EXHIBIT A 

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IN THE UNITED STATES DISTRICT COURT

FOR THE WESTERN DISTRICT OF TEXAS

SAN ANTONIO DIVISION

ANNA GONZALEZ and RONALD K. PAGE, 

on behalf of themselves and all others similarly 

situated,

Plaintiffs,

v.

STATE FARM LIFE INSURANCE 

COMPANY,

Defendant.

Civil Action No. SA-20-CV-617-FB

FIRST AMENDED CONSOLIDATED CLASS ACTION COMPLAINT

AND DEMAND FOR JURY TRIAL

Plaintiffs Anna Gonzalez and Ronald K. Page (“Plaintiffs”), individually and on behalf of 

all others similarly situated, for their First Amended Consolidated Class Action Complaint against 

Defendant State Farm Life Insurance Company (“Defendant” or “State Farm”), state and allege as 

follows:

INTRODUCTION

1. This is a class action to recover amounts that Defendant charged and collected from 

Plaintiffs and other similarly situated life insurance policy owners in excess of amounts authorized 

by the express terms of their policies. Plaintiffs’ claims and those of the proposed class members 

are exclusively supported by the explicit provisions of their life insurance policies and are not 

derived from any alleged conversations had, or documents reviewed, at the time of sale.

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2. The terms of Plaintiffs’ life insurance policy provide for an “Account Value” 

consisting of monies held in trust by Defendant for Plaintiffs. Over the course of several years, 

Defendant deducted monies from Plaintiffs’ Account Value in breach of their policies’ terms. 

3. Defendant is contractually bound to deduct only those charges explicitly identified 

and authorized by the terms of its life insurance policies, which are fully integrated agreements. 

Defendant deducts charges from the Account Values of Plaintiffs and the proposed class members 

in excess of amounts specifically permitted by their life insurance policies.

4. Defendant has caused material harm to Plaintiffs and the proposed class members 

by improperly draining monies they accumulated in the Account Values of their policies. Every 

unauthorized dollar taken from policy owners is one less dollar on which policy owners earn 

interest and one less dollar that can be: applied to pay future premiums; used to increase the death 

benefit; used as collateral for policy loans; or withdrawn as cash. 

5. Plaintiffs bring this case as a class action under Federal Rule of Civil Procedure 23, 

individually and as representatives of the following (the “Class”): All persons who own or owned 

a universal life policy issued by State Farm on its policy form 94030 in the State of Texas.

PARTIES

6. Plaintiff Ronald K. Page is an individual and resident of the State of Texas.

7. Plaintiff Anna Gonzalez is an individual and resident of the State of California.

8. Defendant State Farm Life Insurance Company is a life insurance company 

organized and existing under the laws of the State of Illinois, and maintains its principal place of 

business in Bloomington, Illinois.

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JURISDICTION AND VENUE

9. This Court has jurisdiction over all causes of action asserted herein pursuant to 

28 U.S.C. § 1332(d) because this is a class action with diversity of citizenship between parties 

and the matter in controversy exceeds $5,000,000, exclusive of interest and costs, and the 

proposed Class contains more than 100 members. 

10. Venue is proper in this Court pursuant to 28 U.S.C. § 1391 because Defendant is 

a resident of this District and a substantial portion of the events giving rise to Plaintiffs’ causes 

of action occurred in this District.

FACTUAL BACKGROUND

11. Plaintiff Page owns a flexible premium adjustable insurance policy issued by 

Defendant in Texas and bearing the policy number LF-1518-9386, and a policy date of February 

3, 1997, with an initial basic amount of $100,000. A true and accurate copy of Plaintiff Page’s 

policy is attached hereto as Exhibit A and incorporated herein by reference. Plaintiff Page is both 

the “owner” and “insured” under his policy.

12. Plaintiff Gonzalez owns a flexible premium adjustable insurance policy issued by 

Defendant in Texas and bearing the policy number LF-2153-7359, and a policy date of May 17, 

2004, with an initial basic amount of $100,000. A true and accurate copy of Plaintiff Gonzalez’s 

policy is attached hereto as Exhibit B and incorporated herein by reference. Plaintiff Gonzalez 

is both the “owner” and “insured” under her policy.1

13. Defendant is the effective and liable insurer of the Policies.

1 The relevant provisions of Plaintiff Page’s and Plaintiff Gonzalez’s policies (hereinafter referred 

to as “Policy” or “Policies”) are the same. Therefore, references are only made as to Plaintiff 

Page’s Policy, attached hereto as Exhibit A. 

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14. The Policies are valid and enforceable contracts between Plaintiffs and 

Defendant.

15. “The [P]olicy is the entire contract,” and it consists of “the Basic Plan, any 

amendments, endorsements, and riders, and a copy of the application.” Ex. A at p. 12.

16. The terms of the Policies are not subject to individual negotiation and are 

materially the same for all policy owners. They cannot be altered by an agent’s representations 

at the time of sale. 

17. The Policies provide that, “[o]nly an officer has the right to change this policy. 

No agent has the authority to change the policy or to waive any of its terms. All endorsements, 

amendments, and riders must be signed by an officer to be valid.” Ex. A at p. 12.

18. Defendant administered and currently administers all aspects of the Policies, and 

all policies that fall within the Class definition set forth above, including collecting premiums 

and setting, assessing and deducting policy charges.

19. In addition to a death benefit, the Policies provide policy owners a savings, or 

interest-bearing, component that is identified in the Policies as the “Account Value.” 

20. Generally speaking, premium dollars are deposited into the Account Value, from 

which Defendant deducts those monthly charges authorized by the terms of the Policies. The 

Account Value earns interest as provided by the Policies. 

21. The money that makes up the Account Value is the property of the policy owner 

and is held in trust by Defendant. 

22. Under the express terms of the Policies, a “premium expense charge” is taken 

from each premium payment in the amount of 5% of each premium paid. Ex. A at p. 3.

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23. The Account Value is equal to 95% of the initial premium less the monthly 

deduction for the first policy month, and thereafter:

The account value on any deduction date after the policy date is the account value 

on the prior deduction date:

(1) plus 95% of any premiums received since the prior deduction date,

(2) less the deduction for the cost of insurance for any increase in Basic Amount 

and the monthly charges for any riders that became effective since the prior 

deduction date,

(3) less any withdrawals since the prior deduction date,

(4) less the current monthly deduction,

(5) plus any dividend paid and added to the account value on the current 

deduction date, and

(6) plus any interest accrued since the prior deduction date.

The account value on any other date is the account value on the prior deduction 

date:

(1) plus 95% of any premiums received since the prior deduction date,

(2) less the deduction for the cost of insurance for any increase in Basic Amount 

and the monthly charges for any riders that became effective since the prior 

deduction date,

(3) less any withdrawals since the prior deduction date, and

(4) plus any interest accrued since the prior deduction date.

Ex. A at p. 9. 

24. The “Policy Date” is “[t]he effective date of this Policy,” and the “Deduction 

Date” is “[t]he policy date and each monthly anniversary of the policy date.” Ex. A at p. 5. 

Therefore, the Deduction Date under Plaintiff Page’s Policy is the 3rd of each month. Ex. A. at 

p. 3.

25. Defendant may access and withdraw funds from the Account Value only as 

expressly authorized by the Policies.

26. The Policies expressly define the specific charges that Defendant may assess and 

deduct from a given policy owner’s premium payments and the accumulated Account Value. 

Defendant may deduct only those charges allowed by the Policies.

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27. The Policies authorize Defendant to take a “Monthly Deduction” from the policy 

owner’s Account Value each month. Ex. A at p. 9.

28. The Policies expressly define the Monthly Deduction as follows:

Monthly Deduction. This deduction is made each month, whether or not premiums 

are paid, as long as the cash surrender value is enough to cover that monthly 

deduction. Each deduction includes:

(1) the cost of insurance,

(2) the monthly charges for any riders, and

(3) the monthly expense charge.

Ex. A at p. 9.

29. The Policies state that the monthly expense charge (“Expense Charge”) is $5.00. 

Ex. A at p. 3.

30. The Policies also expressly define how the charge for the monthly “Cost of 

Insurance” (“Cost of Insurance Charge”) is determined and calculated:

Cost of Insurance. This cost is calculated each month. The cost is determined 

separately for the Initial Basic Amount and each increase in Basic Amount.

The cost of insurance is the monthly cost of insurance times the difference between 

(1) and (2), where:

(1) is the amount of insurance on the deduction date at the start of the month 

divided by 1.0032737, and

(2) is the account value on the deduction date at the start of the month before 

the cost of insurance and the monthly charge for any waiver of monthly 

deduction benefit rider are deducted.

Until the account value exceeds the Initial Basic Amount, the account value is part 

of the Initial Basic Amount. Once the account value exceeds that amount, if there 

have been any increases in Basic Amount, the excess will be part of the increases 

in order in which the increases occurred.

Ex. A at p. 10.

31. The Policies specify the factors Defendant may use to determine “Monthly Cost 

of Insurance Rates,” which are used to calculate the Cost of Insurance Charges that are deducted 

from the Account Value each month:

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Monthly Cost of Insurance Rates. These rates for each policy year are based 

on the Insured’s age on the policy anniversary, sex, and applicable rate class. A 

rate class will be determined for the Initial Basic Amount and for each increase. 

The rates shown on page 4 are the maximum monthly cost of insurance rates for 

the Initial Basic Amount. Maximum monthly cost of insurance rates will be 

provided for each increase in the Basic Amount. We can charge rates lower than 

those shown. Such rates can be adjusted for projected changes in mortality but 

cannot exceed the maximum monthly cost of insurance rates. Such adjustments 

cannot be made more than once a calendar year.

Ex. A at p. 10.

32. Defendant admits that a rate “based on” factors explicitly identified in the Policies 

must be determined using only those factors identified and no other unidentified factors. See 

Alleman v. State Farm Life Ins. Co., 334 F. Appx. 470, 472 (3d Cir. 2009) (affirming summary 

judgment in State Farm’s favor and rejecting plaintiff insured’s argument that a provision in the 

life insurance policy stating a charge would be “based on the Insured’s age last birthday and sex” 

should be read to include other undisclosed factors, because “[b]y the plain language of these 

policies, it is clear that the insureds’ age and sex are the only mortality factors relevant to the rate 

....”) (emphasis added).

33. Thus, under the explicit terms of the Policies, Defendant is authorized to determine 

Monthly Cost of Insurance Rates for each policy year using only the Insured’s age, sex, applicable 

rate class, and projected changes in mortality. Ex. A. at p. 10. 

34. Policy year, age, sex, and rate class are factors commonly used within the life 

insurance industry to determine the mortality expectations of an insured or group or class of 

insureds.

35. By specifically identifying Cost of Insurance Rates for each policy year as based 

on age, sex, and rate class and no other factors, Defendant agrees that mortality expectations 

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determine the Monthly Cost of Insurance Rates under the Policies, as confirmed by the additional 

provision that “[s]uch rates can be adjusted for projected changes in mortality.” Ex. A at p. 10.

36. Given the language of the Monthly Cost of Insurance Rates provision in the 

Policies, and its context in the Policies as a whole, no reasonable layperson would expect that the 

Policies permitted Defendant to use any factor it wanted to determine Cost of Insurance Rates for 

the Policies. A reasonable layperson would instead read policy year, age, sex, and rate class, in 

combination with the contractual limitation that rates can only be adjusted for “projected changes 

in mortality,” to mean that only mortality expectations are used to determine Monthly Cost of 

Insurance Rates for the Policies. 

37. The Policies authorize Defendant to make periodic deductions from policy owners’ 

Account Values including, specifically, Cost of Insurance Charges that are calculated using rates 

that Defendant must determine based on specified factors, and that can be adjusted for projected 

changes in mortality.

38. The Policies also disclose a premium expense charge set at a fixed percentage of 

five percent of each premium payment made. The Policies further disclose a separate, monthly 

expense charge within the Monthly Deduction that Defendant set at a fixed amount of $5.00 per 

month.

39. Although the Policies authorize Defendant to use only certain, specified factors in 

determining Monthly Cost of Insurance Rates, Defendant uses other factors, not authorized by the 

Policies, when determining those rates, including, without limitation, profits and expenses.

40. By loading these factors into Monthly Cost of Insurance Rates, Defendant 

knowingly causes those rates to be higher than what is explicitly authorized by the Policies and, 

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as a result, withdraws Cost of Insurance Charges from policy owner Account Values in amounts 

greater than what is permitted by the Policies. 

41. By loading unauthorized factors in Monthly Cost of Insurance Rates, Defendant 

repeatedly and continuously breaches the Policies and impermissibly inflates those rates. 

42. As a direct and proximate result of Defendant’s breaches, Plaintiffs and the Class 

have been damaged, and those damages are continuing in nature in that Defendant deducted and 

will continue to deduct unauthorized Cost of Insurance Charges from policy owners’ Account 

Values.

43. By loading expense factors in Monthly Cost of Insurance Rates, Defendant 

repeatedly and continuously breaches the Policies by impermissibly deducting from the Account 

Values of Plaintiffs and the Class amounts in excess of the fixed expense charges expressly 

authorized by the Policies. 

44. As a direct and proximate result of Defendant’s breaches, Plaintiffs and the Class 

have been damaged and those damages are continuing in nature in that Defendant has deducted 

and will continue to deduct expenses, including without limitation, maintenance, administrative, 

and other expenses, from the Account Values of Plaintiffs and the Class in amounts not authorized 

by the Policies.

45. The nature of Defendant’s conduct is such that Plaintiffs and each member of the 

Class would be unaware that Defendant was engaging in wrongdoing by taking inflated charges 

and improper amounts from their Account Values. Defendant possesses the actuarial information 

and equations underlying the computation of rates and charges for the Policies. The Monthly Cost 

of Insurance Rates used to calculate the monthly Cost of Insurance Charges are not disclosed to 

policy owners, nor are the components or factors that comprise those rates. Even if they were, 

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Plaintiffs and the Class would lack the knowledge, experience, and training to reasonably ascertain 

how Defendant calculated the rates and charges. 

46. Defendant was aware that Plaintiffs and each member of the Class did not know 

about the improper deductions because of Defendant’s superior knowledge of the aforementioned 

computations. Defendant sent Plaintiffs annual statements that identified each month’s Cost of 

Insurance Charge while affirmatively concealing the factors Defendant used to calculate the Cost 

of Insurance Rates. Moreover, Defendant provided Plaintiffs illustrations that refer to the Cost of 

Insurance Charges as “current mortality charges” and “current mortality,” yet did not disclose the 

factors Defendant used to calculate the Cost of Insurance Rates. Despite reasonable diligence on 

their part, Plaintiffs were kept ignorant by Defendant of the factual bases for these claims for relief. 

Defendant’s withholding of material facts concealed these claims and tolled all applicable statutes 

of limitation.

47. Plaintiffs reasonably relied to their detriment on Defendant’s fraudulent 

concealment of its misconduct and material omission of the factors actually used to calculate the 

deductions from their Account Values. As a result of such concealment, Plaintiffs did not believe 

that they had suffered any injury or that it was necessary to file a lawsuit. Plaintiffs did not 

discover, and exercising reasonable diligence could not have discovered, the facts establishing 

Defendant’s continuing breaches or the harm caused thereby. 

