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

THE X. Y. INSURANCE 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 upon receipt at the home office of the company in --------of due proof of the death of A. B., of ---------of County of ---------, State of ---------, herein called the insured, within --------- years from the date hereof --------dollars, less any indebtedness hereon to the company, and any unpaid portion of the premium for the then current policy year, at said home office, to C. D., beneficiary, with --------- [insert "out" if so desired] right of revocation.

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 that as stated above, as follows: --------- [insert special provisions, if any].

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 such agents.

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 such 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 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 --------- [here 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 (The policy, at the option of the company, may here provide for a further option as follows):

3. 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, or at the expiration of the term, but withdrawable on any anniversary of the policy.

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

Privilege of Renewal. - The owner of this policy, if the insured be not over the age of sixty-five years, may renew this policy for further terms of --------years each by written notice to the company at its said home office, accompanied by this policy for suitable endorsement on or before the expiration of the insurance hereunder, and by paying the premiums to be fixed by the age on the birthday nearest to the date of such renewal in accordance with the following table for each one thousand dollars of insurance; if the insured shall be over the age of sixty-five years, this policv may, upon similar notice, be surrendered for an ordinary life policy, which shall require premiums during life in accordance with the following table for each' one thousand dollars of insurance.

Table Of Premiums For Renewals

Attalsed Age

Years Term Premium

Payable in Advance far Each $1,000

Attalsed Age

Ordinary Life Premium

Payable in Advance far Each $1,000


Privilege to Change to Other Forms of Policies. - The owner of this policy may at any time within the first --------- years exchange this policy for a participating policy for the same amount or any less amount upon the ordinary life, limited payment life or endowment plan upon any anniversary of the policy or within the month of grace by surrendering the policy to the company at said home office with written notice of the election, and by paying the premium, to be fixed by the age on the birthday nearest to the date of such exchange, according to the rates of the company then in force.

Assignment. - No assignment of this policy shall be binding upon the company, until it be filed with the company at its said home office. The company assumes no responsibility as to the validity of any assignment.

(If the term of this policy is for more than twenty years, the company shall provide for continuance of insurance on surrender or lapse in the following form):

Continuance of Insurance on Lapse. - In event of default in premium payments after this policy shall have been in force three full years, the reserve hereon, according to the --------- [designate the 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 the policy, will be applied to the purchase of non-participating continued temporary insurance for the face amount of this policy at net single premium rates at the attained age of the insured, according to the same table of mortality and rate of interest.

Table Of Continued Insurance

At End of Years

Continued insurance
















(Etc.) Figures for later yearswill be furnished upon request.

(If the term policy is for more than twenty years, the company shall pro-Vide for reinstatement in the following form):

Reinstatement. - Upon evidence of insurability satisfactory to the company, this policy may be reinstated within the first three years of the term for which the insurance is continued by payment of arrears of premiums, with interest at --------- [here insert not greater than six] per centum per annum.

Options at Maturity. - The insured, by written notice to the company at its home office and with written consent of the assignee and irrevocable beneficiary, if any, may elect to have the net sum payable under this policy paid either in cash or as follows:

1. By the payment of interest thereon at ---------per centum per annum, payable annually, to the payee under this policy at the end of each year during the life of the payee, and by the payment upon the death of the payee of the said net sum and accrued interest to the executors, administrators or assigns of the payee, unless otherwise directed in said notice.

2. By the payment of equal annual instalments for a specified number of years, the first instalment being payable immediately, in accordance with the following table for each $1,000 of said net sum.

3. By the payment of equal annual instalments, payable at the beginning of each year, for a fixed period of twenty years, and for so many years longer as the payee shall survive, in accordance with the following table for each $1,000 of said net sum.

Instalments payable under options (2) or (3), which shall not have been paid prior to the death of the payee shall be paid, unless otherwise directed in said notice, to the executors, administrators or assigns of the payee.

If the insured shall not have directed otherwise, the beneficiary may, after the death of the insured, by like written notice, and with written consent of the assignee, if any, select either of the above options.

Unless otherwise specified by the insured, the payee may on any interest day receive the amount yet due under option (1), and may at any time receive the commuted value of payments yet to be made, computed on the same basis as option (2) in the following table, provided, that no such commutation will be made under (3), except after the death of the payee occurring within the aforesaid twenty years.

Table Of Instalments For Each $1,000 Option (2) Option (3)

Number of Annual Instalments

Amount of Each Instalment

Age of Payee When Policy becomes Payable

Amount of Each Instalment

Agents are not authorized to modify this policy or to extend the time for paying a premium.

In witness whereof, etc.

See references under 5 3870.