2120 - Served '2121 - Served

2220 - Not Sewed 2221 - Not Served~~-

2320 - Served By Mail 2321 -

~~ ~~~

Sewed By Mail
2420 - Served By Publication 2421 - Served by Publication
SUMMONS ALIAS - SUMMONS (Rev. 3/21/95) CCG-1 A

IN THE CIRCUIT COURT O F COOK COUNTY, ILLINOIS

COUNTY DEPARTMENT, CHANCERY DIVISION

(Name all parties)

SUSAN MILLER

Plaintiff
bpe dp ~ l l f l s
NO. 9'7CH0432a
NSURNACE COMPANY

SUMMONS

To each defendant:
YOU ARE SUMMONED and required to file an answer to the complaint in this case, a copy of which is
hereto attached, or otherwise file appearance, in the office of the Clerkof this Court (located in the Richard J.
Daley Center, Room* 802 , Chicago, Illinois 60602) within 30 days after service of this summons, not counting
the day of service. I F YOU FAIL T O DO SO, A JUDGMENT BY DEFAULT MAY BE ENTERED AGAINST
YOU FOR THE RELIEF ASKED IN THE COMPLAINT.
To the officer:
This summons must be returned by the officer or other person to whom it was given for service, with
endorsement of service and fees, if any, immediately after service. If service cannot be made, this summons shall be
returned so endorsed. This summons may not be served later than 30 days after its date.

or you may present an Application to Sue or Defend as WITNESS, ,T ......................

A P R 08- ,19.....
.~
. . .
a Poor Person (form #CCG-19). If approved by the
Presiding Judge, the fee will be waived.
...........................................
Clerk of Court
Name Christopher V. Langone
Attorney for Plaintiff(s) Date of service: ....................... ... , 19.
Address One East Wacker Drive (To be inserted by officer on copy left with
City Chicago defendant o r other personj
Telephone (312) 464-7200
Atty. No. 34257
**Service by Facsimile Transmission will be accepted at: (3121464-0077
(Area Code) (Facsimile Telephone Number)

AURELIA PUCINSKI, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, IL1,IWOIS

*Law Division Room 801

Chancery-Divorce Room 802
County Division Room 801
Probate Division Room 1202
 IN THE CIRCUIT COURT OF COOK COUNTY
COUNTY DEPARTMENT, CHANCERY DIVISION

SUSAN MILLER and all others ) I ,

similarly situated, )

Plaintiff,
)
) CLASS ACTION
97CH04324
1
v. )
)
ROYAL MACCABEES LIFE ) JURY TRIAL REQUESTED
INSURANCE COMPANY, 1
)
Defendant. )

CLASS ACTION COMPLAINT

Introduction

1. This action seeks redress for breach of contract in connection with the sale

of insurance.

Parties

2. Plaintiff, SUSAN MILLER, is an individual who is a citizen of Illinois.

3. Defendant. ROYAL MACCABEES LIFE INSURANCE COMPANY

("MACCABEES"), is an insurance company, licensed to sell insurance in the State of

Illinois.

Alle~ationsParticular to Miller

4. On approximately September 15, 1987, Defendant sold a policy of insurance

to Plaintiff ("the Policy"). A true and correct copy of this policy is attached here and

incorporated as Exhibit A.

5. The Policy, which is a form document sent to numerous persons

states, on the page designated on the lower left hand corner "L-5 (FPAL-6)", under the

heading "Cost of Insurance Benefits," that: "Monthly Cost of Insurance Rates will be
determined by the Company from time to time based on its expectations as to future

mortality experience."

6. On September 15, 1991, Defendant, in its "Annual Statement

Policy Year Ending September 14, 1991," attached as Exhibit B, which is a computer

generated form document sent to numerous persons, stated in relevant part that: "starting

Sep 15, 1991, current monthly insurance charges on this policy will be adjusted . . . The

adjustments reflect the increasing number of AIDS -related deaths and, for policies which

are not part of a pension plan, new federal corporate insurance taxes."

Class Allegations

7. Plaintiff bring this action on behalf a class.

8. The class consists of all persons nationwide, who:

(a) within the last ten years brought a policy of insurance similar to the
one attached as Exhibit A and which indicated that the premium
increases would be related solely to expectations of "futuremortality
experience;" and

(b) had their premiums increased for reasons other than

expectations of "future mortality experience".

9. Joinder of all Plaintiffs is impracticable because, on information

and belief, Exhibit A is a standard, form insurance contract, which has been entered into

by hundreds or thousands of individuals.

10. Questions of fact and law common to all members of the class predominate

over those peculiar to individual class members. These common questions include:
 (a) whether the statement, in E x h i b i t , that "Monthly Cost of
Insurance Rates will be determined by the Company from time to
time based on its expectations as to future mortality experience."
amounts to a representation that rates will not be increased unless
mortality rates change ;

(b) whether Maccabees breached their contract with the consumers of

insurance by increasing rates, as stated in Exhibit B, because of
"new federal corporate insurance taxes."

11. The Plaintiff will fairly and adequately protect the interests of the class

because the Plaintiffs claims are typical of the claims of all of the members of the class

and because all claims are based on the same factual and legal theories.

12. Plaintiff and Plaintiff's counsel will fairly and adequately represent the

interests of the class members and will vigorously pursue this matter.

13. Certification of the class is appropriate. A class action is the only

appropriate means of resolving this controversy because of the relatively small amount of

money in controversy and the fact that class members are not aware of their rights. In the

absence of a class action, a failure of justice will result. Prosecution of separate actions

by individual members of the class would create the risk of inconsistent or varying

adjudications resulting in the establishment of inconsistent or varying standards for the

parties.

14. By its conduct described above, Defendant Maccabees breached its contract

by increasing its insurance rates for reasons other than those provided for in the contract

with the Plaintiff.

 WHEREFORE, Plaintiff, SUSAN MILLER, requests that the Court grant the

following relief in her favor and on behalf of the class members and against ROYAL

MACCABEES LIFE INSURANCE COMPANY such that:

a. all money collected by ROYAL MACCABEES LIFE INSURANCE

COMPANY as a result of increases in insurance payments that are
not authorized by its contract with consumers be repaid to the class; and

b. Any such other relief that the Court deems appropriate and just under the
circumstances.

Respectfully submitted,

One of Her Attorneys

Christopher V. Langone, Esq.

Brian K. Hodes, Esq.
Langone & Hodes
One East Wacker, Suite 2420
Chicago, IL 60601
(3 12) 464-7200

Dated: April 8, 1997

v. rnaeabees eamp.wpd
\\Chris\lawd~e~\CASESV\CTIVE\Milier\mill
 S C H E D U L E O F a E N F F I T S A h u I N I T I A L MONTHLY E X P E N S E CnARGES

nthEFIT INITIAL D A T E TO WHICH IFIITIAL

TYPE SPECIFIED COVERAGE I S HONTHLY
BENEFIT PROVIDED EXPENSE
AMOUNT CHARGE

F L E X I a L F PRFMIUM S250rPt3+ SEPTEMRER 15, 2 0 4 2 s49.9i

AOJIJSTABLF L I F E V I - 1 5 ' 3
*THIS AMOUVT DOES I N C L U D E T H E A C C U M U L A T I O N V A L U E

MA X I MUM A D M I hII S T R A T I V E CHARGE:

MAXINUM SURRENDER CHARGE: $3,987.50
.
S 5 I3 0 M A X I M U M P R E M I U M LOAD:
WITHDRAWAL CHARGE:
6.53%
$25.00
COVERAGE C O N T I N U A T I O N COMPONENT: $72.91

NOTE: T H E T E R M I N A T I J N D A T E I S T H A T E L E C T E D B Y THE OWNER. I T I S

P O S S I B L E T H A T COVERAGE M I L L C E A S E P R I O R TO T H E M A T U R I T Y
SHOWN I F SURSEOUENT P R E M I U M S AND I N T E R E S T C R F D I T E D ARE
I Y S U F F T C I E N T TO C O N T I N U E COVERAGE TO S U C t i A DATE.

