EX-99.4(O) 2 a51440a1exv99w4xoy.htm EXHIBIT 4(O) EXHIBIT 4(O)
SVER TERM INSURANCE RIDER
This Rider (“Rider”) becomes a part of the policy to which it is attached (“the Policy”). All terms of the Policy that do not conflict with this Rider’s terms apply to this Rider.
Rider Benefit Summary – This Rider provides term insurance on the Insured under the Policy as long as the Policy is In Force and this Rider has not terminated. The Face Amount of this Rider contributes to the Total Face Amount, and consequently to the Death Benefit, of the Policy. This rider has no Accumulated Value of its own, but affects the Policy’s Accumulated Value because the charges for the Rider are deducted from the Accumulated Value of the Policy.
Insured – As used in this Rider, the “Insured” means the individual covered under the Policy’s Basic Coverage, as shown in the Policy Specifications.
Rider Coverage Layer – is a layer of insurance coverage under this Rider. There may be one or more Rider Coverage Layers. Any elective increase in Rider Face Amount will comprise a new Rider Coverage Layer. Each Rider Coverage Layer has its own Face Amount, Risk Class, effective date, and set of charges. The Face Amount, Risk Class, effective date, and set of charges for the initial Rider Coverage Layer are shown in the Policy Specifications. The Face Amount, Risk Class, effective date, and set of charges for any Rider Coverage Layer added at a later time will be shown in a Supplemental Schedule of Coverage sent to you at that time.
Rider Face Amount –The Face Amount of this Rider is the sum of the Face Amounts of all Rider Coverage Layers.
Elective Increases in Rider Face Amount – Elective increases in the Face Amount of this Rider are increases that you apply for after the Policy has been issued. Not all policies allow for such increases. If the Policy allows elective increases in Face Amount, then increases in this Rider are also allowed.
You may submit an application to increase the Rider Face Amount. Your application must include Evidence of Insurability satisfactory to us and is subject to our approval. The effective date of the increased Rider Face Amount will be the first Monthly Payment Date on or next following the date all required conditions are met or any other date you request and we approve. We reserve the right to limit increases to one per policy year and to charge a fee, not to exceed $100, to evaluate insurability. Upon approval of any such increase, we will send you a Supplemental Schedule of Coverage, which will include the following information:
•   the increased Rider Face Amount and the effective date of the increase;
 
•   the Risk Class for the increase;
 
•   the Maximum Monthly Cost of Insurance Rates applicable to the increase;
 
•   the Maximum Monthly Coverage Charge for the increase; and
 
•   if the Guideline Premium Test is used, the new Guideline Premiums.
Decrease in Rider Face Amount – You may decrease the Rider Face Amount, subject to the provisions in the Policy. If there are Coverage Layers with the same effective date, they will be decreased or eliminated in the following order:
•   first, the Face Amount of any other Rider that contributes to the Total Face Amount will be decreased or eliminated;
 
•   then, the Face Amount of this Rider will be decreased or eliminated; and
 
•   finally, the Face Amount of Basic Coverage under the Policy will be decreased.
Charge for this Rider – On each Monthly Payment Date prior to the Monthly Deduction End Date, there is a charge for this Rider equal to the sum of the Rider Coverage Charge and the Rider Cost of Insurance Charge. Such charges may vary by Class, and for the purpose of this Rider, Class includes the Policy form to which this Rider is attached.

Page 1 of 2

 

Rider Coverage Charge – The Coverage Charge for this Rider is the sum of the Coverage Charge for each Rider Coverage Layer. The Coverage Charge for the initial Rider Coverage Layer will not exceed the Coverage Charge shown in the Policy Specifications. The Coverage Charge for any later Rider Coverage Layer will not exceed the Coverage Charge shown in the Supplemental Schedule of Coverage to be sent to you when the Coverage Layer is added. This charge is based on the Face Amount of the Rider Coverage Layer as of its effective date. The Coverage Charge will not decrease even if the Face Amount of the associated Rider Coverage Layer is decreased.
Rider Cost of Insurance Charge – The Cost of Insurance Charge for this Rider is the sum of the Cost of Insurance Charge for each Rider Coverage Layer. The Cost of Insurance Charge for each Rider Coverage Layer is equal to (1) multiplied by (2), where:
(1) is the Maximum Monthly Cost of Insurance Rate for the Coverage Layer divided by 1000; and
(2) is the Net Amount at Risk allocated to the Coverage Layer.
The Net Amount at Risk is allocated proportionately to each Coverage Layer, including each Coverage Layer of other Riders that contribute to the Total Face Amount and each Coverage Layer of Basic Coverage under the Policy, according to Face Amount.
Effective Dates – This Rider is effective on the Policy Date unless otherwise stated. It will terminate on the earlier of:
•   your Written Request;
 
•   the date the Rider or the Policy ceases to be In Force.
Signed for Pacific Life Insurance Company,
     
-s- Signature   -s- Signature
Chairman, President and Chief Executive Officer   Secretary

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POLICY NUMBER: AAAAAAAAAAA
POLICY SPECIFICATIONS
SUMMARY OF COVERAGES EFFECTIVE ON THE POLICY DATE
SECTIONS FOR OTHER COVERAGES
         
R09SVERI   SVER TERM INSURANCE RIDER
 
 
  FACE AMOUNT:    $100,000
 
  INSURED:   LELAND STANFORD
 
  SEX AND AGE:   MALE 35
 
  RISK CLASS:   STANDARD NONSMOKER

Page 3.1

 

POLICY NUMBER: AAAAAAAAAAA
POLICY SPECIFICATIONS
TABLE OF COST OF INSURANCE RATES
FOR SVER TERM INSURANCE RIDER
INSURED:                     LELAND STANFORD
MAXIMUM MONTHLY COST OF INSURANCE RATES PER $1000.00 OF NET AMOUNT AT RISK APPLICABLE TO THIS COVERAGE.
         
