Cova Financial Life Insurance Company
4100 Newport Place Drive, Suite 840
Newport Beach, CA 92600
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WAIVER OF WITHDRAWAL CHARGE FOR NURSING HOME
OR HOSPITAL CONFINEMENT RIDER
This Rider forms a part of the Contract to which it is attached and is effective
as of the Issue Date. In the case of a conflict with any provision in the
Contract, the provisions of this Rider will control.
After the first Contract Anniversary, the Withdrawal Charge will be waived upon
a withdrawal if:
1. you are confined to a Nursing Home and/or Hospital for at least 90
consecutive days or confined for a total of at least 90 days if there is no
more than a 6-month break in the confinement and the confinements are for
related causes;
2. the confinement referred to in (1) above begins on or after the first
Contract Anniversary;
3. the withdrawal request and proof satisfactory to us of confinement are
received by us at our Annuity Service Office either while you are confined
or within 90 days after such confinement;
4. confinement in a Nursing Home and/or Hospital is prescribed by a Physician
and is Medically Necessary; and
5. you have been the Owner continuously since the Issue Date, or have become
the Owner as spousal Beneficiary who continues the Contract.
In the case of Joint Owners, this Rider applies to either Joint Owner. If the
Owner is not a natural person, this Rider applies to the Annuitant.
DEFINITIONS
Hospital -- A facility which:
(1) is located in the United States or its territories;
(2) is licensed as a hospital by the jurisdiction in which it is located;
(3) is supervised by a staff of licensed physicians;
(4) provides nursing services 24 hours a day by, or under the supervision of, a
registered nurse (R.N.);
(5) operates primarily for the care and treatment of sick and injured persons
as inpatients for a charge; and
(6) has access to medical and diagnostic facilities.
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Intermediate Care Facility -- A facility which:
(1) is located in the United States;
(2) is licensed and operated as an Intermediate Care Facility according to the
laws of the jurisdiction in which it is located;
(3) provides continuous 24 hours a day nursing service by, or under the
supervision of, a registered nurse (R.N.) or a licensed practical nurse
(L.P.N.); and
(4) maintains a daily medical record of each patient.
Medically Necessary -- Appropriate and consistent with the diagnosis in accord
with accepted standards of practice and which could not have been omitted
without affecting the individual's condition.
Nursing Home -- A facility which is a Skilled Nursing Facility, an Intermediate
Care Facility or Residential Care Facility. Nursing Home does not mean:
(1) a home for the aged, a community living center or place that primarily
provides domiciliary, residency or retirement care; or
(2) a place owned or operated by a member of the Owner's immediate family.
Immediate family members include the Owner's spouse, children, parents,
grandparents, grandchildren, siblings and in-laws.
Physician -- Any person duly licensed and legally qualified to diagnose and
treat sickness and injuries. A physician must be providing services within the
scope of his or her license. A Physician may not be a member of the Owner's
immediate family.
Residential Care Facility -- A facility which:
(1) is located in the United States or its territories;
(2) is licensed and operated as a Residential Care Facility according to the
laws of the jurisdiction in which it is located; and
(3) provides nursing care under the supervision of a registered nurse (R.N.).
Skilled Nursing Facility -- A facility which:
(1) is located in the United States or its territories;
(2) is licensed and operated as a Skilled Nursing Facility according to the
laws of the jurisdiction in which it is located;
(3) provides skilled nursing care under the supervision of a licensed
physician;
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(4) provides continuous 24 hours a day nursing services by, or under the
supervision of, a registered nurse (R.N.); and
(5) maintains a daily medical record of each patient.
This Rider will terminate on the Annuity Date.
Cova Financial Life Insurance Company has caused this Rider to be signed by its
President and Secretary.
Form 7021 (11/00)