48. Defendant is estopped from asserting a statute of limitations defense. Defendant’s 

conduct in failing to disclose the true factors it used—and continues to use—to calculate the Cost 

of Insurance Rates misled Plaintiffs and prevented them from learning the factual bases for these 

claims for relief. Plaintiffs proceeded diligently to file suit once they discovered the need to 

proceed. Defendant’s continuing breaches of the Policies are ongoing.

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CLASS ALLEGATIONS

49. Plaintiffs bring this lawsuit under Fed. R. Civ. P. 23, individually and as 

representatives of the following Class: All persons who own or owned a universal life policy 

issued by State Farm on its policy form 94030 in the State of Texas.

50. Excluded from the Class is the Defendant, any entity in which the Defendant has 

a controlling interest, any of the officers, directors, or employees of the Defendant, the legal 

representatives, heirs, successors, and assigns of the Defendant, any State Farm independent 

contractor insurance agents, anyone employed with Plaintiffs’ counsel’s firms, any Judge to 

whom this case is assigned, and the Judge’s immediate family. Excluded from the Class is any 

policy that explicitly discloses all of the factors Defendant uses to calculate its rates and charges.

51. Plaintiffs’ claims satisfy the numerosity, commonality, typicality, and adequacy 

requirements of Federal Rule of Civil Procedure 23(a), and the requirements for class treatment 

under Rules 23(b)(1), (b)(2), and (b)(3). 

52. The numerosity requirement is satisfied because there are thousands of Class 

members who are geographically dispersed, making joinder impracticable, and the disposition of 

Class member claims in a single action will provide a substantial benefit to all parties and to the 

Court. 

53. Class members are ascertainable from information and records in Defendant’s 

possession, custody, or control. Notice of this action can therefore be readily provided to the 

Class, via first class mail or other appropriate means, using information contained in Defendant’s 

records. 

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54. Plaintiffs’ claims are typical of the claims of the Class, because the express terms 

of the Policies purchased from Defendant by Plaintiffs and proposed Class members contain 

identical limitations on the amounts Defendant can charge under the Policies.

55. Plaintiffs will fairly and adequately represent the Class because they are members

of the Class and their interests are aligned with, and do not conflict with, the interests of those 

they seek to represent. The interests of the Class members will be fairly and adequately protected 

by Plaintiffs and their counsel, who have extensive experience prosecuting complex class 

litigation.

56. There are questions of fact and law common to the Class that predominate over 

any questions affecting only individual members, and a class action is superior to other available 

methods for the fair and efficient adjudication of the controversy. The questions of law and fact 

common to the Class arising from Defendant’s actions include, without limitation, the following:

a. Whether Defendant is permitted by the Policies to determine its Monthly Cost of 

Insurance Rates using factors other than those specified in the Policies;

b. Whether Defendant added, included, or relied on factors not specified in the 

Policies when determining the Monthly Cost of Insurance Rates used to calculate 

Cost of Insurance Charges for the Policies;

c. Whether Defendant added, included, or relied on factors unrelated to its mortality 

expectations in determining Monthly Cost of Insurance Rates that the Policies 

provide are determined using specified mortality factors and no other specified 

factors;

d. Whether Defendant is permitted by the Policies to charge expense amounts to 

policy owners in excess of the amounts disclosed in the Policies;

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e. Whether Defendant charged amounts in excess of those specifically authorized by 

the Policies;

f. Whether Defendant acted in bad faith;

g. Whether Defendant breached the terms of the Policies;

h. Whether Defendant converted Class members’ property;

i. Whether Defendant’s conduct violated the Texas Insurance Code;

j. Whether Defendant’s conduct was an unfair or deceptive trade practice;

k. Whether the Class was injured and sustained damages as a result of Defendant’s 

wrongful conduct; 

l. Whether the Class is entitled to damages, restitution, treble damages, punitive 

damages, and/or other relief as a remedy for Defendant’s conduct; and

m. Whether the Class is entitled to declaratory relief stating the proper construction 

and/or interpretation of the Policies.

57. The questions set forth above predominate over any questions affecting only 

individual persons, and a class action is superior to all other available means of fair and efficient 

adjudication of the claims of Plaintiffs and Class members. The injury suffered by each individual 

Class member is relatively small in comparison to the burden and expense of individual 

prosecution of these claims. Even if Class members could afford to pursue individual litigation, 

the court system could not. Individualized litigation would risk inconsistent or contradictory 

judgments while increasing the delay and expense to all parties, and to the judicial system, from 

the complex legal and factual issues presented here. By contrast, the class action device presents 

far fewer management difficulties, and provides the benefits of single adjudication, an economy 

of scale, and comprehensive supervision by a single court.

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58. Defendant has acted or refused to act on grounds generally applicable to Plaintiffs

and Class members, making final injunctive relief and declaratory relief appropriate with respect 

to the Class as a whole.

COUNT I: BREACH OF CONTRACT

(Cost of Insurance Charge)

59. The preceding paragraphs are incorporated by reference as if fully alleged herein.

60. Plaintiffs and the Class purchased life insurance policies—defined herein as the 

Policies—from Defendant.

61. The Policies are valid and enforceable contracts between the Defendant and Class 

members, including Plaintiffs.

62. Plaintiffs and the Class members substantially performed their obligations under 

the terms of the Policies.

63. By determining Monthly Cost of Insurance Rates inconsistent with the terms of the 

Policies and loading unauthorized factors in Monthly Cost of Insurance Rates, Defendant 

impermissibly caused and continues to cause those rates to be higher than what is explicitly 

authorized by the Policies. 

64. Because Defendant calculates Cost of Insurance Charges inconsistent with the 

terms of the Policies, including using Monthly Cost of Insurance Rates that are higher than those 

authorized by the Policies, Defendant deducted Cost of Insurance Charges from the Account 

Values of Plaintiffs and the Class in amounts greater than those authorized by their Policies. 

65. Defendant’s practice of deducting charges in amounts not authorized by the Policies 

constitutes a breach of the Policies. 

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66. As a direct and proximate result of Defendant’s ongoing and continuing breaches, 

Plaintiffs and the Class have sustained damages that are continuing in nature in an amount to be 

determined at trial.

COUNT II: BREACH OF CONTRACT

(Expense Charge)

67. The preceding paragraphs are incorporated by reference as if fully alleged herein.

68. By loading Monthly Cost of Insurance Rates with undisclosed and unauthorized 

expenses, Defendant impermissibly deducts expenses from the Account Values of Plaintiffs and 

the Class in amounts in excess of the fixed expense charges expressly authorized by the Policies.

69. By deducting unauthorized expense charges from the Account Values of Plaintiffs

and the Class, Defendant has breached the Policies.

70. As direct and proximate result of Defendant’s ongoing and continuing breaches, 

Plaintiffs and the Class have sustained damages that are continuing in nature in an amount to be 

determined at trial.

COUNT III: CONVERSION

71. The preceding paragraphs are incorporated by reference as if fully alleged herein.

72. Plaintiffs and the Class were the owners of the funds Defendant deducted from their 

Account Values in excess of the amounts permitted by the terms of the Policies. 

73. Defendant intentionally and substantially interfered with that property interest. By 

deducting Cost of Insurance Charges and expense charges in unauthorized amounts from the 

Account Values of Plaintiffs and the Class, Defendant assumed and exercised dominion and 

control over, and misappropriated or misapplied specific funds placed in the custody of Defendant 

for the benefit of Plaintiffs and the Class members, without authorization or consent and in hostility 

to the rights of Plaintiffs and Class members.

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74. Defendant continues to retain these funds unlawfully. At no time did Plaintiffs or 

any Class member consent to such wrongful retention of funds by Defendant. 

75. Defendant’s wrongful exercise of control over the personal property of Plaintiffs

and Class members constitutes conversion. Demand is excused because Defendant’s possession of 

the property was acquired wrongfully and because demand would be useless.

76. As a direct and proximate result of Defendant’s conduct, Plaintiffs and the Class 

have been damaged, and these damages are continuing in nature.

77. Although requiring expert testimony, the amounts of unauthorized Cost of 

Insurance Charges and expense charges Defendant took from Plaintiffs and the Class are capable 

of determination, to an identified sum, by comparing Plaintiffs’ actual Cost of Insurance Charge 

each month to a Cost of Insurance Charge computed using a Monthly Cost of Insurance Rate 

determined using only the mortality factors provided for in the Policy.

78. Defendant intended to cause damage to the Plaintiffs and the Class by deducting 

more from their Account Values than was authorized by the Policies.

79. By reason of the foregoing, Plaintiffs and Class members are entitled to recover 

from Defendant all damages and costs permitted by law, including all amounts Defendant 

wrongfully converted.

COUNT IV: BREACH OF THE DUTY OF GOOD FAITH AND FAIR DEALING

80. The preceding paragraphs are incorporated by reference as if fully alleged herein.

81. The Policies are valid and enforceable life insurance contracts between the 

Defendant and Class Members, including Plaintiffs.

82. Defendant owed Plaintiffs and the Class Members a duty of good faith and fair 

dealing.

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83. Defendant breached the duty of good faith and fair dealing with Plaintiffs and the 

Class by loading Monthly Cost of Insurance Rates with undisclosed and unauthorized profits and 

expenses. 

84. As a direct and proximate cause of these breaches of the duty of good faith and fair 

dealing, Plaintiffs and the Class have been damaged in an amount to be proven at trial.

COUNT V: VIOLATIONS OF THE TEXAS INSURANCE CODE

85. The preceding paragraphs are incorporated by reference as if fully alleged herein.

86. Although Defendant represented that it would use only certain, specified factors in 

determining Monthly Cost of Insurance Rates, Defendant uses other factors, not authorized by the 

Policies or disclosed to Plaintiffs and the Class, when determining those rates, including, without 

limitation, profits and expenses. 

87. By loading these factors into Monthly Cost of Insurance Rates, Defendant 

knowingly and intentionally causes those rates to be higher than what is explicitly authorized by 

the Policies and, as a result, withdraws Cost of Insurance Charges from policy owner Account 

Values in amounts greater than what is permitted by the Policies. 

88. Defendant’s conduct violates sections (1), (2), (3), and (5) of § 541.061 of the Texas 

Insurance Code, which provides:

It is an unfair method of competition or an unfair or deceptive act or practice in the 

business of insurance to misrepresent an insurance policy by:

(1) making an untrue statement of material fact;

(2) failing to state a material fact necessary to make other statements made not 

misleading, considering the circumstances under which the statements were made;

(3) making a statement in a manner that would mislead a reasonably prudent person 

to a false conclusion of a material fact;

(4) making a material misstatement of law; or

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(5) failing to disclose a matter required by law to be disclosed, including failing to 

make a disclosure in accordance with another provision of this code.

89. Additionally, despite knowing the Cost of Insurance Charges were loaded with nonmortality related expenses and profits, Defendant knowingly and intentionally provided Plaintiffs 

and the Class with untrue and misleading illustrations that refer to the Cost of Insurance Charges 

as “current mortality charges” and “current mortality.” These illustrations failed to state that nonmortality related expenses and profits were incorporated into the Cost of Insurance Charges. 

90. This conduct also violates § 541.051 of the Texas Insurance Code, which states in 

relevant part: 

It is an unfair method of competition or an unfair or deceptive act or practice in the 

business of insurance to:

(1) make, issue, or circulate or cause to be made, issued, or circulated an estimate, 

illustration, circular, or statement misrepresenting with respect to a policy issued or 

to be issued:

(A) the terms of the policy

91. Defendant alone, and not Plaintiffs and Class Members, possesses the actuarial 

information and equations underlying the computation of rates and charges for the Policies, such 

that Plaintiffs and Class Members were unaware of Defendant’s acts or practices.

92. Plaintiffs and the Class sustained actual damages caused by Defendant’s actions or 

practices, including unfair or deceptive actions or practices in the business of insurance.

93. Defendant’s conduct is ongoing and continues unabated.

94. Moreover, as alleged below, Defendant’s unlawful and deceptive trade practices 

also violate the Texas Insurance Code. 

95. Plaintiffs provided written notice to Defendant more than 60 days from the date of 

this filing advising of the allegations herein.

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96. Plaintiffs and the Class Members are entitled to recover from Defendant their actual 

damages, treble damages, costs, and attorneys’ fees. 

COUNT VI: VIOLATIONS OF THE TEXAS DECEPTIVE TRADE 

PRACTICES-CONSUMER PROTECTION ACT

97. The preceding paragraphs are incorporated by reference as if fully alleged herein.

98. By their purchase of the Policies from Defendant, Plaintiffs and Class Members are 

consumers as defined by Tex. Bus. & Com. Code Ann. § 17.45(4).

99. Defendant’s violations of the Texas Insurance Code, alleged above, also violate the 

Texas Deceptive Trade Practices-Consumer Protection Act (“DTPA”). See Tex. Bus. & Com. 

Code Ann. § 17.50(a)(4). 

100. In addition, Defendant separately violated the DTPA by representing the Policies 

“had sponsorship, approval, characteristics, ingredients, uses, benefits, or quantities which they do 

not have.” Id., § 17.46(b)(5).

101. Specifically, Defendant represented that only certain, specified factors would be 

used in determining Monthly Cost of Insurance Rates, but Defendant uses other factors, not 

authorized by the Policies or disclosed to Plaintiffs and the Class, when determining those rates, 

including, without limitation, profits and expenses. 

102. Defendant’s undisclosed inclusion of unauthorized factors into Monthly Cost of 

Insurance Rates causes those rates to be higher than what is authorized by the Policies.

103. Because Defendant knowingly and intentionally includes unauthorized factors in 

Monthly Cost of Insurance Rates that it knows will case those rates to be higher than what is 

otherwise authorized by the Policies, Defendant knowingly and intentionally withdraws Cost of 

Insurance Charges from policy owner Account Values in amounts greater than what is permitted 

by the Policies.

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104. Defendant’s violations of the DTPA caused Plaintiffs and the Class economic 

damages.

105. Defendant’s conduct is ongoing and continues unabated.

106. Plaintiffs provided written notice to Defendant more than 60 days from the date of 

this filing advising of the allegations herein.

107. Plaintiffs and Class Members are entitled to recover from Defendant their actual 

damages, treble damages, costs, and attorneys’ fees. 

COUNT VII: DECLARATORY AND INJUNCTIVE RELIEF

108. The preceding paragraphs are incorporated by reference as if fully alleged herein. 

109. An actual controversy has arisen and now exists between Plaintiffs and the Class, 

on the one hand, and Defendant, on the other, concerning the respective rights and duties of the 

parties under the Policies.

110. Plaintiffs contend that Defendant breached and continues to breach the Policies in 

the following respects:

a. By using unauthorized and undisclosed factors to compute the Monthly 

Cost of Insurance Rates under the Policies, Defendant impermissibly increased Monthly 

Cost of Insurance Rates for the Policies and, as a result, withdraws Cost of Insurance 

Charges from the Account Values of Plaintiffs and the Class in amounts greater than those 

authorized by the Policies; and

b. By inflating Monthly Cost of Insurance Rates under the Policies with 

expense factors that are not disclosed as being used to determine those rates, Defendant 

impermissibly deducted expense charges from the Account Values of Plaintiffs and the 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 21 of 64
21

Class in amounts in excess of the fixed expense charges expressly authorized by the 

Policies.

