ar 10 PREMIUMS (FIRST YEAR TERM AND 19 PREMIUMS) LIFE POLICY WITH DISABILITY BENEFITS. No. 99999. AGE 35. PREMIUM $350.70. JEFFERSON STANDARD LIFE INSURANCE COMPANY GREENSBORO, NORTH CAROLINA. Does Hereby Insure John Washington Doe, hereinafter talled the Insured, of Greensboro, in the County of Guilford, State of N. C. in the sum of Ten Thousand Dollars, payable at its Home Office in the City of Greensboro, N. C., unto Mary E. Doe, wife, immediately upon receipt of due proof of death of the Insured within one year from the date hereof, or thereafter while this policy is in force. In event of the prior death of the beneficiary the benefits hereunder will be paid to the executors, administrators, or assigns of the Insured. DIVIDENDS. This Policy shares in the surplus earnings of the Company, contributed by policies of its class, and an apportionment of its shares of said surplus will be made by the Company at the end of the first policy year and annually thereafter, and when so dapportioned may be used, (1) in the reduction of the next annual & premium; or (2) may be used in the purchase of paid-up additions to the face of this Policy. Dividends will be due and payable only upon payment of the next succeeding annual premium. 2 TOTAL AND PERMANENT DISABILITY. Upon receipt of due proof of the total and permanent blindness or deafness of the Insured, or of the loss of both hands at or above the wrist; or of the loss of both feet at or above the ankle; or of the loss of one limb and one eye; or of the loss of one hand at or above the wrist and of one foot at or above the ankle; or that he has become wholly disabled by bodily injuries, or disease, and will be permanently, continuously and wholly prevented thereby from pursuing any and all gainful occupations, after one full annual payment shall have been made and before a default in the payment of any subsequent premium the Company by endorsement in writing on this contract will agree to pay for the Insured the premiums which shall thereafter become payable during the continuance of such disability. In any such case the premiums so paid shall not be a lien on this contract and the values in the Table of Values on the second page hereof shall increase in the same manner as if the premiums were being paid by the Insured. The Company will grant, in lieu of paying for the Insured the premiums as provided hereunder, an endowment for the face value of the policy, payable in ten equal annual installments, the first installment to be paid immediately upon receipt of satisfactory proof of any such disability or incapacity. If the Insured should not live to draw the total number of installments, the remainder will be continued to the beneficiary, or commuted and paid in one sum. If, however, the Insured shall recover so as to be able to engage in any gainful occupation during the premium paying period, the Company's obligation to pay the premiums or installments shall cease and the Insured shall resume the payment of premiums in accordance with this contract on the premium due date following such recovery, any premiums already having been paid by the Company not being charged as a lien thereon; but any installments paid hereunder shall be counted a lien on this Policy. Proof of total and permanent disability of the Insured will be required on forms prescribed by the Company, and any medical adviser of the Company shall be allowed to examine the person of the Insured in respect to any alleged disability. Provided, however, that such total and permanent disabil shall occur before the Ínsured attains the age of sixty years. STATE OF NORTH CAROLINA INSURANCE DEPARTMENT 191 This Policy is registered and secured by pledge of bonds, stoc or securities deposited with this department as provided by law. Insurance Commissioner. STIPULATIONS AND AGREEMENTS. SPECIAL PRIVILEGES.-Instead of using the dividends annually provided on the first page hereof, the Insured may elect to lea the dividends with the Company to be used as follows: To Pay Up All Premiums.-Whenever at the end of any p icy year its share of the surplus together with the reserve equ the single premium at the attained age of the Insured, it may come a fully paid-up participating policy; but the Insured may co tinue the payment of premiums to the end of the premium payi period to increase its share of profits, or to mature as an endo ment. If the Insured elect a paid-up participating policy, paid up the application of dividends, or at the end of the premium payi period, the dividends will be paid annually thereafter in cash, u less left to mature this Policy as an endowment. To Mature This Policy as an Endowment.- -Whenever t surplus together with the reserve equals the face of this Policy, shall mature as an endowment and be payable at once to the 1 sured. In the event of the death of the Insured while this Policy is force, all surplus which has been apportioned and left with t Company under either of the foregoing options will be paid to t beneficiary in addition to the sum insured. NON-FORFEITURE PROVISIONS.