PREMIUMS FOR LOAN INSURANCE BASED ON $100
and applying pro rata to other amounts

AMERICAN CENTRAL LIFE INSURANCE COMPANY
TOTAL AND PERMANENT DISABILITY BENEFIT.

Supplemental Contract attached to and part of Policy No. 99999, on the life of Abner Alston, the insured.

If, while no premium is in default, the Company shall, before the Insured shall have attained the age of sixty years nearest birthday, receive due proof of the disability of the Insured, as hereinafter defined, provided such disability has at the time of the receipt of such proof existed for not less than sixty days, the Company will, by an endorsement on the policy, waive the payment of any premium or premiums which may thereafter become payable under the policy. The premiums so waived shall not be deducted from the amount of insurance, and the loan and cash values shall increase from year to year as though the premiums were being paid in cash.

Disability of the Insured within the meaning of this supplemental contract shall exist if the Insured, as the result of accident or disease, shall have become totally, permanently and incurably disabled to such an extent that he is thereby prevented and will be permanently and continuously thereby prevented from performing any work for compensation or profit or from following any gainful occupation. Permanent and complete loss of the sight of both eyes,. or loss by severance of both hands at or above the wrists, or of both feet at or above the ankles, or such loss of one entire hand and one entire foot, shall be considered disability within the meaning of this supplemental contract. Provided always that such disability shall not have been incurred while engaged in military or naval service in time of war or as the result of such service.

Even though proof of disability may have been accepted, the Company may demand of the Insured from time to time proof of the continuance of such disability; and if such proof be not furnished on the Company's demand, or if it shall appear that the Insured is able to perform any work for compensation or profit, or to follow any gainful occupation, the Insured shall resume payment of all premiums thereafter due, but the premiums already waived by the Company shall not become a policy indebtedness.

The premium for the disability benefit is $1.80 and is included in the premium for the policy stated on the third page thereof. The disability premium shall cease on the policy anniversary of the Insured nearest his age sixty years, when the amount of premium stated in the policy will be reduced by a sum equal to the premium for the disability benefit. HERBERT M. WOOLLEN, President.

Attest:

H. W. BUTTOLPH, Actuary.

APPLICATION.

I hereby make application for insurance in American Central Life Insurance Company of Indianapolis, Indiana, and agree that the statements and agreements herein and the statements to the Medical Examiner in Part II of Application are made for the purpose of securing this insurance and declare that all such statements are complete and true without exception unless such exception is indicated.

7. I desire policy to be issued as of date. .and I agree that the period to cover which the first premium is paid shall end one year after said date, and that each insurance year shall end on successive anniversaries of said date. I also agree that the insurance applied for shall not take effect until the payment of the first premium thereon, and the approval of this application by the Company.

15. I further agree that any physician may disclose to the American Central Life Insurance Company, its successors or assigns, any facts or information communicated to, or acquired, by him as my physician, and I waive any and all provisions of law which now, or may hereafter, exist exempting or prohibiting any physician from disclosing any facts acquired in his professional capacity or rendering such physician incompetent as a witness.

.due.

16. I have settled for the first premium on policy applied for with the Agent.. .in the following manner: Cash $. Note.. for $.. .on condition that, if risk is not assumed by the Company the sum paid by me shall be returned in accordance with the provisions of the binding receipt which I have accepted subject to the provisions thereof.

MEDICAL EXAMINER'S FORM.

In continuation of and forming a part of my application for insurance to the American Central Life Insurance Company of Indianapolis, Indiana, dated.. .191....

I hereby certify that I have read the above questions and that my answers thereto are true.

Largest Amount of Insurance it will write on a Single Life, "Indefinite." All above $10,000 reinsured. Premiums for Each $1,000 Insurance

(Nonparticipating). Adopted March 1, 1913.

95 97 76 27

For semi-annual rates, add 4 per cent and divide by 2.
For quarterly rates, add 6 per cent and divide by 4.

For policies with Disability rider additional charge of 15c to 90c per $1.000 is made depending

apon age and form of policy.

(Limit "Indefinite"-All above $10,000 reinsured.)

Premium Rates Including Total Disability
(Nonparticipating) for $1,000.

For semi-annual rates, add 4 per cent and divide by 2.
For quarterly rates, add 6 per cent and divide by 4.

Cash or Loan Values on $1,000 Nonparticipating Policies.