EX-99.(4)(KK) 8 d942812dex994kk.htm SCHEDULED INCREASE RIDER (FORM R15SIR) AND SPECIFICATIONS PAGES (FORM R15SIR SP) Scheduled Increase Rider (form R15SIR) and specifications pages (form R15SIR SP)

SCHEDULED INCREASE RIDER

This rider (“Rider”) becomes a part of the policy to which it is attached (“Policy”). If the Rider is effective after the Policy Date, the effective date for this Rider will be shown on the Policy Specifications. If the provisions of this Rider and those of the Policy do not agree, the provisions of this Rider will apply. Please read it carefully.

Rider Benefit Summary – This Rider provides for scheduled increases in Face Amount to Basic Life Coverage or to any rider that provides for scheduled annual renewable term coverage on the Insured’s life as long as:

 

  The Policy or Rider is In Force and this Rider has not terminated.
  We have approved such increase; if approval is required (see Evidence of Financial Insurability May Be Required).

Each such increase is referred to in this Rider as a Scheduled Increase, and is scheduled for a particular Policy anniversary as shown in the applicable Policy Specifications. The Face Amount of each Coverage Layer contributes to the Total Face Amount and, consequently, to the Policy’s Death Benefit. The Policy’s Death Benefit is determined according to the provisions 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 and the charges for any Scheduled Increase that may result from it are deducted from the Accumulated Value of the Policy.

Evidence of Financial Insurability May Be Required – Evidence of Financial Insurability (“Evidence”) with respect to this Rider means financial documentation required by us at the time we evaluate the Scheduled Increase that is consistent with our financial underwriting standards and practices. Each Scheduled Increase may be subject to our approval based on the Evidence you provide at the time the said increase is evaluated. If Evidence is required for one or more Scheduled Increases, the applicable Policy Specifications will so state. If Evidence is required, the Scheduled Increase will only occur if you provide the required Evidence at least 15 days before said increase is planned to occur, and only if we approve the Scheduled Increase by determining that the Evidence meets our financial underwriting standards and practices. If you fail to provide the required Evidence or if we determine that the Evidence you provide does not meet our financial underwriting standards and practices, we will not approve the Scheduled Increase, and the Scheduled Increase shown in your Policy Specifications will not take effect. We reserve the right to approve an increase for an amount less than the Scheduled Increase, in which case the lesser amount will take effect. When this rider is in effect, Evidence of Financial Insurability may be required for scheduled increases that are generated by any rider that provides for scheduled annual renewable term coverage.

SCHEDULED INCREASES

Scheduled Increase – Each Scheduled Increase is an increase either to Basic Life Coverage or to scheduled annual renewable term coverage on the Insured that is provided by a rider. In the Policy Specifications, Scheduled Increases to Basic Life Coverage are shown in a Table of Scheduled Increases in Basic Life Coverage, and Scheduled Increases to scheduled annual renewable term coverage is shown in a Table of Term Coverage applicable to the rider to which it applies. When a Scheduled Increase to Basic Life Coverage goes into effect, it will become a part of, and be administered according to, the applicable Policy. Likewise, when a Scheduled Increase to scheduled annual renewable term coverage goes into effect, it will become a part of, and be administered according to the rider to which the Scheduled Increase applies.

Changes in Scheduled Increases – Future Scheduled Increases may be forfeited if you:

 

  request a decrease or termination of any Coverage Layer that has already gone into effect;
  decline a Scheduled Increase that has been approved;
  do not provide Evidence of Financial Insurability; or
  transfer ownership of the Policy to any person or entity without an insurable interest in the life of the Insured.

The amount of a Future Scheduled Increase will not be forfeited if we:

  do not approve a Scheduled Increase that requires Evidence; or,
  do approve an increase for an amount less than the full amount of the Scheduled Increase.

When this rider is in effect, Changes in Scheduled Increases as described above may apply to any rider that provides for scheduled annual renewable term coverage.

 

R15SIR Page [1]


We will send you a Supplemental Schedule of Coverage to reflect any change to your Scheduled Increases.