-This Policy is non-forfeitable follows: After three full years from the date hereof, if there be indebtedness to the Company, the Insured shall, within sixty da from the date of the non-payment of any premium after the thi be entitled to a surrender value in cash, paid-up non-participati insurance, or extended insurance-as set forth in the table belo Values after the twentieth year will be furnished upon applicati GUARANTEED OPTIONS. Any indebtedness existing against this Policy at the time of any settl ment thereof shall be deducted from the Cash Surrender Value of th Policy, and the other values shall be diminished proportionately. LOANS.-After three full years from the date hereof, if premiums on this Policy have been fully paid, the Company will lend hereon at six per cent per annum-subject to its loan agreements then in use the sum named in the table above. Any subsequent loan shall not exceed the amount in said table indicated for the year it is applied for, less the amount of any prior loan with interest. NON-LAPSING.-If the Insured does not elect one of the guaranteed options above, the Company will charge the unpaid premium against the loan value hereon, as a loan, continuing the Policy in full force the same as if the premium had been paid by the Insured in cash. Such premium loans shall be continued as long as the loan value on the policy, less indebtedness, will meet the premiums as they fall due, with interest at six per cent added. The Policy shall not lapse while the loan value, less all prior loans and accrued interest, so applied will suffice for a quarterly premium. At any time while the Policy is thus in force the Insured may pay up all loans with interest, or continue such loans as a lien against this Policy, and resume the payment of premiums without medical examination. GRACE IN PAYMENT OF PREMIUMS.-In the payment of any premium under this Policy, except the first, a grace of thirty days will be allowed, without interest. INCONTESTABILITY. After one year from date, if premiums have been duly paid, this Policy shall be incontestable for any cause, except military and naval service in time of war, for which permission must be obtained at the Company's regular rates. SELF-DESTRUCTION.-In case of self-destruction committed, whether sane or insane, within one year from the date hereof, the extent of recovery hereunder shall be the premium paid. ADMISSION OF AGE.-The Company will admit age upon satisfactory proof; otherwise, if age is not truly stated in application, the benefits hereunder will be what the premiums actually paid would have purchased at the true age. REINSTATEMENT.-Should this Policy cease and determine for non-payment of any premium, it may be reinstated at any time by the payment of the defaulted premiums with six per cent interest, and by complying with the Company's health requirements. ASSIGNMENT.-No assignment of this Policy shall take effect unless made in writing in duplicate, the original attached to this Policy, and the duplicate filed in the Home Office of the Company. The Company will not assume any responsibility for the validity of an assignment. as CHANGE OF BENEFICIARY.-Provided this Policy be not signed, the Insured may at any time and from time to time change the beneficiary hereunder. Such change to take effect upon the written endorsement of the same upon the Policy by the Company. NOTICE.-Only the President, Vice-President, or Secretary, whose authority will not be delegated, shall have the power to make, modify, or alter this contract, to bind the Company by making any promise, or by accepting any representation or information not contained in the application for this Policy; and, if done by them, shall be binding only when in writing, duly signed and attached hereto. HOW PAYABLE. The amount insured under this Policy is payable in one sum; but, upon written application by the Insured to the Company, may be made payable in a definite number of equal annual installments, or in equal annual installments to continue during the life of the beneficiary. Full information will be supplied upon application to the Home Office. $92.90. PREMIUMS.-The insurance provided for by this Policy is based upon the payment of premiums annually in advance, but after the first year the annual premium may be paid by installments as follows: Semi-annually in advance, $182.40, or quarterly in advance, The payment of any such installment shall not have the effect to continue this Policy in force longer than until the next installment is due. This Policy does not take effect until the first annual premium shall have been actually paid and the Policy delivered during the life time and good health of the Insured. Subsequent premiums are payable to the Company at its Home Office, but may be paid to an authorized agent in exchange for an offi receipt signed by the Secretary and countersigned by the agent. any settlement under this Policy the remainder of the then curr year's premium, if