-~

D A T E O F 1SSUE:SEPTEHBEK 159 1987

INSgRED: SUSAN C M I L L E R t4ATUR ITY DATE: SEPTEMBER 1 5 r 2 3 4 9

SEX: FEMALE I S S U E AGE: 46

PREMIUM CLASS: STANDARD-NONSMOKER MONTHLY D E D U C T I O N DAY I S : THE 1 5 T t i

D A Y O F E A C H MONTH

INITICL PREMIUM: ~ ~ 7 ac
5 . P L A N N E D P E R I O D I C PREMIUM:
5875.80 (ANNUAL)

DO NOT SIJRRENDER YOUR P O L I C Y OR ALLOW I T TO L A P S E FOR ANY REASON N I T H O U T

C O N S U L T I N G THE COYPANY. I?$
CASE D F ANY Q U E S T I O N ABOUT T H I S P O L I C Y I CONTACT
YOUR L O C A L MACCABEES AGENCY OR W R I T E THE COMPANY A T I T S HOME O F F I C E .

MM-SPEC-83 PAGE 3
" B'
 INSURANCE PROCEEDS
PROCEEDS PAYABLE
This Policy shall terminate upon the death of the
Insured. The Company will pay the lnsurance
Proceeds subject to the provisions of this Policy to the
Beneficiary upon receipt of due proof of the lnsured's
death. The Company will require surrender of this
Policy as a condition of payment.
The lnsurance Proceeds payable depend on the
Specified Benefit Amount Option in effect at the date
of death.
Two Specified Benefit Amount Options are available
under this Policy:
LEVEL OPTION-The Specified Benefit Amount as
shown on the Schedule Page Includes the
Accumulation Value. Under this option, the lnsurance
Proceeds at the lnsured's date of death shall equal
the greater of:
1) the Specified Benefit Amount on the date of
death; or
2) the Accumulation Value on the date of death
multiplied by the percentage shown in the Table
of Minimum Death Benefit Percentages for the
Insured's attained age.
INCREASING OPTION-The Specified Benefit
Amount as shown on the Schedule Page is in addition
to the Accumulation Value. Under this option, the
lnsurance Proceeds at the lnsured's date of death
shall equal the greater of:
1) The Specified Benefit Amount on the date of
death, plus the Accumulation Value on the date
of death; or
2) the Accumulation Value on the date of death
multiplied by the percentage shown in the Table
of Minimum Death Benefit Percentages for the
Insured's attained age.
Any increases or decreases made to the Specified
Benefit Amount may change the lnsurance Proceeds
payable. Any loan, Withdrawal, or Partial Surrender
of this Policy will be subtracted from the lnsurance
Proceeds.
If the Insured is living on the Maturity Date and this
Policy is in force, this Policy shall terminate and the
Company shall pay the Surrender Value to the Owner.
The Maturity Dafe is shown on the Schedule Page.
It is possible that coverage will terminate prior to the
Maturity Date if premiums paid following payment of
the Initial Premium are insufficient to continue
coverage to such date. It is also possible that
coverage will terminate prior to the Maturity Date
shown if the Company changes the interest rate or
the Monthly Cost of lnsurance Rates.
CHANGES IN SPECIFIED BENEFIT AMOUNT OPTION
The Schedule Page shows the option elected In the
original application. The option may be changed by
the Owner as allowed by the Company.
If the lncreasing Option is in effect and the Owner
I
changes to the Level Option, the Specified Benefit
Amount subsequent to this change will equal the total
of the Specifled Benefit Amount prior to the change
plus the Accumulation Value. Thereafter, the
Specifled Beneflt Amount will include the
Accumulation Value. If the Level Option is in effect
and the Owner changes to the lncreasing Option, the
Specified Benefit Amount subsequent to this change
will equal the Specified Benefit Amount prior to the
change less the Accumulation Value. Thereafter, the
Specified Benefit Amount will not include the
Accumulation Value.
CHANGES IN SPECIFIED BENEFIT AMOUNT
The Specified Benefit Amount of this Policy may be
increased or decreased upon written request by the
Owner Subject to the following conditions:
1) Any decrease will become effective on the
Monthly Deduction Day that falls on or next
follows the date the request is received by the
Company. Such decrease will reduce the
Specified Benefit Amount in the following order:
a) It will decrease the insurance provided by the
most recent increases successively; then
b) it will decrease the Initial Specified Benefit
Amount.
2) The Specified Benefit Amount may not be
decreased to an amount less than $25.000.
3) The Specified Benefit Amount may not be
changed by an amount less than $10,000.
4) Any request for an increase must be applied for
on a supplemental application. Such increase will
be subject to evidence of insurability satisfactory
to the Company. Any increase will be subject to
the sufficiency of the Accumulation Value, less
any indebtedness, to cover the next Monthly
Expense Charge. Any increase will become
effective on the effective date shown on the
Specification Endorsement.
5) The Specified Benefit Amount may not be
increased if there has been a prior decrease.
APPLICATION FOR ADDITIONAL INSURANCE
Additional insurance on the life of the lnsured's
spouse or child may be applied for by supplemental
application. Approval of the additional insurance shall
be subject to evidence of insurability satisfactory to
the Company. Additional insurance shall also be
subject to the sufficiency of the Accumulation Value,
less any indebtedness, to cover the next Monthly
Expense Charge. Such new insurance will be
provided by rider and will become effective on the
effective date shown on the Specification
Endorsement.
 DEFINITIONS

