CCGUL3IN 1
TRANSAMERICA LIFE INSURANCE COMPANY
Home Office: [Cedar Rapids, IA 52499]
A Stock Company
Subject to the provisions of this Certificate, we will pay the Death Benefit in a lump sum to the Beneficiary if the
Insured dies before the Maturity Date. If the Insured is living on the Maturity Date, and this Certificate is in force,
we will pay the Cash Surrender Value, if any, to the Owner.
This Certificate is signed for the Company at our Home Office to take effect on the Certificate Date.
[ ] [ ]
General Counsel and Secretary President
YOU HAVE PURCHASED LIFE INSURANCE AS DESCRIBED IN THIS CERTIFICATE. PLEASE REVIEW IT
CAREFULLY FOR LIMITATIONS.
THIS CERTIFICATE MAY BE RETURNED WITHIN 30 DAYS FROM THE DATE YOU RECEIVED IT FOR A FULL
REFUND, EITHER BY RETURNING IT TO THE AGENT OR TO US. WE WILL REFUND TO YOU ANY
PREMIUMS PAID, LESS ANY PARTIAL SURRENDERS.
AFTER 30 DAYS, CANCELLATION MAY RESULT IN A SUBSTANTIAL PENALTY KNOWN AS A SURRENDER
CHARGE. YOU WILL INCUR SURRENDER CHARGES IF COVERAGE IS TERMINATED WITHIN THE
SURRENDER CHARGE PERIOD. THE TABLE OF SURRENDER CHARGE FACTORS CAN BE FOUND IN THE
TABLES SECTION OF THE CONTRACT DATA PAGES STARTING ON PAGE 6.
THE CERTIFICATE DATE CAN BE FOUND ON THE CONTRACT DATA PAGES.
Group Certificate for Flexible Premium Adjustable Life Insurance
(Universal Life Insurance)
Flexible Premium Adjustable Life Insurance
Flexible Premiums Payable During the Life of the Insured to the Maturity Date
Death Benefit Payable at Death of Insured Prior to the Maturity Date
Cash Surrender Value, if any, Payable at the Maturity Date
Nonparticipating - No Annual Dividends
Administrative Office:
[1400 Centerview Drive, PO Box 8063
Little Rock, AR 72203-8063]
Customer Service: [1-888-763-7474]
E-Mail Address: [customer service@Transamerica.com]
Web Address: [www.transamericaemployeebenefits.com]
CCGUL3IN 2
CERTIFICATE SUMMARY
This Certificate summarizes the insurance coverage provided under the Group Master Policy (“Policy”) issued to
the Policyholder named on the Contract Data Pages. We have issued this Certificate based on information that
enabled us to determine that the Insured met all of the eligibility requirements set forth in the Policy. A copy of the
Policy is on file with the Policyholder and may be examined at any reasonable time during normal business hours.
TABLE OF CONTENTS
Certificate Provisions Page(s) Certificate Provisions Page(s)
CONTRACT DATA PAGES .................................... 3
Additional Riders ................................................. 4
Tables Section:
Table of Surrender Charge Factors ................. 6
Table of Guaranteed Monthly COI Rates ........ 8
Table of Death Benefit Factors ...................... 10
DEFINITIONS ........................................................ 12
OWNERSHIP ......................................................... 13
BENEFICIARY PROVISIONS................................ 13
DEATH BENEFIT ................................................... 14
CERTIFICATE EFFECTIVE DATE ........................ 14
CERTIFICATE TERMINATION DATE ................... 15
PREMIUMS ............................................................ 15
REINSTATEMENT................................................. 15
CONTRACT VALUES ............................................ 16
LOANS ................................................................... 17
PARTIAL SURRENDER ........................................ 17
NONFORFEITURE OPTION ................................. 18
PAYMENT OF CASH VALUE AND LOANS .......... 18
CERTIFICATE STATEMENTS AND
ILLUSTRATIONS ................................................... 18
PORTABILITY OPTION ......................................... 18
BASIS OF COMPUTATION ................................... 18
GENERAL PROVISIONS ...................................... 19
CCGUL3IN 3
CONTRACT DATA PAGES
POLICYHOLDER [ABC ELIGIBLE GROUP] GOVERNING JURISDICTION [STATE OF ISSUE]
INSURED [JOHN DOE] CERTIFICATE NUMBER [99999999]
FACE AMOUNT [$50,000] PLANNED PREMIUM [$84.08 MONTHLY]
INSURED AGE [35] CERTIFICATE DATE [MAY 01, 2013]
CLASS OF RISK [TOBACCO] OWNER [JOHN DOE]
MINIMUM MONTHLY MINIMUM MONTHLY
PREMIUM [$79.04] PREMIUM DATE [MAY 01, 2023]
DEATH BENEFIT MATURITY DATE [MAY 01, 2078]
OPTION [OPTION A]
LOAN INTEREST RATE [8.0% (7.40% IN ADVANCE)]
_____________________________________________________________________________________________
PLEASE NOTE THAT COVERAGE MAY EXPIRE BEFORE THE MATURITY DATE IF THE CASH SURRENDER
VALUE IS LESS THAN THE MONTHLY DEDUCTION DUE.
GUARANTEED MINIMUM INTEREST RATE: [3]% PER ANNUM
GUARANTEED EXPENSE CHARGE: [5]% OF ANY PREMIUM PAYMENT
RECEIVED
GUARANTEED CERTIFICATE FEE: $[2.00] PER MONTH
GUARANTEED MONTHLY ADMINISTRATIVE FEE: $[3.48] PER $1,000 OF FACE AMOUNT
(YEARS [1-20]) AND $[1.80] (YEARS [21+]
MAXIMUM UNSCHEDULED PREMIUM: $[500] IN EXCESS OVER THE
ANNUALIZED PLANNED PREMIUM IN
ANY CALENDAR YEAR
INTEREST RATE ON ACCUMULATION VALUE
SECURING LOANS: [5.5]%
RESERVE INTEREST RATE [3.50]%
PLEASE REFER TO THE COST OF INSURANCE (COI) PROVISION FOR A DESCRIPTION OF HOW THE COST
OF INSURANCE IS CALCULATED. A TABLE OF GUARANTEED MONTHLY COST OF INSURANCE RATES IS
LOCATED IN THE TABLES SECTION OF THE CONTRACT DATA PAGES.
CCGUL3IN 4
CONTRACT DATA PAGES (Continued)
ADDITIONAL RIDERS
THE INITIAL MONTHLY CHARGE DEDUCTED FROM THE ACCUMULATION VALUE FOR ANY ADDITIONAL
BENEFITS WHICH ARE PROVIDED BY RIDER IS SHOWN BELOW. THE COMPLETE RIDER PROVISIONS
ARE INCLUDED IN THE RIDER.