CHARGES

Charge for this Rider – On each Monthly Payment Date, there is a Rider Charge that will be part of the Policy’s Monthly Deduction. Such charges may vary by Class, and for the purpose of this Rider, Class includes the Policy form to which this Rider is attached. The maximum Rider Charge and Rider Duration are shown in the Policy Specifications. We may charge less than such maximum charge. All charges will apply uniformly to all members of the same Class. The Rider Charge will apply whether or not a particular Scheduled Increase goes into effect and regardless of whether any Scheduled Increases stay in effect.

Charges for Scheduled Increases – Any Scheduled Increase that has gone into effect as a result of this Rider may have an associated Coverage Charge, Cost of Insurance Charge and, in the case of a Scheduled Increase in Basic Coverage, an associated Surrender Charge, all of which are shown in your Policy Specifications. The charges for increases in Basic Coverage are described in the Policy. The charges for increases in scheduled annual renewable term coverage are described in the rider, to which the Scheduled Increases apply.

GENERAL PROVISIONS OF THIS RIDER

Insured – As used in this Rider, the Insured means the individual covered under the Policy’s Basic Coverage, as shown in the Policy Specifications.

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 terminates; or
  The death of the Insured.

Reinstatement – If the Policy is reinstated, any Scheduled Increases that would have otherwise occurred when the Policy was lapsed will be forfeited. Scheduled Increases that are scheduled to occur after reinstatement will be handled as if the Policy had never lapsed.

Effect of Additional Benefits on Rider Provisions – Your policy may include additional benefits that were added by rider or endorsement. These rider and endorsement forms may include provisions that replace or amend provisions in this contract. Please read this rider and all other forms carefully.

Signed for Pacific Life Insurance Company,

 

 

LOGO LOGO LOGO LOGO

 

Chairman and Chief Executive Officer    

 

Secretary

[www.PacificLife.com]            [(800) 347-7787]

 

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POLICY NUMBER: [VF99999990]

POLICY SPECIFICATIONS

Summary of Coverages Effective On The Policy Date

 

 

 

  
LOGO

 

R15SIR

 

Scheduled Increase Rider

LOGO

R15SIR SP

 

Rider Charge:

 

Rider Charge Duration:

 

Rider Effective Date:

 

$[30.50] Per Month

 

[20] Years

 

[June 1, 2015]

 

[P12MVP] Page [1]


POLICY NUMBER: [VF99999990]

POLICY SPECIFICATIONS

Table of Scheduled Increases In Basic Life Coverage

 

Insured:                               [JOHN DOE]

[* Increase is not guaranteed. Evidence of financial insurability will be required.]

 

  For Each Scheduled Increase First
Effective In The Policy Year Shown

Totals For All Scheduled Increases That

Have Become Effective By The Policy Year Shown

Policy

Year

Face

Amount

Face

Amount

Coverage

Charge

[1 $0 $0 $0
2 100,000[*] 100,000 21.01
3 100,000[*] 200,000 42.32
4 100,000[*] 300,000 63.91
5 100,000[*] 400,000 85.77
6 100,000[*] 500,000 107.94
7 100,000[*] 600,000 130.48
8 100,000[*] 700,000 153.39
9 100,000[*] 800,000 176.68
10 100,000[*] 900,000 200.33
11 100,000[*] 1,000,000 224.40
12 0 1,000,000 224.40
13 0 1,000,000 224.40
14 0 1,000,000 224.40
15 0 1,000,000 224.40
16 0 1,000,000 224.40
17 0 1,000,000 224.40
18 0 1,000,000 224.40
19 0 1,000,000 224.40
20 0 1,000,000 224.40
21 0 1,000,000 224.40
22 0 1,000,000 225.09
23 0 1,000,000 226.50
24 0 1,000,000 228.66
25 0 1,000,000 231.59
26 0 1,000,000 235.32
27 0 1,000,000 239.87
28 0 1,000,000 245.27
29 0 1,000,000 251.55
30 0 1,000,000 258.74
31 0 1,000,000 266.87
32 0 1,000,000 275.29
33 0 1,000,000 283.99
34 0 1,000,000 292.98
35 0 1,000,000 302.28
36 0 1,000,000 311.89
37 0 1,000,000 321.83
38 0 1,000,000 332.11
39 0 1,000,000 342.73
40 0 1,000,000 353.71
41 0 1,000,000 365.07
42 0 1,000,000 376.81
43 0 1,000,000 388.95
44 0 1,000,000 401.50

