Age ---------.

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

THE X. Y. COMPANY OF --------- [name of State]

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 its home office in --------- dollars in twenty equal instalments of $------- to the insured, the first instalment to be payable on the

--------- day of ---------, 19-. If the insured shall die before receiving all the twenty instalments herein provided for, the remainder of such twenty instalments shall be payable as they fall due to--------- (herein called the beneficiary),

[insert "his" or "her"] executors, administrators, or assigns, with ---------

[insert "out" if so desired] right of revocation, if --------- [insert "he" or "she"] survives the insured, otherwise to the executors, administrators or assigns of the insured.

Should the insured die before --------- [insert date of maturity], this policy shall be payable to the beneficiary --------- [insert "his" or "her"] executors, administrators or assigns, if--------- [insert "he" or "she"] survives the insured, otherwise to the executors, administrators or assigns of the insured (the first instalment being payable immediately upon receipt of due proof of the death of the insured). Any indebtedness to the company on this policy, together with the balance, if any, of the then current years' premium, will be deducted from the amounts first payable under this contract.

Should the insured or beneficiary live to receive the twenty instalments payable as above provided, the company, beginning one year after the date when the twentieth instalment payable hereunder shall fall due, will pay the sum of $-------- annually to the insured, or, in the event of the death of the insured, to the beneficiary, the said annual payment to be due and payable so long as either the insured or beneficiary is living.

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. If a new beneficiary shall be designated only twenty annual instalments will be payable under this policy, and future --------- [if necessary, insert "semi" or "quarter"] annual premiums will be reduced to ---------dollars each.

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

Upon return of this policy to the company, accompanied by evidence satisfactory to the company of the death of the beneficiary, the company will reduce the future --------- [here insert "annual," "semi-annual" or "quarterly"] premiums to $---------each.

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 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, or if the age of the beneficiary has been overstated the amount payable hereunder shall be such as the premium paid would have purchased at the correct age.

Participation. - This policy shall 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 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 the 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, payable in twenty annual instalments at the same times as the original amount insured under this policy is payable. The payment of such twenty instalments shall discharge the company from all liability on account of such dividend additions, or