============================== Exhibit (d)(4)================================
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THE NORTHWESTERN MUTUAL LIFE INSURANCE COMPANY AGREES TO PAY THE
BENEFITS PROVIDED IN THIS POLICY, SUBJECT TO ITS TERMS AND CONDITIONS.
SIGNED AT MILWAUKEE, WISCONSIN ON THE DATE OF ISSUE.
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SPECIMEN COPY
/s/ ▇.▇. ▇▇▇▇▇▇▇▇ /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇
CHAIRMAN SECRETARY
SINGLE PREMIUM VARIABLE WHOLE LIFE POLICY
ELIGIBLE FOR ANNUAL DIVIDENDS
Insurance payable at death of Insured.
Benefits reflect investment results.
Variable benefits described in Sections 4 through 8.
The Death Benefit for the first policy year will be the Face Amount shown on
page 3, less any policy debt. The Death Benefit after that may increase or
decrease on each policy anniversary depending on investment results. However,
the Death Benefit will not be less than the Face Amount shown on page 3, less
any policy debt.
The cash value under this policy may increase or decrease daily depending on
investment results. There is no guaranteed minimum cash value.
RIGHT TO RETURN POLICY - Please read this policy carefully. The policy may be
returned by the Owner for any reason within (1) ten days after it was received
or (2) forty-five days after the application was signed, whichever is later. The
policy may be returned to your agent or to the Home Office of the Company at ▇▇▇
▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇. If returned, the policy will be
considered void from the beginning. Any premium paid will then be refunded.
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▇▇▇▇ MUTUAL LIFE(R)
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THIS POLICY IS A LEGAL CONTRACT BETWEEN THE OWNER AND THE
NORTHWESTERN MUTUAL LIFE INSURANCE COMPANY.
READ YOUR POLICY CAREFULLY.
GUIDE TO POLICY PROVISIONS
PAGE
BENEFITS AND PREMIUM 3
SECTION 1. THE CONTRACT 5
Life Insurance Benefit payable on death of Insured.
Incontestability. Suicide. Definition of dates.
Misstatement of age.
SECTION 2. OWNERSHIP 5
Rights of the Owner. Assignment as collateral.
SECTION 3. DIVIDENDS 6
Annual dividends. Paid-up additions and other uses of
dividends. Dividend at death.
SECTION 4. THE SEPARATE ACCOUNT 6
The Separate Account and the Investment Divisions.
SECTION 5. ALLOCATIONS OF PREMIUM; TRANSFER OF ASSETS 7
SECTION 6. DETERMINATION OF VALUES 7
How variable life insurance works. Investment Bases.
SECTION 7. DEATH BENEFIT 8
Determination of Death Benefit.
Variable Insurance Amount.
SECTION 8. CASH VALUE 9
Cash value. Basis of values.
SECTION 9. LOANS 10
Policy loans. Effect of policy debt. Interest on loans.
SECTION 10. EXCHANGE OF POLICY 10
SECTION 11. BENEFICIARIES 11
Naming and change of beneficiaries.
Marital deduction provision for spouse of Insured.
Succession in interest of beneficiaries.
SECTION 12. PAYMENT OF POLICY BENEFITS 12
Payment of surrender or death proceeds.
Payment plans for policy proceeds.
Right to increase income under payment plan.
Guaranteed payment tables.
APPLICATION Attached to the policy
MM 16
BENEFITS AND PREMIUMS
DATE OF ISSUE - JULY 1, 1985
FACE SINGLE
PLAN AND ADDITIONAL BENEFITS AMOUNT PREMIUM
SINGLE PREMIUM
VARIABLE WHOLE LIFE $ 100,000 $ 24,593.00
THE ALLOCATION OF THE NET PREMIUM OF $24,443.00 ON THE POLICY DATE IS:
MONEY MARKET DIVISION 40%
BOND DIVISION 20%
STOCK DIVISION 20%
MASTER DIVISION 20%
THIS POLICY IS ISSUED IN A SELECT PREMIUM CLASS.
DIRECT BENEFICIARY ▇▇▇▇ ▇ ▇▇▇, WIFE OF THE INSURED
OWNER ▇▇▇▇ ▇ ▇▇▇, THE INSURED
INSURED ▇▇▇▇ ▇ ▇▇▇ AGE AND SEX 35 MALE
POLICY DATE JULY 1, 1985 POLICY NUMBER VL 1 700 017
PLAN SINGLE PREMIUM FACE AMOUNT $ 100,000
VARIABLE WHOLE LIFE
MP 16 PAGE 3
TABLE OF VALUES
(ACTUAL CASH VALUES ARE NOT GUARANTEED. THEY MAY BE LARGER OR SMALLER
THAN VALUES SHOWN. SEE SECTION 8.1.)
ADJUSTED
END OF TABULAR TABULAR
POLICY CASH CASH
YEAR JULY 1, VALUES VALUES
1 1986 $25,266 $23,265
2 1987 26,114 24,261
3 1988 26,987 25,297
4 1989 27,883 26,373
5 1990 28,802 27,491
6 1991 29,745 28,652
7 1992 30,709 29,855
8 1993 31,697 31,103
9 1994 32,707 32,398
10 1995 33,742 33,742
11 1996 34,800 34,800
12 1997 35,881 35,881
13 1998 36,986 36,986
14 1999 38,118 38,118
15 2000 39,273 39,273
16 2001 40,453 40,453
17 2002 41,655 41,655
18 2003 42,877 42,877
19 2004 44,119 44,119
20 2005 45,376 45,376
AGE 60 2010 51,915 51,915
AGE 65 2015 58,806 58,806
AGE 70 2020 65,742 65,742
TABULAR CASH VALUES DO NOT REFLECT THE CASH VALUE OF ANY VARIABLE INSURANCE
AMOUNT OR PAID UP ADDITIONS AND DIVIDEND ACCUMULATIONS OR THE AMOUNT OF POLICY
DEBT.
THE CASH VALUE OF THIS POLICY INCREASES AND DECREASES TO REFLECT THE INVESTMENT
EXPERIENCE OF THE SEPARATE ACCOUNT. THERE IS NO GUARANTEED MINIMUM CASH VALUE.
INSURED ▇▇▇▇ ▇ ▇▇▇ AGE AND SEX 35 MALE
POLICY DATE JULY 1, 1985 POLICY NUMBER VL 1 600 016
PLAN SINGLE PREMIUM FACE AMOUNT $ 100,000
VARIABLE WHOLE LIFE
MP 16 PAGE 4
TABLE OF NET SINGLE PREMIUMS
FOR $1.00 OF VARIABLE INSURANCE AMOUNT OR FIXED BENEFIT
OR VARIABLE BENEFIT PAID-UP INSURANCE
END OF NET SINGLE END OF NET SINGLE
POLICY YEAR JULY 1, PREMIUM POLICY YEAR JULY 1, PREMIUM
0 1985 $.24443
1 1986 .25266 36 2021 $ .67131
2 1987 .26114 37 2022 .68513
3 1988 .26987 38 2023 .69878
4 1989 .27883 39 2024 .71216
5 1990 .28802 40 2025 .72522
6 1991 .29745 41 2026 .73792
7 1992 .30709 42 2027 .75028
8 1993 .31697 43 2028 .76234
9 1994 .32707 44 2029 .77417
10 1995 .33742 45 2030 .78581
11 1996 .34800 46 2031 .79725
12 1997 .35881 47 2032 .80843
13 1998 .36986 48 2033 .81926
14 1999 .38118 49 2034 .82966
15 2000 .39273 50 2035 .83956
16 2001 .40453 51 2036 .84899
17 2002 .41655 52 2037 .85799
18 2003 .42877 53 2038 .86665
19 2004 .44119 54 2039 .87507
20 2005 .45376 55 2040 .88338
21 2006 .46650 56 2041 .89175
22 2007 .47939 57 2042 .90034
23 2008 .49246 58 2043 .90938
24 2009 .50571 59 2044 .91918
25 2010 .51915 60 2045 .92990
26 2011 .53274 61 2046 .94171
27 2012 .54648 62 2047 .95448
28 2013 .56031 63 2048 .96770
29 2014 .57418 64 2049 .98062
30 2015 .58806 65 2050 1.0000
31 2016 .60192
32 2017 .61578
33 2018 .62963
34 2019 .64352
35 2020 .65742
INSURED ▇▇▇▇ ▇ ▇▇▇ AGE AND SEX 35 MALE
POLICY DATE JULY 1, 1985 POLICY NUMBER VL 1 600 016
PLAN SINGLE PREMIUM FACE AMOUNT $ 100,000
VARIABLE WHOLE LIFE
MP 16 PAGE 4A
SECTION 1. THE CONTRACT
1.1 LIFE INSURANCE BENEFIT
The Northwestern Mutual Life Insurance Company will pay a benefit on the
death of the Insured. Subject to the terms and conditions of the policy:
- payment of the Death Benefit determined under Section 7 will be made
after proof of the death of the Insured is received at the Home Office;
and
- payment will be made to the beneficiary or other payee under Sections 11
and 12.