RIDER NUMBER SCHEDULE OF ADDITIONAL RIDERS AND BENEFITS MONTHLY CHARGE
[CRLAD100 ACCIDENTAL DEATH AND DISMEMBERMENT RIDER $[ 4.00]
ACCIDENTAL DEATH BENEFIT: [$50,000]
SEATBELT BENEFIT: [10]% OF ACCIDENTAL DEATH BENEFIT
AIR BAG BENEFIT: [5]% OF ACCIDENTAL DEATH BENEFIT
COMMON CARRIER BENEFIT: [100]% OF ACCIDENTAL DEATH BENEFIT]
[CRLCH100 CHILD LEVEL TERM INSURANCE RIDER $[ 2.50]
RIDER DEATH BENEFIT (EACH CHILD): [$10,000]]
[CRLWM100 WAIVER OF MONTHLY DEDUCTIONS FOR TOTAL DISABILITY RIDER $[ 2.50]]
[CRLWL100 WAIVER OF MONTHLY DEDUCTIONS FOR LAYOFF/STRIKE RIDER $[ 0.04]]
[CRLAI100 AUTOMATIC FACE INCREASE RIDER (BASED ON SCHEDULED INCREASE
OF [MONTHLY] PLANNED PREMIUM PAYMENTS ON EACH OPTION DATE)
OPTION FACE AMOUNT MONTHLY DEDUCTION
DATE INCREASE INCREASE
[MAY 01, 2014] [$2,575] $[ 4.33]
[MAY 01, 2015] [$2,446] $[ 4.33]
[MAY 01, 2016] [$2,324] $[ 4.33]
[MAY 01, 2017] [$2,207] $[ 4.33]
[MAY 01, 2018] [$2,097] $[ 4.33]]
[CRLCC100 ACCELERATED DEATH BENEFIT FOR CRITICAL CONDITION RIDER $[ 11.80]
MAXIMUM BENEFIT: LESSER OF (A) $[100,000] OR
(B) [50]% OF THE APPLICABLE DEATH BENEFIT]
GUARANTEED MONTHLY CHARGE PER $1,000: $[0.72167]
WAITING PERIOD: [30] DAYS
ADMINISTRATIVE EXPENSE CHARGE: $[250]]
[CRLLT100 ACCELERATED DEATH BENEFIT FOR CHRONIC CONDITION RIDER $[ 2.96]
PERCENTAGE OF DEATH BENEFIT AMOUNT FOR MONTHLY BENEFIT: [4]%
PERCENTAGE OF DEATH BENEFIT AMOUNT FOR ONE-TIME LUMP SUM BENEFIT: [20]%
ELIMINATION PERIOD: [90] DAYS
WAITING PERIOD: [30] DAYS
GUARANTEED MONTHLY CHARGE PER $1,000: $[0.0975]]
[CRLEX100 EXTENSION OF BENEFIT RIDER $[ 2.00]
MONTHLY INCREASE AMOUNT: [4]%
INCREASE IN ONE-TIME LUMP SUM BENEFIT: [5]%
[PAID-UP BENEFIT AMOUNT: [25]% ]
GUARANTEED MONTHLY CHARGE PER $1,000: $[0.0700]]
[CRLRE100 BENEFIT RESTORATION RIDER $[ 2.55]
GUARANTEED MONTHLY CHARGE PER $1,000: $[0.0890]]
[CRLTI100 ACCELERATED DEATH BENEFIT FOR TERMINAL CONDITION RIDER $[ 0.00]
MAXIMUM BENEFIT: LESSER OF (A) $[100,000] OR
(B) [75]% OF THE APPLICABLE DEATH BENEFIT]
ADMINISTRATIVE EXPENSE CHARGE: $[100]]
CCGUL3IN 5
CONTRACT DATA PAGES (Continued)
CURRENT COST OF INSURANCE RATES, CERTIFICATE FEES, ADMINISTRATIVE FEES, EXPENSE
CHARGES, RIDER CHARGES AND INTEREST RATES ARE NOT GUARANTEED, NOR ARE THEY ESTIMATES
OR PROMISES FOR THE FUTURE.
PLEASE REFER TO THE NONFORFEITURE OPTION SECTION FOR A DESCRIPTION OF HOW THE
SURRENDER CHARGE IS CALCULATED. SURRENDER CHARGES ARE COMPUTED SEPARATELY FOR THE
ORIGINAL FACE AMOUNT AND EACH INCREASE IN FACE AMOUNT AND THEN COMBINED. PLEASE
REFER TO THE PARTIAL SURRENDER PROVISION FOR A DESCRIPTION OF HOW THE PARTIAL
SURRENDER CHARGE IS CALCULATED. THE TABLE OF SURRENDER CHARGE FACTORS STARTS ON
PAGE 6, WHICH IS LOCATED IN THE TABLES SECTION OF THE CONTRACT DATA PAGES. PLEASE USE
THE CLASS OF RISK, ISSUE AGE OF THE INSURED ON THE EFFECTIVE DATE OF COVERAGE, AND THE
CERTIFICATE YEAR (CY) FACTOR FROM THE EFFECTIVE DATE OF COVERAGE FROM THE TABLE OF
SURRENDER CHARGE FACTORS TO DETERMINE THE APPLICABLE SURRENDER CHARGE OR PARTIAL
SURRENDER CHARGE IN ANY GIVEN YEAR.
PREMIUMS ARE SUBJECT TO REFUND UNDER CONDITIONS DESCRIBED IN THE CERTIFICATE.
THE INTEREST RATE APPLICABLE TO THE ACCUMULATION VALUE SECURING ANY LOAN(S) MAY DIFFER
FROM THE INTEREST RATE APPLICABLE TO THE ACCUMULATION VALUE NOT SECURING THE LOAN(S).
THE FOLLOWING TABLES ARE INCLUDED IN THE TABLES SECTION OF THE CONTRACT DATA PAGES:
TABLE OF SURRENDER CHARGE BASE FACTORS
TABLE OF SURRENDER CHARGE CONTRACT YEAR PERCENTAGES
TABLE OF GUARANTEED MONTHLY COST OF INSURANCE RATES
TABLE OF DEATH BENEFIT FACTORS
CCGUL3IN 6
CONTRACT DATA PAGES (Continued)
TABLE OF SURRENDER CHARGE BASE FACTORS
SURRENDER CHARGE (SC) BASE PER $1,000 FACE AMOUNT
NONTOBACCO AND TOBACCO
NONTOBACCO
TOBACCO
ISSUE
AGE
SC BASE
ISSUE
AGE
ISSUE
AGE
SC
BASE
ISSUE
AGE
SC
BASE
0
5.02
41
0
N/A
41
25.97
1
5.06
42
1
N/A
42
26.80
2
5.10
43
2
N/A
43
27.68
3
5.14
44
3
N/A
44
28.59
4
5.19
45
4
N/A
45
29.54
5
5.25
46
5
N/A
46
30.54
6
5.31
47
6
N/A
47
31.58
7
5.36
48
7
N/A
48
32.69
8
5.42
49
8
N/A
49
33.87
9
5.49
50
9
N/A
50
35.13
10
5.55
51
10
N/A
51
36.47
11
5.62
52
11
N/A
52
37.91
12
5.70
53
12
N/A
53
39.42
13
5.77
54
13
N/A
54
41.02
14
5.85
55
14
N/A
55
42.68
15
5.94
56
15
N/A
56
42.75
16
6.02
57
16
8.84
57
42.73
17
6.10
58
17
9.29
58
42.72
18
6.18
59
18
9.76
59
72.73
19
6.27
60
19
10.23
60
42.76
20
6.36
61
20
10.73
61
42.79
21
6.46
62
21
11.24
62
42.81
22
6.56
63
22
11.78
63
42.82
23
6.67
64
23
12.35
64
42.79
24
6.78
65
24
12.92
65
42.73
25
10.43
66
25
13.53
66
42.64
26
11.11
67
26
14.19
67
42.53
27
11.82
68
27
14.88
68
42.41
28
12.56
69
28
15.61
69
42.31
29
13.34
70
29
16.37
70
42.21
30
14.14
71
30
17.16
71
42.10
31
14.98
72
31
18.00
72
41.97
32
15.87
73
32
18.88
73
41.83
33
16.80
74
33
19.81
74
41.68
34
17.77
75
34
20.80
75
41.54
35
18.80
76
35
21.84
76
41.43
36
19.26
77
36
22.44
77
41.35
37
19.74
78
37
23.07
78
41.30
38
20.25
79
38
23.73
79
41.26
39
20.79
80
39
24.44
80
41.12
40
21.35
40
25.18
N/A = NOT APPLICABLE.
