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Instructions for Total and Permanent

Disability Claim Form

NOTICE TO THE CLAIMANT:

This section contains important information concerning your claim for the waiver of premium benefit due to

total and permanent disability. Before you file your claim, please take a few moments to review the

requirements listed below. By doing so, you may save yourself the time and expense of filing a claim

prematurely or unnecessarily.

In order to qualify for the waiver of premium benefit due to total and permanent disability:

1)

The policy must contain the waiver of premium benefit on the life of the insured filing the claim.

2)

The insured must be totally and continuously disabled (uninterrupted disability for at least 6

months which prevents the Insured from engaging in his own occupation for the first 2 years

and from any gainful occupation, employment or business thereafter).

3)

The policy and the Total Disability Waiver (TDW) rider must be in force (premium paying) at the

time of total and permanent disability.

4)

The insured must furnish medical evidence of total and permanent disability.

5)

If disability begins on or after age 60 and before age 65, each premium will be waived up to

age 65 only and after which all premiums will then become payable. Each premium waived will

be the modal premium in effect when total disability begins.

While your disability claim is pending, please continue to pay the premiums in the usual manner to keep

your policy in force.

For more detailed explanation of the coverage provided by the waiver of premium provision, please refer to

your TDW contract. If you have any questions concerning your policy coverage, your servicing agent will

be happy to assist you or may call our Claims & Settlement Department at Tel. No. (632) 884-5427 or 8845429 or toll free at 1-800-1888-6268.

Instructions:

1)

Complete and sign the Claimant’s Statement of Total and Permanent Disability form. This form

should be signed by the insured, if possible. If someone...