1I Whenever used in the Policy, thefollowing words MATURITY DATE II

mean:
The date specified as such on the Schedule Page,
ACCUMULATION VALUE upon which the Surrender Value will become payable
if the lnsured is living.
The amount of money that is credited with interest to MONTHLY DEDUCTION DAY
the Policy on a monthly basis.
The day of each month shown on the Schedule Page
BENEFICIARY when the Accumulation Value of the Policy is
calculated and the Monthly Expense Charge is
The person named in writing by the Owner to receive deducted. The first Monthly Deductior Day shall be
the Insurance Proceeds in the event of the Insured's the Date of lssue.
death.
MONTHLYEXPENSE CHARGE
CASH VALUE The total amount deducted each month for the
coverage provided under the Policy and any additional
The amount of Accumulation Value of this Policy less benefits provided by rider.
any Surrender Charges.
OWNER
COMPANY The person to whom this Policy belongs
The Maccabees Mutual Life Insurance Company. PARTIAL SURRENDER
DATE OF ISSUE An amount available in cash at any time upon request
equal to 50% or more of the Surrender value.
The date shown on the Schedule Page from which PLANNED PERIODIC PREMIUM PAYMENT
policy years, months and anniversaries shall be
determined. The amount of regular premium payment elected by
the lnsured. This amount and the frequency of
HOME OFFICE OF THE COMPANY payment are shown on the Schedule Page. The
Owner may change the amount and frequency of the
25800 Northwestern Highway, P.O. Box 2165, Planned Periodic Premium Payment at any time
Southfield, Michigan 48037-2165 subject to the policy provisions. Any change in
frequency and amount will be reflected in the Annual
INDEBTEDNESS Report provided by the Company.
The sum of any unpaid policy loans and any unpaid SPECIFIED BENEFIT AMOUNT
policy loan interest. The initial amount of coverage shown on the Schedule
Page. This Amount may be changed by the Owner
INITIAL PREMIUM at any time subject to the policy provisions. Any
change in the Specified Benefit Amount will be
The amount due at the Date of lssue shown on the reflected in a Specification Endorsement.
Schedule Page and payable in advance.
SURRENDERCHARGE
INSURANCE PROCEEDS The amount deducted by the Company from the
The total amount the Company will pay upon the Accumulation Value if the Policy is surrendered.
death of the lnsured. SURRENDERVALUE
INSURED The amount of Cash Value, plus the cash value Of any
paid up dividend additions, less any indebtedness,
The person named on the Schedule Page whose life available in cash or an Optional Method of Settlement
this Policy insures. upon the termination or maturity of this Policy.
WITHDRAWAL
LOAN VALUE
An amount available in cash at any time upon request
The amount that can be borrowed under the Policy. which is less than 50% of the Surrender Value.
 GENERAL BRBVIS!ON§
THE CONTRACT
This Policy, the attached appiication for this Pollcy,
any attached riders, any supplemental applications tor
Increases in the Specified Benefit Amount, and any
Specification Endorsements make up the entire
contract between the parties.
This Policy shall take effect upon delivery, provided
the Initial Premium has been paid, the Insured is
living, and there has been no material chmge In the
health of the lnsured s shown in the application.
All statements made in the appllcatlon are, in the
absence of fraud, deemed representations and not
warranties. No statement made by the lnsured or on
his behalf will be used In defense of a claim under
this Policy unless it is made in a written appiication
and a copy of the application containing that
statement is attached to the Policy when iseued.
Policy years, policy months, and policy anniversaries
are measured from the Date of Issue of the Policy.
Attained age means age iast birthday on the prior
policy anniversary.
Any change or waiver of any provision of this Policy
must be in writing and signed by an officer of the
Company.
SUICIDE
If the lnsured dies by suicide while sane or insane,
within two years from the Date of issue, the lnsurance
Proceeds will not be pald. The amount payable will
be the total of premiums paid less any indebtedness
on thls Policy, and less any Withdrawal and Partial
Surrender amounts paid. A new tweyear period will
apply to any increase in the Specified Benefit Amount
beginning on the date of each increase. The amount
payable under this provision attributable to a policy
increase will be the Costs of lnsurance for that
Increase if death by suicide, while sane or insane,
occurs during the first two years following the
increase.
The amount payable under this provision will be paid
to the Beneficiary.
INCONTESTABILITY
After this Policy has been in force during the insurds
iifetlme for two years from the Date of Issue, the
Company loses the right to contest a claim based on
statements made in the appiication.
After this Policy has been in force during the Insured's
ilfetlme for two years from the date on which the
SpsciHed Benefit Amount is increased, the Company
loses the right to contest a claim which involves the
increase in Spscifled Benefit Amount.
This provision doe8 not apply to any Disability Benefit
or Accidental Beneftt attached to thls Pollcy.
MISSTA?EYENTOFAGEORSU(
If the Insured's age or k x has been misstated, the
proceeds payable upon death will be:
1) the Accumulation Value on the date of death; plus
2) that amount of Insurancewhich would have been
purchased by the most recent Coat of Insurance
deduction had the mrrect Coat of Insurance Rate 1I
II
been used.
ANNUALREPORT
At least once each year the Company will send the
Owner an Annual Report which shows:
1) The current Accumulation Value;
II II
2) The current Surrender Value;
3) The amount of any outstanding policy loan;
4) Premiums paid since the last Report;
5) Expense Charges since the last Report;
6) The Specified Benefit Amount;
7) Interest credited since the iast Report; and
8) Any Partial Surrenders or Withdrawals sincethe
last report.
II
ILLUSTRATIVE REPORT
The Company will provide an illustrative report of
projected future InsuranceProceeds and Cash Values
which will be sent to the Owner upon request. The
Company may charge a reasonable fee for providing
such a Report.
I1 CONTROL OF POLICY II
BENEFICIARY CHANGE OF OWNERSHIP

The Insurance Proceeds will be paid to the Beneficiary
last named in writing by the Owner. Two or more
Beneficiaries will receive equal shares of the proceeds
unless a different allocation is specified. A Beneficiary
must survive the lnsured. Otherwise, his share will be
paid to the surviving Beneficiary or Beneficiaries in
equal shares. If no Beneficiary has been named or
there are no surviving Beneficiaries, the Insurance
Proceeds will be paid to the Owner, if living; otherwise
to the Owner's estate.
CHANGE OF BENEFICIARY
The Owner may change any Beneficiary at any time
while the Insured is living. A written notice of change
must be sent to the Company at its Home Office. The
change will take effect on the day it was signed,
subject to any action taken by the Company prior to
the recording of the change at the Home Office.
The Owner may name a new Owner by written notice
mailed to the Company. The change will take effect
on the day it was signed, subject to any action taken
by the Company prior to the recording of the change
at the Home Office.
ASSIGNMENT
This Policy may be assigned by the Owner as
collateral. Any assignment must be in writing and a
signed copy sent to the Company at its Home Office.
The rights of the Owner and the interest of any
Beneficiary will be subject to the rights of any
assignee of record as specified in the assignment. The
Company is not subject to the rights of any assignee
of record. The Company is not responsible for the
validity or effect of any assignment.

OWNERSHIP

This Policy belongs to the Owner. If the Owner dies,

this Policy belongs to the Owner's designee, or the
Owner's estate if no Owner's designee has been
named.

DIVIDEND PROVISION

This Policy, while in force, may participate in any AUTOMATIC OPTION

divisible surplus of the Company. The amount of any
such dividend shall be determined by the Board of If no option is selected, dividends will be added to the
Directors. Accumulation Value of the Policy and treated as
additional premium.
DIVIDENDS

Each annual dividend when payable may be applied

under one of the following options:

1) Paid in cash;