111. Plaintiffs therefore seek a declaration of the parties’ respective rights and duties 

under the Policies and requests the Court to declare the aforementioned conduct of Defendant as 

unlawful and in material breach of the Policies so that future controversies may be avoided.

112. Pursuant to a declaration of the parties’ respective rights and duties under the 

Policies, Plaintiffs further seek an injunction temporarily, preliminarily, and permanently 

enjoining Defendant from continuing to collect unlawfully inflated charges in violation of the 

Policies.

PRAYER FOR RELIEF

113. WHEREFORE, Plaintiffs, individually and on behalf of all others similarly 

situated, request relief as follows:

(a) That the Court enter an order certifying the class, appointing Plaintiffs as 

representatives of the Class, appointing Plaintiffs’ counsel as Class counsel; and 

directing that reasonable notice of this action, as provided by Federal Rule of Civil 

Procedure 23(c)(2), be given to the Class;

(b) For a judgment against Defendant for the causes of action alleged against it;

(c) For compensatory damages in an amount to be proven at trial;

(d) For treble damages;

(e) For punitive and exemplary damages;

(f) For a declaration that Defendant’s conduct as alleged herein is unlawful and in material 

breach of the Policies;

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 22 of 64
22

(g) For appropriate injunctive relief, enjoining Defendant from continuing to collect 

unlawfully inflated charges in violation of the Policies;

(h) For pre-judgment and post-judgment interest at the maximum rate permitted by law;

(i) For Plaintiffs’ attorneys’ fees;

(j) For Plaintiffs’ costs incurred; and

(k) For such other relief in law or equity as the Court deems just and proper.

DEMAND FOR JURY TRIAL

Plaintiffs hereby demand a trial by jury of all claims so triable.

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 23 of 64
23

Dated: March 1, 2021 Respectfully submitted,

STUEVE SIEGEL HANSON LLP

/s/ Ethan M. Lange

Norman E. Siegel (admitted pro hac vice)

siegel@stuevesiegel.com

Ethan M. Lange (Tex. Bar No. 24064150) 

lange@stuevesiegel.com

460 Nichols Road, Suite 200

Kansas City, Missouri 64112

Tel: 816-714-7100

Fax: 816-714-7101

John J. Schirger (admitted pro hac vice)

jschirger@millerschirger.com

Matthew W. Lytle (admitted pro hac vice)

mlytle@millerschirger.com

Joseph M. Feierabend (admitted pro hac vice)

jfeierabend@millerschirger.com

MILLER SCHIRGER, LLC 

4520 Main Street, Suite 1570

Kansas City, Missouri 64111

Tel: 816-561-6500

Fax: 816-561-6501

James J. Pizzirusso (admitted pro hac vice)

jpizzirusso@hausfeld.com

Nathaniel C. Giddings (admitted pro hac vice)

ngiddings@hausfeld.com

Melinda R. Coolidge (admitted pro hac vice)

mcoolidge@hausfeld.com

HAUSFELD LLP

1700 K Street, NW

Washington, DC 20006

Tel: (202) 540-7200

Fax: (202)540-7201

James T. Clancy (Tex. Bar No. 00795292)

jclancy@branscomblaw.com

BRANSCOMB, PLLC 

802 N. Carancahua, Suite 1900

Corpus Christi, TX 78401-0036

Tel: (361) 886-3800

Fax: (361) 886-3805

Kimberly Fetsick (admitted pro hac vice)

kfetsick@hausfeld.com

HAUSFELD LLP

33 Whitehall Street, 14th Floor

New York, NY 10004

Tel: (646) 357-1100

Fax: (212) 202-4322

Warren T. Burns (TX Bar No. 24053119)

wburns@burnscharest.com

Will Thompson (TX Bar No. 24094981)

whompson@burnscharest.com

BURNS CHAREST LLP

900 Jackson Street, Suite 500

Dallas, TX 75202

Tel: (469) 904-4550

Fax: (469) 444-5002

Larry D. Lahman (admitted pro hac vice)

larry.lahman@sbcglobal.net

Roger L. Ediger (admitted pro hac vice)

rle@mdpllc.com

MITCHELL DeCLERK

202 West Broadway Avenue

Enid, OK 73701

Tel: (580) 234-5144

Fax: (580) 234-8890

Sophia Goren Gold (pro hac vice pending)

sgold@kalielpllc.com

KALIEL PLLC

1875 Connecticut Avenue NW, 10th Floor

Washington, DC 20009

Tel: (202) 350-4783

Fax: (202) 871-8180

David M. Wilkerson (pro hac vice pending)

The Van Winkle Law Firm

11 N. Market Street

Asheville, NC 28801

Phone: 828-258-2991

Fax: 828-257-2767

dwilkerson@vwlawfirm.com

Attorneys for Plaintiffs Ronald K. Page and Anna Gonzalez

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 24 of 64
EXHIBIT A 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 25 of 64
I- 

-i+ 

* a' 

HOME OFFICE: ONE STATE FARM PLAZA. BlOOMINGTON, ILLINOIS 817100001 

STATI FARM 

INSURANC 

INSURED RONALD K PAGE 

Male) 

AGE 

POLICY NUMBER LF-1518-9386 

POLICY DATE 

INITIAL BASIC AMOUNT 

February 3, 1997 

$100,000 

This policy is based on the application and the payment of premiums, as specified in the 

policy. State Farm Life Insurance Company will pay the proceeds to the beneficiary when 

due proof is received that the Insured died before this policy terminated. If the Insured is 

alive on the maturity date, the cash surrender value on the maturity date will be paid to the 

Owner and this policy will terminate. 

30-Day Right to Examine the Policy. This policy may be returned within 30 days of its 

receipt for a refund of all premiums paid. Return may be made to State Farm Life Insurance 

Company or one of its agents. If returned, this policy will be void from the policy date. 

Read this policy with care. This is a legal contract between the Owner and State Farm Life 

Insurance Company. 

Secretary President 

BASIC PLAN DESCRIPTION 

Flexible premium adjustable life insurance. A death benefit is payable if the Insured dies 

before the matur ty date. The cash surrender value is payable if the Insured is alive on the 

maturity date. Coverage may terminate prior to the maturity date. Flexible premiums are 

payable while the Insured is alive until the maturity date. The basic plan is eligible for 

annual dividends. 

FORM 94033-43 PAGE 1 931215 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 26 of 64
CONTENTS 

PAGE 

Policyldentification . . .. ......... . . ..... . .. .......... ... 1II 3 

Schedule of BeiefIts . . . . . . . . . . . . . . . , 3 

ScheduleofPreniliiins...... 1e* ... ........................ 3 

Mont1I.l3T1:eductloIs .....tS ............................................ 3 

$vliduIe of Surrender Charges ........ . . . . . . . .......... . . . . . . ........ . . . 4 

cost of Insurance Rates and Monthly Charges . . . . . .. . . . . . . . . ...... * . . . . ..... 4 

Ieflnitlons.............. ...... .. ............. .. ...... ... ....... ...*...... .. 5 

OvuierslIp ......... . . . . . . . . . . . . . . . . ........... . . * . . . . . . . . . . . . . . . . . . . . . . . . . . 5 

Owner. Change of Owner. 

Death Benefit and l)eath Benefit Options. . . . . . . . . . . . .......................... 6 

Death Benefit. Change in Basic Amount. 

Death Benefit Options. Change in Death Benefit Option. 

PayinentofBenefits * ........... . ........... . ...... ........... . ........ .... 7 

Beneficiary Designation. Methods of Payment. 

Change of Beneficiary Designation. Minimum Payment. 

Order of Payment on the Insured's Basis of Computation for Payments. 

Death. Additional Amounts Payable. 

Prentluins....... .. ....................................................... . 9 

Payment of Premiums. Grace Period. 

Premium Limitations. Reinstatement. 

Guai'aiiteed \Ta,lues . . . . . . . . . . . . ................... . . ....... . . . . . . . . ......... 9 

Account Value. Cash Surrender Value. 

Monthly Deduction. Withdrawals. 

Cost of Insurance. Surrender Charge. 

Monthly Coat of Insurance Rates. Basis of Computation. 

Interest. 

Pollc3'I.oe.n . ............... .. .................. ., .,.,..... ........... 12 

Loan. Loan Interest. 

Loan Value. Loan Repayment. 

General............................. .. .................................... 12 

The Contract. Assignment. 

Annual Report. Error in Age or Sex. 

Projection of Benefits and Values. Incontestability. 

Annual Dividends. Limited Death Benefit. 

Dividend Options. 

The Application and any Riders and Endorsements follow page 14. 

FORM 94030.43 PAGE 2 93050? 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 27 of 64
POLICY IDENTIFICATION 

Insured RONALD K PAGE Age I 

(Male) 

Policy Number LF-1518-9386 Initial Basic Amount $1001000 Policy Date February 3, 1997 

Issue Date February 20, 1997 

p SCHEDULE OF BENEFITS 

Universal Life Basic Plan: 

Death Benefit Option 2 (Basic Amount plus the Account Value) 

Basic Amount (Standard Rate Class-Male Non-Tobacco): $100,000 

Maturity Date: February 3, 2053 

SCHEDULE OF PREMIUMS 

The Initial Premium is $508.38. 

Planned premiums are included in the schedule shown below. The payment period for the 

planned premiums is 1 month starting on March 3, 1997 payable until the maturity 

date. 

A premium expense obarge of 5% is deducted from each premium paid. 

Total Premiums 

Beginning: For Policy Year 

February 3, 1997 $1,493.98 

February 3, 1998 1,020.00 

MONTHLY DEDUCTIONS 

The deduction date is the 3rd of each month. 

Maximum monthly cost of insurance rates are shown on page 4. Cost of insurance is 

deductible to the maturity date. 

The monthly expense charge is $5.00. 

NOTE: Insurance may terminate prior to the maturity date if premiums paid are not 

sufficient to continue the insurance to that date. 

Form 94030 Page 3 970220 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 28 of 64
SCHEDULE OF SURRENDER CHARGES 

Beginning Beginning 

Policy Policy Surrender Policy Policy Surrender 

Year Month Charge Year Month Charge 

I I $76.00 1 12 $912.00 

1 2 152.00 2 1 912,00 

1 3 228.00 3. 1 912.00 

1 4 304.00 4 1 798.00 

1 5 380.00 5 1 684.00 

1 6 456.00 6 1 570.00 

1 7 532.00 7 1 456.00 

1 8 608.00 8 1 342.00 

1 9 684.00 9 1 228.00 

1 10 760.00 10 1 114.00 

1 11 836.00 11 1 0.00 

COST OF INSURANCE RATES AND MONTHLY CHARGES 

Maximum Monthly Cost of Insurance Rates 

Per $1000 

(Standard Rate Class-Male Non-Tobacco) 

Age Rate Age Rate Age Rate Age Rate 

44 .3649 58 1.1894 72 4.2723 86 15.6263 

45 .3950 59 1.2942 73 4.7329 87 16.9762 

46 .4277 60 1.4109 74 5.2401 88 18.3754 

47 .4620 61 1.5430 75 5.7847 89 19.8343 

48 .4989 62 1.6923 76 6.3595 90 21.3788 

49 .5399 63 1.8597 71 6.9577 91 23.0518 

50 .5852 64 2.0454 78 7.5852 92 24.9371 

51 .6381 65 2.2459 79 8.2619 93 27.2442 

52 .6968 66 2.4605 80 9.0119 94 30.4453 

53 .7640 67 2.6886 81 9.8582 95 35.4922 

54 .8380 68 2.9344 82 10.8223 96 44.5151 

55 .9180 69 3.2068 83. 11.9024 97 62.8314 

56 1.0030 70 3.5147 84 13.0775 98 73.0824 

57 1.0932 71 3.8670 85 14.3247 99 83.3333 

Fori 94030 Page 4 970220 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 29 of 64
DEFINITIONS 

We, us, and our refer to State Farm Life Insuraiice Company. 

You and your refer to the Owner. 

Application. Includes any life insurance application, any application for change in the policy, 

medical history, questionnaire, and other documents from you or any other person proposed for 

insurance which are made a part of this policy. 

Basic Amount. The Initial Basic Amount plus 

any increases less any decreases. 

Basic Amount Mininum. On or after the policy 

anniversary when the Insured is age 55, the Basic 

Amount cannot be less than $25,000. Otherwise 

the Basic Amount cannot be less than $50,000. 

Benefit Period Ends. For any rider, the policy 

anniversary in the year shown under this heading 

on page 3 is the date the rider terminates. 

Deduction Date The policy date and each 

monthly anniversary of the policy date. 

Dollars. Any money we pay, or which is paid to 

us, must be in United States dollars. 

Effective Date. Coverage starts on this date. 

Initial Basic Amount. The amount of coverage 

on the Insured provided by the Basic Plan on the 

policy date. 

Insurance Amount. The amount of coverage 

on the effective date of each rider shown on page 

3. 

Maturity Date. The policy anniversary when 

the Insured is age 100. 

Monthly Charge Deductible. A monthly 

charge for any rider is deducted as part of the 

monthly deduction until the policy anniversary in 

the year shown on page 3. 

Officer. The president, a vice president, the 

secretary, or an assistant secretary of State Farm 

Life Insurance Company. 

Payee. On the Insured's death, the beneficiaries shown in the application, unless changed. 

If you cash surrender this policy or this policy 

matures, the persons that you have named. A 

payee can be other than a natural person only if 

we agree. 

Planned Premium. The premium amount that 

you have chosen, This amount is shown on page 3 

for the payment period that you have chosen. 

Policy Date. The effective date of this policy. 

Policy Month, Year, or Anniversary. A policy 

month, year, or anniversary is measured from the 

policy date. 

Proceeds. The amounts payable on the death of 

the Insured. 

Rate Class. The underwriting class of the person insured. A rate class will be determined for 

the Initial Basic Amount and each increase in the 

Basic Amount. 

Request. A written request signed by the person making the request. Such request must be 

sent to and be in a form acceptable to u8. 

Rider. Any benefit, other than the Basic Plan, 

made a part of this policy. 

OWNERSHIP PROVISIONS 

Owner. The Owner is as named in the application, unles changed. You may exercise any policy 

provision only by request and while the Insured is 

alive. 

Change of Owner. You may change the ownership of this policy by sending us a request while 

the Insured is alive. We have the right to request 

this policy to make the change on it. The change 

will take effect the date you sign the request, but 

the change will not affect any action we have 

taken before we receive the request. A change of 

owner does not change the beneficiary designation. 

FORM 94030.43 PAGE 5 921215 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 30 of 64
I DEATH BENEFIYI' AND DEATH BENEFIT OPTIONS PROVISIONS 

1 Death Benefit. The amount of death benefit is 

an amount of insurance based on the death 

benefit option plus any insurance amounts payable under any riders on the Insured and the part 

of the cost of insurance for the part of the policy 

month beyond the Insured's death less any loan, 

accrued loan interest1 and, if the Insured dies 

during the grace period, the monthly deductions 

from the start of the grace period. 

