[POLICY NUMBER: VF99999990]

POLICY SPECIFICATIONS

Summary of Coverages Effective On The Policy Date

	R17RTA	Annual Renewable Term Rider – Additional Insured  [(Guaranteed Issue)]
	S17RTA
		Rider Face Amount: Insured: Sex and Age: Risk Class: [Effective Date:	[$100,000] [JANE DOE] [FEMALE 35] [STANDARD NONSMOKER] [November 1, 2018]]

[ICC17 S17PDP]

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[POLICY NUMBER: VF99999990]

POLICY SPECIFICATIONS

Table Of Cost Of Insurance (COI) Rates

For Annual Renewable Term Rider – Additional Insured [(Guaranteed Issue)]

Insured:[JANE DOE]

Maximum Monthly Cost Of Insurance Rates Per $1000.00 Of Face Amount Applicable to This Coverage

Policy Year	COI Rate	Policy Year	COI Rate
[1	0.06000	45	3.02400
2	0.06750	46	3.38390
3	0.07590	47	3.81920
4	0.08340	48	4.31770
5	0.09000	49	4.88230
6	0.09500	50	5.53990
7	0.10010	51	6.29510
8	0.10340	52	7.16850
9	0.10670	53	8.12330
10	0.11090	54	9.18690
11	0.11510	55	10.36600
12	0.12430	56	11.65650
13	0.13340	57	13.02740
14	0.14430	58	14.51730
15	0.15600	59	16.12710
16	0.16850	60	17.74000
17	0.18270	61	19.48390
18	0.19860	62	21.69750
19	0.21610	63	24.16480
20	0.23530	64	26.90050
21	0.25700	65	29.87570
22	0.28130	66	33.06210
23	0.30800	67	36.18440
24	0.33810	68	39.38720
25	0.37240	69	42.61620
26	0.41180	70	45.81470
27	0.45610	71	48.91540
28	0.50560	72	51.84510
29	0.56170	73	55.82890
30	0.62460	74	60.24070
31	0.69520	75	65.15650
32	0.77330	76	70.67220
33	0.85990	77	76.91040
34	0.95580	78	83.33330
35	1.06120	79	83.33330
36	1.17760	80	83.33330
37	1.30350	81	83.33330
38	1.44220	82	83.33330
39	1.59470	83	83.33330
40	1.76540	84	83.33330
41	1.95850	85	83.33330
42	2.17590	86	83.33330
43	2.42540	87+	0]
44	2.70570

ICC17 S17RTA

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