1.2 ENTIRE CONTRACT; CHANGES
This policy with the attached application is the entire contract.
Statements in the application are representations and not warranties. A change
in the policy is valid only if it is approved by an officer of the Company. The
Company may require that the policy be sent to it for endorsement to show a
change. No agent has the authority to change the policy or to waive any its
terms.
1.3 INCONTESTABILITY
The Company will not contest this policy after it has been in force during
the lifetime of the Insured for two years from the Date of Issue. In issuing the
policy, the Company has relied on the application. While the policy is
contestable, the Company, on the basis of the misstatement in the application,
may rescind the policy or deny a claim.
1.4 SUICIDE
If the Insured dies by suicide within one year from the Date of Issue, the
amount payable by the Company will be limited to the premium paid.
1.5 DATES
The contestable and suicide periods begin with the Date of Issue. Policy
months, years and anniversaries are computed from the Policy Date. Both dates
are shown on page 3.
1.6 MISSTATEMENT OF AGE
If the age of the Insured has been misstated, the amount payable will be
the amount which the premium paid would have purchased at the correct age.
1.7 PAYMENTS BY THE COMPANY
All payments by the Company under this policy are payable at its Home
Office.
SECTION 2. OWNERSHIP
2.1 THE OWNER
The Owner is named on page 3. All policy rights may be exercised by the
Owner, his successor or his transferee:
- without the consent of any beneficiary.
- while the Insured is living and, after his death, only as provided in
Sections 11 and 12.
2.2 TRANSFER OF OWNERSHIP
The Owner may transfer the ownership of this policy. Written proof of
transfer satisfactory to the Company must be received at its Home Office. The
transfer will then take effect as of the date it was signed. The Company may
require that the policy be sent to it for endorsement to show the transfer.
2.3 COLLATERAL ASSIGNMENT
The Owner may assign this policy as collateral security. The Company is not
responsible for the validity or effect of a collateral assignment. The Company
will not be responsible to an assignee for any payment or other action taken by
the Company before receipt of the assignment in writing at its Home Office.
The interest of any beneficiary will be subject to any collateral
assignment made either before or after the beneficiary in named.
A collateral assignee is not an Owner. A collateral assignment is not a
transfer of ownership. Ownership can be transferred only by complying with
Section 2.2.
5
SECTION 3. DIVIDENDS
3.1 ANNUAL DIVIDENDS
This policy will share in the divisible surplus of the Company. This
surplus is determined each year. The policy's share will be credited as a
dividend on the policy anniversary.
3.2 USE OF DIVIDENDS
Dividends may be paid in cash or used for one of the following:
- VARIABLE BENEFIT PAID-UP ADDITIONS. Dividends will purchase variable
benefit paid-up additional insurance. Each dividend will be allocated
to the Divisions as provided in Section 5.1. Paid-up additions share
in the divisible surplus.
- DIVIDEND ACCUMULATIONS. Dividends will accumulate at interest.
Interest is credited at an annual effective rate of 3 1/2%. The
Company may set a higher rate.
Other uses of dividends may be made available by the Company.
If no direction is given for the use of dividends, they will purchase
paid-up additions.
3.3 ADDITIONS AND ACCUMULATIONS
Paid-up additions and dividend accumulations increase the policy's cash
value. They are payable as part of the policy's proceeds. The cash value of
variable benefit paid-up additions will vary daily, and the death benefit
annually. However, there is not a minimum guaranteed death benefit for variable
benefit paid-up additions.
Additions may be surrendered and accumulations may be withdrawn unless they
are used for a loan.
3.4 DIVIDEND AT DEATH
A dividend for the period from the beginning of the policy year to the date
of the Insured's death will be payable as part of the policy proceeds.
SECTION 4. THE SEPARATE ACCOUNT
The Northwestern Mutual Variable Life Account (the Separate Account) has
been established by the Company pursuant to Wisconsin law and is registered as a
unit investment trust under the Investment Company Act of 1940.
The Separate Account has four Divisions--Stock Division, Bond Division,
Money Market Division and Master Division. Assets of the Separate Account are
invested in shares of Northwestern Mutual Variable Life Series Fund, Inc. (the
Fund). The Fund is registered under the Investment Company Act of 1940 as an
open-end, diversified management investment company. The Fund has four
Portfolios--Stock Portfolio, Bond Portfolio, Money Market Portfolio and Master
Portfolio. Assets of each Division of the Separate Account are invested in
shares of the corresponding Portfolio of the Fund. Shares of the Fund are
purchased for the Separate Account at their net asset value.
Assets will be allocated to the Separate Account to support the operation
of this policy and other variable life insurance policies. Assets may also be
allocated for other purposes, but not to support the operation of any contracts
or policies other than variable life insurance. Income and realized and
unrealized gains and losses from assets in the Separate Account are credited to
or charged against it without regard to other income, gains or losses of the
Company.
The assets of the Separate Account will be valued on each business day.
They are the property of the Company. The portion of these assets equal to
policy reserves and liabilities will not be charged with liabilities arising out
of any other business the Company may conduct. The Company reserves the right to
transfer assets of the Separate Account in excess of these reserves and
liabilities to its General Account.
The Owner may exchange this policy for a fixed benefit life insurance
policy if the Fund changes its investment advisor or if a Portfolio has a
material change in its investment objectives or restrictions. The Company will
notify the Owner if there is any such change. The Owner may exchange this policy
within 60 days after the notice or the effective date of the change, whichever
is later.
If, in the judgment of the Company, a Portfolio no longer suits the
purposes of this policy due to a change in its investment objectives or
restrictions, the Company may substitute shares of another portfolio of the Fund
or shares of another mutual fund. Any such substitution will be subject to any
required approval of the Securities and Exchange Commission (SEC), the Wisconsin
Commissioner of Insurance or other regulatory authority.
The Company also may, to the extent permitted by applicable laws and
regulations (including any order of the SEC), make changes as follows;
- the Separate Account or a Division may be operated as a management
company under the Investment Company Act of 1940, or in any other form
permitted by law, if deemed by the Company to be in the best interest
of the policyowners.
- the Separate Account may be deregistered under the Investment Company
Act of 1940 in the event registration is no longer required.
- the provisions of this and other policies may be modified to comply
with any other applicable federal or state laws.
In the event of a substitution or change, the Company may make appropriate
endorsement on this and other policies having an interest in the Separate
Account and take other actions as may be necessary to effect the substitution or
change.
MM 16 6
SECTION 5. ALLOCATION OF PREMIUM; TRANSFER OF ASSETS
5.1 ALLOCATION OF NET PREMIUM AND DIVIDENDS
The net premium paid for this policy will be allocated to the Divisions as
shown on page 3. This allocation will also apply to dividends used to purchase
variable benefit paid-up additions, unless the allocation is changed by the
Owner. The Owner may change the allocation, but the change will not take effect
until the first policy anniversary following receipt of a written request at the
Home Office. Allocations must be in whole percentages. If a Division is to
receive any allocations, the allocation must be at least 10% of the dividend.
5.2 TRANSFER OF ASSETS
The Owner may transfer the assets (other than policy debt) supporting the
policy to any of the Divisions. Transfers may be made as often as four times in
a policy year.
The transfer will take effect on the date a written request is received in
the Home Office. A fee may be required.
SECTION 6. DETERMINATION OF VALUES
6.1 HOW VARIABLE LIFE INSURANCE WORKS
The Death Benefit and cash value provided by this policy are derived from
the net premium credited to the Separate Account and the investment earnings it
generates. These earnings determine a Rate of Return. The Rate of Return can be
either positive or negative because it includes capital gains and losses (both
realized and unrealized), as well as earnings from dividends and interest.
If the Rate of Return were to equal 4% each and every year, the policy's
cash value each year would equal the value for that year shown in the table of
Adjusted Tabular Cash Values on page 4. Likewise, the Death Benefit would always
equal the Face Amount shown on page 3. This is because 4% is the earnings rate
the Company assumed when it calculated the net premium.