CCGUL3IN 7
CONTRACT DATA PAGES (Continued)
TABLE OF SURRENDER CHARGE FACTORS
CONTRACT YEAR PERCENTAGES
NONTOBACCO AND TOBACCO
CONTRACT
YEAR
PERCENTAGE
ISSUE AGES
0 TO 50
ISSUE AGE
51
ISSUE AGE
52
ISSUE AGE
53
ISSUE AGE
54
ISSUE AGE
55+
1
100%
100%
100%
100%
100%
100%
2
100%
100%
100%
100%
100%
100%
3
100%
100%
100%
100%
100%
100%
4
100%
100%
100%
100%
100%
100%
5
100%
100%
100%
100%
100%
100%
6
90%
90%
90%
90%
90%
90%
7
85%
85%
85%
85%
85%
75%
8
80%
80%
80%
80%
70%
55%
9
75%
75%
75%
65%
50%
25%
10
70%
70%
70%
50%
25%
0%
11
40%
40%
40%
25%
0%
0%
12
30%
30%
20%
0%
0%
0%
13
20%
20%
0%
0%
0%
0%
14
10%
0%
0%
0%
0%
0%
15 +
0%
0%
0%
0%
0%
0%
CCGUL3IN 8
CONTRACT DATA PAGES (Continued)
TABLE OF GUARANTEED MONTHLY COST OF INSURANCE (COI) RATES
PER $1,000*
NONTOBACCO
INSURED'S
MONTHLY
INSURED'S
MONTHLY
INSURED'S
MONTHLY
AGE
COI RATE
AGE
COI RATE
AGE
COI RATE
0
0.05500
40
0.12167
80
5.45333
1
0.03583
41
0.13167
81
6.06500
2
0.02583
42
0.14417
82
6.70917
3
0.02000
43
0.15833
83
7.40500
4
0.01750
44
0.17500
84
8.17333
5
0.01667
45
0.19250
85
9.00750
6
0.01750
46
0.21083
86
9.92833
7
0.01833
47
0.22667
87
10.94333
8
0.01833
48
0.24083
88
12.00917
9
0.01917
49
0.25833
89
13.09917
10
0.01917
50
0.28000
90
14.08750
11
0.02250
51
0.30667
91
15.01750
12
0.02750
52
0.33833
92
16.09167
13
0.03167
53
0.37500
93
17.32750
14
0.04083
54
0.42000
94
18.74167
15
0.05000
55
0.47000
95
20.22750
16
0.05833
56
0.52250
96
21.70667
17
0.06500
57
0.57417
97
22.94333
18
0.06833
58
0.62583
98
23.92167
19
0.07000
59
0.68500
99
25.23750
20
0.07083
60
0.75583
21
0.07083
61
0.84083
22
0.07167
62
0.93917
23
0.07250
63
1.04500
24
0.07333
64
1.15667
25
0.07500
65
1.27250
26
0.07833
66
1.39167
27
0.08083
67
1.51750
28
0.08000
68
1.65083
29
0.07917
69
1.79917
30
0.07833
70
1.97167
31
0.07833
71
2.18000
32
0.08000
72
2.42083
33
0.08250
73
2.67583
34
0.08583
74
2.94917
35
0.09000
75
3.24667
36
0.09500
76
3.58083
37
0.10083
77
3.96583
38
0.10667
78
4.40750
39
0.11333
79
4.89917
* TO DETERMINE THE AMOUNT OF THE MONTHLY COST OF INSURANCE DURING EACH CERTIFICATE
YEAR, SEE THE COST OF INSURANCE (COI) PROVISION.
CCGUL3IN 9
CONTRACT DATA PAGES (Continued)
TABLE OF GUARANTEED MONTHLY COST OF INSURANCE (COI) RATES
PER $1,000*
TOBACCO
INSURED'S
MONTHLY
INSURED'S
MONTHLY
INSURED'S
MONTHLY
AGE
COI RATE
AGE
COI RATE
AGE
COI RATE
0
40
0.23000
80
7.38750
1
41
0.25083
81
8.09500
2
42
0.27583
82
8.82000
3
43
0.30583
83
9.58417
4
44
0.33917
84
10.43083
5
45
0.37333
85
11.35000
6
46
0.40833
86
12.34833
7
47
0.44000
87
13.43417
8
48
0.46667
88
14.54500
9
49
0.50083
89
15.64083
10
50
0.54167
90
16.56917
11
51
0.59333
91
17.38500
12
52
0.65500
92
18.32667
13
53
0.72667
93
19.39167
14
54
0.81083
94
20.68000
15
55
0.90000
95
22.11500
16
0.06500
56
0.99417
96
23.50500
17
0.07667
57
1.08167
97
24.60333
18
0.08500
58
1.16667
98
25.38333
19
0.09083
59
1.26500
99
26.51000
20
0.09667
60
1.38167
21
0.10167
61
1.52250
22
0.10583
62
1.68250
23
0.11167
63
1.85250
24
0.11833
64
2.02417
25
0.12417
65
2.19333
26
0.13083
66
2.36083
27
0.13583
67
2.53333
28
0.13667
68
2.71083
29
0.13750
69
2.90583
30
0.13833
70
3.12917
31
0.14000
71
3.40000
32
0.14333
72
3.70917
33
0.14917
73
4.02500
34
0.15583
74
4.36583
35
0.16333
75
4.74000
36
0.17333
76
5.15250
37
0.18500
77
5.62333
38
0.19833
78
6.15583
39
0.21250
79
6.73833
* TO DETERMINE THE AMOUNT OF THE MONTHLY COST OF INSURANCE DURING EACH CERTIFICATE
YEAR, SEE THE COST OF INSURANCE (COI) PROVISION.
CCGUL3IN 10
CONTRACT DATA PAGES (Continued)
TABLE OF DEATH BENEFIT FACTORS
NONTOBACCO
INSURED'S
FACTOR
INSURED'S
FACTOR
INSURED'S
FACTOR
AGE
AGE
AGE
0
16.85
34
5.19
68
1.77
1
16.37
35
5.01
69
1.73
2
15.84
36
4.84
70
1.68
3
15.30
37
4.67
71
1.64
4
14.76
38
4.51
72
1.61
5
14.23
39
4.36
73
1.57
6
13.72
40
4.21
74
1.54
7
13.22
41
4.06
75
1.50
8
12.75
42
3.93
76
1.47
9
12.29
43
3.79
77
1.44
10
11.84
44
3.67
78
1.41
11
11.42
45
3.54
79
1.39
12
11.01
46
3.43
80
1.36
13
10.62
47
3.31
81
1.34
14
10.24
48
3.21
82
1.32
15
9.89
49
3.10
83
1.30
16
9.56
50
3.00
84
1.28
17
9.25
51
2.90
85
1.26
18
8.95
52
2.81
86
1.24
19
8.66
53
2.72
87
1.23
20
8.38
54
2.64
88
1.21
21
8.10
55
2.55
89
1.20
22
7.84
56
2.48
90
1.19
23
7.58
57
2.40
91
1.17
24
7.33
58
2.33
92
1.16
25
7.08
59
2.26
93
1.15
26
6.84
60
2.20
94
1.14
27
6.62
61
2.13
95
1.12
28
6.40
62
2.07
96
1.11
29
6.18
63
2.02
97
1.09
30
5.97
64
1.96
98
1.07
31
5.77
65
1.91
99
1.04
32
5.57
66
1.86
100
1.00
33
5.38
67
1.81
CCGUL3IN 11
CONTRACT DATA PAGES (Continued)
TABLE OF DEATH BENEFIT FACTORS
TOBACCO
INSURED'S
FACTOR
INSURED'S
FACTOR
INSURED'S
FACTOR
AGE
AGE
AGE
0
13.71
34
4.24
68
1.62
1
13.29
35
4.10
69
1.59
2
12.84
36
3.97
70
1.55
3
12.39
37
3.84
71
1.52
4
11.95
38
3.71
72
1.49
5
11.51
39
3.59
73
1.47
6
11.09
40
3.47
74
1.44
7
10.69
41
3.36
75
1.41
8
10.30
42
3.26
76
1.39
9
9.92
43
3.15
77
1.37
10
9.56
44
3.05
78
1.35
11
9.21
45
2.96
79
1.32
12
8.87
46
2.87
80
1.31
13
8.55
47
2.78
81
1.29
14
8.25
48
2.70
82
1.27
15
7.96
49
2.62
83
1.25
16
7.68
50
2.54
84
1.24
17
7.42
51
2.47
85
1.22
18
7.18
52
2.40
86
1.21
19
6.94
53
2.33
87
1.20
20
6.72
54
2.26
88
1.19
21
6.50
55
2.20
89
1.18
22
6.29
56
2.14
90
1.17
23
6.09
57
2.09
91
1.16
24
5.89
58
2.04
92
1.15
25
5.70
59
1.98
93
1.14
26
5.52
60
1.93
94
1.13
27
5.35
61
1.89
95
1.12
28
5.17
62
1.84
96
1.11
29
5.01
63
1.80
97
1.09
30
4.85
64
1.76
98
1.07
31
4.69
65
1.72
99
1.04
32
4.54
66
1.69
100
1.00
33
4.39
67
1.65
CCGUL3IN 12
DEFINITIONS
Terms important to understanding this Certificate are defined below and are capitalized in this Certificate.
Accumulation Value - The amount described in the Accumulation Value provision under the Contract Values
section.
Age or Issue Age – The Insured’s Age as it appears on the Contract Data Pages is the Issue Age as of the
Certificate Date. The Insured’s Age will increase by one year on each Certificate Anniversary.
Amendment, Endorsement, or Rider - Any form issued by us which adds, modifies, changes, or deletes any
Policy or Certificate provisions or benefits.
Anniversary - The month and date of each calendar year that is the same month and date as your Certificate Date.
When any date is referred to, the effective time will be at 12:01 a.m. at the Policyholder’s main place of business.