any, together with all indebtedness will be f deducted. In case of default in the payment of any premium note given for any premium or portion thereof, this Policy sl cease and determine, and the payments received hereon shall come the property of the Company, except as specified on the sec page hereof. The Insurance Hereunder is granted in consideration of application for this policy, which is a part hereof and copy attacl hereto, and of the premium of Three Hundred Fifty and 70/ Dollars, to be paid on delivery hereof. This policy will be renewed and extended as a Limited P ment Life Contract on the same terms and for the same amou in the further consideration of the payment of a like sum, to paid one year from date, and every year thereafter while the pol is in force, until twenty such premiums, including the first, sh have been paid, after which no further premiums will be requir In Witness Whereof, the Jefferson Standard Life Insurar Company has caused this contract to be signed by its Preside and Secretary, at its Home Office in the City of Greensboro, N. on this the Twentieth day of September, One Thousand Nine Hu dred and Twelve. GEO. A. GRIMSLEY, President Secretary. APPLICATION. 1st. I hereby agree for myself and for any person who m have or claim an interest in any contract which may be issued up this application, that every statement and representation her above contained is material and true. 2nd. Any Policy issued under this application shall be g erned by the laws of the State of North Carolina. * 3rd. Any distribution of surplus or apportionment of prof or principles or methods which may be adopted at any time by Company for such distribution or apportionment, and its distrit tion of the amount to any Policy which may be issued under t application, shall be conclusive upon the Insured under said Poli and upon all parties having or claiming any interest thereunder. 4th. That the Company shall incur no liability under this a plication until it has been received and approved, the Policy issu and delivered and the premium has been actually paid to and a cepted by the Company, or its authorized agent, during my 1 time and while I am in good health. MEDICAL EXAMINER'S FORM. I hereby warrant the answers to the foregoing questions be true. OF BOSTON, MASSACHUSETTS. In Consideration of the representations in the application herefor, which is copied hereon and hereby made a part hereof, and of the premium of Three Hundred and Forty-eight and 70-100 Dollars to be paid on delivery of this policy, and of the payment of a like premium on or before the First day of January in each succeeding year until the premiums for Twenty full years shall have been paid, or until the prior death of the Insured, the JOHN HANCOCK MUTUAL LIFE INSURANCE COMPANY hereby insures the life of John Hancock, of Boston, Massachusetts, in the sum of Ten Thousand Dollars, and promises to pay said sum at its Home Office in Boston, subject to the conditions and provisions hereinafter recited, upon receipt of due proof of the death of the Insured during the continuance of this policy, and on its surrender, to his wife, Dorothy Q. Hancock, if living, or to such other beneficiary as may, according to the conditions hereof, be finally designated and recognized by endorsement hereon, or if no such beneficiary be then living, then to the executors or administrators of the said Insured; deducting from said sum any indebtedness to the Company hereon or secured hereby and any unpaid instalments of premium for the balance of the policy year. WHEN IN EFFECT. This policy shall not take effect until the first premium or regular instalment, as herein provided, shall be actually paid during the lifetime of the Insured. POLICY AND APPLICATION ENTIRE CONTRACT.-This policy and the application herefor constitute the entire contract between the parties hereto. All statements made by the Insured as the basis for the contract shall, in the absence of fraud, be deemed representations and not warranties, and no such statement shall avoid the policy or be used in defense to a claim hereunder unless it is contained in the written application herefor and unless a copy thereof is endorsed hereon when this policy is issued. CHANGE OF BENEFICIARY.-The Insured may change the beneficiary from time to time (subject, however, to the rights of any assignee), by written request upon the blanks of the Company filed at its Home Office, but such change shall take effect only upon endorsement hereon. PAYMENT OF PREMIUMS.All premiums hereunder are payable on or before the specified dates, at the Home Office of the Company, or to a duly authorized agent presenting the official receipt signed by the President or Secretary, and countersigned by the agent designated on such receipt. Premiums hereunder are payable annually in advance, but may be paid in regular semi-annual or quarterly instalments at the rates and dates stated on the filing back. Except as herein (Rpressly provided, the payment of any premium or instalment ther |