 

R15SIR SP Page [2]


POLICY NUMBER: [VF99999990]

POLICY SPECIFICATIONS

Table of Scheduled Increases In Basic Life Coverage

Continued

 

Insured:                                   [JOHN DOE]

[* Increase is not guaranteed. Evidence of financial insurability will be required.]

 

 

For Each Scheduled

Increase First Effective In

The Policy Year Shown

Totals For All Scheduled Increases That

Have Become Effective By The Policy Year Shown

Policy

Year

Face

Amount

Face

Amount

Coverage

Charge

45 $0 $1,000,000 $414.47
46 0 1,000,000 427.88
47 0 1,000,000 441.74
48 0 1,000,000 456.07
49 0 1,000,000 470.90
50 0 1,000,000 486.23
51 0 1,000,000 502.07
52 0 1,000,000 518.44
53 0 1,000,000 535.37
54 0 1,000,000 552.88
55 0 1,000,000 570.98
56 0 1,000,000 589.69
57 0 1,000,000 609.04
58 0 1,000,000 629.04
59 0 1,000,000 649.71
60 0 1,000,000 671.09
61 0 1,000,000 693.19
62 0 1,000,000 716.05
63 0 1,000,000 739.68
64 0 1,000,000 764.10
65 0 1,000,000 789.35
66 0 1,000,000 815.46
67 0 1,000,000 842.45
68 0 1,000,000 870.36
69 0 1,000,000 899.22
70 0 1,000,000 929.05
71 0 1,000,000 959.89
72 0 1,000,000 991.77
73 0 1,000,000 1024.73
74 0 1,000,000 1058.81
75 0 1,000,000 1094.05
76 0 1,000,000 1130.48
77 0 1,000,000 1168.15
78 0 1,000,000 1207.09
79 0 1,000,000 1247.35
80 0 1,000,000 1288.97
81 0 1,000,000 1332.01
82 0 1,000,000 1376.50
83 0 1,000,000 1422.50
84 0 1,000,000 1470.06
85 0 1,000,000 1519.22
86 0 1,000,000 1570.05
  87+ 0 1,000,000 0]

 

R15SIR SP Page [3]


POLICY NUMBER: [VF99999990]

POLICY SPECIFICATIONS

Table of Term Coverage Applicable to

Scheduled Annual Renewable Term Rider

 

[This table will print in lieu of any other Table of Term Coverage applicable to scheduled annual term coverage provided by a rider.]

[*Increase is not guaranteed. Evidence of Financial Insurability will be required.]

 

Insured:                                   [JOHN DOE]

 

Policy

Year

Rider Increase
Amount

Total Rider

Face Amount

Coverage

Charge

[1 $0 $0 $0
2 100,000[*] 100,000 30.06
3 100,000[*] 200,000 30.06
4 100,000[*] 300,000 30.06
5 100,000[*] 400,000 30.06
6 100,000[*] 500,000 30.06
7 100,000[*] 600,000 30.06
8 100,000[*] 700,000 30.06
9 100,000[*] 800,000 30.06
10 100,000[*] 900,000 30.06
11 100,000[*] 1,000,000 30.06
12 0 1,000,000 30.06
13 0 1,000,000 30.06
14 0 1,000,000 30.06
15 0 1,000,000 30.06
16 0 1,000,000 30.06
17 0 1,000,000 30.06
18 0 1,000,000 30.06
19 0 1,000,000 30.06
20 0 1,000,000 30.06
21 0 1,000,000 30.96
22 0 1,000,000 31.89
23 0 1,000,000 32.85
24 0 1,000,000 33.83
25 0 1,000,000 34.84
26 0 1,000,000 35.90
27 0 1,000,000 36.98
28 0 1,000,000 38.08
29 0 1,000,000 39.22
30 0 1,000,000 40.40
31 0 1,000,000 41.62
32 0 1,000,000 42.86
33 0 1,000,000 44.15
34 0 1,000,000 45.48
35 0 1,000,000 46.84
36 0 1,000,000 48.25
37 0 1,000,000 49.69
38 0 1,000,000 51.19
39 0 1,000,000 52.73
40 0 1,000,000 54.31
41 0 1,000,000 55.94
42 0 1,000,000 57.61
43 0 1,000,000 59.35
44 0 1,000,000 61.13

