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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OTHER INSURED TERM 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 Other Insured specified amount shown in the Schedule as soon as
we receive written proof of the Other Insured's death.
OTHER INSURED
Unless changed, the Other Insured is the individual named in the application for
this rider.
PREMIUM
The premium for this rider is determined as (1) times (2) where:
(1) is the Other Insured specified amount; and
(2) is the monthly cost of insurance rate on the monthly date.
The monthly cost of insurance rate is based on the sex, age nearest birthday and
rate classification of the Other Insured. We can charge less than, but not more
than, the maximum guaranteed mortality risk charge rates shown in the Schedule.
We determine the rate we will charge on each policy anniversary. This rate will
apply for the succeeding policy year.
CHANGE OF BENEFITS
The Other Insured face amount may be changed any time after this rider is one
year old by written notice to us. These conditions apply to any change in
coverage:
(1) The Other Insured specified amount may not be less than $50,000.
(2) Any increase requires proof of insurability satisfactory to us.
(3) Any approved change will become effective on the monthly date after we
receive written notice.
(4) Changed benefits will be shown on a Supplemental Schedule.
CONVERSION
On written request from the owner prior to the Other Insured's 65th birthday,
the Other Insured may convert to a permanent plan of insurance then available
from us at the Other Insured's then attained age. The amount converted may be no
greater than the Other Insured specified amount. No proof of insurability will
be required for the conversion policy, except for any benefits added by rider.
BENEFICIARY
Unless you give us written notice, the beneficiary is the Other Insured's
estate.
OWNERSHIP
The owner of this policy is the owner of this rider.
TERMINATION
This rider terminates on the earliest of:
(1) the policy date on or next following the Other Insured's 70th birthday;
(2) the date you give us written notice to terminate it; or
(3) the date the policy terminates.
This rider may be reinstated as part of the policy if the policy is reinstated
unless this rider was terminated because of age or by written notice. Proof of
the Other Insured's insurability may be required for reinstatement.
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 issue date is the issue date
shown on the Policy Schedule. If this rider is effective after the policy issue
date, or if coverage is increased, decreased or reinstated, it's the rider issue
date is shown in a Supplemental Policy Schedule.
Signed for the Company at its Executive Office, CNA Plaza, Chicago, Illinois
60685.
/s/BERNARD L. HENGESBAUGH /s/DAVID L. STONE
Chief Executive Officer Group Vice President
VULR-106 (8/99)