Application or Enrollment Form - The form completed and signed to apply for this life insurance coverage.
Beneficiary - The person to receive the proceeds of this Certificate in the event of the Insured's death.
Cash Surrender Value - The Cash Value, less any Loans.
Cash Value - The Accumulation Value, less any Surrender Charge.
Death Benefit - The amount payable upon the Insured's death, subject to any adjustments as described in the
Adjustments to the Death Benefit provision in the Death Benefit section in this Certificate.
Face Amount - The amount upon which Death Benefits are determined. The initial Face Amount is shown on the
Contract Data Pages.
Insured - The person covered for this insurance and named on the Contract Data Pages.
Lapse - The termination of this Certificate for the nonpayment of premium or insufficient premium amount, subject
to the terms of the Grace Period provision.
Loan - The indebtedness to us for Loans secured by the Cash Value of this Certificate.
Loan Value - The maximum amount which may be borrowed under the Loans section of this Certificate.
Maturity Date - The date we pay the Cash Surrender Value, if any, to you if the Insured is living on that date and if
this Certificate is in force.
Monthly Date - The date of each month that is the same date as the Certificate Date shown on the Contract Data
Pages.
Owner, you, your, or yours - The person or entity named on the Contract Data Pages who has certain rights
under this Certificate, as listed in the Ownership section. The Owner will be the employee or member unless a
different Owner is listed on the Application or a written request is received by us to transfer ownership.
Policy – The complete contract of insurance, which includes the Policy as issued to the Policyholder, the
Policyholder Application, the Certificate, and any Amendments, Endorsements, and Riders.
Policyholder - The entity named on the Contract Data Pages to whom the Policy is issued.
Reinstate, Reinstated, and Reinstatement - To restore coverage after this Certificate has Lapsed, subject to the
Conditions for Reinstatement provision.
Surrender Charge - A charge for any partial or full surrender of this Certificate made during a Surrender Charge
Period.
CCGUL3IN 13
Surrender Charge Period - The period from the Certificate Date that the Owner will incur Surrender Charges if a
partial or full surrender of this Certificate is made during this period. Any approved Face Amount increase will have
its own Surrender Charge Period beginning on the effective date of the increase.
Transamerica Life Insurance Company, the Company, we, us, or our – The insurer that underwrites this
coverage.
OWNERSHIP
You have certain rights while the Insured is living and this Certificate is in force, including but not limited to:
1. Changing the Beneficiary;
2. Changing the Face Amount;
3. Requesting a Loan;
4. Assigning any right or benefit under this Certificate;
5. Reinstating coverage that has Lapsed, subject to the Reinstatement provision;
6. Surrendering all or a portion of this Certificate;
7. Exercising an option under any Rider attached to this Certificate;
8. Continuing coverage under the Portability Option provision; and
9. Transferring ownership.
If you, as the Owner, are not the Insured, and you die before the Insured, the executor or administrator of your
estate will have these rights.
BENEFICIARY PROVISIONS
Who Receives the Death Benefit - If the Insured dies while this Certificate is in force, we will pay the Death
Benefit to the Beneficiary, subject to the provisions of this Certificate. The Beneficiary will be as designated on the
Application for this insurance coverage, unless changed as provided under the How to Change the Beneficiary
provision.
If a Beneficiary is Not Named in the Application or the Stated Beneficiary Dies - The interest of any
Beneficiary who dies before the Insured will end at the death of the Beneficiary. Except to the degree that benefits
have already been paid, the interest of any Beneficiary who dies at the time of, or within 30 days after, the Insured's
death will end at their death. If the interest of all named Beneficiaries has ended, or if a Beneficiary was not named
in the original Application, benefits will be payable to the Insured's survivors in the following order of preference:
1. Spouse or Other Adult Dependent;
2. Child(ren) (in equal amounts);
3. Parents (in equal amounts);
4. Siblings (in equal amounts);
5. The Owner; or
6. The executor or administrator of the Owner's estate.
The existence of multiple Beneficiaries will not increase the benefit payable.
Protection of the Death Benefit - To the extent permitted by law, the Death Benefit will not be subject to the
claims of the Beneficiary's creditors or to any legal process against the Beneficiary.
Facility of Payment - We may pay all or part of the Death Benefit to any person who paid any expense in
connection with the Insured's last illness or death. That person must give us a copy of the receipt describing the
expense and the amount paid for such expense. Reimbursement will not exceed $500. The Death Benefit will be
reduced by any payment made under this provision.
How to Change the Beneficiary - You may change the Beneficiary at any time while the Insured is living. The
change must be in writing on a form approved by us. The change will not be effective until the date it is recorded.
If the Insured is not living on the date the change is recorded, the change will be effective on the date you signed it.
However, any benefits paid before the change is recorded will not be subject to it.
CCGUL3IN 14
DEATH BENEFIT
Death Benefit Options - You have a choice of two different Death Benefit options -- Option A and Option B. If you
did not choose a Death Benefit option on the Application or Enrollment Form, Death Benefit Option A automatically
applies. The Death Benefit option will be shown on the Contract Data Pages. Once the Death Benefit Option has
been chosen, it cannot be changed.
Death Benefit Option A - The Death Benefit will be the greater of:
1. The Face Amount on the date the Insured dies; or
2. The Death Benefit factor multiplied by the Accumulation Value on the date of the Insured's death.
Death Benefit Option B - The Death Benefit will be the greater of:
1. The Face Amount plus the Accumulation Value on the date the Insured dies; or
2. The Death Benefit factor multiplied by the Accumulation Value on the date of the Insured's death.
The Accumulation Value is fully explained in the Contract Values section of this Certificate. You will find the Death
Benefit factors in the Tables section in the Contract Data Pages. The Death Benefit factors vary by the Insured's
Age and Class of Risk.
Adjustments to the Death Benefit - We will reduce the Death Benefit by: (1) the amount of any outstanding Loans
on the date the Insured dies; and (2) the monthly deduction s due during the Grace Period. The Death Benefit may
also be affected by partial surrenders, the election of a nonforfeiture option, or error in Age or tobacco use status.
Increase in the Face Amount - After this coverage has been in force for a year, you may, upon written request,
increase the Face Amount. Any increase will be subject to our underwriting requirements as well as the Suicide
Exclusion and Incontestability provisions in the General Provisions of this Certificate. Only one change to the Face
Amount will be allowed per year.
If we approve the request, the effective date of the increase will be the Monthly Date that coincides with or next
follows the date of our approval. The increase will have its own Surrender Charge Period, beginning on the
effective date of the increase.
Decrease in the Face Amount - After this coverage has been in force for a year, you may, upon written request,
decrease the Face Amount. The decrease will be applied to any increases in the reverse order in which they
occurred. However, no decrease in Face Amount will be allowed if the resulting Death Benefit would be less than
the minimum Death Benefit allowed by the Company. Only one change to the Face Amount will be allowed per
year.
The effective date of the decrease will be the Monthly Date that coincides with or next follows the date of the
request. We will not charge a Surrender Charge on the decrease. Instead, any subsequent Surrender Charge will
be based on the original Face Amount of this Certificate and the original Face Amount of any increase in Face
Amount.
Tax Qualification -- This Certificate is intended to qualify under Section 7702 of the Internal Revenue Code as a
life insurance certificate for federal tax purposes. The Death Benefit under this Certificate is intended to qualify for
the federal income tax exclusion. The provisions of this Certificate (and any attached Amendments, Endorsements,
or Riders) will be interpreted to ensure tax qualification, regardless of any language to the contrary. The Death
Benefit under this Certificate will never be less than the amount necessary to ensure tax qualification. If the Death
Benefit is increased, we will make appropriate adjustments in the monthly deduction s or supplemental benefits as
of that time, retroactively or otherwise, that are consistent with the increase. Such adjustments may be made by
right of offset against the Death Benefit.
CERTIFICATE EFFECTIVE DATE
The insurance under this Certificate will start on the Certificate Date if:
1. Your Application has been approved by us on or before such date;
2. All Insureds under this Certificate are living; and
3. The initial premium payment has been received by us.
CCGUL3IN 15
CERTIFICATE TERMINATION DATE
The insurance under this Certificate will stop on the earliest of:
1. The Monthly Date that coincides with or next follows the date we receive your written request to terminate
coverage;
2. The Maturity Date;
3. The date the Insured dies;
4. The date this Certificate Lapses, subject to the Grace Period provision; or
5. The date the Policy terminates, subject to the Portability Option provision.
Our acceptance of premium or deductions for any period after the date of termination of this certificate will not
create a liability for us nor will it constitute a waiver of the termination. Any such premium or deduction will be
returned.