Death Benefit Options. There are two death 

benefit options. If you do not choose an option, we 

will use option 2. The account value on the date of 

death is used in determining the amount of 

insurance. 

Option 1. The amount of insurance will be 

the greater of (1) the Basic Amount plus 95% of 

any premium received since the last deduction 

date plus interest earned on that amount of 

premium or (2) a percentage of the account value. 

Such percentage is based on the Insured's age at 

the start of the current policy year. 

Option 2. The amount of insurance will be 

the greater of (1) the Basic Amount plus the 

account value or (2) a percentage of the account 

value. Such percentage is based on the Insured's 

age at the start of the current policy year. 

Percentage of Account Value Table 

Are Percente Are Pereentare 

0-40 250% 61 128% 

41 243% 62 126% 

42 236% 63 124% 

43 229% 64 122% 

44 222% 65 120% 

45 215% 66 119% 

46 209% 67 118% 

47 203% 68 117% 

48 197% 69 116% 

49 191% 70 115% 

50 185% 11 113% 

51 178% 72 111% 

52 171% 73 109% 

53 164% 74 107% 

54 157% 75.90 105% 

55 150% 91 104% 

56 146% 92 103% 

57 142% 93 102% 

58 138% 94 101% 

59 124% 95&up 100% 

60 130% 

Change In Basic Amount. You may request a 

change in the Basic Amount once each policy 

year. The minimum amount of change is $25,000 

for an increase and $10,000 for a decrease. For 

any change in Basic Amount, we will send you a 

revised page 3 to be placed with this policy. 

If you request an increase, an application must be 

completed, evidence of insurability satisfactory to 

us must be furnished, and there must be enough 

cash surrender value to make a monthly deduction which includes the cost of insurance for the 

increase. No increases will be allowed after the 

policy anniversary when the Insured is age 80. 

The revised page 3 will show the amount of the 

increase and its effective date. 

If you request a decrease, the Basic Amount 

remaining after the decrease cannot be less than 

the Basic Amount Minimum. We reserve the right 

to not accept a request for a decrease in the Basic 

Amount if such decrease could result in this policy 

being disqualified as a life insurance contract 

under any section of the United States Internal 

Revenue Code, as amended from time to time. 

Any decrease will first be used to reduce the most 

recent increase. Then, the next most recent increases will be reduced. Finally, the Initial Basic 

Amount Will be reduced. The revised page 3 will 

show the amount of decrease and its effective 

date. The decrease will take effect on the date we 

receive the request. 

Change of Death Benefit Option. You may 

request a change of death benefit option once 

each policy year. For a change in death benefit 

option, we will send you a revised page 3 to be 

plaéed with this policy. The revised page will 

show the effective date of the change. 

If the change is to option 1, the Basic Amount will 

be increased by the account value on the effective 

date of the increase. We reserve the right to not 

accept a request for a change to option 1 U such 

change could result in this policy being disqualified as a life insurance contract under any section 

of the United States Internal Revenue Code, as 

amended from time to time. 

FORM 94030 PAGE 6 

If the change is to option 2, the Basic Amount will 

be decreased by the account value on the effective date of the decrease. 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 31 of 64
PAYMENT OF BENEFITS PROVISIONS 

Beneficiary Designation. This is as shown in 

the application, unless you have made a change. It includes the name of the beneficiary and the 

order and method of payment. If you name 

"estate" as a beneficiary, it means the executors 

or administrators of the last survivor of you and 

all beneficiaries. If you name "children" of a 

person as a beneficiary, only children born to or 

legally adopted by that person will be included. 

We may rely on an affidavit as to the ages, names, 

and other facts about all beneficiaries. We will 

incur no liability if we act on such affidavit. 

Change of Beneficiary Designation. You may 

make a change while the Insured is alive by 

sending us a request. The change will take effect 

the date the request is signed, but the change will 

not affect any action we have taken before we 

receive the request. We have the right to request 

your policy to make the change on it. 

Order of Payment on the Insured's Death. 

When the Insured dies, we will make payment in 

equal shares to the primary beneficiaries living 

when payment is made. If a primary dies after 

the first payment is made, we will pay that 

primary's unpaid share in equal shares to the 

other primaries living when payment is made. If 

the last primary dies, we will make payment in 

equal shares to the successor beneficiaries living 

when payment is made. If a successor dies while 

receiving payments, we will pay that successor's 

unpaid share in equal shares to the other successors living when payment is made. If, at any time, 

no primary or successor is alive, we will make a 

one sum payment in equal shares to the final 

beneficiaries. If, at any time, no beneficiary is 

living, we will make a one sum payment to you, if 

living when payment is made. Otherwise, we will 

make a one sum payment to the estate of the last 

survivor of you and all beneficiaries. "When 

payment is made" means (1) the date that a 

periodic payment is due or (2) the date that a 

request is signed for a cash withdrawal or a one 

sum payment. You may change this order of 

payment by sending us a request while the Insured is alive. 

Methods of Payment. We will pay the proceeds under the Interest method unless you 

choose another method. If the payee is other than 

a natural person, we will make payment under 

the One Sum method. 

All payment intervals are measured from the 

date the policy is surrendered or from the date 

the Insured dies. No part of any payment can be 

assigned before the payment is made. 

Alter the Insured's death, anyone who has the 

right to make a withdrawal may change the 

method of payment and may name a successor to 

their interest. The successor payee may be their 

estate. 

Method 1 (Interest Method). We will pay interest at the end of each monthly interval. The 

interest rate will be at least 3% a year. If 

chosen, we will pay interest at the end of 3,6, or 

12 month intervals. Withdrawals may be made at 

any time, but any withdrawal must be at least 

$500. We will pay interest to the date of withdrawal on the amount withdrawn. 

Method 2 (FIxed Years Method). We will 

make equal payments at the end of each monthly 

interval for a fixed number of years. These 

payments include interest, The guaranteed interest rate is 34% a year. The present value of any 

unpaid payments may be withdrawn at any time. 

FIXED YEARS TABLE 

Monthly payments that $1000 will provide for the 

number of years chosen. Payments for years not 

shown will be given, if requested. 

Yeari P.menta Years Psinenta 

I $84.90 8 $11.93 2 43.18 9 10.18 3 29.28 10 9.86 4 22.33 15 7.12 5 18.17 20 5.77 6 15.39 25 L98 

7 13.41 30 t46 

FORM 94030 PAGE 7 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 32 of 64
PAYMENT OF BENEFITS PROVISIONS (CONTINUED) 

Method 3 (Life Income Method). We will 

make equal payments at the end of each monthly 

interval as long as the payee is alive. We base the 

amount of each payment on the payee's age and 

sex at the start of the first monthly interval. We 

may require proof of the payee's age and sex. The 

payee maynot withdraw the present value of the 

payments. If the payee dies during a certain 

period, we will continue the payments to the end 

of the certain period; or the successor payee may have the present value of any remaining payments paid in one sum. 

LIFE INCOME TABLE 

Monthly payments for life that $i000 will pro- vide. Payments for ages not shown will be given, if requested. 

Life with 

Age Last Life 10 Years Certain 

Birthday Male Female Male Female 

50 $4.50 $4.15 $446 $4.13 55 4.91 4.48 4.84 4.45 60 5.47 4.92 536 486 

65 6.25 5.68 5.98 5.41 70 7.34 6.88 6.76 6.12 75 885 7.64 7.62 7.01 Method 4(F'ixed Amount Method). We 

will make equal payments at the end of 1,8,6, or 

12 month intervals. We will continue payments until the amount put under this method together 

with compound interest has been paid. The interest rate will be at least 34% a year. The payment interval chosen must provide a total annual payment of at least $100 for each $1000 put under 

this method. The unpaid balance may be withdrawn at any time. 

Method 5 (Joint Life Income Method). 

We will make equal payments at the end of each 

monthly interval as long as at least one of the two 

payees is alive. We will base each payment on the 

age and sex of both payees at the start of the first 

monthly interval. We may require proof of the 

age and sex of each payee. The payees may not 

withdraw the present value of any payments. 

Monthly payments that $1000 will provide áilöng 

as at least one of the two payees is alive. Payments for age combinations not shown will be 

given, if requested. 

Age Last . Female 

Birthday 60 

Msle 

65 70 75 

60 $4.45 $4.69 $4.91 $5.10 

65 4.60 4.92 6.24 5.55 70 4.71 6.11 5.56 6.02 75 4.79 5.26 5.83 6.47 

FORM 94030 PAGE 8 

Method 6 (One Sum Method). We will pay the cash surrender value or the proceeds in one 

sum. Interest at the rate of at least 3%% a year 

will be paid from the date of the Insured's death 

to the date of payment. 

Method 7 (Other Method). Payment by 

any other method may be made if we agree. 

Minimum Payment. If any payment, except the last, under a method of payment would be less 

than $100 per payee, we will pay the present 

value of any unpaid payments in one sum. 

Basis of Computation for Payments. The 

monthly payments shown for methods 3 and 5 are 

guaranteed payments based on an interest rate of 

3% a year and the 1983 Table a, projected 10 

years using Projection Scale G. 

Any present values will be based on the interest 

rate used in determining the payments for the 

method. 

Additional Amounts Payable. Each year we 

may apportion and pay dividends or additional 

interest under any method of payment. 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 33 of 64
I PREMIUM PROVISIONS 

Payment of Premiums. You may pay premiums at our Home Office, a regional office, or to 

one of our agents. We will give you a receipt 

signed by one of our officers, if you request one. 

The initial premium is shown on page 3 and is due 

on the policy date. All other premiums may be 

paid in any amount and at any time if: 

(I) the amount is at least $25 and 

(2) in a policy year, the total premiums, excluding the initial premium, do not exceed 

without our consent, the total Planned 

Premiums for a policy year. 

Premium Limitations. We reserve the right to 

refund any premium paid if such premium 

amount would be in excess of the guideline premium limitation as defined by SectIon 7702, Internal Revenue Code of 1988 (or as later amended). No expense charge will be deducted from the 

refunded premium. 

Grace Period. If, on any deduction date, the 

cash surrender value is not enough to cover the 

monthly deduction, the policy will stay in force 

until the end of the grace period. The grace period is 61 days and starts on that deduction 

date. We will mail a notice at least 31 days prior 

to the end of the grace period to you and to any 

assignee of record. A premium large enough to 

cover the monthly deductions for the grace period and any increase in the surrender charges must 

be paid before the end of the grace period; 

otherwise, this policy will lapse and terminate 

without 'value. 

Reinstatement. If the policy is terminated at 

the end of the grace period, you may apply to 

reinstate it within 5 years after lapse. You must 

give us proof of the Insured's insurability that is 

satisfactory to us. You must pay premiums (1) to 

keep the policy in force for 2 months and (2) to 

pay the monthly deductions for the grace period. 

Reinstatement will take effect on the date we 

approve the application for reinstatement. 

GUARANTEED VALUES PROVISIONS 1 

Account Value. The account value on the policy date 1895% of the initial premium less the 

monthly deduction for the first policy month. 

The account value on any deduction date after 

the policy date is the account value on the prior 

deduction date: 

(1) plus 95% of any premiums received since 

the prior deduction date, 

(2) less the deduction for the cost of insurance 

for any increase in Basic Amount and the 

monthly charges for any riders that became effective since the prior deduction 

date, 

(3) less any withdrawals since the prior deduction date, 

(4) less the current monthly deduction, 

(5) plus any dividend paid and added to the 

account value on the current deduction 

date, and 

(6) plus any interest accrued since the prior 

deduction date. 

The account value on any other date is the 

account value on the prior deduction date: 

(1) pIus 95% of any premiums received since 

the prior deduction date, 

(2 less the deduction for the cost of insurance 

for any increase in Basic Amount and the 

monthly charges for any riders that became effective since the prior deduction 

date, 

(3) less any withdrawals since the prior deduction date, and 

(4) plus any interest accrued since the prior 

deduction date. 

Monthly Deduction. This deduction is made 

each month, whether or not premiums are paid, 

as long as the cash surrender value is enough to 

cover that monthly deduction. Each deduction 

includes: 

(1) the cost of insurance, 

(2) the monthly charges for any riders, and 

(8) the monthly expense charge. 

FORM 9408G43 PAGE 9 981215 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 34 of 64
I GUARANTEED VALUES PROVISIONS (CONTINUED) 

I Cost of Insurance. This cost is calculated each 

month. The cost is determined separately for the 

Initial Basic Amount and each increase in Basic 

Amount. 

The cost of insurance is the monthly cost of 

insurance times the difference between (1) and 

(2), where: 

(1) is the amount of insurance on the deduction date at the start of the month divided 

by 1.0032737, and 

(2) is the account value on the deduction date 

at the start of the month before the cost of 

insurance and the monthly charge for any 

waiver of monthly deduction benefit rider 

are deducted. 

Until the account value exceeds the Initial Basic 

Amount, the account value is part of the Initial 

Basic Amount. Once the account value exceeds 

that amount, if there have been any increases in 

Basic Amount, the excess will be part of the 

increases in order in which the increases occurred. 

Monthly Cost of Insurance Rates. These rates 

for each policy year are based on the Insured's 

age on the policy anniversary, sex, and applicable 

rate class, A rate class Will be determined for the 

Initial Basió Amount and for each increase. The 

rates shown on page 4 are the maximum monthly 

cost of insurance rates for the Initial Basic 

Amount. Maximum monthly cost of insurance 

rates will be provided for each increase in the 

Basic Amount. We can charge rates lower than 

those shown Such rates can be adjusted for 

projected changes in mortality but cannot exceed 

the maximum monthly cost of insurance rates. 

Such adjustments cannot be made more than 

once a calendar year, 

Interest. An interest rate of at least 4% a year 

will be applied to the account value. The rate 

applied to the amount of account value up to the 

amount of any loan may differ from the rate 

applied to the account value in excess of the 

amount of any loan. We will determine these 

rates at least once a year. 

Cash Surrender Value. You may request surrender of this policy at any time. This policy will 

terminate on the date we receive the request or 

later date if you so request it. We will pay you the 

cash surrender value as of the date coverage 

ceases plus the monthly deduction for the part of 

the policy month beyond that date. We will pay 

you in one sum unless you choose another method 

of payment. The cash surrender value of this 

policy is its account value less any surrender 

charge and any loan and accrued loan interest. 

The cash surrender value on the maturity date 

will be the account value on that date less any 

loan and accrued loan interest. The cash surrender value will not be less than zero. If this policy 

is surrendered within 31 dags after a policy 

anniversary, the cash surrender value will not 

decrease within that period except for any loans 

or withdrawals. We may defer paying you the 

cash surrender value for up tO 6 months after 

receiving your request. 

Withdrawals. You may request to withdraw 

part of the account value while this policy is in 

force. No more than 4 withdrawals can be made 

in any policy year. Any withdrawal must be at 

least $500 and must be less than the cash surrender value. We may defer paying you a withdrawal 

for up to 6 months unless the withdrawal is to pay 

premiums on other policies with us. 

If death benefit option 1 is in effect, then the 

Basic Amount will be reduced by the withdrawal, 

effective with the date of the withdrawal; how-. 

ever, no withdrawal can be made which will 

reduce the Basic Amount to less than $25,000. 