If the Rate of Return in a given year is greater than 4%, the earnings in
excess of 4% are converted to paid-up variable life insurance. If the Rate of
Return in a given year is less than 4% the result is negative paid-up variable
life insurance. The total amount of paid-up variable life insurance is called
the Variable Insurance Amount.
The Variable Insurance Amount is zero during the first policy year. On each
policy anniversary, the positive (or negative) paid-up variable life insurance
is added to (or subtracted from) the Variable Insurance Amount for the prior
year. If the resulting Variable Insurance Amount is positive, the policy's cash
value and Death Benefit on the policy anniversary will be greater than the
amounts shown on pages 3 and 4. On the other hand, if the Variable Insurance
Amount is negative, the policy's cash value on the policy anniversary will be
less than the Adjusted Tabular Cash Value shown on page 4. The Death Benefit,
however, will be equal to the Face Amount shown on page 3, since that is the
minimum death benefit, unless there is policy debt.
In this policy, amounts used in calculations may be negative. When a
negative amount is added, the result is the same as if the corresponding
positive amount had been subtracted.
6.2 VALUATION PERIOD
Each business day, together with any non-business day or consecutive
non-business days immediately preceding it, will constitute a valuation period.
A business day is any day on which the New York Stock Exchange is open for
trading.
6.3 NET INVESTMENT FACTOR
The Net Investment Factor for a valuation period for a particular Division
is obtained by dividing (a) by (b) and then subtracting (c) where:
(a) is: - the value of a Fund share in the corresponding Portfolio at the close
of the current valuation period; plus
- the per share amount of any investment income and capital gains
distributed by the Fund for the current valuation period; minus
- any amount per share charged against the Division in the valuation
period for taxes.
(b) is: the value of the share at the close of business of the preceding
valuation period.
(c) is: a charge not exceeding .00001367 for each day in the valuation
period. This is the equivalent of a charge not exceeding .50% per
year for mortality and expense risks and other contingencies.
6.4 DIVISION INDEX
The Division Index for the valuation period which included the first day on
which there were assets in the Division was 1.000000. The Index for each
subsequent valuation period is the Division Index for the immediately preceding
valuation period multiplied by the Net Investment Factor for the subsequent
valuation period. The Index for a valuation period applies to each day in that
period.
6.5 RATE OF RETURN
The Rate of Return for a Division is equal to the change in the Division
Index over the applicable period divided by the Division Index at the beginning
of such period.
The Rate of Return for policy debt is the interest earned on one dollar
over the applicable period, assuming an annual effective interest rate
equivalent to the policy loan interest rate or rates in effect during that
period, less a charge by the Company for expenses and taxes.
MM 16 7
6.6 INVESTMENT ADJUSTMENT RATE
The Investment Adjustment Rate for a Division or policy debt is equal to
its Rate of Return less the interest earned on one dollar over the applicable
period assuming an annual effective rate of 4%. The Investment Adjustment Rate
for a Division may be positive or negative.
6.7 INVESTMENT ADJUSTMENT
The Investment Adjustment for each Investment Base is equal to (a) the
Investment Adjustment Rate for the corresponding Division multiplied by the
average Investment Base plus (b) the Investment Adjustment Rate for policy debt
multiplied by the average amount of policy debt allocated to the Investment
Base.
6.8 INTERIM VALUE ADJUSTMENT
The Interim Value Adjustment is the accumulation of all Investment
Adjustments made during the period for which the Interim Value Adjustment is
calculated. On each policy anniversary it is applied as a Net Single Premium to
increase (or decrease) the Variable Insurance Amount. However, any Interim Value
Adjustment attributable to variable benefit paid-up additions is applied as a
Net Single Premium to increase (or decrease) such additions.
6.9 INVESTMENT BASES
The Investment Bases will be determined at the end of each policy year and
at any other time it is necessary to recognize requests by the Owner for
transfer of assets, policy loan increases or repayments, or other transactions
concerning policy values.
The Investment Base in a Division is:
- its portion of the current Tabular Cash Value; plus
- its portion of the current Net Single Premium for the Variable
Insurance Amount in effect; plus
- its portion of the current Net Single Premium for the amount of
variable benefit paid-up additions; plus
- its contribution to the current Interim Value Adjustment; less
- its portion of the current policy debt. Policy debt and repayments will
be allocated in proportion to the sum of the current Tabular Cash Value,
current Net Single Premiums and current Interim Value Adjustment in each
Investment Base.
SECTION 7. DEATH BENEFIT
7.1 BENEFIT
The Death Benefit will equal:
- the minimum death benefit; less
- any policy debt; plus
- any positive Variable Insurance Amount; plus
- the amount of variable benefit paid-up additions; plus
- the amount of any dividend accumulations and any dividend at death.
The minimum death benefit is the Face Amount shown on page 3. All values will be
determined as of the date of death.
7.2 VARIABLE INSURANCE AMOUNT
The Company will determine at the beginning of each policy year the
Variable Insurance Amount for that year. It remains at a constant amount during
the year and may be positive or negative. It is zero during the first policy
year.
The Variable Insurance Amount for a policy year is the sum of the Variable
Insurance Amount for the past year plus the amount of paid-up variable life
insurance as determined on the policy anniversary. The amount of paid-up
variable life insurance, which may be positive or negative, is determined by
dividing (a) by (b) where:
(a) equals the Interim Value Adjustment for the past policy year, less
that portion of the Interim Value Adjustment attributable to
additions. (see Section 7.3)
(b) equals the Net Single Premium per $1.00 of Variable Insurance Amount
at the end of the policy year.
7.3 VARIABLE BENEFIT PAID-UP ADDITIONS
If variable benefit paid-up additions have been purchased by dividends,
the Company will determine at the beginning of each policy year the amount of
insurance provided by the additions for that year. The amount of such insurance
for a policy year is the sum of the amount for the past year plus an additional
amount determined on the policy anniversary. The additional amount, which may be
positive or negative, is determined by dividing (a) by (b) where:
(a) equals the sum of the portion of Interim Value Adjustment
attributable to existing additions and the amount of the current
dividend to be used to purchase additions.
(b) equals the Net Single Premium per $1.00 of Variable Insurance Amount
at the end of the policy year.
The amount of insurance provided by dividends remains constant during the
year, unless additions are surrendered.
MM16 8
SECTION 8. CASH VALUE
8.1 CASH VALUE
The cash value on any date will be equal to the sum of:
- the current Adjusted Tabular Cash Value; plus
- the current Net Single Premium for the Variable Insurance Amount; plus
- the current Net Single Premium for the amount of variable benefit
paid-up additions; plus
- the current Interim Value Adjustment; plus
- the current amount of dividend accumulations; less
- the current policy debt.
8.2 SURRENDER
The Owner may surrender this policy for its cash value. A written surrender
of all claims, satisfactory to the Company, will be required. The date of
surrender will be the date of receipt at the Home Office of the written
surrender. The policy will terminate, and the cash value will be determined, as
of the end of the last valuation period prior to the date of surrender. The
Company may require that the policy be sent to it.
8.3 DEFERRAL OF PAYMENTS
During any period when:
- the sale of securities or the determination of a Division Index is not
reasonably practicable because
(i) the New York Stock Exchange is closed, or
(ii) conditions are such that, under rules and regulations adopted by
the SEC, trading is deemed to be restricted or an emergency is
deemed to exist, or
- the SEC, by order, permits deferral for the protection of the Company's
policyowners;
the Company reserves the right:
- to defer determination of cash values and payment of the cash value;
- to defer payment of a loan;
- to defer determination of a change in the Variable Insurance Amount or
other variable amounts payable on death, and, if such determination has
been deferred, to defer payment of any portion of the Death Benefit
equal to the Variable Insurance Amount or such other variable amounts;
and
- if payment of all or part of the Death Benefit is deferred, to defer
application of the Death Benefit to a payment plan under Section 12.
8.4 TABULAR CASH VALUES
Tabular Cash Values and Adjusted Tabular Cash Values are shown on page 4
for the end of the policy years indicated. They do not reflect the cash value of
any Variable Insurance Amount, amounts resulting from dividends or policy debt.
Tabular Cash Values and Adjusted Tabular Cash Values during a policy year will
reflect time elapsed in that year.
Values for policy years not shown are calculated on the same basis as those
on page 4. A list of these values will be furnished on request. All values are
at least as great as those required by the state in which this policy is
delivered.
8.5 BASIS OF VALUES
Tabular Cash Values are the reserves for the Face Amount. These and the Net
Single Premiums are based on the Commissioners 1980 Standard Ordinary Mortality
Table-B. Interest is based on an annual effective rate of 4%.