2) Added to the Accumulation Value of the Policy

and treated as an additional premium; or

3) Left to accumulate with the Company at interest

of not less than 3% per year. These dividends
may be withdrawn in cash at any time.
 PREMIUMS
PAYMENT
The Initial Premium is due on the Date of lssue and
is payable in advance. Subsequent premiums are
payable in advance of the period to which they apply.
No benefit will be provided on the basis of any
premium until that premium has been paid. The
amounts and frequency of Planned Periodic Premium
Payments are shown on the Schedule Page.
Premiums must be paid to the Company at its Home
Office. Upon request, a receipt signed by the
President or Secretary of the Company will be
.
furnished for anv, ,oremium oavment.
, rider. The Coveraae Continuation Cornoonent in effect
Changes in frequency and increases or decreases in
the amount of Planned Periodic Premium Payments
may be made by the Owner. The Planned Periodic
Premium cannot be changed to an amount less than
$50.00. Premium payment notices will be sent to the
Owner upon written request. The notices may be sent
annually, semi-annually, or quarterly.
Under the special payment facility, Planned Periodic
Premium Payments of $25.00 or more may be made
on a monthlv basis.
Additional payments may be made at any
time during the continuance of this Policy.
The Company reserves the right to refuse to accept
any premiums which would disqualify this Policy from
favorable tax treatment as life insurance under federal
law. If premiums paid during any policy year exceed
the federal life insurance premium guidelines, the
Company will return the excess premiums with
interest of at least 4% within sixty days after the end
of the policy year.
GRACE PERIOD
Except as provided below, this Policy will enter the
Grace if the Surrender On the Monthly
Deduction Day is insufficient to cover the Monthly
Expense Charge. (The Accumulation Value,
Surrender Value, and Expense Charge are
described in the Nonforfeiture Provisions.)
The above notwithstanding, prior to the ninth policy
anniversary, this Policy will enter the Grace Period if:
The Accumulation Value less indebtedness on the
Monthly Deduction Day is less than the Monthly
Expense Charge;
or if
The Surrender Value on the Monthly Deduction
Day is less than the Monthly Expense Charge;
and
The sum of the premiums paid since the Date of
Issue, less any loans, Withdrawals or Partial
Surrenders, is less than the Coverage
Continuation Requirement as of the Monthly
Deduction Day.
1
1 h
As of each Monthly Deduction Day during the first nine
policy years, the Coverage ContinuationRequirement
shall be the sum of the Coveraae Continuation
Components applicable to each polit$month from the
Date of lssue.
The Coverage Continuation Component in effect on
the Date of lssue is shown on the Schedule page. The
Coverage Continuation Component will change as of
the effective date of any increase in the Specified
Benefit Amount, or any addition of, or increase in, any
as of any ~ o n t h hDeduction Day will apply to the
policy month next fol,owing. The Company wil notify
the Owner of any change in the Coverage
Continuation Component.
A Grace Period of sixty-one days will be allowed for
the payment of premiums sufficient to cover any past
due Monthly Expense Charges and applicable loan
interest. Written notice of such premium will be mailed
to the last known address of the Owner and any
assianee of record at least thirtv davs before the
race Period ends. If such premiim is ;lot paid within
the Grace Period, all coverage will terminate without
value at the end of the Grace Period. If a claim by
death during the Grace Period becomes payable
under the Policy, any overdue Monthly Expense
Charge will be deducted from the Insurance
Proceeds.
REINSTATEMENT
If this Policy terminates as provided in the Grace
Period provision, the Owner may apply for
reinstatement. The application must be received by
the company at its Home office five years of
the date of termination, but before the Maturity Date,
and must include:
1) evidence of insurability of the Insured satisfactory
. ..
to the Comoanv:
2) payment of a premium sufficient to prevent this
Policy from entering a Grace Period for at least
three months after the date of reinstatement;
3) payment or reinstatement of any policy loan; and
4) payment of interest on the reinstated loan from the
date of reinstatement to the end of the policy year.
Reinstatement will not be effective until the date the
application is approved by the Company.
The Incontestability provision with respect to the
reinstatement application and the Suicide provision
will apply from the effective date of reinstatement.
 NONFORFEITURE PROVISIONS
(( ACCUMULATION VALUE
The Accumulation Value on the Date of lssue shall
be at least 931/2 percent of premiums paid on or before
the Date of lssue, less the Monthly Expense Charge
for the first month. On each Monthly Deduction Day
II
the Accumulation Value shall be calculated as (a), plus
(b) plus (c), minus the sum of (d) plus (e) where:
(a) is the Accumulation Value on the preceding
Monthly Deduction Day;
(b) is one month's interest on (a);
(c) is 93112 percent or more of all premiums received
since the preceding Monthly Deduction Day;
I (d) is the amount of any Partial Surrender, Partial
Surrender Charge, Withdrawal and Withdrawal
I fee since the preceding Monthly Deduction Day;
(e) is the Monthly Expense Charge for the month
following the Monthly Deduction Day.
On any day other than a Monthly Deduction Day, the
Accumulation Value shall be calculated as (f) plus (g)
minus (h), where:
(f) is the Accumulation Value as of the preceding
Monthly Deduction Day;
(g) is 93% percent or more of all premiums received
since the preceding Monthly Deduction Day;
(h) is the amount of any Partial Surrender, Partial
Surrender Charge, Withdrawal or Withdrawal fee
since the preceding Monthly Deduction Day.
MONTHLYEXPENSECHARGE
The Monthly Expense Charge shall be calculated as
(i) plus (j),where:
(i) is the Cost of lnsurance (as described below) plus
the cost of additional benefits provided by rider:
(j) is the Administrative Charge.
The Administrative Charge shall not exceed, but may
be less than, the Maximum Administrative Charge
shown on the Schedule Page.
INTEREST RATE
The interest rate used in the calculation of the
Accumulation Value is guaranteed to be a minimum
of ,32737 Percent Per month, compounded monthly,
which is equal to 4 Percent Per Year compounded
//
annually. Interest in excess of the guaranteed
minimum rate may be credited as determined by the
Company's Board of Directors. Interest credited on
the portion of the Accumulation Value that is loaned
will at no time be less than the guaranteed minimum
interest rate.
COST OF INSURANCE
II
The Cost of lnsurance is determined on a monthly
basis. The Cost of lnsurance is determined separately
for the Initial Specified Benefit Amount and for each
increase in Specified Benefit Amount.
/I
The Cost of Insurance is calculated as (a), multiplied
by the result of (b) minus (c), where:
(a) is the Cost of lnsurance Rate as described in the
Cost of lnsurance Rates section;
(b) is the lnsurance Proceeds at the beginning of the
policy month divided by 1.0032737;
(c) is the Accumulation Value at the beginning of the
policy month.
If the Accumulation Value is included in the Specified
Benefit Amount and there have been increases in the
lnsurance Proceeds, then the Accumulation Value
shall be first considered a part of the Initial Specified
Benefit Amount. If the Accumulation Value exceeds
the Initial Specified Benefit Amount, it shall then be
considered a part of additional Specified Benefit
Amounts resulting from increases in the order of the
increases.
Any deduction for the Cost of lnsurance during the
Grace Period shall not be considered a waiver by the
Company of the terms of the Grace Period provision.
Any such charge shall be deducted from the
Accumulation Value as of the date of the charge.
COST OF INSURANCE RATES
The monthly Cost of lnsurance Rate is based on the
sex, attained age, and rating class of the person
insured. Monthly Cost of lnsurance Rates will be
determined by the Company from time to time based
on its expectations as to future mortality experience.
However, the Cost of lnsurance Rates will not be
greater than those shown in the Table of Guaranteed
Maximum lnsurance Rates or as the same are
1
amended by the rating factor, if any, shown on the
Schedule Page. Any change in the Cost of lnsurance
Rates will be on a uniform basis for insureds of the
same age, sex and classification whose policies have
been in force for the same lenath of time. The interest
rate used to calculate the- guaranteed Cost of
insurance ~~t~~ is 4% per year, The Table of
Guaranteed Maximum Insurance Rates is also
applicable to increase amounts of insurance subject
to
~. anv
.~.., aoalicable
rr...--.- ratina
~w factor shown on the Schedule
~~
Paae.
-~"-
The guaranteed Cost of Insurance Rates are based
on the 1980 Smoker or Nonsmoker Commissioner's
Standard Ordinary Mortality Table (CSO), Age Last
Birthday.
rr
 NONFORFEITURE PROVISIONS (Continued)
CASH VALUE
The Cash Value shall be calculated as the
Accumulation Value less the Surrender Charge.
SURRENDERCHARGE
The Surrender Charge is the lesser of (a) or (b), where:
(a) is the Accumulation Value;
(b) is the Maximum Surrender Charge shown on the
Schedule Page multiplied by the factor from the
Table of Surrender Charge Factors that
corresponds to the policy year of surrender.
/I SURRENDER CHARGE FOR INCREASES IN
SPECIFIED BENEFIT AMOUNT
If the Specified Benefit Amount is increased, a
separate Surrender Charge will be applied at the time
of the increase. The Specification Endorsement
providing for the increase will include the Maximum
Additional Surrender Charge resulting from the
increase. The Additional Surrender Charge will equal
the Maximum Additional Surrender Charge shown on
the Specification Endorsement multiplied by the factor
from the Table of Surrender Charge Factors that
corresponds to the number of years since the
increase.
The Additional Surrender Charge resulting from an
increase shall be added to the amount specified in
(b) above to determine the total Surrender Charge.
BASIS OF COMPUTATIONS
Accumulation Values are based on the 1980 Smoker
or Nonsmoker CSO Mortality Table, Age Last
Birthday, with interest at 4 percent per year
compounded annually. Accumulation Values are at
least equal to those required on the Date of Issue by
the state in which this Policy was purchased.
Reserves are based on the 1980 Smoker or
Nonsmoker CSO Mortality Table, Age Last Birthday,
with interest at the Calendar Year Statutory Valuation
Interest Rate. Reserves are calculated using a
Modified Preliminary Term method, but are not less
than the reserves calculated using the
Commissioner's Reserve Valuation method.
Where required, a detailed statement of the method
of computation of Accumulation Values and reserves
under this Policy has been filed with the insurance
department of the state in which this Policy was
purchased.
CONTINUATION OF INSURANCE
In the event Planned Periodic Premium payments are
not continued, insurance coverage under this Policy
and any benefits provided by rider will be continued
in force.
17
Such coverage shall be continued until termination
as provided in the Grace Period provision. This
provision shall not continue the Policy beyond the
Maturity Date nor continue any rider beyond the date
for its termination, as provided in the rider. If the
Insured is living on the Maturity Date and the Policy
is still in force, the Company will pay the Surrender
Value to the Owner.
WITHDRAWAL
A Withdrawal from this Policy may be made at any
time prior to termination upon wrinen request by the
Owner to the Company at its Home Office. The sum
of all Withdrawals cannot equal or exceed 50% of the
Surrender Value.
When a Withdrawal is made, the amount of the
