2d. That said Company shall not be liable, under the policy hereby applied for, if my death shall be the result or consequence of violation of law, or while I am resisting or attempting to escape arrest therefor. It is also understood and agreed, that if I shall engage in blasting, submarine labor, aeronautic travel, the manufacture or handling of highly inflammable or explosive substances, or service upon any vessel or railroad, or in any military or naval service in the time of war, without first obtaining the consent of said Company in writing, then the policy shall be null and void, and of no effect, except as provided in the policy.

3d. That inasmuch as only the officers at the Home Office of said Company, in the City of Lincoln, Nebraska, have authority to determine whether or not a policy shall issue on any application, and as they act on the written statements and representations referred to, no statements, representations, promises, or information made or given by or to the person soliciting or taking this application for a policy, or by or to any other person, shall be binding on said Company, or in any manner affect its rights, unless such statements, representations, promises, or information be reduced to writing, and presented to the officers of said Company, at the Home Office, in this application.

4th. That in any distribution of surplus or profits, the principles and methods which may be adopted by said Company for such distribution, and its determination of the amount equitably belonging to any policy which may be issued under this application, shall be and are hereby ratified and accepted by and for every person who shall have or claim any interest under such policy.

5th. And it is agreed that there shall be no contract of insurance until a policy shall have been issued and delivered by the said Company, and the first premium thereon paid while the person proposed for insurance is living and in the same condition of health described in this application.

6th. That the contract, contained in such policy and in this application, shall be construed according to the law of the State of Nebraska, the place of said contract being agreed to be the Home Office of said Company in the City of Lincoln, Nebraska.

7th. That no suit shall be brought against said Company under said contract after the lapse of two years from the time when the cause of action accrues.

I also understand that no person is authorized to erase, waive, or change in any manner any of the blanks or printed matter used or furnished by the Company, or to promise any other terms or conditions than those published by the Company in its printed matter.

I Hereby Declare That I am the party described in the accompanying Application signed by me for $... .'. insurance on the plan, and that I have given true answers to all the questions put to me by the medical examiner, which questions and answers are considered as an essential part of the application, and as forming with it the basis of the proposed contract of insurance.

I hereby declare that I have read the above questions, and written answers, and that the answers as written are true. presence of

In

...Medical Examinr.

Person Examined.

LIFE POLICY PAID-UP IN 20 YEARS.

No. 99,999.
AMOUNT, $10,000.

AGE, 35

ANNUAL PREMIUM, $383.40 THE BANKERS RESERVE LIFE COMPANY

In consideration of the application for this Policy, which is hereby made a part of this contract, and of an advance premium of Three Hundred Eighty-three Dollars and Forty Cents, to be actually paid in cash on or before the delivery hereof, for one year's insurance from date of this Contract and for the advance reserve required hereon, and upon condition of the further payment in advance of a like amount on or before the First day of the month of January in every succeeding year during the con tinuance of this Policy, or until Twenty years' premiums shall have been paid, hereby

Insures the life of Richard Roe of Omaha, County of Douglas and State of Nebraska, in the sum of Ten Thousand Dollars, and upon receipt of due proof of the death of said insured while this Policy is in full force, promises to pay, at its home office. in the city of Omaha, to Mary Roe, his Wife, if living, or, if not living, then to the executors, administrators or assigns of said insured the said sum insured after deducting therefrom the balance of the current year's premiums, if any, and any indebtedness of the insured to the Company hereon.

TABLE OF NONFORFEITURE OPTIONS, EXCLUSIVE OF DIVIDEND ADDITIONS, IF ANY.

Values for future years will be furnished upon application and will be computed upon the same basis as for above table. Values at the end of fractional parts of any policy year paid for will be proportionately increased.

The Provisions and Conditions hereinafter stated are hereby

made a part of this Contract.

Signed and dated at the Home Office of THE BANKERS RESERVE LIFE COMPANY, in the city of Omaha, this First day of January, 1908. B. H. ROBISON,

Attest:

R. C. WAGNER, Secretary.

President.

PROVISIONS AND CONDITIONS.

REFERRED TO ON THE FIRST PAGE OF THIS POLICY.

1. INCONTESTABILITY. This policy and the application therefor constitute the entire contract between the insured and the company and shall be incontestable after one year from date hereof, except for non-payment of premiums or for military or naval services in time of war without the written consent of the Company.

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 the written application therefor, a copy of which is attached hereto or dorsed hereon when issued.

en

If the age of the insured has been misstated, the amount payable hereunder shall be such as the premium paid would have purchased at the correct age.

2. GRACE. A grace of one month (not less than thirty days), subject to an interest charge at the rate of six per centum per annum, shall be granted for 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 in any settlement hereunder.

3. VALUATION. The first year's insurance under this policy is term insurance.

4. CHANGE OF BENEFICIARY. The insured may at any time during the continuance of this policy, provided said policy has not been assigned, change the beneficiary, upon written request to the home office of the Company, together with a surrender of the policy. 5. PAYMENT OF PREMIUMS. Premiums hereon after the first are due and payable in advance, either at the home office or to an agent of the Company, upon delivery of a receipt signed by the President, Secretary or Treasurer.

Except as herein otherwise 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.