 

R15SIR SP Page [4]


POLICY NUMBER: [VF99999990]

POLICY SPECIFICATIONS

Table of Term Coverage Applicable to

Scheduled Annual Renewable Term Rider, Continued

 

 

Insured:                                   [JOHN DOE]

[*Increase is not guaranteed. Evidence of Financial Insurability will be required.]

 

Policy

Year

Rider Increase
Amount

Total Rider

Face Amount

Coverage

Charge

45 $0 1,000,000 $62.96
46 0 1,000,000 64.85
47 0 1,000,000 66.80
48 0 1,000,000 68.81
49 0 1,000,000 70.87
50 0 1,000,000 73.00
51 0 1,000,000 75.19
52 0 1,000,000 77.44
53 0 1,000,000 79.78
54 0 1,000,000 82.16
55 0 1,000,000 84.64
56 0 1,000,000 87.18
57 0 1,000,000 89.80
58 0 1,000,000 92.49
59 0 1,000,000 95.26
60 0 1,000,000 98.12
61 0 1,000,000 101.07
62 0 1,000,000 104.11
63 0 1,000,000 107.23
64 0 1,000,000 110.46
65 0 1,000,000 113.77
66 0 1,000,000 117.19
67 0 1,000,000 120.71
68 0 1,000,000 124.33
69 0 1,000,000 128.07
70 0 1,000,000 131.91
71 0 1,000,000 135.87
72 0 1,000,000 139.95
73 0 1,000,000 144.15
74 0 1,000,000 148.47
75 0 1,000,000 152.94
76 0 1,000,000 157.52
77 0 1,000,000 162.25
78 0 1,000,000 167.13
79 0 1,000,000 172.14
80 0 1,000,000 177.31
81 0 1,000,000 182.64
82 0 1,000,000 188.13
83 0 1,000,000 193.77
84 0 1,000,000 199.59
85 0 1,000,000 205.58
86 0 1,000,000 211.75
  87+ 0 1,000,000 0]

 

R15SIR SP Page [5]


POLICY NUMBER: [VF99999990]

POLICY SPECIFICATIONS

[Table of Scheduled Increases

Surrender Charges as of Start of Policy Year

 

Insured:                                   [JOHN DOE]

 

  For Each Scheduled Increase First
Effective In The Policy Year Shown
Totals For All Scheduled Increases That Have
Become Effective By The Policy Year Shown

Policy

Year

Surrender

Charge

Surrender

Charge

Reduction

Factor

[1 $0.00 $0.00 $0.00
2 2,784.75 2,784.75 $0.00
3 2,784.75 5,569.50 1,392.38
4 2,784.75 6,961.87 1,531.62
5 2,784.75 8,215.00 1,670.86
6 2,784.75 9,328.89 1,784.24
7 2,784.75 10,329.40 1,923.48
8 2,784.75 11,190.67 2,062.32
9 2,784.75 11,913.10 2,340.79
10 2,784.75 12,357.06 2,619.26
11 2,784.75 12,522.55 2,784.75
12 0 9,737.80 2,784.75
13 0 6,953.05 1,392.37
14 0 5,560.68 1,253.13
15 0 4,307.55 1,113.89
16 0 3,193.66 1,000.51
17 0 2,193.15 861.27
18 0 1,331.88 722.43
19 0 609.45 443.96
20 0 165.49 165.49
21+ 0 0.00 0.00]]

 

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