Certificate of Insurance Template

Policy Information

Policy Number

123123

Date

January 4, 2019

General Information

Policy Initial Owner / Applicant

John Michaels Smith

Birthplace of Applicant

San Francisco

Birthday of Applicant

January 13, 1979

Residence Address of Applicant

textbox_sample5, textbox_sample6

textbox_sample7, textbox_sample8, textbox_sample9

Bahrain

Email Address

test@test.com

Age of the Applicant at issuance of policy

Name of Employer

Interlogy, Llc.

Nature of Business

test org

Estimated Annual Income

2000000

Home Phone

(123) 123-1231

Mobile Phone

(12312) 123-123123

Business Phone

(12312) 123-123123

Business Address

123 rodeo drive

City of Angels, C.A., 12131

Philippines

Information of the person's life insured

Name of Life Insured

Angela Williams Smith

Birthday of Insured

Tuesday, January 11, 1983

Birthplace of Insured

San Antonio

Residence Address of Insured

123 rodeo drive, Addr2

City 3, State 4, 1231

Philippines

Age of the Insured at issuance of policy

Email Address

john@example.com

Certificate of Insurance Template

Name of Employer

Employer name

Nature of Business

SASS

Estimated Annual Income

160000

Business Phone

(123123) 123-123112

Mobile Phone

(123) 123123

Home Phone

(123) 123123

Business Address

23042 N Main St., textbox_sample6

Prairie View, IL, 60069-0000

Bahrain

Policy Details

Effectivity Date

Wednesday, January 2, 2019

Maturity Date

Sunday, January 2, 2050

Beneficiary

Named Primary Beneficiary

Relationship

Named Secondary Beneficiary

Relationship

Summary of benefits payable

Basic Benefit Premium

10000

Accidental Death

800

Total Disability

500

Total Annual Premium Payable

11300

Certificate of Insurance Template

Acknowledgement

I acknowledge that I have applied with Signature Insurance, Inc. for an Insurance Policy an have reviewed the provisions shoiwng how a life insurance policy performs using the company's assumptions based on the Insurance Commissioner's guidelines on interest rates.

I likewise understand that the performance of fund may vary, the values of my units are not guaranteed and will depend on the actual performance of a given period. The value of my policy could be less than the premiums paid.

I understand that the risks of invesment under this policy shall be borne by me, as the policy owner.

Name of Applicant

John Michaels Smith

Date signed

Friday, January 4, 2019

Certificate of Insurance Template

Provisions

The Contract

The proposals, the application form, any endorsements and amendments agreed upon in writing after this policy is issued shall constitute the entire Contract. The benefits payable shall be based on the performance fo the investment funds chosen by you.

Effectivity

The effectivity of this policy initiates upon the initial payment of its Premium and the delivery of the Policy to the Owner while the Insured is in good health.

Currency and Place of Payment

All amounts payable either to or by us will be in the currency specified in the Policy details. Acceptance of placement of payments shall be at any of our offices or such other location as determined by us from time to time

Incontestability

After two years from the time of effectivity or from last reinstatement of the contract, the said contract shall be incontestable except for non-payment of Premium and Insurance Charges or any other ground recognized by law.

Suicide

No liability shall be borned by the Company if in case the life insured dies by suicide. However, if the death by suicide happens in the state of insanity, the life insured shall be compensated regardless of the date of the commission, within the period of effectivity of this Policy.

In case the death benefit is not payable, the liability of the Company shall be limited to:

The Basic Premium
The value of the account based on the Unit price of the relevant fund, not including bonuses.
Premiums paid under any part of the Contract for which the benefit of death is not payable.

Certificate of Insurance Template

Beneficiaries

The assigned or named beneficiaries shall be as named or assigned in the application.

The benefit proceeds are payable to the Beneficiaries named, or in his absence, the Contingents. In cas no beneficiary is indicated, the benefit proceeds shall be payable to the life insured, if living, or to his estate.

Separability Clause

Should any provision of this Contract be held invalid by any competent court, the same shall apply only to the provision involved and the remaining provisions hereto shall remain valid and enforceable.

Agreement Modification

No modification or alteration of this Contract shall be considered as having been made unless executed in writing and duly signed by the parties hereto.

Signature of President

Signature of Corporate Secretary