VALLEY FORGE LIFE INSURANCE COMPANY
Executive Office: A Stock Company Home Office:
CNA Plaza 401 Penn St.
Chicago, Illinois 60685 Reading, Pennsylvania 19601
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ADDITIONAL INSURANCE RIDER
This rider forms a part of the policy to which it is attached. It is issued in
consideration of your application and premium paid.
BENEFIT
We will pay the Additional Insurance death benefit as soon as we receive due
written proof of the Insured's death. The additional insurance death benefit
will be the Additional Insurance specified amount shown in the Schedule less the
excess, if any, of (1) over (2) or (3), where:
(1) is the cash value on the date of death times the applicable percentage of
cash value shown on the Policy Schedule;
(2) is the specified amount, if Death Benefit Option 1 is shown on the Policy
Schedule; and
(3) is the specified amount plus the cash value, if Death Benefit Option 2 is
shown on the Policy Schedule.
PREMIUM
The premium for this rider is determined as (1) times (2) where:
(1) is the Additional Insurance death benefit; and
(2) is the monthly cost of insurance rate on the monthly date.
The monthly cost of insurance rate is based upon the sex, age nearest birthday
and rate class of the Insured. We may charge less than, but not more than, the
maximum guaranteed monthly cost of insurance rates shown in the Policy Schedule.
The rate we will charge will be determined by us on each policy anniversary and
will apply for the succeeding policy year.
CHANGE OF BENEFITS
The Additional Insurance face amount may be changed any time after this rider is
one year old by written notice to us. The following conditions may apply to any
change:
(1) The Additional Insurance specified amount may not be less than $25,000.
(2) Any increase requires proof of insurability satisfactory to us.
(3) Any change will become effective on the monthly date after we approve the
change.
(4) Changed benefits will be shown on a Supplemental Policy Schedule.
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BENEFICIARY
Unless the owner gives us written notice, the beneficiary is the beneficiary of
the base policy.
OWNERSHIP
The owner of this policy is the owner of this rider.
TERMINATION
This rider terminates:
(1) when the owner gives written notice to terminate it; or
(2) when the policy terminates; or
(3) on the policy anniversary on or next following the Insured's 95th birthday.
This rider may be reinstated as part of the policy if the policy is reinstated.
GENERAL
All provisions of the policy not in conflict with this rider apply to this
rider. If this rider is issued with the policy, its effective date is the policy
date shown on the Policy Schedule. If this rider is issued after the policy
date, or if coverage is increased, decreased or reinstated, its effective date
is shown in a Supplemental Policy Schedule.
Signed for the Company at its Executive Office in Chicago, Illinois.
/s/BERNARD L. HENGESBAUGH /s/DAVID L. STONE
Chief Executive Officer Group Vice President
VULR-103 (6/99)