The reduction will be made as if a decrease in the 

Basic Amount had been requested. 

FORM 94030-43 PAGE 10 981215 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 35 of 64
I GUARANTEED VALUES PROVISIONS (CONTINUED) 

I Surrender Charge. The schedule of surrender 

charges is shown on page 4. For each increase in 

Basic Amount, additional surrender charges will 

apply. A revised page 4 will show a revised 

schedule of surrender charges which includes 

those additional charges. 

Upon reinstatement, the surrender charges will 

be adjusted for any surrender charge deducted at 

the time of lapse. A revised page 4 will show a 

schedule of the adjusted surrender charges. 

A schedule of surrender charges is determined 

separately for the Initial Basic Amount and for 

each increase in Basic Amount. A schedule is 

determined using a Base Surrender Charge and 

covers 120 policy months following the policy date 

or the effective date of an inrease in Basic 

Amount. For the Initial Basic Amount, use the 

surrender charge at the Insured's age on the 

policy date. For each increase in Basic Amount, 

use the surrender charge at the Insured's age on 

the policy anniversary on or first preceding the 

effective date of that increase. Take that surrender charge times the Initial Basic Amount, or the 

amount of the increase, if applicable divided by 

1,000. Then, divide that result by 12 to determine 

the surrender charge that will apply for that 

amount of insurance for the first policy month 

after its effective date. The surrender charge 

increases by that amount for each of the next 11 

policy months. The surrender charge then remains level for the next 24 policy months. The 

surrender charge decreases after 36 policy 

months and then decreases by that same amount 

after each successive 12 policy months. The 

amount of each decrease is equal to the surrender 

charge in effect at the end of 36 policy months 

divided by & 

Basis of Computation. The guaranteed values 

in this policy are at least as large as those 

required by law in the state where it is delivered 

based on the Commissioners 1980 Standard Ordinary Mortality Table with an interest rate of 

4% a year. The insurance authority there has a 

statement of how these values are determined. 

The guaranteed values and maximum cost of 

insurance rates are based on the Insured's age 

last birthday and sex. The interest rate is 4% a 

year. The Commissioners 1980 Standard Ordinary Mortality Table is used. Modifications are 

made for rate classes other than standard. 

BASE SURRENDER CHARGE 

The base surrender chirge ii for each $1,000 of 

Initial Basic Amount or amount of increase in 

Basic Amount. 

Bus Base 

Surrender 

Ae Charte Ane 

Surrender 

Charfe 

0-19 ; 120 45 $9.72 

20 1.32 48 10.32 

21 1.44 47 10.80 

22 158 48 11.40 

23 1.80 49 11.88 

24 2.04 50 12.72 

25 2.40 51 13.44 

26 2.64 52 14.04 

21 2.88 53 14.88 

28 3.12 54 15.36 

29 3.36 55 18.02 

30 2.60 66 16.20 

31 3.84 57 16.68 

32 4.20 58 17.16 

33 4.68 59 17.40 

34 4.68 60 18.00 

35 5.16 61 18.36 

38 5.40 62 18.48 

37 5.64 63 18.60 

38 6.86 84 18.60 

39 8.72 65 19.40 

40 7.88 66 19.56 

41 7.44 61 19.80 

42 8.16 68 20.40 

43 8.76 69 20.64 

44 9.12 70-80 21.00 

FORM 94030-43 PAGE 11 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 36 of 64
POLICY LOAN PROVISIONS I Loan. You may borrow against this policy. This 

policy is the sole security for such loan. We may 

defer a loan for up to 6 months after receiving 

your request unless the loan will be used to pay premiums on other policies with us. 

You may borrow the loan value less any existing 

loan and accrued interest and monthly deductions 

for the next 2 months. If your unpaid loan plus 

accrued interest exceeds the loan value on the 

monthly deduction date, the Grace Period provision will apply. 

Loan Value. The loan value is the account 

value of this policy lees the surrender charge. 

Loan Interest. Interest accrues and is payable 

each day at a rate of 8% a year. Any interest not 

paid is added to the loan on each policy anniversary. 

Loan Repayment. You may repay all or part of 

a loan at any time before the Insured dies or the 

policy is surrendered or terminated. 

GENERAL PROVISIONS I The Contract. The policy contains the Basic 

Plan, any amendments, endorsements, and riders, 

and a copy of the application. A copy of any 

application for a change to this policy will be sent 

to you to be placed with the policy. Such applications become part of this policy. The policy is the 

entire contract. We have relied on the statements 

in the application in issuing this policy. We 

reserve the right to investigate the truth and 

completeness of those statements. In the absence 

of fraud, they are representations and not warrarities. Only material misstatements in the ap- plication will be used to contest this policy or 

deny a claim. 

Only an officer has the right to change this policy. 

No agent has the authority to change the policy or 

to waive any of its terms. All endorsements, 

amendments, and riders muSt be signed by an 

officer to be valid. 

Annual Report. Each year, we will send you a 

report. This report will show: 

(1) the account value, the cash surrender value, any loan and accrued loan interest, and 

the amount of the death benefit as of the 

date of the report and 

(2) any premiums paid, any deductions made, 

and any withdrawals made since the last 

report 

Projection of Benefits and Values. You may 

request a projection of death benefits, account 

values, and cash surrender values. We may 

charge a reasonable fee not to exceed $25 for 

providing this projection. 

Annual Dividends. We do not expect to pay 

dividends on this policy; however, we may apportion and pay dividends each year. Any such 

dividends Will be paid only at the end of the 

policy year. There is no right to a partial or pro rated dividend prior to the end of the policy year. 

Dividend Options. You may choose to have 

your dividend used under one of these options: 

1. Cash. We will pay it to you in cash. 

2. Addition to Account Value. We will 

add it to the account value at the end of the policy 

year. 

If you do not choose an option or the option you 

choose is not available, we will use option 2. You 

may request to change the option. The change 

will apply only to dividends paid after we receive 

the request. 

Assignment. You may assign this policy or any 

interest in it. We will recognize an assignment 

only if it is in writing and filed with us. We are 

not responsible for the validity or effect of any 

assignment. An assignment may limit the interest 

of any beneficiary. 

FORM 94080-43 PAGE 12 931215 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 37 of 64
GENERAL PROVISIONS (CONTINUED) 

I Error in Age or Sex. If the Insured's date of 

birth or sex is not as stated in the application, we 

will adjust each benefit on the Insured to the 

benefit payable had the Insured's age and sex 

been stated correctly. Such adjustment will be 

based on the ratio of the correct monthly deduction for the moSt recent deduction date for that 

benefit to the monthly deduction that was made. 

For the Basic Plan1 the adjustment is made to the 

amount of insurance less the account value. 

Incontestability. We will not contest the Basic 

Plan after it has been in force during the Insured's lifetime for 2 years from the issue date of 

the policy. We will not contest any increase in 

Basic Amount or reinstatement after it has been 

in force during the lifetime of the Insured for 2 

years from the effective date of the increase in 

Basic Amount or reinstatement. We will not 

contest an increase due to a change to Death 

Benefit Option 1. Any contest of any increase in 

Basic Amount or reinstatement will be limited to 

material misstatements contained in the application for such increase or reinstatement. 

Each rider has its own incontestability provision. 

Limited Death Benefit. If the In8ured dies by 

suicide while sane or by selfdestruction while 

insane within 2 years from the issue date of the 

policy, the Basic Amount will not be paid. The 

proceeds in this case will be limited to the 

premiums paid on the Basic Plan less any loan, 

accrued loan interest, any withdrawals from the 

account value, and any dividends paid on the 

Basic Plan. 

Any increase in Basic Amount or amount reinstated will not be paid if the Insured's death 

results from suicide while sane or self-destruction 

while insane within 2 years from the effective 

date of such increase or reinstatement. The proceeds of the increase will be limited to the 

monthly deductions for the increase. This does 

not apply to an increase due to a change to Death 

Benefit Option 1. The proceeds of a reinstated 

policy will be limited to the premiums paid on the 

Basic Plan since reinstatement less any loan, 

accrued loan Interest, any withdrawals from the 

account value, and any dividends paid on the 

Basic Plan. 

Each rider has its own limited death benefit 

provision. 

FORM 94030.43 PAGE 13 931016 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 38 of 64
fterf (B)V 

To: lState Farm life Insurance Company 0 State Farm life and Accident Assurance 

Re: Policy No.(s) 10 7 909 Name of insured 

_ 

P. ft1Am A 

0 CHANGE MAIL ADDRESS TO Policyowner's Telephone No. ___________________ O CHANGE MODE OF PREMIUM PAYMENT TO 0 PREMIUM OFFSET (Mode of payment must be annual) 0 Annuaily 0 SemI-annually 0 Quarterly Dividend method must be Paid-up Additions or 

O Monthly 0 Special Monthly ifype)_______ Accumulate; if not change Dividend Method below. 

O CHANGE METhOD OF DIVIDEND PAYMENT TO 

O Accumulate 0 PaId In Cash 0 PaId-up AdditIons 0 Reduce Premium 

0 CHANGE NAME OF 

- To__________________________ W O Nanie) t* New Nune 

If tt najn of the Poiicyowner Is being changed, sige the new name as "Signature of Policyowner' below. 

CHANGE OWNERSHIP TO 

(New PcI ycwns.s Adsss) (New 'OICVW. SoiI Sscwitv ND.) ALL OThER OWNERSHIP PROVISIONS AND RIGHTS WILL REMAIN THE SAME UNLESS SPECIFICALLY 

CHANGED. It endorsement Is required by policy prcvisbn recording by the Company and mailing to the new owner 

a copy of this instrument shall constitute such endorsement PLEASE SEND IN A NEW W-9 FORM. 

I'ERM CONVERSION a, Convert i9ht: rn OAJAL. bJuA#J to h3 . Li, L.. 

ad Ain (N d Dividend Option___________________________ Mode of premium payment 

Inthepastl2rnonths,haveyouusedtobaccouianyform? 0 11 

If yes, specify: 

Automatic Premium Loan Provision Vie No,P 

elected, If applicable? 0 Universal UfelSecond to Die Only: 

CAL Provlion elected? (Assurance Co. only) 0 th Benefit Opt. 1 Ot. 2 

Is WPD, or WMD. iesire Planned Premium 

Is the insured currently disabled? 0 (3' 

Complete a change of beneficiary request If you desire a change. 

IfthlslsaconversionofAddjtlonalhisured'scoverage,statewhowlUbetheownerofthenewpollcyandcompletea cnge of beneficiary request. 

13'OTHER ( V 

o rv ur ôM-' ov Jrq 7c U i-, 

i4- iS 1 :y3jjcjg.... 

7.71/5 /.S A reRfh cThuQiO).% CyeO,r Pv'3sys 5'& /) ",IV' C6I? 

Swe 

oiWitness 

AGENT'S CODE STAMP t. 

.4GC Vc, ZCc* 

1⁄4 Fjj 

231189828 P,lnt&I I U.S.A. 

Ic 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 39 of 64
PART (C) 

Ev 

CHANGE OF BENEFICIARY ANDIOR SETtLEMENT SPECIFICA11ONS A SEPARATE FORM IS REQUIRED FOR EACH INSURED PERSON WHOSE BENEFICIARY IS TO BE CHANGED. 

To: State Farm Life Insurance Company 0 State Farm Life and Accident Assurance Company 

Policy No(s) /57S 9 '& insurei Person 

_ ALI,tJAL _ PA . This change applies to: Name of 0 Principal Insured 0 AdditIonal Insured Additional Insured 

I request payment of any sum payable on the insured person's death be made as shown bef ow. Payment will be sublect to any assignment. Any prior provisions for payment upon the Insured person's death are revoked, when this request ts recorded. For Additional Insured's or Children's rider, the rider's beneficiary provisions are revoked, and the policy's beneficiary proviStons will control "Additional Insured", insured Chikr, or "Annultant", will be used in place of insured. 

COMPLETE SECTIONS FOR ALL BENEFICIARIES, EVEN IF UNCHANGED, GIVING ThE FULL NAME, AGE, ADDRESS (If different from the Insured's) AND RELATIONSHIP TO ThE INSURED PERSON FOR EACH. FOR CHILDREN AS A CLASS, NAME THOSE NOW UVING. PLEASE TYPE OR PRINT IN INK AND INITIAL ANY CROSS-OUTS. 

BENEFICIARIES METHODS OF SETTLEMENT 

PRIMARY - Name, Age, Relationship, Address Check one: iterest Option Done Sum 0 Other-Explain: Taxpayer Identification Number (if aval 

,%RrtM 4. PdLu4 

SUCCESSOR - Name, Age, Relationship, Address Method of settlement for Suocesor If no Primary survives Taxpayer identification Number (It available) 

p . Pm,e 

Insured Person. 

Check one: nterest Option DOne Sum 0 Other-ExplaIn: 

FINAL - Name, Age, Relationship, Address 

Taxpayer IdentIficatIon Number (If available) 

Settlement Only 

Unless changed by this request 

If Primary Beneficiary survives the insured person, any payment due a Successor Beneficiary will be in one sum. Two or morn surviving beneficiaries of a class wE share equally If children of a person are named as a dass, only children born to or legally adopted by that person will be included as beneficiaries. 

Any beneficiary to whom a "tthe clauW applies will be deemed not to have survived the insured person If that beneficiary Is not living on the 30th day after Insured person's death. 

Special Pmvlalons The Company will not be responsible for use of any sum payable by a trustee or authorized representative of a beneficiary. Payment to a trustee or authorized representative of a beneficiary will fully discharge all 

liability of the Company to the extent of such payment. 

If a trust is not in force, or If qualifying conditions for trust under will are not met payment will be made to the 

succeeding beneficiary, If any. 

Qualifying Conditions for Trust under WilL The Will must be admitted to Probate within 180 days after Insured person's death, and trustee must qualify withIn 1 year after insured persons death. 

The change will take effect Wi accordance with policy provisions, but the change will not affect any action we may have taken before we receive the request If the policy requires endorsement, recording and mailing a copy of this form (and endorsement form, if any) to me will constitute the e*rsement. 

[,J:;i,:i. - Wi" WL.VL 

Recorded by: 

Date z-3-'11 - Stats Farm Lila Inawsacs Compasty!*t.t. Farm Ut. sad Accidant Aas*uancs Company 

AGENT'S CODE STAMP 

, rpi is. AY., !rlc. 8067. 

CORF ChR1TI Fl 11 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 40 of 64
EXHIBIT B 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 41 of 64
STATE FARM LIFE INSURANCE COMPANY 

HOME OFFICE, ONE STATE FARM PLAZA, BLOOMINGTON, ILLINOIS 61110 INSURED ANNA M GONZAEEZ 

(Female) 

FARM 

AGE :21 I POLICY NUMBER LF-2153-7359 

[IThF1L I. POLICY DATE May 17, 2004 

INITIAL BASIC AMOUNT $100,000 

This policy is based on the application and the payment of premiums, as specified in the 

policy. State Farm Life Insurance Company will pay the proceeds to the beneficiary when 

due proof is received that the Insured died before this policy terminated. If the Insured is 

ah've on the maturity date, the cash surrender value on the maturity date mu be paid to the 

Owner and this policy will terminate. 