Adjusted Tabular Cash Values are based on the Commissioners 1980 Standard
Ordinary Mortality Table-B. Interest is based on an annual effective rate of:
- 5% for the first 10 policy years, and
- 4% after that.
All calculations assume the immediate payment of claims.
MP 16 9
SECTION 9. LOANS
9.1 POLICY LOANS
The Owner may obtain a loan from the Company in an amount that, when added
to existing policy debt, is not more than the loan value. The making of a policy
loan will have a permanent effect on the cash values and the Death Benefit
payable under the policy. Loans will decrease and repayments will increase the
Investment Bases as described in Section 6.9.
The loan may be obtained on written request.
9.2 LOAN VALUE
The loan value in the first two policy years is 75% of the sum of the cash
value and any existing policy debt on the date of the loan. The loan value after
that is 90% of the sum of the cash value and any existing policy debt on
the date of the loan.
9.3 POLICY DEBT
Policy debt consists of all outstanding loans and accrued interest. It may
be paid to the Company at any time. Any policy debt will be deducted from the
policy proceeds.
If the cash value decreases to zero, this policy will terminate unless a
sufficient portion of the policy debt is repaid. Termination occurs 31 days
after a notice has been mailed to the Owner and to any assignee on record at the
Home Office. The notice will state the amount that must be repaid to keep the
policy in force.
9.4 LOAN INTEREST
The Specified Rate loan interest option or the Variable Rate loan interest
option is elected on the application. The Owner may change this election at any
time, but the change will not take effect until the January 1st following
receipt of a written request at the Company's Home Office.
Interest accrues and is payable on a daily basis from the date of the loan.
Unpaid interest is added to the loan.
9.5 SPECIFIED RATE LOAN INTEREST OPTION
Interest is payable at an annual effective rate of 8%.
9.6 VARIABLE RATE LOAN INTEREST OPTION
Interest is payable at an annual effective rate that is set by the Company
annually and applied to new or outstanding policy debt during the year beginning
each January 1. The highest loan interest rate that may be set by the Company is
the greater of 5% or a rate based on the Moody's Corporate Bond Yield
averages--Monthly Average Corporates for the immediately preceding October. This
Average is published by ▇▇▇▇▇'▇ Investors Service, Inc. If it is no longer
published, the highest loan interest rate will be based on some other similar
average established by the insurance supervisory official of the state in which
this policy is delivered.
The loan interest rate set by the Company will not exceed the maximum rate
permitted by the laws of the state in which this policy is delivered. The loan
interest rate may be increased only if the increase in the annual effective rate
is at least 1/2%. The loan interest rate will be decreased if the decrease in
the annual effective rate is at least 1/2%.
SECTION 10. EXCHANGE OF POLICY
Within 24 months after the Date of Issue shown on page 3, the Owner may
exchange this policy without evidence of insurability for a similar fixed
benefit life insurance policy issued by the Company on the life of the Insured.
To effect the change the Owner must send this policy, a completed
application for change, and any required payment to the Home Office of the
Company. The change will be effective on the later of the date of the
application or the date the required items are received at the Home Office.
The new policy will have the same face amount, policy date and issue age as
this one, and the cash values will be the same as those for policies issued on
the Date of Issue of this policy.
MM 16 10
SECTION 11. BENEFICIARIES
11.1 DEFINITIONS OF BENEFICIARIES
The term "beneficiaries" as used in this policy includes direct
beneficiaries, contingent beneficiaries and further payees.
11.2 NAMING AND CHANGE OF BENEFICIARIES
BY OWNER. The Owner may name and change the beneficiaries of death proceeds:
- while the Insured is living.
- during the first 60 days after the date of death of the Insured, if the
Insured just before his death was not the Owner. No one may change this
naming of a direct beneficiary during this 60 days.
BY DIRECT BENEFICIARY. A direct beneficiary may name and change the contingent
beneficiaries and further payees of his share of the proceeds:
- if the direct beneficiary is the Owner;
- if, at any time after the death of the Insured, no contingent
beneficiary or further payee of that share is living; or
- if, after the death of the Insured, the direct beneficiary elects a
payment plan. The interest of any other beneficiary in the share of that
direct beneficiary will end.
These direct beneficiary rights are subject to the Owner's rights during
the above 60 days.
BY SPOUSE (MARITAL DEDUCTION PROVISION).
- POWER TO APPOINT. The spouse of the Insured will have the power alone and
in all events to appoint all amounts payable to the spouse under the
policy if:
a. the Insured just before his death was the Owner; and
b. the spouse is a direct beneficiary; and
c. the spouse survives the Insured.
- TO WHOM SPOUSE CAN APPOINT. Under this power, the spouse can appoint:
a. to the estate of the spouse; or
b. to any other persons as contingent beneficiaries and further payees.
- EFFECT OF EXERCISE. As to the amounts appointed, the exercise of this
power will:
a. revoke any other designation of beneficiaries;
b. revoke any election of payment plan as it applies to them; and
c. cause any provision to the contrary in Section 11 or 12 of this
policy to be of no effect.
EFFECTIVE DATE. A naming or change of a beneficiary will be made on receipt at
the Home Office of a written request that is acceptable to the Company. The
request will then take effect as of the date that it was signed. The Company is
not responsible for any payment or other action that is taken by it before the
receipt of the request. The Company may require that the policy be sent to it to
be endorsed to show the naming or change.
11.3 SUCCESSION IN INTEREST OF BENEFICIARIES
DIRECT BENEFICIARIES. The proceeds of this policy will be payable in equal
shares to the direct beneficiaries who survive and receive payment. If a direct
beneficiary dies before he receives all or part of his full share, the unpaid
part of this share will be payable in equal shares to the other direct
beneficiaries who survive and receive payment.
CONTINGENT BENEFICIARIES. At the death of all of the direct beneficiaries, the
proceeds, or the present value of any unpaid payments under a payment plan, will
be payable in equal shares to the contingent beneficiaries who survive and
receive payment. If a contingent beneficiary dies before he receives all or part
of his full share, the unpaid part of his share will be payable in equal shares
to the other contingent beneficiaries who survive and receive payment.
FURTHER PAYEES. At the death of all of the direct and contingent beneficiaries,
the proceeds, or the present value of any unpaid payments under a payment plan,
will be paid in one sum:
- in equal shares to the further payees who survive and receive payment; or
- if no further payees survive and receive payment, to the estate of the
last to die of all of the direct and contingent beneficiaries.
OWNER OR HIS ESTATE. If no beneficiaries are alive when the Insured dies, the
proceeds will be paid to the Owner or to his estate.
11.4 GENERAL
TRANSFER OF OWNERSHIP. A transfer of ownership of itself will not change the
interest of a beneficiary.
CLAIMS OF CREDITORS. So far as allowed by law, no amount payable under this
policy will be subject to the claims of creditors of a beneficiary
SUCCESSION UNDER PAYMENT PLANS. A direct or contingent beneficiary who succeeds
to an interest in a payment plan will continue under the terms of the plan.
MM16 11
SECTION 12. PAYMENT OF POLICY BENEFITS
12.1 PAYMENT OF PROCEEDS
Proceeds that are payable due to the death of the Insured will be paid
under the payment plan that takes effect on the date of death. The Interest
Income Plan (Option A) will be in effect if no payment plan has been elected.
Interest will accumulate from the date of death until a payment plan is elected
or the proceeds are withdrawn in cash.
Proceeds from the surrender of this policy will be paid in cash or under a
payment plan that is elected.
12.2 PAYMENT PLANS
INTEREST INCOME PLAN (OPTION A). The proceeds will earn interest which may be
received each month or accumulated. The first payment is due one month after the
date on which the plan takes effect. Interest that has accumulated may be
withdrawn at any time. Part or all of the proceeds may be withdrawn at any time.
INSTALLMENT INCOME PLANS. Payments will be made each month on the terms of the
plan that is elected. The first payment is due on the date that the plan takes
effect.
- SPECIFIED PERIOD (OPTION B). The proceeds with interest will be paid
over a period of from one to 30 years. The present value of any unpaid
installments may be withdrawn at any time.
- SPECIFIED AMOUNT (OPTION D). Payments of not less than $10.00 per
$1,000 of proceeds will be made until all of the proceeds with
interest have been paid. The balance may be withdrawn at any time.
LIFE INCOME PLANS. Payments will be made each month on the terms of the plan
that is elected. The first payment is due on the date that the plan takes
effect. Proof of the date of birth, acceptable to the Company, must be furnished
for each person on whose life the payments are based.
