Form 140 Dividend Option Change Catholic Order Of Foresters Page 4

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BRINGING CATHOLIC VALUES TO LIFE!

DEFINITIONS

A Catholic Fraternal Benefit Life Insurance Society Since 1883

FOR QUESTIONS, PLEASE CONTACT INSURANCE SERVICES AT 800-552-0145.

Mailing address: Catholic Order of Foresters, 355 Shuman Blvd., PO Box 3012, Naperville, IL 60566-7012

PAID IN CASH

The Policy Owner receives a check by mail for the earned dividends each year, following the policy’s anniversary date.

ACCUMULATE AT INTEREST

Catholic Order of Foresters retains the policy’s earned dividends at an interest rate determined by the High Court.

The dividends accumulate as a part of the policy’s value. The Owner may withdraw dividends at any time upon

signed request.

PAID-UP ADDITIONS

The policy’s annual dividend is used to purchase additional Single Premium Paid-Up Insurance. The Owner may

withdraw dividends at any time upon signed request, but forfeits additional Paid-Up Insurance once the withdrawal

request is made.

SHORTENED PAY PERIOD

Not available with Genesis Life. Each year, prior to the policy’s anniversary date, the annual premium is paid using

the dividends earned. To use this option, dividends must remain in the account. Dividend values are based on current

rates, are not guaranteed and subject to change. If the dividend account drops below the premium due or the dividend

rate changes, the Owner may again be responsible for out-of-pocket premium payments.

DIVIDENDS TO REDUCE PREMIUM

Not available with Pre-Authorized Checking Plan (PAC) mode. Applies the current-year dividends earned to the

premium amount and bills the Owner for any difference. Dividend values are based on current rates, are not

guaranteed and subject to change. If the dividend rate changes, the Owner may have to pay the full premium

amount due.

INTERNAL PAID-UP INSURANCE

Only offered for the Genesis Life product. The policy’s annual dividend amount is used to convert ordinary

insurance to Paid-Up Insurance. The Owner may withdraw Internal Paid-Up Insurance at any time upon signed

request, but forfeits additional Paid-Up Insurance once the withdrawal request is made.

Option may result in a taxable event. COF does not provide tax advice and you should contact your tax advisor prior to completing this form for specific questions.

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Form 140 (5/15) 15-05-039A