30-Day Right to Examine the Policy. This policy may be returned within 30 days of its 

receipt for a refund of all premiums paid Return may be made to State Farm Life Insurance 

Company or one of its agents If returned, this policy will be void from the policy date 

Read this policy with care. This is a legal contract between the Owner and State Farm Life 

Insurance Company. 

Secretary 

Registrar 

BASIC PLAN DESCRIPTION 

President 

Flexible premium adjustable life insurance. A death benefit is payable if the Insured dies 

before the maturity date The cash surrender value is payable if the Insured is alive on the 

maturity date coverage may terminate prior to the maturity date Flexible premiums are 

payable while the Insured is alive until the maturity date The basic plan is eligible for 

annual dividends. 

FORM 94030-43 PAGE 1 931215 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 42 of 64
CONTENTS 

PAGE l'o1icr Identification . , ............. .:g ................................................ 3 

ScheduleofBeuefits ,,..,., ..... ,.,, ........................................ 3 

Schedule of F'reiniuiiis ...................................................... -, 3 

MonthlyDeductions......................................................... 3 

ScheduleofSurrenderCharges .......................... 4 

Cost of Insurance Rates and Monthly Charges ................ ,,. ........... 4 

Defiiiitioi,.s .......................... -5 

Ovvnersliip..................................................................... 5 

Owner. Change of Owner. 

DeathBenefitandfleathBenefitOptions ............................. .... ....... 6 

Death Benefit, Change in Basic Amount. 

Death Benefit Options. Change in Death Benefit Option. 

Payitientof Benefits .......................................... . * , . .......... 7 

Beneficiary Designation. Methods of Payment. Change of Beneficiary Designation, Minimum Payment. Order of Payment on the Insured's Basis of -Computation for Payments-. Death. Additional Amounts Payable. 

Prenii.inis ........... . .......... -., ............................................... 9 

Payment of Premiums. Grace Period. 

Premium Limitations. Reinstatement. 

Guaranteed \Ialues ............................ * ........... , ....................... . . 9 

Account Value. Cash Surrender Value. 

Monthly Deduction, Withdrawals. 

Cost of Insurance, Surrender Charge. Monthly Cost of Insurance Rates. Basis of Computation. Interest. 

Policy- Loan ............ , , ........................................................ 12 

Loan. Loan Interest. 

Loan Value. Loan Repayment. 

Genei'al .......................................................................... 12 

The Contract. Assignment. Annual Report. Error in Age or Sex, 

Projection of Benefits and Values Incontestability Annual Dividends, Limited Death Benefit. 

Dividend Options. 

The Application and any Riders and Endorsements follow page 14. 

FORM 94030-43 PAGE 2 930507 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 43 of 64
POLICY IDENTIFICATION 

Insured ANNA M GONZALEZ Age 21 

(Female) 

Policy Number LF-2153-7359 Initial Basic Amount $100,000 

Policy Date May 17, 2004 

Issue Date June 1, 2004 

SCHEDULE OF BENEFTS 

Universal Life Basic Plan: 

Death Benefit Option 2 (Basic Amount plus the Account Value) 

Basic Amount (Standard Rate Class-Female Non-Tobacco): $100,000 

Maturity Date: May 17, 2083 

Riders: 

Benefit Monthly 

Insurance Period Charge 

Form Description Amount Ends Deductible 

94206 Waiver of Monthly Deduction In 2043 To 2043 

Effective Date: June 1, 2004 

Issue Date: June 1, 2004 

SCHEDULE OF PREMIUMS 

The Initial Premium is $30.00. 

Planned premiums are included in the schedule shown below. The payment period for the 

planned premiums is 1 month starting on June 17, 2004 payable until the maturity 

date. 

A premium expense charge of 5% is deducted from each premium paid 

Total Premiums 

Beginning: For Policy Year 

May 17, 2004 $580.00 

May 17, 2005 600.00 

MONTHLY DEDUCTIONS 

The deduction date is the 17th of each month. 

Maximum monthly cost of insurance rates are shown on page 4. Cost of insurance is 

deductible to the maturity date. 

Continued on Next Page 

Form 94030 Page 3 20040601 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 44 of 64
MONTHLY DEDUCTIONS 

Continued from Page 3 The monthly expense charge is $5.00. 

NOTE: Insurance may terminate prior to the maturity date if premiums paid are not 

sufficient to continue the insurance to that date. 

Form 94030 Page 3 Continued 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 45 of 64
SCHEDULE OF SURRENDER CHARGES 

Beginning Beginning 

Policy Policy Surrender Policy Policy Surrender 

Year Month Charge Year Month Charge 

1 1 $12.00 1 12 $144.00 

1 2 24.00 2 1 144.00 

1 3 36.00 3 1 144.00 

1 4: 48.00 4 1 126.00 

1 5 60.00 5 1 108.00 

1 6 72.00 6 1 90.00 

1 7 84.00 7 1 72.00 

1 8 96.00 8 1 54.00 

1 9 108.00 9 1 36.00 

1 10 120.00 10 1 18.00 

1 11 132.00 11 1 0.00 

COST OF INSURANCE RATES AND MONTHLY CHARGES 

Monthly Cost of Insurance Rates 

Per $1000 

(Standard Rate Class-Female Non-Tobacco) 

Age Rate Age Rate Age Rate Age Rate 

21 .0900 41 .2295 61 .8826 81 6.7294 

22 .0917 42 .2487 62 .9626 82 7.5789 

23 .0934 43 .2671 63 1.0586 83 8.5491 

24 .0959 44 .2871 64 1.1675 84 9.6289 

25 .0976 45 .3072 65 1.2832 85 10.8111 

26 .1001 46 .3273 66 1.4033 86 12.0908 

27 .1034 47 .3498 67 1.5235 87 13.4694 

28 .1067 48 .3741 68 1.6473 88 14.9520 

29 .1101 49 .4000 69 1.7866 89 16.5557 

30 .1142 50 .4285 70 1.9508 90 18.3060 

31 .1184 51 .4595 71 2.1528 91 20.2498 

32 .1226 52 .4947 72 2.4040 92 22.4699 

33 .1284 53 .5332 73 2.7057 93 25.1552 

34 .1343 54 .5726 74 3.0550 94 28.7360 

35 .1418 55 .6129 75 3.4445 95 34.1581 

36 .1518 56 .6523 76 3.8688 96 43.5428 

37 .1635 57 .6901 77 4.3247 97 62.1940 

38 .1777 58 .7279 78 4.8190 98 72.7637 

39 .1935 59 7699 79 5.3700 99 83.3333 

40 .2111 60 .8204 80 5.9999 

Continued on Next Page 

Form 94030 Page 4 20040601 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 46 of 64
COST OF INSURANCE RATES AND MONTHLY CHARGES 

Continued from Page 4 

Monthly Charges Per $1 of Monthly Deductions for Waiver of Monthly Deduction 

Monthly Monthly Monthly Monthly 

Age Charge Age Charge Age Charge Age Charge 

21 .0240 31 .0332 41 .0585 51 .1336 

22 .0251 32 .0344 42 .0618 52 .1448 

23 .0264 33 .0358 43 .0644 53 .1598 

24 .0275 34 .0375 44 .0682 54 .1790 

25 .0285 35 .0395 45 .0739 55 .2060 

26 .0293 36 .0419 46 .0805 56 .2288 

27 .0297 37 .0448 47 .0900 57 .2534 

28 .0306 38 .0480 48 .1015 58 .2843 

29 .0S14 39 .0515 49 .1129 59 .3589 

30 .0323 40 .0550 50 .1231 

Form 94fl30 Page 4 Continued 20040601 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 47 of 64
DEFINITIONS 

I We, us and our refer to State Farm Life Insurance Company. 

You and your refer to the Owner. 

Application. Includes any life insurance application, any application for change in the policy, 

medical history, questionnaire, and other documents from you or any other person proposed for 

insurance which are made a part of this policy. 

Basic Amount. The Initial Basic Amount plus 

any increases less any decreases. 

Basic Amount Mininuin. On or after the policy 

anniversary when the Insured is age 55, the Basic 

Amount cannot be less than $25,000, Otherwise, 

the Basic Amount cannot be less than $50,000. 

Benefit Period Ends. For any rider, the policy 

anniversary in the year shown under this heading 

on page 3 is the date the rider terminates, 

Monthly Charge Deductible. A monthly 

charge for any rider is deducted as part of the 

monthly deduction until the policy anniversary in 

the year shown on page 3. 

Officer. The president, a vice president, the 

secretary, or an assistant secretary of State Farm 

Life Insurance Company. 

Payee. On the Insured's death, the beneficiaries shown in the application, unless changed. 

If you cash surrender this policy or this policy 

matures, the persons that you have named. A 

payee can be other than a natural person only if 

we agree. 

Planned Premium. The premium amount that 

you have chosen. This amount is shown on page 3 

for the payment period that you have chosen. 

Policy Date. The effective date of this policy. 

Deduction Date. The policy date and each Policy Month, Year, or Anniversary. A policy 

monthly anniversary of the policy date month, year, or anniversary is measured from the 

policy date. 

Dollars. Any money we pay, or which is paid to 

us, must be in United States dollars. 

Effective Date. Coverage starts on this date. 

Initial Basic Amount. The amount of coverage 

on the Insured provided by the Basic Plan on the 

policy date. 

Insurance Amount. The amount of coverage 

on the effective date of each rider shown on page 

3. 

Maturity Date, The policy anniversary when 

the Insured is age 100, 

Proceeds. The amounts payable on the death of 

the Insured, 

Rate Class. The underwriting class of the person insured. A rate class will be determined for 

the Initial Basic Amount and each increase in the 

Basic Amount. 

Request. A written request signed by the person making the request. Such request must be 

sent to and be in a form acceptable to 'us. 

Rider. Any benefit, other than the Basic Plan, 

made a part of this policy. 

I OWNERSHIP PROVISIONS I Owner. The Owner is as named in the application, unless changed. You may exercise any policy 

provision only by request and while the Insured is 

alive. 

Change of Owner. You may change the ownership of this policy by sending us a request while 

the Insured is alive. We have the right to request 

this policy to make the change on it. The change 

will take effect the date you sign the request, but 

the change will not affect any action we have 

taken before we receive the request. A change of 

owner does not change the beneficiary designation. 

FORM 94030-48 PAGE 5 931215 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 48 of 64
DEATH BENEFIT AND DEATH BENEFIT OPTIONS PROVISIONS 

I Death Benefit. The amount of death benefit is 

an amount of insurance based on the death 

benefit option plus any insurance amounts pay- able under any riders on the Insured and the part of the cost of insurance for the part of the policy month beyond the Insured's death less any loan, accrued loan interest, and, if the Insured dies during the grace period, the monthly deductions from the start of the grace period. 

Death Benefit Options. There are two death benefit options If you do not choose an option, we 

will use option 2. The account value on the date of 

death is used in determining the amount of 

insurance, 

Option 1. The amount of insurance will be the greater of (1) the Basic Amount plus 95% of 

any premium received since the last deduction 

date plus interest earned on that amount of 

premium or (2) a percentage of the account value, Such percentage 5 based on the Insured's age at the start of the current policy year. 

Option 2. The amount of insurance will be the greater of the Basic Amount plus the 

account value or (2) a percentage of the account 

value. Such percentage is based on the Insured's 

age at the start of the current policy year. 

Percentageof Account Value Table 

Age Percentage Age Percentage 0-40 250% 61 128% 

41 243% 62 126% 

42 286% 63 124% 

43 229% 64 122% 

44 222% 65 120% 

45 215% 66 119% 

46 209% 67 118% 

47 :203% 68 117% 

48 197% 69 116% 

49 191% 70 115% 

50 185% 71 118% 

51 178% 72 111% 

52 171% 73 109% 

53 164% 74 107% 

54 157% 75-90 105% 

55 150% 91 104% 

56 146% 92 103% 

57 142% 93 102% 

68 138% 94 101% 

59 134% 95 & up 100% 

60 130% 

Change in Basic Amount! You may request a 

change in the Baste Amount once each policy 

year, The minimum amount of change is $25,000 for an increase and $10,000 for a decrease For 

any change in Basic Amount, we will send you a 

revised page 3 to be placed with this policy 

If you request an increase, an application must be 

completed, evidence of insurability satisfactory to 

us must be furnished, and there must be enough cash surrender value to make a monthly deduction which includes the cost of insurance for the 

increase. No increases will be allowed after th 

policy anniversary when the Insured is age 80. 

The revised page 3 will show the amount of the 

increase and its effective date. 

If you request a decrease, the Basic Amount 

remaining after the decrease cannot be less than 

the Basic Amount Minimum. We reserve the right to not accept a request for a decrease in the Basic 

Amount if such decrease could result in this policy being disqualified as a life insurance contract 

under any section of the United States Internal 

Revenue Code, as amended from time to time. 

Any decrease will first be used to reduce the most 

recent increase. Then, the next most recent increases will be reduced Finally, the Initial Basic 

Amount will be reduced, The revised page 3 will 

show the amount of decrease and its effective 

date, The decrease will take effect on the date we 

receive the request. 

Change of Death Benefit Option. You may request a change of death benefit option once 

each policy year. For a change in death benefit 

option, we will send you a revised page 3 to be 

placed with this policy. The revised page will 

show the effective date of the change. 

If the change is to option 1, the Basic Amount will 

be increased by the account value on the effective 

date of the increase. We reserve the right to not 

accept a request for a change to option 1 if such 

change could result in this policy being disquali- fied as a life insurance contract under any section 

of the United States Internal Revenue Code, as 

amended from time to time. 

If the change is to option 2, the Basic Amount will 

be decreased by the account value on the effective date of the decrease. 

FORM 94030 PAGE 6 930507 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 49 of 64
I PAYMENT OF BENEFITS PROVISIONS 

I Beneficiary Designation. This is as shown in 

the application, unless you have made a change. It includes the name of the beneficiary and the 

order and method of payment. If you name 

"estate" as a beneficiary, it means the executors 

or administrators of the last survivor of you and 

all beneficiaries. If you name "children" of a 

person as a beneficiary, only children born to or 

legally adopted by that person will be included 

We may rely on an affidavit as to the ages, names, 

and other facts about all beneficiaries We will 

incur no liability if we act on such affidavit 

Change of Beneficiary Designation. You may 

make a. change while the Insured is alive by 

sending us a request. The change will take effect 

the date the request is signed, but the change will 

not affect any action we have taken before we 

receive the request. We have the right to request 

your policy to make the change on it. 

Order of Payment on the Insured's Death. 