Withdrawal will be deducted from the Accumulation
Value. The lnsurance Proceeds shall be reduced by
the amount of the Withdrawal. An additional fee of
$25.00 will be deducted from the Accumulation Value
for each Withdrawal. Not more than three Withdrawals
will be allowed in any policy year.
The Company reserves the right to defer a Withdrawal
for a period permitted by law, but not for more than
six months from the date of receipt of the request by
the Company at its Home Office, unless such payment
would be used to pay premiums on policies in force
with the Company.
PARTIAL SURRENDER
A Partial Surrender of this Policy may be made at any
time prior to termination by written request of the
Owner to the Company at its Home Office. A Partial
Surrender is an amount which when added to all
previous Partial Surrenders and Withdrawals equals
or exceeds 50% of the Surrender Value. If a Partial
Surrender is made, an additional fee will be deducted
from the Accumulation Value as follows. The
additional fee will equal the Surrender Charge
multiplied by the ratio that the Partial Surrender bears
to the Surrender Value. After a Partial Surrender, the
Surrender Charge for the Policy will be reduced by
the additional fee. The lnsurance Proceeds, the
Accumulation Value, and the Cash Value will be
reduced by the amount of the Partial Surrender. Not
more than three Partial Surrenders will be allowed in
any policy year.
The Company reserves the right to defer a Partial
Surrender for a period permitted by law, but not for
more than six months from the date of receipt of the
request by the Company at its Home Office, unless
such payment would be used to pay premiums on
policies in force with the Company.
 The NONFORFEITURE PROVISIONS (Continued)
SURRENDER ANDSURRENDERVALUE
This Policy may be surrendered at any time prior to
termination upon written request by the Owner to the
Company at its Home Office. The amount payable on
surrender of this Policy shall be the Surrender Value.
which is the Cash Value including the cash value of
any paid up dividend additions, less any
indebtedness, on the date of surrender. The
Surrender Value will be paid in cash or under an
elected Settlement Option.
If surrender is requested under this section within 30
POLICY LOAN PROVISIONS
POLICY LOANS
The Owner can borrow against this Policy as sole
security for any amount up to the Loan Value plus the
cash value of any dividend additions at any time prior
to the termination of this Policy. The loan must be
requested by the Owner in writing.
On a policy anniversary, premium due date, or during
a Grace Period the Loan Value is the Cash Value less
any loan and accrued interest. Otherwise, the Loan
Value is the amount with interest which equals the
Loan Value on the next policy anniversary.
Before advancing the loan amount, the Company may
withhold an amount sufficient to pay interest on total
indebtedness to the end of the policy year and any
Monthly Expense Charges due during the next three
months, or to the end of the policy year, whichever
occurs first.
The Owner may be required to sign a loan agreement
assigning this Policy to the Company as security. The
Company may delay the payment of the loan.
Payment may be delayed up to six months from the
date the request was recieved unless such payment
would be used to pay premiums on policies in force
with the Company.
LOAN INTEREST RATE
lnterest is payable in advance on the first interest
payment due aate and on each policy anniversary that
follows. The first lnterest payment oue date IS the date
of the loan
days after a policy anniversary, the Surrender Value
shall not be less than the Surrender Value on that
anniversary, less any Partial Surrenders, Withdrawals.
or loans made on or after such anniversary.
Ifthis Policy is surrendered, coverage shall terminate
as of the next Monthly Deduction Day. The Company
reserves the right to defer the payment of the
Surrender Value for the period permitted by law, but
not for more than six months from the date of receipt
of the request by the Company at Its Home Office,
unless such payment would be used to pay premiums
on policies in force with the Company.
Loans under this policy will bear interest at a rate that
is subject to adjustment on each policy anniversary.
The initial interest rate charged on any loan will be
the Company's Adjustable Loan lnterest Rate in effect
on the previous policy anniversary. As of each
subsequent policy anniversary, the interest rate
charged for the policy year following will be the
Adjustable Loan lnterest Rate in effect on that policy
anniversary.
The Owner will be notified of the initial interest rate
at the time the loan request is made. The Company
will also notify the Owner of any change in the interest
rate applicable to an outstanding policy loan. NO
Policy will terminate in a policy year as the sole result
of a change in the interest rate during that policy year.
Insurance will remain in force until the time it would
have otherwise terminated had the interest rate not
been changed.
lnterest not paid when due is added to the loan and
bears interest at the same rate as the loan.
The Adjustable Loan lnterest Rate will be determined
as of the first day of each January, April. July, and
October, and will be determined by comparing the
Adjustable Loan lnterest Rate in effect for the
preceding three months with a maximum interest rate
defined by law and described below. Any change in
the Adjustable Loan lnterest Rate will be subject to
the following:
 POLICY LOAN PROVISIONS (Continued)
.
a. The Adjustable Loan lnterest Rate will be lowered
to be equal to or less than the legal maxlmum
interest rate if such legal maximum rate Is .5%
or more lower than the Adjusted Loan lnterest
Rate for the preceding three months.
b. The Adjustable Loan lnterest Rate may be
increased by at least .5% but not higherthan the
legal maximum lnterest rate, if the legal maximum
interest rate is .5oh or more higher than the
Adjustable Loan lnterest Rate for the preceding
three months.
The Adjustable Loan lnterest Rate will not exceed the
greater of:
(1) .The Published Monthly Average for the calendar
month ending two months before the date on
which the rate Is determined; or
(2) The interest rate used to compute the
Accumulation Value under the Pollcy during the
applicable period plus 1% per year.
The Published Monthly Average is Moody's Corporate
Bond Yield Average-Monthly Average Corporate as
published by Moody's Investors Service, Inc., or any
successor to it. In the event that Moody's Corporate
Bond Yleld Average-Monthly Average Corporate is no
longer published, the Published Monthly Average wili
be a substantially slmilar average established by
regulations Issued by the Insurance Commissioner of
the state in which thls Policy was purchased.
REPAYMENT AND TERMINATION
Policy loans, including accrued interest, may be
repaid in whole or part a. any time prior to termination
of thls Pollcy. A loan outstanding at the end of the
Grace Period may not be repaid until this Policy is
reinstated. All funds received by the Company under
this Policy will be credited as premium payment
unless clearly marked for loan repayment.
Whenever the policy loan plus accrued interest equals
or exceeds the Cash Value of this Policy, written
notification wili be sent to the last known address of
the Owner and assignee, if any. This Policy will
terminate sixty-one days after the date of mailing the
notification. Any accumulated dividends will be paid
In cash at that time.
 SETTLEMENT OPTIONS
AVAILABILITY
The lnsurance Proceeds of this Policy will be paid in
one sum unless a payment option is chosen. All or
part of the lnsurance Proceeds may be applied under
one of the following options. However, the amount to
be applied must be at least $3,500.00. The amount
must also provide a periodic payment of at least
$20.00 to each payee. If the payee is not a natural
person, the proceeds may not be placed under a
Settlement Option without the consent of the
r,,,,,..
""'""a'ly.
1) ELECTION
The Owner may elect a Settlement Option or change
a prior election at any time while the Insured is living.
The election must be recorded by the Company at its
Home Office before it is effective. The Company shall
not be liable for any payments it mav have made
/1 before receiving thai notice.
I If no option is in effect at the Insured's death, any
Beneficiary may choose a Settlement Option.
Unless this election is made irrevocable before the
proceeds are placed under a Settlement Option, the
payee may change the election at any time.
1 OPTIONS
1, INTEREST OPTION. Left on deposit with the
Company with the interest payable at not less
than 3% per year. The deposit period and
withdrawal rights will be as agreed at the time of
the election.
2. INSTALLMENT OPTION, FIXED PERIOD.
Payable in equal installments for the number of
years elected (not more than 20). The amount of
each payment is shown in the Settlement Option
Tables. Rights of commutation of unpaid
installmentswill be as approved by the Company
at the time of election.
3. LIFE INCOME OPTIONS. 10 or 20 YEARS
CERTAIN. Payable in installments for certain
period elected, and continuing thereafter for the
remaining lifetime of the person on whose life the
income depends. The amount of each installment
is shown in the Settlement Option Tables.
4, INSTALLMENT OPTION, FIXED AMOUNT.
Payable in installments until the proceeds applied.
together with interest on the unpaid balance at the
effective rate of 3% per year, are exhausted.
Amounts of installments and withdrawal rights will
be as approved by the Company at the time of
election.
,
1
7 ri
5. ANNUITY OPTION. Annuitv, ,oavments , will be
made during the lifetime of a payee; or jointly to
two payees, one of whom must be the lnsured,
during their lifetimes; and contiruing to the
survivor during his remaining lifetime.
Payments will be made under any single premium
immediate life or joint and survivor annuity
contract as may be issued by the Company on
the date proceeds become payable. The amount
of each annuity payment will be 102% of the
Davment which the amount retained bv the
~ d m ~ a nwould
v otherwise ourchase.' The
company's rates in use on such date will be used
as the basis for payment. 1I
The amount payable under any option shall be the
actuarial equivalent of the amount of Insurance
proceeds applied under that option,
Under Options and 59 proof the
tiompany /I
a) of the date of birth and sex of the payees; and
b) that the payee is alive
may be required before payment is made.
In the event of the death of a Payee under a
Settlement Option containing a period certain, any
remaining proceeds shall be paid to the Beneficiary
or Beneficiaries designated by the Owner. If no
Beneficiary has been named or there are no surviving
Beneficiaries, the proceeds will be paid to the Payee's
designated Beneficiary or the Payee's estate.
PAYMENT
The first payment under Options 2, 3 and 4 will be
due the date the proceeds are applied under the
Settlement Option. If the proceeds are payable due
to the Insured's death, the first payment will be due
on the date of death. The first payment under Options
1 and 5 will be due one, three, six, or twelve months
thereafter, depending on the mode of payment
selected.
EXCESS INTEREST
The interest payments under Option 1 and the
uaranteed payments under Opt~ons2, 3, or 4 are
f!ased on a guaranteed interest rate of 3% per year.
o i the
The interesi payments under Option
guaranteed payments under Options 2 and 3 may be
increased by excess interest as declared by the
Company. Excess interest will be used to extend the
period under Option 4.
PROTECTION OF PROCEEDS
The proceeds of payments due or to become due
under any option may not be assigned by the
Beneficiary. To the extent permitted by law, the
proceeds will not be subject to the claims of creditors
of the Beneficiary or the lnsured.
 r OPTION 2
FIXED PERIOD
SETTLEMENT OPTION TABLES
MONTHLY P4YMENTS FOR EACH $1,000 OF PROCEEDS