This policy is based upon premiums payable annually in advance, but upon written notice to the Company the insured shall have the option at the time any premium falls due of paying an annual, semi-annual or quarterly premium, according to the Company's schedule for this kind of policy, and the same will continue this policy in force for the time paid for, the receipt for which must be signed as aforesaid.

6. DIVIDENDS. This policy shall participate in the surplus of the Company, and beginning at the end of the third policy year the Company will annually determine and account for the portion of the divisible surplus accruing hereon.

Dividends accrued as above may at the option of the insured 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, or

(4.) Left to accumulate to the credit of the policy with interest at three per centum per annum and payable at the maturity of the policy, but withdrawable on any anniversary thereof. When at the end of any policy year the dividends so accumulated, plus the cash surrender value hereon, shall equal or exceed the net single premium for a Whole Life Policy at the attained age, the Company will at the option of the insured issue in lieu of this policy a paid-up non-participating Whole Life Policy for the face amount hereof.

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

7. AUTOMATIC PAID-UP INSURANCE-First Option. After three full years' premiums have been paid hereon, upon default in the payment of any premium, if the insured has selected no other option, the Company, without action on the part of the insured, will continue this Policy as a paid-up non-participating Whole Life Policy for the amount stated in the table on the first page hereof, plus any outstanding dividend additions, purchasable by the reserve according to the American Experience Table of Mortality and three and one-half per cent interest, less not more than two and one-half per centum of the amount insured by this Policy and of any existing dividend additions hereto and less any existing indebtedness to the Company hereon..

8. EXTENDED INSURANCE-Second Option. If after three full years' premiums have been paid hereon, this policy shall lapse by default in the payment of any premium when due, then, upon surrender of this policy within one month after such default, the reserve hereon and on any existing dividend additions hereto, according to the American Experience Table of Mortality and three and one-half per cent interest, less not more than two and one-half per centum of the amount insured by this Policy and of any existing dividend additions hereto and less any existing indebtedness to the Company hereon, shall be applied to the extension of this Policy for its face amount and any outstanding dividend additions, for the term stated in the second option in the table on the first page hereof, without further payment of premiums, but without future participation or the right to loans.

9. CASH SURRENDER VALUE-Third Option. After three full years' premiums have been paid hereon, if this policy is surrendered to the Company within one month after the non-payment of any premium when due, the Company will pay therefor, within sixty days from the date of such surrender, the amount stated in the table on the first page hereof, plus the reserve on any existing dividend additions, according to the American Experience Table of Mortality and three and one-half per cent interest, less not more than one per centum of the amount insured by this policy and of any existing dividend additions hereto and less any existing indebtedness to the Company hereon. The cash value hereby available is at least equal to the amount otherwise applicable to the purchase of raid up insurance and is greater than the amount otherwise applicable to the purchase of extended insurance.

10. LOANS-Fourth Option. After three full years' premiums have been paid hereon, and while this Policy is in force, the Company, upon written application, will loan, within sixty days after such application is received, an amount not to exceed the loan value of the policy, being the reserve on this policy at end of the current policy year, plus the reserve on any outstanding dividend additions, according to the American Experience Table of Mortality and interest at three and one-half per cent, less one per centim of the amount insured by this policy and of the dividend additions hereto and less any existing indebtedness to the Company hereon. At the time of making such loan the policy shall be duly assigned and surrendered to the Company as sole security therefor. Interest in advance at six per cent to the end of the current policy year, and any unpaid premium for the current policy year shall first be deducted. Failure to repay any such advance, or to pay interest, shall not void this policy, unless the total indebtedness hereon to the Company shall equal or exceed the loan value at the time of such failure, nor until one month after notice shall have been mailed by the Company to the last known address of the insured and of the assignee, if any. No condition other than as herein provided shall be exacted as a prerequisite to any such advance.

11. ASSIGNMENT. No assignment of this policy shall be binding upon the Company until it is filed with and approved by the Company at its Home Office. The Company assumes no responsibility as to the validity of any assignment.

12. REINSTATEMENT. This policy may be reinstated within three years from default in the payment of any premium hereon, upon proof of good health satisfactory to the Company and the er payment of all defaulted premiums with interest thereon at six 1 per cent per annum. This privilege shall not apply if the policy f has been surrendered to the Company for its cash surrender value t and been canceled.

13. POWER OF AGENTS. No person other t than the President or Secretary shall have authority to make, alter or discharge this contract, or to modify or extend any of its terms, conditions or provisions either before or after its issue and delivery. No statement, promise, estimate, representation or waiver of any of the terms, provisions or conditions herein shall be binding upon the Company unless written or printed in the Policy and duly signed by said President or Secretary.

14. PROOFS OF Loss. If this policy shall become a claim by the death of the insured, settlement thereof, less any indebtedness thereon, will be made upon receipt of due proofs of death, and upon due notice of death, blanks will be furnished on which to submit proofs.

15. OPTIONS AT MATURITY. The insured, by written notice to the Company at its Home Office, and with the written consent of the assignee, if any, may elect to have the net sum payable under this policy at the death of said insured, paid either in cash or follows:

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as

(1.) By the payment of interest thereon at three 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.

sum,

1

(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 $1,000.00 of said net, (3. By the payment of equal annual instalments payable TABLE OF INSTALMENTS FOR EACH $1,000.

LIMITEDINSTALMENTS.

CONTINUOUS INSTALMENTS.

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