No.--------- Age ---------

The X. Y. Insurance Company, in consideration of the payment of ---------dollars, the receipt whereof is hereby acknowledged, and of the --------- [insert period for payment] payment of a like sum to the said Company, on or before the --------day of ---------in every year during the lifetime of A. B., of --------- (hereinafter called the Insured), promises, upon receipt of due proof of the death of the Insured, to pay at its Home Office unto C. D., beneficiary, the sum of ---------dollars, less any unpaid premium or premiums for the then current policy year and any other indebtedness to the Company on account of this Policy.

Subject to the rights of any assignee, the Insured (1) may designate one or more Beneficiaries if none be named herein, either with or without reservation of the right to revoke such designation; and (2) may designate one or more Contingent Beneficiaries whose interest shall be as expressed in, or by endorsement of the Company on, this Policy; and (3) may change any Beneficiary not irrevocably designated; and (4) may change any Contingent Beneficiary. If there be more than one Beneficiary the interest of any deceased Beneficiary shall pass to the survivor or survivors unless otherwise directed by the Insured. If no Beneficiary or Contingent Beneficiary survive the Insured the proceeds of this Policy shall be payable to the executors, administrators or assigns of the Insured. No such designation, revocation, change or direction shall be effective unless duly made in writing and filed at the Home Office of the Company (accompanied by this Policy for suitable endorsement) prior to or at the time this Policy shall become payable.

No assignment of this Policy shall be binding upon the Company until it be filed with the Company at its Home Office. The Company assumes no responsibility as to the validity or effect of any assignment. Satisfactory proof of assignee's interest must be produced on making claim.

This Policy is issued and accepted by the parties in interest subject to the provisions stated on the second and third pages hereof which are a part of this contract.

In witness whereof, etc ---------,



Whole Life Policy; Premiums Payable for Life; Dividends Payable Annually; Y. 1.