PREMIUMS
Initial Premium - The initial premium is the amount due on or before the Certificate Date shown on the Contract
Data Pages and is payable in advance. All premiums are payable to our Administrative Office or to an agent
authorized by us to collect premiums.
Planned Premium Payments - The amount and frequency of the premium is shown on the Contract Data Pages.
However, premium payments are flexible and the Owner may change the amount and frequency of payments.
Interruption of planned premium payments or reduction of such payments may cause your coverage to enter the
Grace Period.
Minimum Monthly Premium - The minimum monthly premium requirements are described in the Grace Period
provision in the General Provisions section.
Premium Limitation - We reserve the right to limit the amount of unscheduled premiums paid if we determine that:
1. Payment of a greater amount may cause the Death Benefit to lose its tax status as life insurance under the
Internal Revenue Code;
2. Payment of a greater amount would increase the difference between the Death Benefit and the Accumulation
Value unless we are provided evidence of insurability satisfactory to us; or
3. Payment of a greater amount would exceed the Maximum Unscheduled Premium shown in the Contract Data
Pages.
An unscheduled premium is any premium paid in excess of the planned premium shown on the Contract Data
Pages or an increase in such planned premium.
REINSTATEMENT
Conditions for Reinstatement - If this Certificate Lapses, it may be Reinstated during the lifetime of the Insured,
provided it was not surrendered. To Reinstate this Certificate, we will require:
1. Your written request for Reinstatement within five years after the date of Lapse and before the Maturity Date;
2. The Insured's written consent for Reinstatement;
3. Evidence of insurability satisfactory to us;
4. Repayment of any Loans that existed when this Certificate lapsed, with interest compounded annually from the
date of lapse at the Loan Interest Rate shown in the Contract Data Pages; and
5. Payment of the Reinstatement Premium.
Reinstatement Premium - The Reinstatement Premium will be calculated as follows:
1. Two monthly deductions at the time of Lapse; plus
2. Three monthly deductions due at the time of Reinstatement; plus
3. Interest, compounded annually on this Reinstatement Premium at the Loan Interest Rate shown in the Contract
Data Pages; interest due will be calculated from the date this Certificate ended.
The Accumulation Value of the Reinstated Certificate will be:
1. Any Surrender Charge taken at the time of Lapse; plus
2.
Any Reinstatement Premium received less t
he expense charge; less
3. Any monthly deductions due.
CCGUL3IN 16
Any Loans that existed when the Certificate Lapsed will not be Reinstated.
The date of Reinstatement will be the Monthly Date on or following the date the Application for Reinstatement is
approved by us, so long as the Insured is still living. With respect to any Reinstated Certificate, the incontestability
period will be based only on statements made in any Reinstatement Application.
If the Certificate is Reinstated within a Surrender Charge Period, the Surrender Charges in effect for the Reinstated
Certificate and any increases in Face Amount will be based on the duration from the Effective Date of coverage to
the date of Lapse.
CONTRACT VALUES
Accumulation Value - The Accumulation Value on the Certificate Date is equal to the initial net premium received
minus the monthly deduction. Thereafter, the Accumulation Value will be determined on each Monthly Date after
the Certificate Date as follows:
The Accumulation Value as of the prior Monthly Date; plus
1. The interest earned for the prior month; plus
2. All net premiums received since the prior Monthly Date; less
3. All partial surrender amounts taken since the prior Monthly Date; less
4. The monthly deduction for the current month.
On any day between Monthly Dates, the Accumulation Value will be determined as follows:
1. The Accumulation Value as of the prior Monthly Date; plus
2. All net premiums received since the prior Monthly Date; less
3. All partial surrender amounts taken since the prior Monthly Date.
Net Premium - The net premium is any premium received less the expense charge. The guaranteed expense
charge is disclosed on the Contract Data Pages. We may use an expense charge lower than the guaranteed
expense charge, but will never charge in excess of the guaranteed expense charge.
Monthly Deduction - On the Certificate Date and each Monthly Date thereafter, a monthly deduction will be
withdrawn from the Accumulation Value. The monthly deduction is equal to:
1. The cost of insurance; plus
2. The Certificate fee; plus
3. The administrative fee, plus
4. Any charges for additional benefits provided by Riders.
Cost of Insurance (COI) - The COI is equal to the COI rate divided by 1,000, then multiplied by the difference
between:
1. The Death Benefit at the beginning of the Certificate month divided by 1.00246627; and
2. The Accumulation Value at the beginning of the Certificate month.
The COI rates are based on the Insured's Age and Class of Risk on the Certificate Date. A Table of Guaranteed
Monthly Cost of Insurance Rates is shown on the Contract Data Pages. We may use lower COI rates, but will
never exceed the guaranteed COI rates. Guaranteed COI rates are based on the Commissioners 2001 Standard
Ordinary Mortality Tables.
If you request an increase in the Face Amount, the COI rates for each Face Amount increase will be based on the
Insured's Age and Class of Risk on the effective date of the increase.
Certificate Fee - The guaranteed Certificate fee is shown on the Contract Data Pages. We may use a Certificate
fee lower than the guaranteed Certificate fee, but will never charge in excess of the guaranteed Certificate fee.
Administrative Fee - The administrative fee is calculated by multiplying the administrative fee per $1,000 by the
Face Amount divided by 1,000. The guaranteed administrative fee per $1,000 is shown on the Contract Data
Pages. We may use an administrative fee per $1,000 lower than the guaranteed administrative fee per $1,000 but
will never charge in excess of the guaranteed administrative fee per $1,000.
CCGUL3IN 17
Interest Rate - The guaranteed minimum interest rate for all Certificate years is shown in the Contract Data Pages.
We may use current interest rates greater than the guaranteed interest rate to calculate the Accumulation Value.
These interest rates will be declared by us. We may apply different interest rates to separate portions of the
Accumulation Value, including the amount of the Accumulation Value equal to any outstanding Loan. However, no
rate will be less than the guaranteed interest rate.
Cash Surrender Value - The Cash Surrender Value may be borrowed, applied under continuation of insurance, if
applicable, or taken in cash as a partial or full surrender of this Certificate. The Cash Value will always equal or
exceed the amount required by the law in effect at issue in the state in which the Policy is delivered.
LOANS
Interest Rate on Accumulation Value Securing Loans - The interest rate for any portion of the Accumulation
Value equal to the amount of any Loan will be at the effective annual interest rate shown in the Contract Data
Pages.
Loans - Upon written request, you may borrow up to the available Loan Value of your Certificate. Loans will be
secured by the most recent addition to the Accumulation Value. Our security interest in the Accumulation Value
has priority over the claims of any assignee or other person. Your Certificate is the sole security for all Loans.
Loan Value - The Loan Value of your Certificate is as follows:
1. The Cash Value; less
2. Any existing Loan; less
3. Loan interest payable in advance to the next Certificate Anniversary; less
4. Three monthly deductions.
If your total indebtedness equals or exceeds the Cash Value, your Certificate will not Lapse except in accordance
with the Grace Period.
Loan Interest - The Loan interest rate is shown in the Contract Data Pages. On each Anniversary, Loan interest
for the next year is due in advance. Interest not paid when due will be added to the Loan.
Loan Repayment - You may repay any part of a Loan at any time while this Certificate is in force. Each payment
must be at least $25, unless the Loan amount is less than $25, in which case full payment is required. All funds
received will be credited to this Certificate as a premium payment, unless clearly marked as a Loan repayment. On
the date received, Loan repayments will be applied to the portion of the Accumulation Value that is securing a
Loan.
PARTIAL SURRENDER
Partial Surrender - You may surrender a portion of this Certificate for its value by sending us a written request.
We will deduct a partial Surrender Charge and the amount requested from the Certificate's Accumulation Value. If
Death Benefit Option A applies, we will also deduct the partial Surrender Charge and the amount requested from
the Certificate's Face Amount. The resulting Face Amount may not be less than the minimum allowed by the
Company. No more than one partial surrender will be allowed in any Certificate year.
