Summary Of Coverages Effective On The Policy Date

	R15SRT	Scheduled Annual Renewable Term Rider [(Guaranteed Issue)]
	S17SRT
		Rider Face Amount:	Refer to the Table of Term Coverage Applicable to Scheduled Annual Renewable Term Rider
		Insured:	[John Doe]
		Sex and Age:	[Male 35]
		Risk Class:	[Standard Nonsmoker]
		Rider Charge:	[$10.00 Per Month]
		Rider Charge Duration:	[20 Years]

[ICC17 S17PDP]

Page [1]

Policy Number:  [VP99999990]

POLICY SPECIFICATIONS

Table of Cost of Insurance (COI) Rates

For Scheduled Annual Renewable Term Rider [(Guaranteed Issue)]

Insured: [JOHN DOE]

Maximum monthly Cost of Insurance Rates per $1000.00 of Net Amount at Risk applicable to this Coverage.

Policy Year	COI Rate	Policy Year	COI Rate	Policy Year	COI Rate
[1	0.11420	30	0.80520	59	20.24350
2	0.12510	31	0.89100	60	21.89610
3	0.13510	32	0.98280	61	23.37870
4	0.14680	33	1.07970	62	25.34290
5	0.15850	34	1.18520	63	27.50320
6	0.17180	35	1.30350	64	29.93860
7	0.18440	36	1.44140	65	32.62170
8	0.19520	37	1.60490	66	35.52070
9	0.20020	38	1.79600	67	38.34190
10	0.20610	39	2.01720	68	41.25060
11	0.21190	40	2.26640	69	44.19530
12	0.21780	41	2.54020	70	47.11980
13	0.22280	42	2.83630	71	49.95900
14	0.22860	43	3.15590	72	52.64660
15	0.23450	44	3.50430	73	56.64960
16	0.24450	45	3.89660	74	61.08170
17	0.25790	46	4.34480	75	66.01940
18	0.27370	47	4.86390	76	71.55390
19	0.29210	48	5.43720	77	77.81150
20	0.31300	49	6.15320	78	83.33330
21	0.33810	50	6.98110	79	83.33330
22	0.36660	51	7.94390	80	83.33330
23	0.39920	52	9.06070	81	83.33330
24	0.43600	53	10.33800	82	83.33330
25	0.47960	54	11.78270	83	83.33330
26	0.52900	55	13.34950	84	83.33330
27	0.58690	56	15.02480	85	83.33330
28	0.65150	57	16.75710	86	83.33330
29	0.72450	58	18.50020	87+	0]

ICC17 S17SRT

Page [2]

Policy Number:  [VP99999990]

POLICY SPECIFICATIONS

Table of Term Coverage Applicable to

Scheduled Annual Renewable Term Rider [(Guaranteed Issue)]

Insured: [JOHN DOE]

Policy Year	Rider Increase Amount	Total Rider Face Amount	Maximum Monthly Coverage Charge
[1	$0	$0	$0
2	10,000	10,000	3.17
3	10,000	20,000	6.34
4	10,000	30,000	9.51
5	10,000	40,000	12.68
6	10,000	50,000	15.86
7	10,000	60,000	19.03
8	10,000	70,000	22.20
9	10,000	80,000	25.37
10	10,000	90,000	28.54
11	10,000	100,000	31.71
12	0	100,000	31.71
13	0	100,000	31.71
14	0	100,000	31.71
15	0	100,000	31.71
16	0	100,000	31.71
17	0	100,000	31.71
18	0	100,000	31.71
19	0	100,000	31.71
20	0	100,000	31.71
21	0	100,000	31.71
22	0	100,000	31.71
23	0	100,000	31.71
24	0	100,000	31.71
25	0	100,000	31.71
26	0	100,000	31.71
27	0	100,000	31.71
28	0	100,000	31.71
29	0	100,000	31.71
30	0	100,000	31.71
31	0	100,000	31.71
32	0	100,000	31.71
33	0	100,000	31.71
34	0	100,000	31.71
35	0	100,000	31.71
36	0	100,000	31.71
37	0	100,000	31.71
38	0	100,000	31.71
39	0	100,000	31.71
40	0	100,000	31.71
41	0	100,000	31.71
42	0	100,000	31.71
43	0	100,000	31.71
44	0	100,000	31.71

ICC17 S17SRT

Page [3]

Table of Term Coverage Applicable to

Scheduled Annual Renewable Term Rider [(Guaranteed Issue)]

Continued

Insured: [JOHN DOE]

Policy Year	Rider Increase Amount	Total Rider Face Amount	Maximum Monthly Coverage Charge
45	$0	100,000	31.71
46	0	100,000	31.71
47	0	100,000	31.71
48	0	100,000	31.71
49	0	100,000	31.71
50	0	100,000	31.71
51	0	100,000	33.30
52	0	100,000	33.30
53	0	100,000	33.30
54	0	100,000	33.30
55	0	100,000	33.30
56	0	100,000	34.97
57	0	100,000	34.97
58	0	100,000	34.97
59	0	100,000	34.97
60	0	100,000	34.97
61	0	100,000	36.71
62	0	100,000	36.71
63	0	100,000	36.71
64	0	100,000	36.71
65	0	100,000	36.71
66	0	100,000	38.55
67	0	100,000	38.55
68	0	100,000	38.55
69	0	100,000	38.55
70	0	100,000	38.55
71	0	100,000	40.47
72	0	100,000	40.47
73	0	100,000	40.47
74	0	100,000	40.47
75	0	100,000	40.47
76	0	100,000	42.49
77	0	100,000	42.49
78	0	100,000	42.49
79	0	100,000	42.49
80	0	100,000	42.49
81	0	100,000	44.61
82	0	100,000	44.61
83	0	100,000	44.61
84	0	100,000	44.61
85	0	100,000	44.61
86	0	100,000	46.85
87+	0	100,000	0]

ICC17 S17SRT

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