THE X. Y. INSURANCE COMPANY

Agreement Supplementary to Policy No. --------

Life of A. B., Insured

(Waiver of premiums in event of total disability before attaining 60 years of age)

In consideration of the payment of an extra premium of ---------dollars (first payment hereby acknowledged), together with each --------- premium required under said Policy, it is agreed that if, after payment of premium for one full year and during the continuance of this Agreement, the Insured shall, prior to his 60th birthday anniversary, furnish' proof satisfactory to the Company that he has become totally and permanently disabled from any cause and is physically or mentally incapacitated to such an extent that he is and presumably will be wholly and permanently unable to engage in any gainful occupation or perform any work for money compensation, the Company on receipt of such proof will by suitable endorsement of this Agreement waive the payment of any and all premiums thereafter falling due under said Policy and this Agreement during the continuance of such disability, except as hereinafter stipulated and agreed:

1. No payment of extra premium under this Agreement shall be required after said Policy shall have become fully paid up or in any case after the sixtieth birthday anniversary of the Insured.

2. Notwithstanding the acceptance of proof of disability the Insured, or his legal representatives, shall annually on the anniversary of the date of said Policy, or with'in 31 days thereafter, file with the Company a declaration of continued disability of the Insured and shall upon request, but not oftener than once a year, furnish proof thereof satisfactory to the Company. If the Insured, or his legal representatives, at any time after such waiver shall, upon such request mailed by the Company to his or their last known address, fail to furnish such proof of continued disability, or if it shall appear to the Company that Insured has so far recovered as to be able to perform work of any kind for compensation, gain or profit, then and in either such event, said waiver shall be deemed to have failed and any premium or premiums then or thereafter falling due under said Policy and this Agreement shall be payable in accordance with the terms thereof the same as if no waiver of premiums had been made.

3. Such premiums as fall due after the receipt by Company of satisfactory proof of disability and prior to acceptance thereof shall be payable by Insured but the same shall be remitted by Company.

4. Waiver of premiums under this Agreement shall not affect the rights of the parties at interest to any benefits or privileges provided in said Policy which shall be the same as if the premiums were paid in cash.

5. It is agreed that total and permanent loss of sight of both eyes, the loss by severance of both hands at or above the wrists, or of both feet at or above the ankles, or of one entire hand and one entire foot, shall, without prejudice to any other cause of disability and upon due proof before age 60, be considered total disability within the terms of this Agreement.

6. The non-payment of the extra premium as required by this Agreement either on the due date or within the days of grace provided by said Policy shall automatically terminate this Agreement but same may be reinstated, provided the said Policy be then in full force, upon evidence satisfactory to Company of the insurability of Insured and payment of all premium arrears with interest at the rate of five per cent. per annum.

7. The premiums paid on this Agreement shall not participate in the surplus of the Company and shall remain the property of the Company in event of the termination thereof in any way. The X. Y. Insurance Company, ---------,---------, 19-. ---------, Secretary.

This contract Is a supplement to that given In $ 3876. See references under Sec. 3870.