When the Insured dies, we will make payment in 

equal shares to the primary beneficiaries living 

when payment is made. If a primary dies after 

the first payment is made, we will pay that 

primary's unpaid share in equal shares to the 

other primaries living when payment is made. If 

the last primary dies, we will make payment in 

equal shares to the successor beneficiaries living 

when payment is made. If a successor dies while 

receiving payments, we will pay that successor's 

unpaid share in equal shares to the other successors living when payment is made. If, at any time, 

no primary or successor is alive, we will make a 

one awn payment in equal shares to the final 

beneficiaries. If, at any time, no beneficiary is 

living, we will make a one sum payment to you, if 

living when payment is made. Otherwise, we will 

make a one sum payment to the estate of the last 

survivor of you and all beneficiaries. "When 

payment is made" means (1) the date. that a 

periodic payment is due or (2) the date that a 

request is signed for a cash withdrawal or a one 

sum payment. You may change this order of 

payment by sending us a request while the Insured is alive, 

Methods of Payment. We will pay the proceeds under the Interest method unless you 

choose another method, If the payee is other than 

a natural person, we will make payment under 

the One Sum method, 

All payment intervals are measured from the 

date the policy is surrendered or from the date 

the Insured dies No part of any payment can be 

assigned before the payment is made 

After the Insured's death, anyone who has the 

right to make a withdrawal may change the 

method of payment and may name a successor to 

their interest The successor payee may be their 

estate. 

Method 1 (Interest Method). We will pay 

interestat the end of each monthly interval. The 

interest rate Will be at least 31⁄4% a year. If 

chosen, we will pay interest at the end of 3, 6, or 

12 month intervals. Withdrawals may be made at 

any time, but any withdrawal must be at least 

$500. We will pay interest to the date of withdrawal on the amount withdrawn. 

Method 2 (Fixed Years Method). We will 

make equal payments at the end of each monthly 

interval for a fixed number of years These 

payments include interest The guaranteed interest rate is 3/2% a year. The present value of any 

unpaid payments may be withdrawn at any time 

FIXED YEARS TABLE 

Monthly payments that $1000 will provide for the 

number of years chosen. Payments for years not 

shown will be given, if requested, 

Years Payments Years Payments 

1 $84.90 8 $11.93 2 48.18 9 10.78 3 29.28 10 9.86 4 22.22 15 7.12 5 18.17 20 5.77 6 15.29 25 4.98 7 13.41 30 4.46 

FORM 94080 PAGE 7 930507 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 50 of 64
I PAYMENT OF BENEFITS PROVISIONS (CONTINUED) 1 

Method 3 (Life Income Method). We will 

make equal payments at the end of each monthly interval as long as the payee is alive. We base the 

amount of each payment on the payee's age and 

sex at the start of the first monthly interval. We 

may require proof of the payee's age and sex. The 

payee may not withdraw the present value of the 

payments. If the payee dies during a certain 

period, we will continue the payments to the end 

of the certain period; or the successor payee may have the present value of any remaining payments paid in one sum. 

LWE INCOME TABLE 

Monthly payments for life that $1000 will provide. Payments for ages not shown will be given, if requested. 

Life with 

Age Last Life 10 Years Certain 

Birthday Male Female Male Female 

50 $4.50 $4.15 $4.46 $4.13 

55 4,91 4.48 4.84 4.45 

60 5.47 4.92 5.34 4.86 

65 6.25 5.53 5.98 5.41 

70 7.34 6.38 6.76 6.12 

75 885 764 762 701 

Method 4(Fixed Amount Method). We 

will make equal payments at the end of 1, 3, 6, or 

12 month intervals. We will continue payments until the amount put under this method together 

with compound interest has been paid. The interest rate will be at least 31/2% a year. The payment interval chosen must provide a total annual payment of at least $100 for each $1000 put under 

this method The unpaid balance may be withdrawn at any time. 

Method 5 (Joint Life Income Method). 

We will make equal payments at the end of each 

monthly interval as long as at least one of the two 

payees is alive We will base each payment on the 

age and sex of both payees at the start of the first 

monthly interval. We may require proof of the 

age and sex of each payee, The payees may not 

withdraw the present value of any payments. 

JOINT LIFE INCOME TABLE 

Monthly payments that $1000 will provide as long 

as at least one of the two payees is alive. Payments for age combinations not shown will be 

given, if reqested. 

Age Last Female 

Birthday 60 65 70 75 

Male 

60 $4.45 $4.69 $4.91 $5.10 

65 4,60 4.92 5.24 5.55 

70 4.71 5.11 5.56 6.02 

75 4.79 5.26 5.83 6.47 

Method 6 (One Sum Method). We will pay the cash surrender value or the proceeds in one 

sum. Interest at the rate of at least 3i/% a year 

will be paid from the date of the Insured's death 

to the date of payment. 

Method, 7 (Other Method). Payment by 

any other method may be made if we agree 

Minimum Payment. If any payment, except 

the last, under a method of payment would be less 

than $100 per payee, we will pay the present 

value of any unpaid payments in one sum. 

Basis of Computation for Payments. The 

monthly payments shown for methods 3 and 5 are 

guaranteed payments based on an interest rate of 

3112% a year and the 1983 Table a, projected 10 

years using Projection Scale G. 

Any present values will be based on the interest 

rate used in determining the payments for the 

method. 

Additional Amounts Payable. Each year we 

may apportion and pay dividends or additional 

interest under any method of payment, 

FORM 94030 PAGE 8 930507 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 51 of 64
I PREMIUM PROVISIONS 

Payment of Premiums, You may pay premiums at our Home Office, a regional office, or to 

one of our agents. We will give you a receipt 

signed by one of our officers, if you request one. 

The initial premium is shown on page 3 and is due 

on the policy date. All other premiumsmay be 

paid in any amount and at any time if: 

(1) the amount is at least $25 and 

(2) in a policy year, the total premiums, ex- cluding the initial premium, do not exceed 

without our consent, the total Planned 

Premiums for a policy year. 

Premium Limitations. We reserve the right to 

refund any premium paid if such premium 

amount would be in excess of the guideline premium limitation as defined by Section 7702, Internal Revenue Code of 1988 (or as later amended), No expense charge will be deducted from the 

refunded premium. 

Grace Period. If, on any deduction date, the 

cash surrender value is not enough to cover the 

monthly deduction, the policy will stay iii force 

until the end of the grace period. The grace 

period is 61 days and starts on that deduction 

date, We will mail a notice at least 31 days prior 

to the end of the grace period to you and to any 

assignee of record, A premium large enough to 

cover the monthly deductions for the grace period 

and any increase in the surrender charges must 

be paid before the end of the grace period; 

otherwise, this policy will lapse and terminate 

without value. 

Reinstatement. If the policy is terminated at 

the end of the grace period, you may apply to 

reinstate it within 5 years after lapse. You must 

give us proof of the Insured's insurability that is 

satisfactory to us, You must pay premiums (1) to 

keep the policy in force for 2 months and (2) to 

pay the monthly deductions for the grace period. 

Reinstatement will take effect on the date we 

approve the application for reinstatement. 

I GUARANTEED VALUES PROVISIONS 

I Account Value. The account value on the policy date is 95% of the initial premium less the 

monthly deduction for the first policy month, 

The account value on any deduction date after 

the policy date is the account value on the prior 

deduction date: 

(l plus 95% of any premiums received since 

the prior deduction date, 

(2) less the deduction for the cost of insurance 

for any increase in Basic Amount and the 

monthly charges for any riders that became effective since the prior deduction 

date, 

(3) less any withdrawals since the prior deduction date, 

less the current monthly deduction, 

(5 plus any dividend paid and added to the 

account value on the current deduction 

date, and 

(6) plus any interest accrued since the prior 

deduction date. 

The account value on any other date is the 

account value on the prior deduction date: 

(1) plus 95% of any premiums received sin Ce 

the prior deduction date, 

(2) less the deduction for the cost of insurance 

for any increase in Basic Amount and the 

monthly charges for any riders that became effective since the prior deduction 

date, 

(3) less any withdrawals since the prior deduction date, and 

(4) plus any interest accrued since the prior 

deduction date. 

Monthly Deduction. This deduction is made 

each month, whether or not premiums are paid, 

as long as the cash surrender value is enough to 

cover that monthly deduction. Each deduction 

includes: 

(1) the cost of insurance, 

(2) the monthly charges for any riders, and 

3) the monthly expense charge. 

FORM 94030-43 PAGE 9 931215 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 52 of 64
I GUARANTEED VALUES PROVISIONS (CONTINUED) 

Cost of Insurance. This cost is calculated each 

month The cost is determined separately for the 

Initial Basic Amount and each increase in Basic 

Amount. 

The cost of insurance is the monthly cost of 

insurance times the difference between (1) and 

(2), where: 

(1) is the amount of insurance on the deduction date at the start of the month divided 

by 1.0032737, and 

is the account value on the deduction date 

at the start of the month before the cost of 

insurance and the monthly charge for any waiver of monthly deduction benefit rider 

are deducted. 

Until the account value exceeds the Initial Basic 

Amount, the account value is part of the Initial 

Basic Amount. Once the account value exceeds 

that amount, if there have been any increases in 

Basic Amount, the excess will be part of the 

increases in order in which the increases occurred. 

Monthly Cost of Insurance Rates. These rates 

for each policy year are based on the Insured's 

age on the policy anniversary, sex, and applicable rate class. A rate class will be determined for the 

Initial Basic Amount and for each increase. The 

rates shown on page 4 are the maximum monthly 

cost of insurance rates for the Initial Basic 

Amount, Maximum monthly cost of insurance 

rates will be provided for each increase in the 

Basic Amount. We can charge rates lower than 

those shown. Such rates can be adjusted for 

proeeted changes in mortality but cannot exceed 

the maximum monthly cost of insurance rates. 

Such adjustments cannot be made more than 

once a calendar year. 

Interest. An interest rate of at least 4% a year will be applied to the account value, The rate 

applied to the amount of account value up to the 

amount of any loan may differ from the rate 

applied to the account value in excess of the 

amount of any loan. We will determine these' 

rates at least once a year. 

Cash Surrender Value. You may request surrender of this policy at any time This policy will 

terminate on the date we receive the request or 

later date if you so request it. We will pay you the 

cash surrender value as of the date coverage 

ceases plus the monthly deduction for the part of 

the policy month beyond that date. We will pay 

you in one sum unless you choose another method 

of payment. The cash surrender value of this 

policy is its account value less any surrender 

charge and any loan and accrued loan interest, 

The cash surrender value on the maturity date 

will be the account value on that date less any loan and accrued loan interest The cash surrender value will not be less than zero. If this policy is surrendered within 31 days after a policy anniversary, the cash surrender value will not 

decrease within that period except for any loans 

or withdrawals. We may defer paying you the 

cash surrender value for up to 6 months after 

receiving your request. 

Withdrawals. You may request to withdraw 

part of the account value while this policy is in 

force. No more than 4 withdrawals can be made 

in any policy year. Any withdrawal must be at 

least $500 and must be less than the cash surrender value We may defer paying you a withdrawal 

for up to 6 months unless the withdrawal is to pay premiums on other policies with us. 

If death benefit option 1 is in effect, then the 

Basic Amount will be reduced by the withdrawal, 

effective with the date of the withdrawal; however, no withdrawal can be made which will 

reduce the Basic Amount to less than $25,000. 

The reduction will be made as if a decrease in the 

Basic Amount had been requested. 

FORM 94030-43 PAGE 10 981215 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 53 of 64
GUARANTEED VALUES PROVISIONS (CONTINUED) 

I Surrender Charge. The schedule of surrender 

charges is shown on page 4. For each increase in 

Basic Amount, additional surrender charges will 

apply. A revised page 4 will show a revised 

schedule of surrender charges which includes 

those additional charges, 

Upon reinstatement, the surrender charges will 

be adjusted for any surrender charge deducted at 

the time of lapse. A revised page 4 will show a 

schedule of the adjusted surrender charges. 

A schedule of surrender charges is determined 

separately for the Initial Basic Amount and for 

each increase in Basic Amount. A schedule is 

determined using a Base Surrender Charge and 

covers 120 policy months following the policy date 

or the effective date of an increase in Basic 

Amount For the Initial Basic Amount, use the 

surrender charge at the Insured's age on the 

policy date. For each increase in Basic Amount, 

use the surrender charge at the Insured's age on 

the policy anniversary on or first preceding the 

effective date of that increase. Take that surrender charge times the Initial Basic Amount, or the 

amount of the increase, if applicable, divided by 

1,000. Then, divide that resultby 12 to determine 

the surrender charge that will apply for that 

amount of insurance for the first policy month 

after its effective date. The surrender charge 

increases by that amount for each of the next 11 

policy months. The surrender charge then remains level for the next 24 policy months. The 

surrender charge decreases after 86 policy 

months and then decreases by that same amount 

after each successive 12 policy months. The 

amount of each decrease is equal to the surrender 

charge in effect at the end of 36 policy months 

divided by 8. 

Basis of Computation. The guaranteed values 

in this policy are at least as large as those 

FORM 94030-48 

required by law in the state where it is delivered 

based on the Commissioners 1980 Standard Ordinary Mortality Table with an interest rate of 

4% a year The insurance authority there has a 

statement of how these values are determined. 

The guaranteed values and maximum cost of 

insurance rates are based on the Insured's age 

last birthday and sex, The interest rate is 4% a 

year. The Commissioners 1980 Standard Ordinary Mortality Table is used. Modifications are 

made for rate classes other than standard. 

BASE SURRENDER CHARGE 

The base surrender charge is for each $1,000 of 

Initial Basic Amount or amount of increase in 

Basic Amount. 

Base Base 

Surrender Surrender 

Me Charge Ae CharEe 

0-19 $ 1.20 45 $9.72 

20 1.32 46 10.32 

21 1.44 47 10.80 

22 1.56 48 11.40 

23 1.80 49 11.88 

24 2.04 50 12.72 

25 2.40 51 13.44 

26 2,64 52 14,04 

27 2.88 53 14.88 

28 3.12 54 15.86 

29 3.86 55 16.02 

30 3.60 56 16.20 

81 3.84 57 16.68 

32 4.20 58 17.16 

38 4.68 59 17.40 

34 4.68 60 18.00 

35 5.16 61 18.36 

38 5.40 62 1&48 

37 5.64 63 18,60 

38 6.86 64 18.60 

39 6.72 65 19.40 

40 7.38 66 19.56 

41 7.44 67 19.80 

42 8.16 68 20,40 

48 8.76 69 20.64 

44 9.12 70-80 21.00 

PAGE 11 930507 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 54 of 64
I POLICY LOAN PROVISIONS 

Loan. You may borrow against this policy. This 

policy is the sole security for such loan We may defer a loan for up to 6 months after receiving 

your request unless the loan will be used to pay premiums on other policies with us. 

You may borrow the loan value less any existing loan and accrued interest and monthly deductions 

for the next 2 months If your unpaid loan plus accrued interest exceeds the loan value on the 

monthly deduction date, the Grace Period provi- sion will apply. 

Loan Value. The loan value is the account 

value of this policy less the surrender charge. 

Loan Interest. Interest accrues and is payable each day at a rate of 8% a year. Any interest not 

paid is added to the loan an each policy anniversary. 

Loan Repayment. You may repay all or part of 

a loan at any time before the Insured dies or the 

policy is surrendered or terminated 

I GENERAL PROVISIONS 

The Contract. The policy contains the Basic 

Plan, any amendments, endorsements, and riders, and a copy of the application. A copy of any application for a change to this policy will be sent 

to you to be placed with the policy Such applica- tions become part of this policy. The policy is the 

entire contract, We have relied on the statements 

in the application in issuing this policy. We 

reserve the right to investigate the truth and 

completeness of those statements. In the absence 

of fraud, they are representations and not warranties. Only material misstatements in the ap- plication will be used to contest this policy or 

deny a claim. 