- SINGLE LIFE INCOME (OPTION C). Payments will be made for a chosen
period and, after that, for the life of the person on whose life the
payments are based. The choices for the period are:
a. zero years;
b. 10 years;
c. 20 years; or
d. a refund period which continues until the sum of the payments
that have been made is equal to the proceeds that were placed
under the plan.
- JOINT AND SURVIVOR LIFE INCOME (OPTION E). Payments are based on the
lives of two persons. Level payments will be made for a period of 10
years and, after that, for as long as one or both of the persons are
living.
- OTHER SELECTIONS. The Company may offer other selections under the
Life Income Plans.
- WITHDRAWAL. The present value of any unpaid payments that are to be
made for the chosen period (Option C) or the 10 year period (Option E)
may be withdrawn only after the death of all of the persons on whose
lives the payments are based.
- LIMITATIONS. A direct or contingent beneficiary who is a natural
person may be paid under a Life Income Plan only if the payments
depend on his life. A corporation may be paid under a Life Income Plan
only if the payments depend on the life of the Insured or, after the
death of the Insured, on the life of his spouse or his dependent.
PAYMENT FREQUENCY. On request, payments will be made once every 3, 6 or 12
months instead of each month.
TRANSFER BETWEEN PAYMENT PLANS. A beneficiary who is receiving payment under a
plan which includes the right to withdraw may transfer the amount withdrawable
to any other plan that is available.
MINIMUM PAYMENT. The Company may limit the election of a payment plan to one
that results in payments of at least $50.
If payments under a payment plan are or become less than $50, the Company
may change the frequency of payments. If the payments are being made once every
12 months and are less than $50, the Company may pay the present value or the
balance of the payment plan.
12.3 PAYMENT PLAN RATES
INTEREST INCOME AND INSTALLMENT INCOME PLANS. Proceeds will earn interest at
rates declared each year by the Company. None of these rates will be less than
an annual effective rate of 3 1/2%. Interest of more than 3 1/2% will increase
the amount of the payments or, for the Specified Amount Plan (Option D),
increase the number of payments. The present value of any unpaid installments
will be based on the 3 1/2% rate of interest.
The Company may offer guaranteed rates of interest higher than 3 1/2% with
conditions on withdrawal.
LIFE INCOME PLANS. Payments will be based on rates declared by the Company.
These rates will provide at least as much income as would the Company's rates,
on the date that the payment plan takes effect, for a single premium immediate
annuity contract, with no charge for issue expenses. Payments under these rates
will not be less than the amounts that are described in Minimum Payment Rates.
MINIMUM PAYMENT RATES. The minimum payment rates for the Installment Income
Plans (Options B and D) and the Life Income Plans (Options C and E) are shown in
the Minimum Payment Rate Table.
MM 16 12
The Life Income Plan payment rates in that table depend on the adjusted age
of each person on whose life the payments are based. The adjusted age is:
- the age on the birthday that is nearest to the date on which the
payment plan takes effect; plus
- the age adjustment shown below for the number of policy years that
have elapsed from the Policy Date to the date that the payment plan
takes effect. A part of a policy year is counted as a full year.
---------------------------------------------------
POLICY POLICY
YEARS AGE YEARS AGE
ELAPSED ADJUSTMENT ELAPSED ADJUSTMENT
---------------------------------------------------
1 to 10 + 8 31 to 35 -1
11 to 15 + 6 36 to 40 -2
16 to 20 + 4 41 to 45 -3
21 to 25 + 2 46 to 50 -4
26 to 30 0 51 or more -5
---------------------------------------------------
12.4 EFFECTIVE DATE FOR PAYMENT PLAN
A payment plan that is elected will take effect on the date of death of the
insured if:
- the plan is elected by the Owner for death proceeds; and
- the election is received at the Home Office while the Insured is
living.
In all other cases, a payment plan that is elected will take effect:
- on the date the election is received at the Home Office; or
- on a later date, if requested.
12.5 PAYMENT PLAN ELECTIONS
FOR DEATH PROCEEDS BY OWNER. The Owner may elect payment plans for death
proceeds:
- while the Insured is living.
- during the first 60 days after the date of death of the Insured, if
the Insured just before his death was not the Owner. No one may change
this election made during those 60 days.
FOR DEATH PROCEEDS BY DIRECT OR CONTINGENT BENEFICIARY. A direct or contingent
beneficiary may elect payment plans for death proceeds payable to him if no
payment plan that has been elected is in effect. This right is subject to the
Owner's rights during the above 60 days.
FOR SURRENDER PROCEEDS. The Owner may elect payment plans for surrender
proceeds. The Owner will be the direct beneficiary.
12.6 INCREASE OF MONTHLY INCOME
A direct beneficiary who is to receive proceeds under a payment plan may
increase the amount of the monthly payments. This is done by the payment of an
annuity premium to the Company at the time the payment plan elected under
Section 12.5 takes effect. The amount that will be applied under the payment
plan will be the net premium. The net premium is the annuity premium less a
charge of not more than 2% and less any premium tax. The net premium will be
applied under the same payment plan and at the same rates as the proceeds. The
Company may limit this net premium to an amount that is equal to the direct
beneficiary's share of the proceeds payable under this policy.
MINIMUM PAYMENT RATE TABLE
MINIMUM MONTHLY INCOME PAYMENTS PER $1,000 PROCEEDS
INSTALLMENT INCOME PLANS (OPTIONS B AND D)
-------------------------------------------------------------------------------
PERIOD MONTHLY PERIOD MONTHLY PERIOD MONTHLY
(YEARS) PAYMENT (YEARS) PAYMENT (YEARS) PAYMENT
-------------------------------------------------------------------------------
1 $84.65 11 $ 9.09 21 $ 5.56
2 43.05 12 8.46 22 5.39
3 29.19 13 7.94 23 5.24
4 22.27 14 7.49 24 5.09
5 18.12 15 7.10 25 4.96
6 15.35 16 6.76 26 4.84
7 13.38 17 6.47 27 4.73
8 11.90 18 6.20 28 4.63
9 10.75 19 5.97 29 4.53
10 9.83 20 5.75 30 4.45
-------------------------------------------------------------------------------
MM 16 13
MINIMUM PAYMENT RATE TABLE
MINIMUM MONTHLY INCOME PAYMENTS PER $1,000 PROCEEDS
LIFE INCOME PLANS (OPTIONS C AND E)
---------------------------------------------------------------
SINGLE LIFE MONTHLY PAYMENTS (OPTION C)
---------------------------------------------------------------
CHOSEN PERIOD (YEARS)
ADJUSTED -------------------------------------------------
AGE* ZERO 10 20 REFUND
---------------------------------------------------------------
55 $ 5.39 $ 5.24 $ 4.85 $ 5.00
56 5.51 5.34 4.91 5.09
57 5.63 5.45 4.97 5.19
58 5.77 5.56 5.03 5.29
59 5.91 5.68 5.10 5.39
60 6.06 5.80 5.16 5.50
61 6.22 5.93 5.21 5.62
62 6.39 6.07 5.27 5.74
63 6.58 6.21 5.33 5.87
64 6.77 6.35 5.38 6.01
65 6.99 6.50 5.43 6.16
66 7.21 6.66 5.48 6.31
67 7.46 6.83 5.52 6.47
68 7.72 7.00 5.56 6.65
69 7.97 7.17 5.60 6.83
70 8.23 7.35 5.63 7.03
71 8.49 7.53 5.66 7.23
72 8.76 7.71 5.68 7.45
73 9.03 7.89 5.70 7.69
74 9.30 8.07 5.72 7.94
75 9.57 8.25 5.73 8.21
76 9.85 8.43 5.74 8.49
77 10.11 8.60 5.74 8.80
78 10.38 8.77 5.75 9.13
79 10.64 8.93 5.75 9.48
80 10.90 9.08 5.75 9.85
81 11.13 9.21 5.75 10.26
82 11.36 9.34 5.75 10.70
83 11.55 9.44 5.75 11.17
84 11.75 9.54 5.75 11.70
85 and over 11.92 9.61 5.75 12.26
---------------------------------------------------------------
--------------------------------------------------------------------------------
JOINT AND SURVIVOR MONTHLY PAYMENTS (OPTION E)
--------------------------------------------------------------------------------
OLDER LIFE YOUNGER LIFE ADJUSTED AGE*
ADJUSTED --------------------------------------------------------------------
AGE* 55 60 65 70 75 80 85 and over
--------------------------------------------------------------------------------
55 $4.33
60 4.45 $4.73
65 4.54 4.89 $5.28
70 4.61 5.01 5.49 $6.04
75 4.66 5.09 5.65 6.32 $7.04
80 4.68 5.14 5.74 6.51 7.39 $8.20
85 and over 4.69 5.16 5.78 6.60 7.57 8.52 $9.15
--------------------------------------------------------------------------------
*See Section 12.3.