POLICY   MONTHLY
YEAR   RATE
1
     0.10090  
2
     0.10670  
3
     0.11170  
4
     0.12010  
5
     0.12840  
6
     0.13760  
7
     0.14930  
8
     0.16350  
9
     0.17930  
10
     0.19940  
11
     0.22110  
12
     0.24200  
13
     0.26460  
14
     0.27790  
15
     0.29380  
16
     0.31390  
17
     0.33900  
18
     0.37330  
19
     0.41180  
20
     0.45950  
21
     0.51560  
22
     0.57510  
23
     0.63890  
24
     0.69180  
25
     0.75230  
26
     0.82540  
27
     0.91630  
28
     1.02660  
29
     1.14970  
30
     1.27900  
31
     1.41510  
32
     1.55240  
33
     1.68980  
34
     1.83930  
35
     1.99170  
36
     2.17330  
37
     2.37670  
38
     2.64820  
39
     2.93180  
40
     3.23010  
41
     3.56140  
42
     3.92360  
43
     4.34570  
44
     4.84010  

Page 4.x

 

POLICY NUMBER: AAAAAAAAAAA
POLICY SPECIFICATIONS
TABLE OF COST OF INSURANCE RATES
FOR SVER TERM INSURANCE RIDER
CONTINUED
INSURED:                     LELAND STANFORD
MAXIMUM MONTHLY COST OF INSURANCE RATES PER $1000.00 OF NET AMOUNT AT RISK APPLICABLE TO THIS COVERAGE.
         
POLICY   MONTHLY
YEAR   RATE
45
     5.41330  
46
     6.04180  
47
     6.76170  
48
     7.51460  
49
     8.33040  
50
     9.24140  
51
     10.27540  
52
     11.43490  
53
     12.71510  
54
     14.10520  
55
     15.59360  
56
     17.17060  
57
     18.67330  
58
     20.26540  
59
     21.97380  
60
     23.81220  
61
     25.79270  
62
     27.64150  
63
     29.65380  
64
     31.85100  
65
     34.25960  
66
     36.90860  
67
     39.06360  
68
     41.41760  
69
     43.99540  
70
     46.82420  
71
     49.93700  
72
     53.37330  
73
     57.18460  
74
     61.42910  
75
     66.18210  
76
     71.53880  
77
     77.62690  
78
     83.33330  
79
     83.33330  
80
     83.33330  
81
     83.33330  
82
     83.33330  
83
     83.33330  
84
     83.33330  
85
     83.33330  
86
     83.33330  
87+
     0  

Page 4.x

 

POLICY NUMBER: AAAAAAAAAAA
POLICY SPECIFICATIONS
TABLE OF MAXIMUM MONTHLY COVERAGE CHARGES
FOR SVER TERM INSURANCE RIDER
INSURED:                     LELAND STANFORD
         
POLICY   COVERAGE
YEAR   CHARGE
1
   $ 0.00  
2
     67.40  
3
     101.10  
4
     101.10  
5
     101.10  
6
     101.10  
7
     101.10  
8
     101.10  
9
     101.10  
10
     101.10  
11
     67.40  
12
     67.40  
13
     67.40  
14
     67.40  
15
     67.40  
16
     67.40  
17
     67.40  
18
     67.40  
19
     67.40  
20
     67.40  
21
     67.40  
22
     67.40  
23
     67.40  
24
     67.40  
25
     67.40  
26
     67.40  
27
     67.40  
28
     67.40  
29
     67.40  
30
     67.40  
31
     67.40  
32
     67.40  
33
     67.40  
34
     67.40  
35
     67.40  
36
     67.40  
37
     67.40  
38
     67.40  
39
     67.40  
40
     67.40  
41
     67.40  
42
     67.40  
43
     67.40  
44
     67.40  

Page 4.x

 

POLICY NUMBER: AAAAAAAAAAA
POLICY SPECIFICATIONS
TABLE OF MAXIMUM MONTHLY COVERAGE CHARGES
FOR SVER TERM INSURANCE RIDER
CONTINUED
INSURED:                     LELAND STANFORD
         
POLICY   COVERAGE
YEAR   CHARGE
45
   $ 67.40  
46
     67.40  
47
     67.40  
48
     67.40  
49
     67.40  
50
     67.40  
51
     67.40  
52
     67.40  
53
     67.40  
54
     67.40  
55
     67.40  
56
     67.40  
57
     67.40  
58
     67.40  
59
     67.40  
60
     67.40  
61
     67.40  
62
     67.40  
63
     67.40  
64
     67.40  
65
     67.40  
66
     67.40  
67
     67.40  
68
     67.40  
69
     67.40  
70
     67.40  
71
     67.40  
72
     67.40  
73
     67.40  
74
     67.40  
75
     67.40  
76
     67.40  
77
     67.40  
78
     67.40  
79
     67.40  
80
     67.40  
81
     67.40  
82
     67.40  
83
     67.40  
84
     67.40  
85
     67.40  
86
     67.40  
87+
     0  

Page 4.x