Insurance Illustration Form

INSURANCE ILLUSTRATION FORM

Applicant and Insured Information

Applicant Name:

Insured Name (if different):

Date of Birth:   Sex: Male Female Other

Primary Phone:   Email:

Policy and Illustration Summary

Illustration Number:   Date of Illustration:

Term Whole Life Universal Life Variable Universal Life

Premium Frequency: Monthly Quarterly Annually

Policy Effective Date:   Policy Anniversary:

Optional Riders and Coverage Selections

Waiver of Premium Accelerated Death Benefit Accidental Death Benefit Disability Income Rider

Illustration Assumptions and Guarantees

Illustrated Interest Rate (non‑guaranteed):   Guaranteed Interest Rate:

Mortality and Expense Basis:

Illustration contains projected, non‑guaranteed values based on assumptions stated above. Guaranteed values are based on contractual provisions and guaranteed interest and charges as stated in the policy.

Projected Values (select illustrative years)

Year 1 — Premiums Paid:   Projected Cash Value:   Guaranteed Cash Value:

Year 5 — Premiums Paid:   Projected Cash Value:   Guaranteed Cash Value:

Year 10 — Premiums Paid:   Projected Cash Value:   Guaranteed Cash Value:

Year 20 — Premiums Paid:   Projected Cash Value:   Guaranteed Cash Value:

Exclusions and Material Limitations

This illustration is not a contract. It does not change or amend any contractual provisions. Values shown are dependent upon the accuracy of the information provided, continuing payment of premiums as illustrated, insurer expenses, mortality experience, credited interest rates and other factors as described in the policy. Material limitations and exclusions may apply, including but not limited to suicide provisions, misstatement of age or sex, nonpayment of premium and policy lapse provisions.

Applicant acknowledges receipt of this illustration and that the applicant has read and understands that illustrated values may be non‑guaranteed and may vary from actual results.
Applicant acknowledges exclusions and limitations described above.

Beneficiary Designation

Producer / Agent Information

Declaration and Applicant Certification

I certify that the information provided in this illustration is true and correct to the best of my knowledge. I understand that this illustration is a summary of projected values under the assumptions stated and is not a contract nor a guarantee of future policy performance except where values are specifically identified as guaranteed. I understand that actual policy performance will depend on the insurer's future experience and policyholder actions.

I authorize the producing agent and insurer to rely on the information provided in this illustration for issuance of coverage and further attest that no material fact has been omitted. I acknowledge receipt of a copy of this illustration.

Applicant's Acknowledgment: I certify that I received and reviewed this illustration.

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