OPTION 3
LIFE INCOME
OPTION 5
LlFE INCOME
-$l
:I
i

PER $1,000 APPLIED PER $1,000 APPLIED PER $1,000 APPLIED

Guaranteed NO GUARANTEED
Period PERIOD
NO. of Annual Monthly 10 20 Age Monthly
Years Payment Payment Male Female Years Years Male Female Payment
1 $1,000.00 $84.47 45 $3.99 $3.87 45 $4.02
2 507.39 42.86 46 4.05 3.92 46 4.09
3 343.23 28.99 47 4.11 3.97 47 4.15
4 261.19 22.06 48 4.17 4.02 48 4.22
5 211.99 17.91 49 4.24 4.07 49 4.29
6 179.22 15.14 45 50 4.31 4.12 45 50 4.37
7 155.83 13.16 46 51 4.38 4.17 46 51 4.45
8 138.31 11.68 47 52 4.45 4.22 47 52 4.53
9 124.69 10.53 48 53 4.53 4.28 48 53 4.62
10 113.82 9.61 49 54 4.61 4.34 49 54 4.71
11 104.93 8.86 50 55 4.70 4.39 50 55 4.81
12 97.54 8.24 51 56 4.79 4.45 51 56 4.91
13 91.29 7.71 52 57 4.88 4.50 52 57 5.01
14 85.95 7.26 53 58 4.97 4.56 53 58 5.12
15 81.33 6.87 54 59 5.07 4.62 54 59 5.24

i
1
1
80
81
82
83
84
85 8.62
8.74
8.85
8.96
9.06
5.50 80
81
82
83
84
85 12.37
12.93
13.54

;:.A
1
/
1
85 9.14 85 15.60
I
-
11
SETT
 TABLE OF MINIMUM DEATH BENEFIT PERCENTAGES
*
Attained Age Attnlned Age Percentage

Through 40 60
41 61
42 62
43 63
44 64
45 65
46 66
47 67
48 68
49 69
50 70
51 71
52 72
53 73
54 74
55 75-90
58 91
57 92
58 93
59 94
9597