MP 16 14
EXHIBIT (e)
LIFE INSURANCE OR ANNUITY APPLICATION TO No. -----------------
Exhibit 1A(10) THE NORTHWESTERN MUTUAL LIFE INSURANCE COMPANY [ ] Life & Disability
MILWAUKEE, WISCONSIN Insurance
-----------------------------------------------------------------------------------------------------------------------
1. INSURED Sex:
or Annuitant ▇▇▇▇ ▇. ▇▇▇ [X] Male
(Please Print) First Middle Initial Last [ ] Female
-----------------------------------------------------------------------------------------------------------------------
2. APPLICANT, if other
than insured Relationship
(Please Print)_____________________________________________________________________ to Insured __________________
First Middle Initial Last
If Business Organization: [ ] Corporation [ ] Partnership [ ] Other type of Business (specify)
-----------------------------------------------------------------------------------------------------------------------
3A. PRESIDENT of Insured: Print 3B. PREMIUM PAYER Send premium notices to:
Street No. [X] Insured [ ] Owner [ ] Applicant
or R.F.D. ▇▇▇▇ ▇▇▇▇ ▇▇.
---------------------------------------------- [ ] Other
City Milwaukee State WI ------------------------------------------
---------------------------- -------------- Name
County Milwaukee Zip Code 53200 at: [X] Insured's address See 3A) or:
-------------------------- ----------
This address will be used for all of Insured's policies. ----------------------------------------------------
------------------------------------------------------------ Street & No. or R.F.D.
4A. Insured's Date of Birth 7 1 50 ------------------------------- -------------------
Mo. Day Year City State
------------------------------------------------------------
4B. Place of Birth: (State or Country if other than U.S.A.) ------------------------------- -------------------
Milwaukee, WI Country Zip Code
Unless directed otherwise, any notices will be sent
to the Owner at the Insured's address.
-----------------------------------------------------------------------------------------------------------------------
5. Has application or informal inquiry ever been made to the Northwestern Mutual for annuity, life or disability
insurance on the life of the Insured? [ ] Yes [X] No If "Yes," Last Policy Number is_________________________
-----------------------------------------------------------------------------------------------------------------------
COMPLETE QUESTION 6 IF EXERCISING ADDITIONAL PURCHASE BENEFIT OPTION
-----------------------------------------------------------------------------------------------------------------------
6A. Number of policy under which this privilege is being 6B. Is application? [ ] Regular Purchase
exercised? [ ] Advance Purchase (See 6C).
-----------------------------------------------------------------------------------------------------------------------
6C. If an ADVANCE PURCHASE, event is the following:
[ ] (1) Marriage Name of [ ] Spouse [ ] Child ________________________________________________________
First Middle Initial Last
[ ] (2) Birth of Child Place and Date of Marriage, Birth or Final Decree of Legal Adoption:
[ ] (3) Adoption of Child _______________________________________________________________
City County State Mo. Day Yr.
-----------------------------------------------------------------------------------------------------------------------
7A. Plan and Amount applied for: 7B. ADDITIONAL BENEFITS (Check those desired):
[X] Life Insurance
[ ] WAIVER OF PREMIUM
Single Premium Variable Life $ 100,000 [ ] $ ______ OF ACCIDENTAL DEATH
--------------------------------------- ------------ [ ] ADDITIONAL PURCHASE $ _____ PER OPTION
Plan Amount [ ] PAYOR BENEFIT
[ ] INDEXED PROTECTION
[ ] LIFE PLAN WITH TERM BENEFIT [ ] OTHER, SPECIFY ___________________________
Basic policy ______________________ $ __________
Plan Amount Amount If any additional benefits cannot be
approved, should the policy be issued without the
benefit?
Term __________________________________ $___________ [ ] Yes [ ] No
Benefit & Years Amount ----------------------------------------------------------
8. SPECIAL DATING:
[ ] Annuity (Flexible Premium Annuity, Single PREPAID: [ ] Short Term to __________________________
Premium Retirement Annuity, Retirement Income) Mo. Day Yr.
[ ] Date to Save Age [ ] Backdate to _______________
________________________ _______________________ Mo. Day Yr.
Plan Age at Maturity
NON PREPAID: Specified Future Date __________________
Complete [ ] To provide monthly income of $ _________ Mo. Day Yr.
only [ ] To provide monthly income based on a
one [ ] Date to Save Age [ ] Backdate to _______________
Mo. Day Yr.
__________________ premium of $ ________________ -----------------------------------------------------------
Mode 9. Shall the PREMIUM LOAN provision, if available become
operative according to its terms? [ ] Yes [ ] No
-----------------------------------------------------------------------------------------------------------------------
LIFE INSURANCE or ANNUITY (CONTINUED)
------------------------------------------------------------------------------------------------------------------------------------
10A. ANNUAL DIVIDENDS until otherwise directed will: 10B. POLICY LOAN INTEREST RATE OPTION:
[ ] Be used to reduce current premium. [ ] 8%
[X] Purchase paid-up additions. [X] Variable Rate. (Not available on all plans, or in
[ ] Accumulate at interest. Substitute Form W-9 Arkansas, District of Columbia, Kentucky, Montana,
{Form 15-1272X) is required. S. Carolina)
[ ] Be cash.
------------------------------------------------------------------------------------------------------------------------------------
11A. DIRECT BENEFICIARY: (Print Name) 12. The Owner will be: (Select ONLY ONE of the choices
▇▇▇▇ ▇. ▇▇▇ A through G. Consider the choice of item E, F and G,
-------------------------------------------------------------- especially if the Insured is under age 15.)
[X] A. The Insured.
-------------------------------------------------------------- [ ] B. The Applicant.
Relationship to Insured: Wife [ ] C. Other, (Print Name)
-------------------------------------- ------------------------------
First Middle Initial Last
11B. CONTINGENT BENEFICIARY: (Print Name)
----------------------------------------------------
-------------------------------------------------------------- Relationship to Insured
-------------------------------------------------------------- [ ] D. See Attached Supplement Form.
Relationship to Insured: [ ] E. The Applicant. If the Applicant dies before the
-------------------------------------- Insured, the Insured will be the Owner.
[ ] F. The Applicant. If the Applicant dies before the
NOTE: Item 1 or 2 may be selected to supplement the contingent Insured, the Owner will be:
beneficiary designation or may be used to designate children or
brothers and sisters as contingent beneficiaries without -------------------------------------------------
specifically naming them. Item 3 may be used to supplement Item First Middle Initial Last
1, 2 or any contingent beneficiary designation.
_____________________________. If both die before
[X] (1) and any (other) children of the Insured. Relationship to Insured
[ ] (2) and any (other) brothers and sisters of the Insured the Insured, the Insured will be the Owner.
born of the marriage of or legally adopted by ___________
and __________ prior to the Insured's death. [ ] G. The Applicant until the Insured attains the age
[ ] (3) any amount a deceased contingent beneficiary would of ______ years. If the Applicant dies before the
have received, if living, will be payable when due in Insured, the Owner will be:
one sum in equal shares to his or her then living
children. (The word "children" includes child and any -------------------------------------------------
legally adopted child.) First Middle Initial Last
11C. FURTHER PAYEES: (Print Name) ______________________________ until the Insured
Relationship to Insured
-------------------------------------------------------------- attains such age. Upon the Insured attaining
such age, or if both die before the Insured, the
-------------------------------------------------------------- Insured will be the Owner.
Relationship to Insured:
--------------------------------------
[ ] SEE ATTACHED SUPPLEMENT FORM.
------------------------------------------------------------------------------------------------------------------------------------
13. PREMIUM PAYABLE: 14. Has the premium for the policy applied for been paid
to the agent in exchange for the Conditional Insurance
[X] Annually [ ] Semiannually [ ] Quarterly [ ] Single Agreement with the same number as the application?
[ ] Monthly (Variable Life only) [X] Yes [ ] No
------------------------------------------------------------------------------------------------------------------------------------
15. Will the insurance (or annuity) applied for replace insurance (or annuities) on the Insured's (or Annuitant's) life in this
Company or elsewhere? If "Yes," agent should explain and submit required papers. [ ] Yes [X] No
------------------------------------------------------------------------------------------------------------------------------------
THE INSURED CONSENTS TO THIS APPLICATION AND DECLARES THAT THE ANSWERS AND STATEMENTS ON BOTH SIDES OF THIS PAGE ARE CORRECTLY
RECORDED, COMPLETE AND TRUE TO THE BEST OF HIS KNOWLEDGE AND BELIEF. STATEMENTS IN THIS APPLICATION ARE REPRESENTATIONS AND NOT
WARRANTIES.
