20007CERTIFICATE

Certi cate of Insurance Template
Policy Information
Policy Number Donec odio justo, Gender of Applicant Date November 21, 1999
sollicitudin ut,
suscipit a, feugiat et, Aenean auctor gravida
Civil Status of Applicant
eros. Vestibulum ac sem. Praesent id
est lacinia nisi massa id nisl venenatis Aenean auctor gravida
venenatis tristique. lacinia. Aenean sit sem. Praesent id
Fusce congue, diam amet justo. massa id nisl venenatis
id ornare imperdiet, lacinia. Aenean sit
sapien urna pretium amet justo.
nisl, ut volutpat
sapien arcu sed
augue.
General Information
Policy Initial Owner / Applicant Birthday of Applicant

Nero Aenean auctor gravida sem. November 21, 1999
Praesent id massa id nisl venenatis
lacinia. Aenean sit amet justo. Lingner
Residence Address of Applicant Age of the Applicant at issuance of Birthplace of Applicant

498 Express Drive, 76 Stuart Road policy Donec odio justo, sollicitudin
Cleveland, Ohio, 44118 Donec odio justo, sollicitudin ut, ut, suscipit a, feugiat et,
United States suscipit a, feugiat et, eros. Vestibulum eros. Vestibulum ac est
ac est lacinia nisi venenatis tristique. lacinia nisi venenatis
Fusce congue, diam id ornare tristique. Fusce congue,
imperdiet, sapien urna pretium nisl, ut diam id ornare imperdiet,
volutpat sapien arcu sed augue. sapien urna pretium nisl, ut
volutpat sapien arcu sed
augue.
Email Address
bahwi@example.com
Name of Employer Nature of Business Estimated Annual Income

Donec odio justo, sollicitudin ut, Donec odio justo, sollicitudin Donec odio justo, sollicitudin
suscipit a, feugiat et, eros. Vestibulum ut, suscipit a, feugiat et, ut, suscipit a, feugiat et,
ac est lacinia nisi venenatis tristique. eros. Vestibulum ac est eros. Vestibulum ac est
Fusce congue, diam id ornare lacinia nisi venenatis lacinia nisi venenatis
imperdiet, sapien urna pretium nisl, ut tristique. Fusce congue, tristique. Fusce congue,
volutpat sapien arcu sed augue. diam id ornare imperdiet, diam id ornare imperdiet,
sapien urna pretium nisl, ut sapien urna pretium nisl, ut
volutpat sapien arcu sed volutpat sapien arcu sed
augue. augue.
Home Phone Business Phone Mobile Phone

+86 (15) 126-6676 +86 (15) 126-6676 +86 (15) 126-6676
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Business Address
498 Express Drive, 76 Stuart Road
Cleveland, Ohio, 44118
United States
Information of the person's life insured
Name of Life Insured Gender of Insured Civil Status of Insured

Nero Aenean auctor gravida sem.
Aenean auctor gravida Aenean auctor gravida sem.
Praesent id massa id nisl venenatis
sem. Praesent id Praesent id massa id nisl
lacinia. Aenean sit amet justo. Lingner
massa id nisl venenatis venenatis lacinia. Aenean sit
Residence Address of Insured lacinia. Aenean sit amet justo.
amet justo.
498 Express Drive, 76 Stuart Road
Cleveland, Ohio, 44118 Birthplace of Insured
United States Birthday of Insured Donec odio justo, sollicitudin ut,
Sunday, November 21, 1999 suscipit a, feugiat et, eros. Vestibulum
ac est lacinia nisi venenatis tristique.
Age of the Insured at Fusce congue, diam id ornare
issuance of policy imperdiet, sapien urna pretium nisl, ut
Donec odio justo, sollicitudin volutpat sapien arcu sed augue.
ut, suscipit a, feugiat et,
eros. Vestibulum ac est Email Address
lacinia nisi venenatis bahwi@example.com
tristique. Fusce congue,
diam id ornare imperdiet,
sapien urna pretium nisl, ut
augue.

Name of Employer Nature of Business Estimated Annual Income

Donec odio justo, sollicitudin ut, Donec odio justo, sollicitudin Donec odio justo, sollicitudin
suscipit a, feugiat et, eros. Vestibulum ut, suscipit a, feugiat et, ut, suscipit a, feugiat et,
ac est lacinia nisi venenatis tristique. eros. Vestibulum ac est eros. Vestibulum ac est
Fusce congue, diam id ornare lacinia nisi venenatis lacinia nisi venenatis
imperdiet, sapien urna pretium nisl, ut tristique. Fusce congue, tristique. Fusce congue,
volutpat sapien arcu sed augue. diam id ornare imperdiet, diam id ornare imperdiet,
sapien urna pretium nisl, ut sapien urna pretium nisl, ut
Home Phone volutpat sapien arcu sed volutpat sapien arcu sed
+86 (15) 126-6676 augue. augue.
Business Address Business Phone Mobile Phone