TABLEOFSURRENDERCHARGEFACTORS

Pollcy Year 01 Surrender

Or Yeara Since lncreaw Factor

1
2
3
4
5
6
7
8
9
10 And After

TBLl (FPAL-8)
 TABLE OF GUARANTEED MAXIMUM MALE INSURANCE RATES
PER $1,000
II NON-SMOKER SMOKER
MONTHLY
RATE AGE
MONTHLY
RATE AGE
MONTHLY
RATE AGE
MONTHLY
RATE 11
(1 TABLE OF GUARANTEED MAXIMUM FEMALE INSURANCE RATES 7
PER $1,000
NON-SMOKER
MONTHLY MONTHLY MONTHLY MONTHLY
AGE RATE AGE RATE AGE RATE AGE RATE
1 .07000 48
2 ,06667 49
3 ,06500 50
4 ,06417 51
5 ,06250 52
6 .06000 53
7 ,05917 54
8 ,05834 55
9 ,05750 56
10 ,05750 57
11 ,05834 58
12 ,06167 59
13 ,06500 60
14 .06834 61
15 ,06667 62
16 .07501 63
17 ,08167 64
18 .08001 65
19 ,08251 66
20 ,08417 67
21 ,08584 68
22 ,08667 69
23 ,08834 70
24 ,09001 71
25 ,09168 72
26 ,09418 73
27 .09584 74
28 ,09834 75
29 10168 76
30 10418 77
31 ,10751 78
32 ,11085 79
33 .I1501 80
34 ,12001 81
35 12585 82
36 ,13418 83
37 ,14419 84
38 15502 85
39 16669 86
40 18087 87
41 ,19587 88
42 .21088 89
43 ,22588 90
44 ,24089 91
45 ,25757 92
46 ,27508 93
47 ,29425 94
95
96
97
98
-
11
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31001H3d 0 3 N N Y l d 3 H l N I 33NVH3 ON 6N011d0 80 1NnOWV l I z l 3 N 3 R 0 3 1 z l I 3 3 d S 3H1
N I 39NVH3 ON I V H l ONV b O I V d SI l S 3 8 3 1 N I SS33X3 UN 1 V H l 'O33YVH3 3YV S3lVtr
33NVYnSNI WnWlXVW 0331NV8Vfl3 3 H l 1 V H l 3WflSSY S3fllVA HSV3 O331NV1Vfl3 3 H l

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 MACCABEES MUTUAL LIFE INSURANCE COMPANY
25800 Northwestern Highway, P.O.Box 2165, Southfield, Michigan 48037-2165

AMENDMENT

Attached to and made part of the Policy as of its effective Date of Issue:

Under the section titled "Policy Loan Provisions," the provision entitled "Loan lnterest
Rate" is hereby deleted and the following language is substituted:

Interest will be charged on all policy loans at a rate of 7.4% per year
compounded annually and payable in advance. lnterest must also be paid
in advance on each policy anniversary thereafter until the loan is repaid.
lnterest which is not paid when due will be added to the loan. Unpaid interest
will bear interest at the same rate.

Signed for the Company at its Home Office in Southfield. Michigan.

/
Secretary President
 AYYLlCATlON FOR INSURANCE T O PART I
a , &r" ""* -'" -'
MACCPSEES M U T U A L LIFE INSURANCE C q M P A L ' "
NO. 592199 4074420

pwsror-, Tp
Print Name Age Rela tionshin

c. a Automatic Prem. Loan

 .
<..:,:.-:;';
.
,<.
..... .
>2,%+ < z;...;:. ::.,:.
DlsABlLlTy INCOME ONLY . , , ' ? > ~ ) ~ ~ " ~ ,:'"
.
:..?..;~.,
"~$
. : - : ....... .;^,.i..i.

23.' ' . Has the proposed Insured(r) in Q u e s t i o ~1 : .

.

..
16. BENEFITS APPLIED FOR ' ' . ' : ........... (Cive details . ' Yes answers in Question a) Yes N O
Plan P -- Bel. .rt B '
' a. a reinstatem. . or an application for life'&
Benefit Pe;iod i7 Lifetime Accident - health insurance pending or contemplated in
Elimination Period ....... (for add'l policy(s1 any company? C #
. . . . c ...j.. f ~. ;, .... ' ," : .,..,
" :. b. arrv intention t o travel or reside outside the
D d l ~ j o BEWE ~ ~ FITS,
~ . .y~~;i.y~>i:i:ji,;2j.~tjrx~~.:ff;.
,.., ?.. ..,+,+.- . United States or Canada? ,, . . aS
tie"efit $ .. : - - O COLA;:;j{;lf:,':>~l;::~.:-:. ... ' C. in the past t w o years flown as a pilot, student
' ; -

DeferredAdd'l Benefit $-.,D CashV+I.ue -:,$ <.::.:, pilot or crew member, or intend to d o so? Ill
(Elirn. Period-~ay~) ., ' D Return ofPrevi@:; yes, complete attached Aviation Questionnaire) O E
0 Future Incyease 0Gt;An $_' d ~ a r t i a Ois'ability
! .;, -. d. engaged in 'un8erwater diving, hang gliding, ,

Hospital Indemnity. $ 0 ROK :;.::a:- parachuting, auto, motorcycle or vehicle rac. 1

. .,!:..
. ing or i s such activity contemplated? g .z
G SOS ( $ _ . - E l i m . d 0 : . ;: . . ' ,

Requested Effective Date: ..: . -. . . . e. ever been convicted of a felony or had a

17. LOSS PAYEE: The Owner(s) shall b e the loss paye- drivers license suspended or revoked, 2 R
. ,
another loss payee is stiown.
24. RtMARKS
1AaWhat were your earnings from your occupation or pro-
iesslon last year? (Cross income less business expenses)
srr-1--4 (.P PC+-- 4a,B
$
apptldp~
pollcy
Rsrvd S-
nd is wn.trandd
b. iV!lar did you contribute t o IRA, HR10, qualified pension
.-
or profit sharing plans? I s this included in l e a ?
L Yes !2 NO %-_ --
c What was "other income" last year from dividends, in-
"ISSUED WITH LEVEL BASIC BENEFIT."
terest. rents, royalties, estates and trusts,. .etc? . . . . .(Circle
......
items) $-
d. What is your"adprokimate
. . . n e t , w o r t h l , ( A S S ?less ~~ : .
liabilities)'$ . . . . . . . . . . .. . .. . .. . ... . . .
19a Insurance'in force, applied f.oror app!ying?greiriuate.:::;
Insurer 'lssui Mo. Elim
(Ifnone,sostate] Date en. I Perio
. .*
-. . . . . .. . I
. .. . . . . ,. I ... ,. .:.. ,. . . .
. . I . .
... . . . . . . .
. . The policy all be issued in English unless the
.....
other language preference i s indicated. E Spanish
Has Proposed Insured(s) in Question #I, in the
... .....
-- . 1. -8 rnnnths:
..- ...... Yes NO ..
s,t,

-
Securiiy? I f l ~ . ~ w h i c h . ~ o l i ~ f i ~. &';$;' : ' ?,aYesP
N o a, been treated by a doctor for or had any known
20. Are you covered under a state disability program?-, +!. .. I:, heart attack, stroke or cancer other than of the
r- er
21. Occupation &
ti^^ infull:'
. . . . . .
.'
..........
". '. ". , .
_ '
..
,
. . . . . . . . _
....... . .
.
any electrocardiogram for chest pain or
other ph sieal compla~ntor taken medication
:for hinh h o o d . ~ r e s s u r e ?
-. .:~:>
. ':, :.
$l

Health S

.........I.S ~vnrlersinorland
11 ~ ~ r p that: . . the answers recorded in Part I above and'Part II, bearing the same number, and any
e d (1) ~ ~

Part I l l required are, to the best of my'knowledge and belief, true and complete and correctly recorded and will become
part o f this application and any contract for insurance issued upon it;f2) Except as provided for i n the attached ReceipUs).
no Insurance shall take effect until the policy is accepted by the Owner and the first premium i s paid t o the Company and
the health, habits and occupation of all proposed insureds remain as stated in the application; (3) Acceptance of anv
p o l ~ c vissued shall constitute a ratification o f any change, correction or addition made by the Company, except in states
n here required: any change in amount, plan of insurance, classification, a e a t issue or benefits shall require the signature
o! the Owner:
- ~ (41 - has the authority to waive the answer to a$ question, to pass on insurability, to waive any
. . That no Agent
of the Company's rights or requirements or to make or alter any contract.

