC Continuation of Benefits Rider Future Monthly LTC Benefit Amounts Available
Based On 0% Inflation Lifetime Benefits
Policy Year Rider Monthly Benefit Amount Total Potential Rider Benefits
1 $6,000.00 Lifetime 2 $6,000.00 Lifetime 3 $6,000.00 Lifetime 4 $6,000.00 Lifetime 5 $6,000.00 Lifetime 6 $6,000.00 Lifetime 7 $6,000.00 Lifetime 8 $6,000.00 Lifetime 9 $6,000.00 Lifetime 10 $6,000.00 Lifetime 11 $6,000.00 Lifetime 12 $6,000.00 Lifetime 13 $6,000.00 Lifetime 14 $6,000.00 Lifetime 15 $6,000.00 Lifetime 20 $6,000.00 Lifetime 25 $6,000.00 Lifetime 30 $6,000.00 Lifetime 35 $6,000.00 Lifetime 40 $6,000.00 Lifetime 45 $6,000.00 Lifetime 50 $6,000.00 Lifetime 55 $6,000.00 Lifetime 60 $6,000.00 Lifetime 65 $6,000.00 Lifetime
Presented By: Valued Agent
Premium Summary
Total First-Year Premium Paid $5,403
Base Policy Premium $3,573
Optional Asset-Care Plus Rider Annual Premium*
$1,830
Cash Value Summary
End of Policy Year
Cash Value Accumulation Fund Value**
Cash Value Accumulation Fund Value** 1 $2,557 $2,557 2 $5,203 $5,203 3 $7,942 $7,942 4 $10,771 $10,771 5 $13,693 $13,693 6 $16,704 $16,704 7 $19,804 $19,804 8 $22,992 $22,992 9 $26,263 $26,263 10 $29,617 $29,617 11 $33,049 $33,049 12 $36,556 $36,556 13 $40,137 $40,137 14 $43,782 $43,782 15 $47,485 $47,485 25 $85,119 $85,119 35 $113,767 $113,767 45 $135,381 $135,381 55 $141,526 $141,526 65 $150,000 $150,000
This is a supplemental illustration.