498 Express Drive, 76 Stuart Road +86 (15) 126-6676 +86 (15) 126-6676
Cleveland, Ohio, 44118
United States
Policy Details
Effectivity Date Maturity Date
Sunday, November 21, 1999 Sunday, November 21, 1999
Bene ciary
Named Primary Bene ciary Relationship Revocable or irrevocable
Nero Lingner Donec odio justo, sollicitudin
Aenean auctor gravida sem.
Praesent id massa id nisl
eros. Vestibulum ac est
Named Secondary Bene ciary venenatis lacinia. Aenean sit
lacinia nisi venenatis
Nero Lingner amet justo.
augue.
Relationship Revocable or irrevocable

Donec odio justo, sollicitudin
Aenean auctor gravida
sem. Praesent id
eros. Vestibulum ac est
massa id nisl venenatis
lacinia nisi venenatis
lacinia. Aenean sit
amet justo.
augue.
Summary of bene ts payable
Basic Bene t Premium Donec odio justo, sollicitudin ut, suscipit a, feugiat et, eros. Vestibulum
ac est lacinia nisi venenatis tristique. Fusce congue, diam id ornare
imperdiet, sapien urna pretium nisl, ut volutpat sapien arcu sed augue.
Accidental Death Donec odio justo, sollicitudin ut, suscipit a, feugiat et, eros. Vestibulum
Total Disability Donec odio justo, sollicitudin ut, suscipit a, feugiat et, eros. Vestibulum
Total Annual Premium Payable 8136

Acknowledgement
I acknowledge that I have applied with Signature Insurance, Inc. for an Insurance Policy an have reviewed the provisions
shoiwng how a life insurance policy performs using the company's assumptions based on the Insurance Commissioner's
guidelines on interest rates.
I likewise understand that the performance of fund may vary, the values of my units are not guaranteed and will depend on
the actual performance of a given period. The value of my policy could be less than the premiums paid.
I understand that the risks of invesment under this policy shall be borne by me, as the policy owner.
Name of Applicant
Nero Aenean auctor gravida sem. Praesent id
massa id nisl venenatis lacinia. Aenean sit amet
justo. Lingner
Date signed
Sunday, November 21, 1999

Provisions
The proposals, the application form, any endorsements and amendments

The Contract
agreed upon in writing after this policy is issued shall constitute the entire
Contract. The bene ts payable shall be based on the performance fo the
investment funds chosen by you.
The effectivity of this policy initiates upon the initial payment of its Premium
Effectivity
and the delivery of the Policy to the Owner while the Insured is in good health.
All amounts payable either to or by us will be in the currency speci ed in the

Currency and Place of Payment
Policy details. Acceptance of placement of payments shall be at any of our
o ces or such other location as determined by us from time to time
After two years from the time of effectivity or from last reinstatement of the
Incontestability
contract, the said contract shall be incontestable except for non-payment of
Premium and Insurance Charges or any other ground recognized by law.
No liability shall be borned by the Company if in case the life insured dies by
Suicide
suicide. However, if the death by suicide happens in the state of insanity, the
life insured shall be compensated regardless of the date of the commission,
within the period of effectivity of this Policy.
In case the death bene t is not payable, the liability of the Company shall be
limited to:
1. The Basic Premium

2. The value of the account based on the Unit price of the relevant fund, not
including bonuses.
3. Premiums paid under any part of the Contract for which the bene t of
death is not payable.

The assigned or named bene ciaries shall be as named or assigned in the

Bene ciaries
application.
The bene t proceeds are payable to the Bene ciaries named, or in his absence,
the Contingents. In cas no bene ciary is indicated, the bene t proceeds shall be
payable to the life insured, if living, or to his estate.
Should any provision of this Contract be held invalid by any competent court, the
Separability Clause
same shall apply only to the provision involved and the remaining provisions
hereto shall remain valid and enforceable.
No modi cation or alteration of this Contract shall be considered as having

Agreement Modi cation
been made unless executed in writing and duly signed by the parties hereto.
Signature of President Signature of Corporate Secretary

20007CERTIFICATE

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Certi cate of Insurance Template

Policy Initial Owner / Applicant Birthday of Applicant

Residence Address of Applicant Age of the Applicant at issuance of Birthplace of Applicant

Name of Employer Nature of Business Estimated Annual Income

Home Phone Business Phone Mobile Phone

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Information of the person's life insured

Name of Life Insured Gender of Insured Civil Status of Insured

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Name of Employer Nature of Business Estimated Annual Income

Business Address Business Phone Mobile Phone

Relationship Revocable or irrevocable

Summary of bene ts payable

Total Annual Premium Payable 8136

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The proposals, the application form, any endorsements and amendments

All amounts payable either to or by us will be in the currency speci ed in the

1. The Basic Premium

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The assigned or named bene ciaries shall be as named or assigned in the

No modi cation or alteration of this Contract shall be considered as having

Signature of President Signature of Corporate Secretary

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