Appl~catlonmade at State D a t e 1 9 I acknowledge receipt of Outline of Coverage

I certiiy that this application accurately records the informa-
tion supplied b y the Applicant. Proposed Insured
Spouse [If to be Insured)
M'ltness Second Proposed Insured
L~censedRes~dentAgent (If loint W.L.)
.I
Appl~cantlOwner BY
(If other than proposed Insured) [Signature & Title o f Officer signing for Firm or Corporation)
illAoolicant 1s a Firm or Corporation, insert nameof Company)
rfin I 11 conttnuation of Application to MACCABEES M U T U A L LIFE INSW-RANCE COMPANY
. ......
><
,. ,,
DETAILS Or "YES" ANSWERS (Tt3~htii)
question number. covered pcbrson
2 \Vht.~itlld I'rol)osr.d Insur(-d last consult a physician? Date 4-67 c i r c l e a p p l i c a b l e itc*ms. I n c l u d l '
Dnc lor.A(lclrc~rs P~CUAZS
LA I ~ I P L Fb I b U 5 0 ~ J77 -~ a , diagnosi<, dates, duratiori and name.
What tr(batrlientwas g1vt.n or reromnicnded? UoNc- 6 FNF a IL 63/3 and address of all physicians a n ( i
medical facilities.)
3 \I'l1txn d ~ d
Sccon(l I'roposed insured last consult a physician? q.F,a- M I /56/
Do( torAddrt.ss
I~=LTW*/ @ ah- 72
S ~ L #L
LVh'it trt,atiiit~nttvds ~ : ~ v tor
* r rrcommrndcd?
i
~p

5
t a parent, brothc~r,or ststcsr of arly person propostad for
t.\,cxr l1.1~1tubcrculosis. diabt*tr.s, canc6.r. high blood pressure,. ,art disease,
~ . l c ~ t ici~wasc.

tj.15
r ~ or mental illness,
,+ti\ I)tbr50n~ > r u l ~ c f i for
t ~ ( lrovc>ragrw ~ t h l nthe past ilve years.
:
0:
J H(.r.ri t~kaniinrdby or c o n s u l t ~ da phvsirlan or o t l i t ~ rpractitioner? d [.:
1) lb.1.11 unr1t.r ol>\t-r\,at~o~i or trt*atiilrnl in a ilosliit.il, s;tnitar~~rrli
or t~ist~tulioii?
K I.:!
( ti;~cl ,in 2-r,ty. c~lrctrorardtograni.blood, urinr or othpr laboratory tests? #: [ ' I
6 11~1, ~ i n \11(.r>c)ri 11ropos(~(I lor (over~%gt, evcLr.
.I
K(.rt>lvt.d h t ~ n c ~ for i i sic-knes or injury o r had lifp or
~ tr\o i i i l ~ r i i s a t ~ ofor
d ~ \ ~ l l ~ i ~nstir~iri(r.
ltty ratc,d 1111. i i ~ o d ~ f ~rc~ierIed.
(*d, canct~Il~.~I or riot r t ~ n e ~ . e dj
i? d
t? Soi1~111 ~ i d 1,v or~ trc.atm(3til
~ for or t ~ t ~ . arrt~slc~cl
r i f ~ or~ h rt . c ~adtltcted
i to
t h ~ t,i s t , (>I alcohol or drugs? L! lp(
1 l i , ~ d'in\ t l ~ \ t ~ o a f%thv
~ ~rel)rodult~vcorgans, grnital organs, breast>, or
.In\ aiiillutatlnn or bodily drforniity, hrrnl'l or rupturr, hemorrhoids or
vcir1(ow v ( ~ i r i \ l Y ii
~ ~

: l l . ~ r.lli\ lir.r\nn ~'ropoxttlfor covt,r'igv h.id or t)(-(,n trt,citt.d for

,I All\. di\t,.r\t, or dtrort1r.r o f thv r y r s . r a r * nost*, throat, or t h y r o ~ dgland? L.1 i#'
Any ( l r i u r l n ~ t yor d i w r d r r of the. 11ach. splnt,. rnusrlcs. Iioncs or lolnts? ! i F'
( (llest l)'iin, littart niilrniur. l i i g l ~blood prrssurr, or any other disease or
cll<ordc,r ot the hrart, rlrculatory systt*ni, blood, or hlootl vessels? 2 X
(1 I'<.II~Ic LIICP~, ~ndtg(\>tlori. or any d l ~ ~ w of ethcl ston~ath.~ntrstines.gall
11l,1dtlrr.I~\,r.r.~~allcrr.a\ or s[~lc,(*n? ;.-. g
c 1 1 r c i I s 1i i i i i I r s or a n i r I o I i s or u : : Ld
t A l b l i n i ~ n pus,
, blood or sugar in ur~nt,,urlnary stone, or other disease of
tht. hldnr.ys. bladdtar or prc~>tatr? :s.. 3 ir(
g Se\.r.rc. htadacties. iaintlng spclls, epilepsy. paralysis. nervousness, men-
t a l dtsortler. or any othcr disease' or disorder o f the brain or nervous system? i: %
11 Kheuniattc or othcr fc\,csr, syphilis. gout, arthritis. goitrr, diabetes,

I Q
cancer, unio or c1isordt.r of the lvnipli nodes1
Ail\. \urgl oprrattoti, trratmrnt. or any illnrss, ailment, abnormality. or
~ n l u r ynut nieiit~onedabove within the past five years?
b( L:

I3 Lk'
8 Is any person proposed for coverage no\%,under treatment or taking any
prescription drug? 0
9 15 an\ person proposed for coverage pregnant? (No. of months ) 000
AVIATJON QUESTIONNAIRE

I v ~ i t01
% Alrcrait i l o w n ? -
t l o n not qu;tlify for a\.iation coverage without ad- I HEREBY DECLARE that allstatenlentsand ansivcr.-
1 1 .I\ ~.ittc)n~ ~ ; l r t ~ c ~ p adoe%
c l ~ t ~ I)rrnilum,
i ~ l plt.~se isrtrr as follo\vs c: Aviatior~ Ekclusion Rider. regarding aviation are c o n i ~ ~ l e tand
e t r u r to lhc
.A\ ~,it~c)ri
cowragv n i t 1 1 al~k)rol~riatt, cxtrct lireniiuni best of my knowledge and belief. ancl I acrct. th;.!
they are a part of the application Part I .
Type of Flying Number Hours Flown
and Date of Last Flight One To Probable Dated and
b Total Two Last 1 2 Next 1 2 Signed at 5y ClIA+?Lk- / C
on 7-13

1'11ot
( rtw \\rnllier

hltlttary
Date

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Years Ago Months Months

(
Signature
L
EI&.
d~d
Other I [Wrtness or Agent)