THE X. Y. INSURANCE COMPANY OF---------

Amount $---------. Age ---------. Premium $---------.

THE X. Y. INSURANCE CO. OF---------

In consideration of --------- dollars, receipt of which is hereby acknowledged, and of the payment of --------- [here insert amounts and times of payments of premiums] until --------- full years' premiums shall have been paid or until the prior death of the insured.

Promises to pay at the home office of the company in ---------, to A. B.,

County of---------, State of ---------, herein called the insured, on the --------- day of --------- if the insured be then living, or upon receipt at said home office of due proof of the prior death of the insured, to C. D. beneficiary --------- with

[insert "out," if so desired], right of revocation --------- dollars, less any indebtedness hereon to the company and any unpaid portion of the premium for the then current policy year.

Change of Beneficiary. - When the right of revocation has been reserved, or in case of the death of any beneficiary under either a revocable or irrevocable designation, the insured, subject to any existing assignment of the policy, may designate a new beneficiary with or without reserving right of revocation by filing written notice thereof at the home office of the company, accompanied by the policy for suitable endorsement thereon. If any beneficiary shall die before the insured, and the insured shall not have designated a new beneficiary, the interest of such beneficiary shall be payable to the insured--------- [insert "his" or "her"], executors, administrators or assigns.

Payment of Premiums. - The company will accept payment of premiums at other times than as stated above, as follows: ---------.

Except as herein provided, the payment of a premium or instalment thereof, shall not maintain the policy in force beyond the date when the next premium or instalment thereof is payable.

All premiums are payable in advance at said home office, or to an agent of the company, upon delivery of a receipt signed by one or more of the following officers of the company --------- [insert titles of officers who may sign receipts], and countersigned by said agent.

A grace of one month, subject to an interest charge at the rate of --------per centum per annum shall be granted for the payment of every premium after the first, during which month the insurance shall continue in force. If the insured shall die during the month of grace the overdue premium will be deducted from any amount payable hereon in any settlement hereunder.

Conditions. - (The policy may here provide for restrictions of liability by reason of travel, occupation, change of residence and suicide. These restrictions, except such as refer to military and naval service in time of war, must be applicable only to cases where the act of the insured provided against occurs within two years after the issuance of the policy.)

Incontestability. - This policy constitutes the entire contract between the parties, and shall be incontestable, from its date, except for non-payment of premiums and except as otherwise provided in this policy. All statements made by the insured shall in the absence of fraud be deemed representations and not warranties, and no such statement shall avoid this policy unless it is contained in a written application and a copy of such application shall be endorsed upon or attached to this policy when issued.

If the age of the insured has been understated, the amount payable hereunder shall be such as the premium paid would have purchased at the correct age.

Participation. - This policy shall not participate in the surplus of the company and beginning not later than the end of the--------- [insert first, second or third] policy year the company will annually determine and account for the portion of the divisible surplus accruing hereon.

Dividends. - Dividends at the option of the owner of this policy shall on the

---------day of---------of each year --------- There may be inserted "after the first policy year" or "after second policy year"], be either-

1. Paid in cash, or

2. Applied toward the payment of any premium or premiums, or

3. Applied to the purchase of paid-up additions to the policy, or

4. Left to accumulate to the credit of the policy with interest at ---------

[here insert a rate not exceeding that used by the company in calculating its reserves] per centum per annum and payable at the maturity of the policy but withdrawable on any anniversary of the policy.

Unless the owner of this policy, shall elect otherwise within three months after mailing by the company of a written notice requiring such election, the dividends shall be paid in cash.

Loans. - After three full years' premiums have been paid the company, at any time while this policy is in force, will advance, on proper assignment of the policy and on the sole security thereof, at a rate of interest not greater than

--------- per centum per annum, which interest, if not paid annually, shall be added to the principal and bear the same rate of interest, a sum equal to, or, at the option of the owner of the policy, less than, the reserve at the end of the current policy year on this policy and on any dividend additions thereto, computed according to the -------- [designate mortality table adopted by the company for computing reserves] mortality table, and interest at the rate of ---------

[designate rate of interest adopted by the company for computing reserves] per centum per annum, less --------- [here may be inserted not more than two and one-half] per centum of the amount insured by this policy and of any dividend additions thereto. The company, however, will deduct from such loan value any existing indebtedness to the company on this policy and any unpaid balance of the premium for the current policy year, and may collect interest in advance on the loan to the end of the current policy year. Such loan may be deferred by the company for not exceeding six months after the application therefor is made. Failure to repay any such advance or to pay interest shall not avoid this policy unless the total indebtedness hereon to the company shall equal or exceed such loan value at time of such failure and until one month after notice shall have been mailed by the company to the last known address of the insured and of the assignee, if any.