Reductions to the Face Amount due to any partial surrender will be in the following order:
1. To the most recent increase in the Face Amount;
2. To the next most recent increase in the Face Amount; or
3. To the initial Face Amount or the current Face Amount, if less.
The partial Surrender Charge is the greater of:
1. $25, or
2. The proportionate Surrender Charge.
The proportionate Surrender Charge will be calculated as follows:
1. The full Surrender Charge at the time of the request (see Table of Surrender Charges for your Class of Risk);
times
2. The partial surrender amount; divided by
3. The Cash Value.
CCGUL3IN 18
In any Certificate year, the minimum partial surrender is $500 and the maximum amount that you may request is:
1. The Cash Surrender Value; less
2. The sum of three monthly deductions.
Any request for an amount that would exceed the maximum described above will be treated as a request for full
surrender of this Certificate.
NONFORFEITURE OPTION
Full Surrender - You may surrender this Certificate for its Cash Surrender Value by sending us a written request.
Coverage under this Certificate will terminate upon full surrender.
Surrender Charge – The Surrender Charge is calculated as follows:
1. The Surrender Charge Base for the Insured’s Issue Age and Class of Risk; multiplied by
2. The applicable Contract Year percentage; multiplied by
3. The Face Amount; divided by
4. 1,000; and
5. Subtract the sum of all partial surrender charges paid to date.
The Surrender Charge Base and the Contract Year percentages appear in the Table of Surrender Charge Factors
found on the Contract Data Pages.
If an increase in the Face Amount is requested and approved, additional Surrender Charges will apply. The
Surrender Charge for any Face Amount increase is calculated as follows:
1. The amount of increase; divided by
2. 1,000; multiplied by
3. The product of the Surrender Charge Base and the Contract Year percentage based on:
a. The Insured’s Age and Class of Risk on the date of the increase; and
b. The number of years the increase was effective.
PAYMENT OF CASH VALUE AND LOANS
After we receive the written request for a surrender or Loan, we may defer the payment of partial or full surrender
values and the making of a Loan for a period of not more than six months. We will not delay any Loan made to pay
a premium due us.
CERTIFICATE STATEMENTS AND ILLUSTRATIONS
We will send you an annual statement showing the Face Amount, values, Loans, partial surrenders, premiums
paid, and any other charges as of the statement date. We will send you an illustration of this Certificate's benefits
and values upon receipt of your written request. We will provide one illustration annually without charge.
PORTABILITY OPTION
If the Insured loses eligibility for this insurance for any reason other than nonpayment of premiums, you will have
the option to continue this Certificate (including any riders) by paying the premiums directly to us at our
Administrative Office. We will bill you for these premiums. We may charge the guaranteed Certificate fee when we
direct bill for the premium. If you stop paying the premiums under this option, this Certificate (and any riders) will
continue subject to the terms of the Grace Period.
BASIS OF COMPUTATION
Reserves are not less than the required minimum reserves calculated using the reserve interest rate shown in the
Contract Data Pages. All of the values are equal to or greater than the minimum set by the governing jurisdiction. If
required, we have filed a detailed statement about this with the insurance department in the state in which the
Policy is issued. All values are based on 100% of the Commissioners 2001 Standard Ordinary Nonsmoker
Mortality Table, age last birthday for Nontobacco and 100% of the Commissioners 2001 Standard Ordinary Smoker
Mortality Table, age last birthday for Tobacco.
CCGUL3IN 19
GENERAL PROVISIONS
Adjustments in the Event of Clerical Error – Clerical error will not void insurance otherwise valid and in force,
nor will it continue or make insurance valid that otherwise would cease or would never have been issued.
Adjustments in the Event of Error in Age or Tobacco Use - If the Age or Tobacco Use status of the Insured is
misstated on the Application, we will adjust the Death Benefit to reflect the amount that the most recent monthly
deduction would buy at the Insured’s correct Age or Tobacco Use status.
Assignment - We are not responsible for whom you elect for any assignment. However, if you file an assignment
with us and it is recorded at our Administrative Office, your rights and the rights of the Beneficiary will be subject to
it.
Claims Procedure - Due proof of the Insured's death must be submitted to us at our Administrative Office. The
Beneficiary or a personal representative can get a claim form by calling our toll-free telephone number listed on the
cover page.
Conformity With State Laws – A provision of the Policy or Certificate that conflicts with a law of the governing
jurisdiction is hereby changed to meet the minimum standards of that law.
Dividends - This is nonparticipating insurance. It does not participate in our profits or surplus. We do not distribute
past surplus or recover past losses by changing the COI rates, Certificate fees, administrative fees, expense
charges or charges for additional benefits provided by Riders or declared interest rates.
Entire Contract; Changes – The Entire Contract consists of the Policy as issued to the Policyholder, the
Policyholder Application, the Certificate, and any attached Amendments, Endorsements, and Riders. Only an
officer of the Company may make any changes to the Policy or this Certificate and then only in writing. No agent or
Policyholder has authority to change the Policy or this Certificate or to waive any of its provisions. Any changes are
subject to the laws of the governing jurisdiction.
Grace Period – If the Cash Surrender Value on any Monthly Date is not sufficient to pay the next monthly
deduction, a Grace Period of 31 days will be provided beginning on such Monthly Date. Written notification will be
sent to your last known address on record at least 31 days prior to termination. If sufficient premium is not paid by
the end of the Grace Period, the Certificate will terminate without value. If the Insured dies during the Grace
Period, we will pay the Death Benefit, less any indebtedness and any unpaid monthly deduction. The Certificate
will Lapse if the total indebtedness equals or exceeds the Cash Value.
During the period beginning on the Certificate Date and ending on the Minimum Monthly Premium Date, as shown
on the Contract Data Pages, the Certificate will not enter the Grace Period if on any Monthly Date the sum of the
premiums that have been paid, less any indebtedness and partial surrenders, equals or exceeds the sum of all
minimum monthly premiums payable from the Certificate Date to the applicable Monthly Date.
The initial Minimum Monthly Premium is shown on the Contract Data Pages. The Minimum Monthly Premium is
increased for each Certificate month following the date of an increase in the Face Amount, or when a benefit rider
is added or increased. The Minimum Monthly Premium is decreased for each Certificate month following the date of
a decrease in the Face Amount or when a benefit rider is decreased or discontinued.
Right to Contest - We will not use any statement to void or reduce benefits after this Certificate has been in force
during the Insured's lifetime for two years from the Certificate Date. Any such statement would have to be in a
signed form. This also applies to all riders. Any increase in the Face Amount is subject to a new two-year
contestable period for the increased amount only.
All statements made are considered representations and not warranties. No such statement will be used in any
contest, unless a copy of such statement has been furnished to you.
Suicide Exclusion - We will not pay the Death Benefit if the Insured dies by suicide, while sane or insane, within
two years from the date coverage is issued. Instead, we will refund the premiums paid for this insurance minus any
outstanding Loans and partial surrenders. Any increase in the Face Amount is subject to a new two-year Suicide
Exclusion period for the increased amount only.
CCGUL3IN 20
Notices Given By Us - Any notice to be given by us will be sent to the Owner at the Owner's last known address
and any assignee of record.
CRLLT100 1
TRANSAMERICA LIFE INSURANCE COMPANY
Home Office: [Cedar Rapids, Iowa]
Administrative Office: [1400 Centerview Drive, PO Box 8063, Little Rock, Arkansas 72203-8063]
(Hereinafter called “the Company,” “we,” “us,” or “our”)
ACCELERATED DEATH BENEFIT FOR CHRONIC CONDITION RIDER
(Living Benefit Rider)
(Death Benefit, Face Amount, Cash Values and Loan Values, if any, will be reduced if an Accelerated Death Benefit is paid.)
SPECIAL NOTICE
Benefits received under this Rider may be taxable as income. Whether any tax liability is incurred when benefits
are paid under this Rider could depend on whether your employer has paid the premium, and how the Internal
Revenue Service interprets applicable provisions of the Internal Revenue Code. As with any tax matter, you and
any other recipient of this benefit should each consult an independent tax advisor to evaluate any tax impact of
this benefit.
Receipt of an Accelerated Death Benefit may adversely affect eligibility for Medicaid or other government benefits
or entitlements. Without exercising this option, the mere fact that this Rider is part of your contract will not, in and
of itself, affect the eligibility for these government programs. However, exercising this option before you apply for
these programs, or while you are receiving government benefits, may affect your continued eligibility. Contact the
Medicaid Unit of the local Department of Public Welfare and/or the Social Security Administration Office for more
information.
This Rider is attached to and made part of the contract as of the Rider Effective Date. It is issued in consideration
of the Application and payment of any required initial premium. All provisions of the contract not in conflict with the
provisions of this Rider will apply to this Rider. This Rider has no cash value.