It is agreed that: (3) If the policy is issued in an extra premium class,
(1) If the premium is not paid when the application is signed, no acceptance of the policy will amend it so that extended term
insurance will be in effect. The insurance will take effect at the insurance can be in force only if:
time the policy is delivered and the premium is paid, if: - the Company gives its consent; or
- the loan value is not large enough to grant to premium
- the Insured is living at that time; and loan.
- the answers and statements in the application are then true
to the best of the knowledge and belief of the Insured. If a premium is not paid within the grace period an extended
term insurance cannot be in force, paid-up insurance will be
(2) If the premium is paid when the application is taken, no life selected.
insurance will have been in effect if Section I of the Conditional
Insurance Agreement applies. (4) No agent is authorized to make or alter contracts or to
waive any of the Company's rights or requirements.
/s/ ▇▇▇▇ ▇. ▇▇▇
------------------------------------------------------------------- -------------------------------------------------------------
Signature of INSURED or Annuitant (if other than Applicant and Signature of APPLICANT
15 yrs. of age and over)
Signed at Milwaukee, WI Date July 1 85 /s/ ▇▇▇▇ ▇. Western
----------------------------------------------- ---------------------- ------------------------------------------
City, County & State Month Day Year Signature of LICENSED AGENT
THE NORTHWESTERN MUTUAL LIFE INSURANCE COMPANY
--------------------------------------------------------------------------------
TO BE COMPLETED BY THE INSURED OR INFORMANT
-----------------------------------------------------------------------------------------------------------
INSURED (Please Print) ▇▇▇▇ ▇. ▇▇▇
-----------------------------------------------------------------------------------------------------------
First Middle Initial Last
-----------------------------------------------------------------------------------------------------------------------------------
If submitted for purpose other than a new insurance application, please
indicate:
[ ] Policy Change [ ] Conversion [ ] Adding _________ Benefit [ ] Reinstatement [ ] Rating Reduction
for Policy(ies) Number _________________________________________________________________________________________________________
[ ] Payor Benefit for Applicant (Payor)_____________________________________________________ Relationship to Insured _______________
First Middle Initial Last
Payor's Date of Birth ___________________________ Policy Number ________________________________________________________________
------------------------------------------------------------------------------------------------------------------------------------
20. Have you ever had life, disability, or hospital insurance COMPLETE QUESTIONS 27-31 IF INSURED AGE 10 OR OLDER
declined, rated, modified, cancelled, or not renewed? 27. Are you a member of, or do you contemplate joining any
(If "Yes" explain in REMARKS) [ ] Yes [X] No branch of the Armed Forces, the R.O.T.C., the National
----------------------------------------------------------------- Guard or any other component of the Armed Forces Re-
21. When was your last previous examination or application serve either on an active or inactive status?
for life, disability, or accidental death insurance? (If "Yes," complete Military Section 90-5) [ ] Yes [X] No
Month Year Company -----------------------------------------------------------------
----------------------------------------------------------------- 28. Except as a fare paying passenger on a regularly sched-
22. Indicate below whether any other Life Insurance on your uled flight, have you flown within the past 3 years, or
Life is individual (Ind) or Group (Grp) and identify In do you contemplate flying in the future?
Force (I), Pending (P) or Contemplated (C). (If "Yes," completed Aviation Section 90-5 [ ] Yes [X] No
If none check: [X] NONE -----------------------------------------------------------------
----------------------------------------------------------------- 29. Have you within the past 2 years participated in or do
Ind or Life Insurance Accidental Death I, P, you contemplate participating in racing (automobile,
Insurer Grp Amount Amount or C snowmobile, motorcycle, boat or go-kart) scuba or skin
----------------------------------------------------------------- diving, sky diving, hang gliding, mountain climbing or
----------------------------------------------------------------- rodeos?
----------------------------------------------------------------- (If "Yes," complete Avocation Section 90-6) [ ] Yes [X] No
----------------------------------------------------------------- -----------------------------------------------------------------
----------------------------------------------------------------- 30. A. What is your Automobile Driver's License Number?
----------------------------------------------------------------- # W▇▇▇▇▇▇▇▇▇▇ State Wis.
----------------------------------------------------------------- ------------------------- -------------------------
23. Marital Single, Widowed or, [ ] I do not drive an automobile.
Status: [ ] or Divorced [X] Married B. In the past 3 years have you been in a motor vehicle
----------------------------------------------------------------- accident, charged with a moving violation or any motor
24. Citizen of: [X] U.S.A. [ ] Other ___________________ vehicle law, or had your license restricted or revoked?
If other: Visa Type __________________ Visa No. _____________ (If "Yes" explain in C., D. and/or REMARKS) [ ] Yes [X] No
----------------------------------------------------------------- C. Moving Violations within the past 3 years:
25. Do you contemplate leaving the United States of -----------------------------------------------------------------
America for travel or residence? Type and Details
(If "Yes" explain in REMARKS) [ ] Yes [X] No Date (Speeding, Reckless Driving, Action (Citation, Accident
----------------------------------------------------------------- Driving While Intoxicated) Fine) (Yes or No)
26. A. What is your occupation(s)? attorney -----------------------------------------------------------------
-------------------------------
What are your duties? ____________________________________
__________________________________________________________
If applying for disability income, are you now actively
at work with no medical restrictions?
(If "No" explain in REMARKS) [ ] Yes [ ] No -----------------------------------------------------------------
B. Employer(s) XYZ Corporation D. Details of any Accidents: (Include date, citations,
----------------------------------------------- damage amounts, injuries.)
Name
750 Street
-----------------------------------------------
Street & No. or R.F.D.
▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇
-----------------------------------------------
City State Zip Code
C. How long so employed? 5 yrs.
-----------------
(If less than 2 years, explain in REMARKS)
------------------------------------------------------------------------------------------------------------------------------------
REMARKS:
------------------------------------------------------------------------------------------------------------------------------------
I declare that my answers and statements are correctly recorded, complete and true to the best of my knowledge and belief.
Statements in this application are representations and not warranties.
Date _____________________________ ___________________________________________________________________
Month Day Year Signature of Insured (or Informant)
(Signature not required if reverse side, 90-4 also completed)
-----------------------------------------------------------------------------------------------------
INSURED
(if not given on Form 90-3) -----------------------------------------------------------------------------------------------------
First Middle Initial Last
------------------------------------------------------------------------------------------------------------------------------------
NONMEDICAL APPLICATIONS ONLY
------------------------------------------------------------------------------------------------------------------------------------
31. A. Have you smoked cigarettes in the past 10 years? 36. Have you ever requested or received a pension, benefits
[ ] Yes [X] No or payment because of any injury, sickness or disability?
B. Present cigarette smokers: [ ] Yes [X] No
(1) How many cigarettes do you smoke per day? ---------------------------------------------------------------
(Number of cigarettes not number of packs) _______ 39. FAMILY HISTORY: Diabetes, cancer, high blood pressure,
(2) How many years have you smoked? _______ heart or kidney disease, mental illness or suicide?
C. Past cigarette smokers: [ ] Yes [X] No
(1) How many cigarettes do you smoke per day? ---------------------------------------------------------------
(Number of cigarettes not number of packs) _______ Age, if Living Cause of Death Age of Death
(2) How many years have you smoked? _______ --------------------------------------------------
(3) When did you quit smoking? _______ Father 59
D. Are you using tobacco in any other form? ---------------------------------------------------------------
If "Yes," specify ___________________ [ ] Yes [X] No Mother 58
---------------------------------------------------------------- ---------------------------------------------------------------
32. Are you now using any medication or drugs? Brothers and Sisters
[ ] Yes [X] No ---------------------------------------------------------------
---------------------------------------------------------------- 40. A. Have you lost weight in the past year? [ ] Yes [X] No
33. HAVE YOU EVER BEEN TREATED FOR OR EVER HAD ANY INDICATION If "Yes,", loss was ________lbs.
OF: B. How long have you been at your present weight? 3 yrs.
A. Disorder of eyes, ears, nose or throat? [ ] Yes [X] No ---------
---------------------------------------------------------------- C. Height 5 ft. 11 in. D. Weight 175 lbs.