NOTICE TO YOU, THE OWNER
FOR INFORMATION, OR TO MAKE A COMPLAINT, CALL [1-888-763-7474]
This Rider is not long term care insurance and does not provide long term care insurance, nor is it intended to
replace long term care insurance coverage. We advise you to review carefully all limitations of this Rider, as well
as those of the contract to which it is attached.
DEFINITIONS
In addition to the definitions contained in the contract, the following definitions apply to this Rider.
Activities of Daily Living – For the purposes of this Rider, each of the following activities is considered an
Activity of Daily Living:
Bathing - The Insured's ability to wash himself or herself by sponge bath; or in a tub or shower, including the
task of getting into and out of the tub or shower.
Continence – The Insured's ability to maintain control of bowel and bladder function; or, when unable to
maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including
caring for catheter or colostomy bag).
Dressing - The Insured's ability to put on and take off all items of clothing and any necessary braces,
fasteners or artificial limbs.
Eating - The Insured's ability to feed himself or herself by getting food into his or her body from a receptacle
(such as a plate, cup or table) or by a feeding tube or intravenously.
Toileting – The Insured's ability to get to and from the toilet, to get on and off the toilet, and to perform
associated personal hygiene.
Transferring - The Insured's ability to move into or out of a bed, chair or wheelchair.
Chronic Illness –
1. The inability, expected to be permanent, to perform, without Substantial Human Assistance, at least two
Activities of Daily Living for a period of at least 90 days; or
2. Severe Cognitive Impairment that is expected to be permanent and that requires Substantial Supervision to
protect the Insured from threats to his or her health and safety.
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Death Benefit Amount – The amount of the Death Benefit in effect on the date immediately following the date
the Insured first satisfies the Eligibility for Benefits provision.
Elimination Period – The number of consecutive days during which the Insured must meet the Eligibility for
Benefits requirements listed under the Benefits provision. During the Elimination Period no benefits are payable
under this Rider. The Elimination Period starts on the day the Insured’s Chronic Illness begins, as stated in a
Physician’s certification. The Elimination Period for this Rider is shown in the Contract Data Pages. The
Elimination Period needs to be satisfied only once during the Insured's lifetime.
Immediate Family Member – Anyone related to an Insured in the following manner: spouse, daughter, son,
stepchild, father, mother, stepparent, sister, brother, stepsister, stepbrother, grandchild, grandparent, father-in-
law, mother-in-law, or the spouse of any of these. The term “spouse” includes a common law marriage partner,
domestic partner, or civil union partner, if legally recognized in the governing jurisdiction.
Medicare – The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as then
constituted or later amended.
Physician –
1. A doctor of medicine or osteopathy as set forth in Section 1861(r)(1) of the Social Security Act, as amended,
who is legally authorized to practice medicine and surgery within the United States by the jurisdiction in which
he or she performs such function or action; and
2. Is not an Immediate Family Member.
Severe Cognitive Impairment – A deficiency in any of the following:
1. The Insured’s short-term or long-term memory;
2. Orientation as to person, place and time;
3. Deductive or abstract reasoning; or
4. Judgment as it relates to safety awareness.
Severe Cognitive Impairment is established by clinical evidence and standardized tests that reliably measure the
Insured’s loss. Severe Cognitive Impairment requires a deficiency comparable to (and including) Alzheimer’s
disease and similar forms of irreversible dementia.
Substantial Human Assistance – Actual hands-on assistance by another individual.
Substantial Supervision – Continuous, arms-length supervision, including but not limited to verbal cueing by
another individual to protect the Insured from harming himself, herself or others, or from threats to the Insured’s
health and safety.
Waiting Period – The period of time, immediately after the Rider Effective Date, which must be satisfied before
any sickness or condition which causes Chronic Illness first manifests itself. The Waiting Period is shown in the
Contract Data Pages. The Waiting Period does not apply to benefits payable for an Insured who has a Chronic
Illness due to an Accident. For purposes of this provision, an Accident means a sudden, unexpected, and
unintended injury that is independent of any illness or disease and occurs after the Rider Effective Date and while
this Rider is in force.
BENEFITS
Eligibility for Benefits – After the Waiting Period has been satisfied, we will pay an Accelerated Death Benefit
under this Rider after we receive written proof that the Insured has met all of the following conditions:
1. A Physician has certified that the Insured has a Chronic Illness;
2. The Insured has satisfied the Elimination Period; and
3. The contract to which this Rider is attached is in force.
Accelerated Death Benefit Options
You may choose one of the following options for submitting a claim for an Accelerated Death Benefit under this
Rider:
Option 1 – Monthly Accelerated Death Benefit – You may request a monthly Accelerated Death Benefit equal
to the applicable percentage of the Death Benefit Amount shown on the Contract Data Pages. This benefit is
payable for each month the Insured satisfies the Eligibility for Benefits provision while this Rider is in force. After
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submitting satisfactory proof of loss, in order to continue receiving the monthly benefit you must provide, every 90
days, a written certification by a Physician that the Insured continues to have a Chronic Illness.
Option 2 - One-Time Lump Sum Accelerated Death Benefit – In lieu of the monthly Accelerated Death Benefit,
you may request a one-time lump sum Accelerated Death Benefit payment equal to the applicable percentage
shown on the Contract Data Pages of the Death Benefit Amount. Upon payment of this lump sum benefit, your
rights under this Rider will end and this Rider will terminate.
Waiver of Monthly Deductions – We will waive the monthly deductions for each contract month or partial
contract month that you receive benefits under this Rider. If you elect the one-time lump sum Accelerated Death
Benefit option, this waiver provision will not apply.
EFFECT ON INSURED’S DEATH BENEFIT
If the Owner receives Accelerated Death Benefit payments in accordance with this Rider, we will deduct any
amounts paid under this Rider from the Death Benefit. The Beneficiary will receive any remaining amount of the
Death Benefit after the Insured dies, provided the contract has not terminated. However, if the entire Death
Benefit proceeds are paid under the terms of this Rider prior to the Insured's death, the Contract will terminate
and there will be no Death Benefit payable upon the Insured's death.
Each Accelerated Death Benefit payment will reduce the following contract values: Death Benefit; Face Amount;
Accumulation Value; Surrender Charge; Guaranteed Cash Value, if applicable; and outstanding Loan balance, if
any, as explained below.
The Death Benefit will be reduced by the amount of the Accelerated Death Benefit.
The Face Amount will be reduced by an amount equal to the reduction in Death Benefit multiplied by the ratio of
the Face Amount to the Death Benefit in effect immediately before the Accelerated Death Benefit payment is
made.
The Accumulation Value will be reduced by an amount equal to the reduction in Death Benefit multiplied by the
ratio of the Accumulation Value to the Death Benefit in effect immediately before the Accelerated Death Benefit
payment is made.
The Surrender Charge will be reduced by an amount equal to the reduction in Death Benefit multiplied by the ratio
of the Surrender Charge to the Death Benefit in effect immediately before the Accelerated Death Benefit payment
is made.
The Guaranteed Cash Value, if applicable, will be reduced by an amount equal to the reduction in Death Benefit
multiplied by the ratio of the Guaranteed Cash Value to the Death Benefit in effect immediately before the
Accelerated Death Benefit payment is made.
The outstanding Loan balance, if any, will be proportionally repaid by an amount equal to the reduction in Death
Benefit multiplied by the ratio of the outstanding Loan balance to the Death Benefit in effect immediately before
the Accelerated Death Benefit payment is made. The amount of this Loan balance repayment will be deducted
from the Accelerated Death Benefit payable to you.
If you elect monthly Accelerated Death Benefit payments under this Rider, the following conditions will apply
during the period that such payments are being made.
1. You cannot change the Face Amount or the Death Benefit option of the Contract, or add any Riders.
2. We will not accept any premium payments.
If monthly Accelerated Death Benefit payments are made, we will provide a monthly report that shows the effect
each benefit payment has on the contract values.
EXCLUSIONS AND LIMITATIONS
We will not pay Rider benefits if the Insured meets the requirements of the Eligibility for Benefits provision as a
result of:
1. Any sickness condition that begins before or during the Waiting Period.
2. An intentionally self-inflicted injury or attempted suicide.
3. War or any act of war, declared or undeclared, or service in the armed forces of any country.
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4. The Insured's alcohol, drug or other chemical dependence, except if the drug dependency is for a drug
prescribed by a Physician in the course of treatment for an injury or sickness.
5. The Insured's commission of, or attempt to commit, a felony; or an injury that occurs because of the Insured's
involvement in an illegal activity.
We will not pay an Accelerated Death Benefit on any other riders attached to the contract.
CLAIMS
The following Claims Procedures apply to this Rider.
Notice of Claim – Written notice of claim must be given to us at our Administrative Office or to our agent. Such
notice should be made within 30 days after a Physician determines the Insured has a Chronic Illness. If it is not
reasonably possible to give notice within that time, the claim may not be denied or reduced due to the delay, so
long as notice is given as soon as reasonably possible.
Claim Forms – Claim forms should be used for filing proof of loss. We will send such form to the claimant within
15 days of receipt of notice of claim. If we fail to supply the proper claim forms within 15 days, you can give proof
in writing, setting forth the nature and extent of the loss within the time stated in the proof of loss provision. You
or a personal representative may obtain a claim form by calling our toll-free telephone number listed on the cover
page of the contract. Such initial notice and ongoing written proof of loss must be sent within the time limit stated
in the following paragraph.
Proof of Loss – Due written proof of loss must be given to us at our Administrative Office. We must receive the
initial proof within 90 days after the expiration of the Elimination Period.
Failure to furnish such proof within such time will not invalidate nor reduce any claim if it was not reasonably
possible to furnish such proof and it was furnished as soon as reasonably possible. In any event, the proof
required must be given no later than one year from the time proof is otherwise required, unless the claimant was
legally incapacitated.
If you submit a claim under the Monthly Accelerated Death Benefit option, we will require subsequent proof of loss
to be submitted periodically after the Insured satisfies the Eligibility for Benefits provision. This means submitting,
every 90 days, certification by a Physician that the Insured continues to have a Chronic Illness.
Physical Examinations – We have the right to have an Insured examined by a Physician of our choice as often
as reasonably necessary while a claim is pending. We will pay for such examination.
Time of Payment of Claims – Benefits for a covered loss will be paid as soon as we receive due written Proof of
Loss.
Payment of Claims – Benefits are payable to the Owner or a payee designated by the Owner.
Legal Actions - No legal action may be brought to recover under the contract within 60 days after written proof of
loss has been provided to us as required nor more than three years from the time written proof of loss is required
to be furnished.
GENERAL RIDER PROVISIONS
Consent For Benefit Payment – If there is an assignment of this contract on record or an irrevocable Beneficiary
on record, we must obtain the consent of any assignee or irrevocable Beneficiary before any Rider benefit is paid.
Contestability – This Rider will be contestable on the same basis as the contract, during the lifetime of the
Insured, for two years from the Rider Effective Date.
Suicide – If the Insured dies by suicide, while sane or insane, within two years from the Rider Effective Date, any
premiums refunded under the Suicide Exclusion provision of the contract will be reduced by the amount of
Accelerated Death Benefits paid, if any, under this Rider.
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RIDER COST
The initial monthly charge and the guaranteed monthly charge for this Rider are shown in the Contract Data
Pages. We may use monthly charges lower than the guaranteed monthly charge but will not use charges higher
than the guaranteed amount.
RIDER EFFECTIVE DATE
This Rider becomes effective on the same date as the contract unless we inform the Owner in writing of a
different date.
TERMINATION
This Rider will terminate on the earliest of the following dates or events:
1. The date the contract terminates;
2. The date the contract Lapses, subject to the Grace Period;
3. The date the Owner requests termination;
4. The date the Insured dies;
5. The date on which cumulative monthly Accelerated Death Benefit payments equal 100% of the Death Benefit
Amount, subject to any rights under an optional Extension of Benefits Rider;
6. The date on which we pay a one-time lump sum Accelerated Death Benefit payment in lieu of any monthly
Accelerated Death Benefit;
7. The date a Nonforfeiture Option under the contract, if any, becomes effective.
This Rider is signed for the Company at our Home Office to take effect on the Rider Effective Date.
[ ] []
[General Counsel and Secretary] [President]
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TRANSAMERICA LIFE INSURANCE COMPANY
Home Office: [Cedar Rapids, Iowa]
Administrative Office: [1400 Centerview Drive, PO Box 8063, Little Rock, Arkansas 72203-8063]
(Hereinafter called “the Company,” “we,” “us,” or “our”)
EXTENSION OF BENEFITS RIDER
This Rider is attached to and made part of the contract as of the Rider Effective Date. It is issued in consideration
of the Application and payment of any required initial premium. All provisions of the contract not in conflict with the
provisions of this Rider will apply to this Rider. Capitalized terms not defined in this Rider have the definitions
given in the contract. This Rider has no cash value.
BENEFITS
This Rider extends benefits under the contract and the Accelerated Death Benefit for Chronic Condition Rider,
as explained in detail below.
Death Benefit Increases – We will increase the Death Benefit by a percentage of the Death Benefit that was in
force on the date the first monthly Accelerated Death Benefit was paid under the Accelerated Death Benefit for
Chronic Condition Rider, subject to all of the following requirements.
1. The Insured must be alive and continue to satisfy the Eligibility for Benefits provision of the Accelerated
Death Benefit for Chronic Condition Rider.
2. The entire Death Benefit must have been paid under the Accelerated Death Benefit for Chronic Condition
Rider before this Rider can be exercised.
3. The cumulative Death Benefit increases under this Rider will not exceed 100% of the Death Benefit that was
in force on the date the first monthly Accelerated Death Benefit was paid under the Accelerated Death
Benefit for Chronic Condition Rider.
4. Additional monthly Death Benefit increases under this Rider will be allowed and become effective the month
immediately following the date the entire previous Death Benefit increase has been paid under the
Accelerated Death Benefit for Chronic Condition Rider.
5. You may not have elected to receive a one-time lump sum accelerated death benefit payment under the
Accelerated Death Benefit for Chronic Condition Rider.
The percentage of the Death Benefit that will be used to determine the increase amount is shown on the
Contract Data Pages.
If you have elected to receive a one-time lump sum accelerated death benefit payment under the Accelerated
Death Benefit for Chronic Condition Rider, we will increase such lump sum payment by a percentage of the
Death Benefit as of the Monthly Date immediately following the date the Elimination Period, as defined in the
Accelerated Death Benefit for Chronic Condition Rider, has been satisfied. Such percentage is shown in the
Contract Data Pages. All other provisions of the Accelerated Death Benefit for Chronic Condition Rider related
to the one-time lump sum benefit will apply to this increased lump sum benefit. After payment of this increased
lump sum benefit, all your rights under this Rider will end and this Rider will terminate.
[Paid-Up Benefit
– As soon as the first increase is applied under this Rider, we will issue a paid-up certificate for
a percentage of the Death Benefit that was in force on the date the first monthly Accelerated Death Benefit was
paid under the Accelerated Death Benefit for Chronic Condition Rider. The percentage that will be used to
calculate the paid-up amount is shown on the Contract Data Pages. This paid-up insurance will have no cash or
loan values. We will not provide this paid-up life insurance benefit if you elect to receive a one-time lump sum
benefit under the Accelerated Death Benefit for Chronic Condition Rider.]
RIDER COST
The initial monthly charge and the maximum monthly charge for this Rider are shown in the Contract Data Pages.
We may use monthly charges lower than the maximum charge but will not use charges higher than the maximum.
RIDER EFFECTIVE DATE
This Rider becomes effective on the same date as the contract unless we inform the Owner in writing of a
different date.
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TERMINATION
This Rider will terminate on the earliest of:
1. The date the contract terminates;
2. The date the contract Lapses, subject to the Grace Period;
3. The date the Owner requests termination;
4. The date the Insured dies;
5. The date, after the entire Death Benefit has been paid under the Accelerated Death Benefit for Chronic
Condition Rider, when the Insured no longer satisfies the Eligibility for Benefits provision;
6. The date the cumulative Death Benefit increases under this Rider total 100% of the Death Benefit in force on
the date the first monthly Accelerated Death Benefit was paid under the Accelerated Death Benefit for
Chronic Condition Rider;
7. The date a Nonforfeiture Option under the contract, if any, becomes effective; or
8. The date we pay you a one-time lump sum payment under the Accelerated Death Benefit for Chronic
Condition Rider.
This Rider is signed for the Company at our Home Office to take effect on the Rider Effective Date.
[ ] [ ]
[General Counsel and Secretary] [President]