B. Dizzy or fainting spells, seizures or convulsions, --- ---- -----
recurrent headache, paralysis or stroke, mental or E. Did agent measure? [ ] Yes [X] No
nervous disorder? [ ] Yes [X] No F. Did agent weight? [ ] Yes [X] No
---------------------------------------------------------------- ---------------------------------------------------------------
C. Persistent shortness of breath, cough, blood spitting; 42. If the Insured is under age 1, what was the weight at
bronchitis, asthma, emphysema, tuberculosis or other birth? ________ lbs ________ ozs.
lung or respiratory disorder? [ ] Yes [X] No ---------------------------------------------------------------
---------------------------------------------------------------- 43. Do you have a personal physician? [ ] Yes [X] No
D. Chest pain, discomfort or tightness, palpitation, high
blood pressure, rheumatic fever, heart murmur, heart Name
attack or other disorder of the heart or blood vessels? -------------------------------------------------------
[ ] Yes [X] No Address
---------------------------------------------------------------- ----------------------------------------------------
E. Jaundice, intestinal bleeding; ulcer, hernia, colitis, Date last seen Reason
diverticulitis, hemorrhoids, recurrent indigestion or ---------------- --------------------
other disorder of the stomach, intestines, liver, gall Mo. Day Yr.
bladder or pancreas? [ ] Yes [X] No ---------------------------------------------------------------
---------------------------------------------------------------- REMARKS. GIVE DETAILS OF "YES" ANSWERS. IDENTIFY QUESTION
F. Sugar, albumin, blood in urine; venereal disease; stone NUMBER. STATE SIGNS, SYMPTOMS AND DIAGNOSIS OF ILLNESS AND
or other disorder of kidney, bladder, prostate or NAME AND ADDRESS OF ANY ATTENDING PHYSICIAN.
reproductive organs? [ ] Yes [X] No ---------------------------------------------------------------
----------------------------------------------------------------
G. Diabetes; thyroid or other endocrine disorders?
[ ] Yes [X] No
----------------------------------------------------------------
H. Rheumatism, arthritis, gout, or disorder of the muscles
or bones, spine, back or joints? [ ] Yes [X] No
----------------------------------------------------------------
I. Deformity, lameness or amputation? [ ] Yes [X] No
----------------------------------------------------------------
J. Disorder of skin, lymph glands, cyst, tumor or cancer?
[ ] Yes [X] No
----------------------------------------------------------------
K. Allergies; anemia or other disorder of the blood?
[ ] Yes [X] No
----------------------------------------------------------------
L. Alcohol or drug habit? [ ] Yes [X] No
----------------------------------------------------------------
34. OTHER THAN ABOVE, HAVE YOU WITHIN THE PAST 5 YEARS:
A. Had any physician or practitioner examine, advise or
treat you? [ ] Yes [X] No
----------------------------------------------------------------
B. Been a patient in a hospital, clinic or medical facility?
[ ] Yes [X] No
----------------------------------------------------------------
C. Had EKG, X-ray, other test? [ ] Yes [X] No
----------------------------------------------------------------
D. Been advised to have any test, hospitalization or
surgery which was not completed? [ ] Yes [X] No
----------------------------------------------------------------
35. Have you ever had military service deferment, rejection or
discharge because of a physical or mental condition?
[ ] Yes [X] No
------------------------------------------------------------------------------------------------------------------------------------
I declare that my answers and statements on both sides of this page are correctly recorded, complete and true to the best of my
knowledge and belief. Statements in this application are representations and not warranties.
/s/ ▇▇▇▇ ▇. ▇▇▇
---------------------------------------------------------------
Signature of Insured (or Informant)
Signed at Milwaukee, WI On 1 1 85 /s/ Vorm M. Western
-------------------------- -------------------- ---------------------------------------------------------------
City State Mo Day Year Signature of Licensed Agent
SUPPLEMENT TO APPLICATION
FOR VARIABLE LIFE INSURANCE
NORTHWESTERN MUTUAL LIFE INSURANCE COMPANY
INSURED ▇▇▇▇ ▇. ▇▇▇
----------------------------------
APPLICATION NUMBER 000 009
-----------------------
201. Allocation of Net Premium
Money Market Division 40 % (Whole percentages
Bond Division 20 % only,
Stock Division 20 % minimum of 10% in
Master Division 20 % Division selected.)
===========
100 %
202. I acknowledge receipt of the prospectus for Variable Life Insurance dated
July 1, 1985
----------------- .
203. I UNDERSTAND THAT THE DEATH BENEFIT FOR THE VARIABLE LIFE INSURANCE POLICY
APPLIED FOR MAY INCREASE OR DECREASE TO REFLECT THE INVESTMENT EXPERIENCE
OF THE NORTHWESTERN MUTUAL VARIABLE LIFE ACCOUNT, BUT WILL NOT BE LESS THAN
THE FACE AMOUNT PROVIDED ALL PREMIUMS ARE PAID AS OF THEIR DUE DATE AND
PROVIDED THERE IS NO POLICY DEBT.
204. I UNDERSTAND THAT THE CASH VALUES FOR THE VARIABLE LIFE INSURANCE POLICY
APPLIED FOR MAY INCREASE OR DECREASE TO REFLECT THE INVESTMENT EXPERIENCE
OF THE NORTHWESTERN MUTUAL VARIABLE LIFE ACCOUNT AND ARE NOT GUARANTEED AS
TO FIXED DOLLAR AMOUNT. THERE ARE NO GUARANTEED MINIMUM CASH VALUES.
205. I believe that a Variable Life Insurance policy is consistent with my
investment objectives and financial needs.
I understand that an illustration of benefits, including death benefits and
cash values, is available upon request to compare:
- a Variable Whole Life policy based on a hypothetical investment return
of 0%, 4% and 8% (or alternatively 0%, 6%, and 12%).
- a fixed benefit Whole Life policy issued by the Northwestern Mutual
Life Insurance Company based on the same gross premium as the Variable
Whole Life policy.
206. Owner's Address
[X] Insured's address in 3A or:
[ ]
----------------------------------------------------------
▇▇▇▇▇▇ & ▇▇. ▇▇ ▇.▇.▇.
----------------------------------------------------------
▇▇▇▇ ▇▇▇▇▇ Zip Code
(Signed) ▇▇▇▇ ▇. ▇▇▇
--------------------------------------- ------------------------------------
Signature of Insured or Informant Signature of Applicant
(if other than Applicant)
Signed at Milwaukee, WI Date 7/1/85
------------------------------ -------------------------------
Based on the information furnished by the Applicant or Informant in this
application, I certify that I have reasonable ground for believing the purchase
of the policy applied for is suitable for the Applicant. I further certify that
a current Prospectus was delivered and that no written sales materials other
than those furnished by the Home Office were used.
Signature of Licensed Agent (Signed) ▇▇▇▇ ▇. Weestern
-----------------------------------------------------
(Registered Representative)
General Agent's Approval
-------------------------------------------------------
Registered Principal's Approval
-------------------------------------------------
(Completed in H.O.)
NORTHWESTERN
MUTUAL LIFE
IT IS RECOMMENDED THAT YOU...
=============================================================================
-----------------------------------------------------------------------------
READ YOUR POLICY.
NOTIFY YOUR NML AGENT OR THE COMPANY AT ▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇,
▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇, OF AN ADDRESS CHANGE.
CALL YOU NMI AGENT FOR INFORMATION --
PARTICULARLY ON A SUGGESTION
TO TERMINATE OR EXCHANGE THIS POLICY
FOR ANOTHER POLICY OR PLAN.
-----------------------------------------------------------------------------
ELECTION OF TRUSTEES
The members of The Northwestern Mutual Life Insurance Company are its
policyholders of insurance policies and deferred annuity contracts. The members
exercise control through a Board of Trustees. Elections to the Board are held
each year at the annual meeting of members. Members are entitled to vote in
person or by proxy.
SINGLE PREMIUM VARIABLE WHOLE LIFE POLICY
ELIGIBLE FOR ANNUAL DIVIDENDS
Insurance payable at death of Insured.
Benefits reflect investment results.
Variable benefits described in Sections 4 through 8.
The Death Benefit for the first policy year will be the Face Amount shown on
page 3, less any policy debt. The Death Benefit after that may increase or
decrease on each policy anniversary depending on investment results. However,
the Death Benefit will not be less than the Face Amounts shown on page 3, less
any policy debt.
The cash value under this policy may increase or decrease daily depending on
investment results. There is no guaranteed minimum cash value.
MM 16
-----------------------------------------------------------------------------
=============================================================================