Only an officer has the right to change this policy. 

No agent has the authority to change the policy or 

to waive any of its terms All endorsements) amendments, and riders must be signed by an 

officer to be valid. 

Annual Report. Each year, we will send you a 

report. This report will show: 

(1) the account value, the cash surrender value, any loan and accrued loan interest, and 

the amount of the death benefit as of the 

date of the report and 

(2) any premiums paid, any deductions made, and any withdrawals made since the last 

report. 

Projection of BenefIts and Values. You may request a projection of death benefits, account 

values, and cash surrender values. We may charge a reasonable fee not to exceed $25 for 

providing this projection. 

Annual Dividends. We do not expect to pay dividends on this policy; however) we may appor- tion and pay dividends each year, Any such 

dividends will be paid only at the end of the 

policy year. There is no right to a partial or pro rated dividend prior to the end of the policy year 

Dividend Options. You may choose to have 

your dividend used under one of these options: 

1. Cash. We will pay it to you in cash. 

2. Addition to Account Value. We will 

add it to the account value at the end of the policy 

year. 

If you do not choose an option or the option you 

choose is not available, we will use option 2, You 

may request to change the option. The change 

will apply only to dividends paid after we receive 

the request. 

Assignment. You may assign this policy or any interest in it. We will recognize an assignment only if it is in writing and filed with us. We are 

not responsible for the validity or effect of any assignment. An assignment may limit the interest 

of any beneficiary. 

FORM 94030-43 PAGE 12 931215 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 55 of 64
I GENERAL PROVISIONS (CONTINUED) 

I Error in Age or Sex. If the Insured's date of 

birth or sex is not as stated in the application, we 

will adjust each benefit on the Insured to the 

benefit payable had the insured's age and sex 

been stated correctly. Such adjustment will be 

based on the ratio of the correct monthly deduction for the most recent deduction date for that 

benefit to the monthly deduction that was made. 

For the Basic Plan, the adjustment is made to the 

amount of insurance less the account value 

incontestability. We will not contest the Basic 

Plan after it has been in force during the Insured's lifetime for 2 years from the issue date of 

the policy. We will not contest any increase in 

Basic Amount or reinstatement after it has been 

in force during the lifetime of the Insured for 2 

years from the effective date of the increase in 

Basic Amount or reinstatement. We will not 

contest an increase due to a change to Death 

Benefit Option 1. Any contest of any increase in 

Basic Amount or reinstatement will be limited to 

material misstatements contained in the application for such increase or reinstatement. 

Each rider has its own incontestability provision. 

Limited Death Benefit. If the Insured dies by 

suicide while sane or by self-destruction while 

insane within 2 years from the issue date of the 

policy, the Basic Amount will not be paid. The 

proceeds in this case will be limited to the 

premiums paid on the Basic Plan less any loan, 

accrued loan interest, any withdrawals from the 

account value, and any dividends paid on the 

Basic Plan. 

Any increase in Basic Amount or amount reinstated will not be paid if the Insured's death 

results from suicide while sane or self-destruction 

while insane within 2 years from the effective 

date of such increase or reinstatement. The proceeds of the increase will be limited to the 

monthly deductions for the increase, This does 

not apply to an increase due to a change to Death 

Benefit Option 1, The proceeds of a reinstated 

policy will be limited to the premiums paid on the 

Basic Plan since reinstatement less any loan, 

accrued loan interest, any withdrawals from the 

account value, and any dividends paid on the 

Basic Plan. 

Each rider has its own limited death benefit 

provision. 

FORM 94030-43 PAGE 13 931016 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 56 of 64
I %1AIVER OF MONTHLY DEDUCTION BENEFIT RIDER 

I General. This rider is part of your policy. It is 

based on the application for this rider and the 

deduction of the monthly charges for this rider, 

Only certain policy provisions are a part of this 

rider They are "Definitions," "Ownership," 

"Death Benefit and Death Benefit Options," 

"Grace Period," "Reinstatement," "Monthly De 

duction," "The Contract," "Assignment," and 

"Error in Age or Sex." 

Monthly Charge for This Rider, The monthly 

charge is (1) times (2) where: 

(1) is the total monthly deduction to which 

this benefit applies before the monthly 

charge for this rider is added and 

(2) is the monthly charge for this rider per 

dollar of monthly deduction. The charges 

per dollar of monthly deduction are shown 

on page 4. 

Waiver of Monthly Deduction Benefit. We 

will waive monthly deductions for this policy as 

defined below if the Insured becomes totally 

disabled and such total disability has existed for 6 

continuous months during the lifetime of the 

Insured We will waive those monthly deductions 

as long as the total disability continues. We will 

only waive monthly deductions on deduction 

dates on and after total disability starts Any 

monthly deductions made after the total disability starts will be added to the account value, with 

interest; however, no monthly deduction will be 

included which was deductible more than one 

year prior to the date we receive notice of the 

claim. If Death Benefit Option 1 is in effect, it 

will be automatically changed to Death Benefit 

Option 2. The effective date of the death benefit 

option change will be the date we start to waive 

monthly deductions. 

The monthly deduction that will be waived includes only those portions of the total monthly 

deduction for which a charge for this rider was 

deducted on the deduction date on or just prior to 

the date total disability starts. 

If part of the monthly deduction that is being 

waived is for the cost of insurance on the Basic 

Amount, any increase in its surrender charges 

that would occur while the total disability continues will be waived. 

Total Disability Defined. Total disability is a 

condition caused by injury or disease. During the 

first 24 months after total disability starts, this 

condition must prevent the Insured from performing substantially all of the work of the 

Insured's regular occupation. After the first 24 

months, the condition must prevent the Insured 

from performing substantially all of the work in 

any occupation for which the Insured is, or becomes, reasonably qualified based upon education, training, or experience. The Insured's total 

and irrecoverable loss, caused by injury or disease, of any of the following will be considered 

total disability even if the Insured is able to work: 

(1) sight in both eyes 

(2) use of both hands, 

3) use of both feet. 

use of one hand and one foot. 

Disabilities Not Covered. We will not waive 

monthly deductions if total disability 

(1) starts before the issue date of this rider 

unless such disability was disclosed in the 

application, 

(2) starts before the policy anniversary when 

the Insured is age 5, 

(3) results from an intended self-injury, or 

(4) results from any act due to war whether or 

not the Insured is in the military service. 

"War" means declared or undeclared war 

or conflict involving the armed forces of 

one or more countries, governments, or 

international organizations. 

Notice and Proof of Total Disability. We 

must receive notice of a claim and due proof of 

total disability while the Insured is alive and 

totally disabled and within 91 days after such 

total disability starts If this is not done, you 

should submit such notice and proof as soon as 

reasonably possible. We may also require you to 

submit proof of the Insured's continuing total 

disability at reasonable intervals. You have at 

least 01 days after the date requested to submit 

such proof. If you do not submit proof when we 

require it, no further monthly deductions will be 

waived. We will not require proof more than once 

a year after the total disability has lasted moi e 

than 2 years, 

FORM 94206-43 920415 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 57 of 64
I WAIVER OF MONTHLY DEDUCTION BENEFIT RIDER (CONTINUED) 

I Premium Payments. If the Insured's total 

disability starts during a grace period, befOre we 

will approve a claim, a premium must be paid which is large enough to cover the monthly 

deductions plus any increase in the surrender 

charge from the start of the grace period through the policy month in which total disability starts. 

Premiums, sufficient to keep the policy in force 

until we approve the claim, are payable. 

Termination. This rider will terminate on the 

policy anniversary shown on page a under Benefit 

Period Ends. We will terminate this rider before 

that date when the policy terminates by surrender or lapse. 

You may request termination of this rider. You 

must send us the request and the policy. This 

rider will terminate on the date the request and 

the policy are received We will revise pages 3 

and 4 of the policy to show this change. 

Termination will not affect any claim for total 

disability which starts before termination. 

Incontestability. We will not contest this rider 

after it has been in force during the lifetime of 

the Insured for 2 years from its issue date unless 

the Insured becomes totally disabled within that 

period. 

Issue Date of This Rider. This is the effective 

date It is the same as the issue date of the policy 

unless a different date for this rider is shown on 

page 3. 

State Farm Life Insurance Company 

President 

Secretary 

FORM 94206-43 920415 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 58 of 64
TII 

__Eflq 

PROPOSED INSURED 1: t48 Mailing Addres 

STATE FARN 00, LIFE INSURANCE COMPANY POLICY COPY 

ILLINOIS 

APPLICATION FOR LIFE INSUR)NCE 

In City? YES 

MARRIED IEMMI1 Age: 21 State: TX Height: Weight: 

U.S. or Canadian Citizen: YES Drivers license no.: State: SS#: 

Bays you used tobacco or any other nicotine products in any orm in the last 12 months 

Occupation: CUSWNER SERVICE Employer: 

Do job duties fall into one of the following occupation categories? 

tamusement/sparts;construction/ explosive/divers liquor; logging/mininggas/oil) **fl*************** k***i*ti*****h ktt** ****t******t**t*****t* *****fl****** ASIC PLAN ANOUNT UNIVERSAL LIFE $ 100,000 Death Benefit Option 2: Basic amount plus account value 

P1 #1 P.IDERS/BENEFITS ANOUNT WMD Planned premium: $ 5000 Additional first year premium: $ 

Dividend option: 

PROPOSED INS REIATIONSRI? 

PRIMARY: 

SUCCESSOR If a beneficiary survives the Insured, any payment to successor will be one sum ess c ed, 

Proposed Insured 1 or Applicant, if other than Proposed Insured 1: Do you own any life insurance or annuities on yourself or others? 

If yes, is this policy a replacement of any of those policies? 

Is the total amount of insurance in force on you more than $200,000? 

Is anyone now applying for life or health insurance on you with any other company? 

Do you plan to leave or travel from the United States or Canada in the next 6 months? Have you ever: 

Applied for or received disability benefits? 

Had any loss of sight or hearing or bad an injury to your neck, back, arm, or leg? 

**t*t**********i**i*****************i t** *********t*i** ********************** 

Life Insurance Application on GONZALEZ, ANNA N 530-6677D13 Page 1 EApp-Life-20O2 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 59 of 64
I POLICY COPY 

Have you, in the last 10 years, had or been treated by a meer of the medical profession for: 

High blood pressure? Stroke? Heart nnrnnur? 

Chest pain? Heart attack? Tumor? 

Lymph gland disorder? Cancer? Pneumonia? 

hysema? Asthma? Ulcer? 

Liver/intestinal disorder? Colitis? fjieinia? Blood disorder? Diabetes? Arthritis? 

Sexually transmitted disease? Kidney disease? Fatigue? 

Chronic diarrhea? Recurrent fever? Night sweats? 

Unexplained weight loss? Mental disorder? Epilepsy? 

Convulsive disorder? Nervous disorder? 

Acquired Imeune Deficiency 

Syndrome (AIDS) or Human 

hununadeficiency Virus (IIV) 

infection? 

** ********fl*******************fl**t******1************************************ 

Have you, in the last 5 years: Used cocaine, marijuana, or any other controlled substance or narcotic not prescribed by a doctor? Been treated/counseled/advised to seek treatment or counsel for alcohol or drug use? Have you, in the last 5 years, for any reason not previouslyexlained 

Had or been advised to have treatment or a test in any medical facility such as a lab, clinic, or hospital? Seen a doctor or psychologist? 

Had medication prescribed? 

Been told surgery was necessary? 

ADtJr.JT NON-MEDICAL EXPLANATIONS CON'T 

Life Insurance Application on GONZALEZ, ANNA N 530-6677-D13 Page 2 E-App-Life2002 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 60 of 64
flM* **M 

NIU*ANCt POLICY COPY 

Rave you in the last 3 years or elan to in the next anths: 

Rngaged in any type of aviation activity (other than as a passenger)? 

Engaged in nountain/rock clithing? 

Engaged In vehicle racing? 

Engaged in SCIJBAf skin diving? 

Engaged in sky diving, hang liding, hot air ballooning? 

Engaged in other such avocations? Have you, in the last 3 years, been convicted of or pleaded guilty to any ving violations or driving 

iaader the influence of alcohol or drugs? 

Life Insurance Application on GONZALEZ, ANNA t S30-66?7-D13 - Page 3 E-App-Life-2002 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 61 of 64
IA1 

POLICY COPY 

Coverage will be effective as of the policy date if the following conditions are met: the first premium is paid 

when the policy is delivered; the Proposed Insureds are living on the delivery date; and, on that delivery date, the 

information given to the Compan' is true and complete without material changes. 

Bowever, if a binding recept has been given and is in effect, its terms apply. 

All Proposed insureds and the Applicant state that the information in this application and any medical history is 

true and complete. It is agreed that the Company can investigate the truth and completeness of such information 

while the policy is contestable, 

By accepting the policy, the Owner agrees to the beneficiaries named, method of payment and cortections made No change in plan, amount, benefits, or age at issue may be made on the applioation unless the Owner agrees in writing. 

Qnl an authorized company officer may change the policy provisions. Neither the agent nor a medical examiner may pass on insurability. 

Any policy issued on this application will be owned by Proposed Insured 1, or the Applicant, if other than Proposed 

Insured 1. 

* Social Security or Tax Identification Number (TIN) Certification. By signing this application, I certify under * * penalties of perjury that (1) the TIN shown on pave 1 of this application is correct, and (2) I am exempt fron backup* * withholding, or that I am not subject to backup withholding either because I have not been notified that I am sithject* * to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service * * has notified me that I am no longer subject to backup withholding. (If you are subject to backup withholding, cross * * out item 2) and (3) I am a U.S. person (including a U.S. resident alien), * * The Internal Revenue Service does not require your consent to any provision of this document other than the * * certifications required to avoid backup withholding. (See instructions) * ********* ********l*** ********************************************************************************************* Date S d ç/ 74 Siature of Proposed Insured 1 at , 4JZI 

Agent as Witness 

ure of Applicant__________________________________________ to all 

otrequired unless applicant is other than Proposed Insured 1. If a firm or corporation is to be owner, give name and signature of authorized 

officer. 

Life Insurance Application on ONZ1LZ, ANNA M 530-6677-D13 - Page 4 of 4 -App-Ijife-2OO2 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 62 of 64
IMPORTANT NOTICE 

To obtain information or make a mpIaint: 

You may call State Farm's toll-free telephone 

number for information or to make a complaint at 

1-800-252-1932 

You may contact the Texas Department of Insur 

ance to obtain information on companies, coyeragea, rights or complaints at 

1-800-252-3439 

You may write the Texas Department of Insurance 

Consumer Services (lu-lA) 

P.O. Box 149091 

Austin, TX 78714-9091 

FAX# (512) 475-1771 

PREMIUM OR CLAIM DISPUTES: Should 

you have a dispute concerning your premium or 

about a claim, you should contact the company 

first, If the dispute is not resolved, you may 

contact the Texas Department of Insurance. 

ATTACH THIS NOTICE TO YOUR 

POLICY: This notice is for information only 

and does not become a part or condition of the 

attached document. 

AVISO IMPORTANTE 

Para obtener informacion o para someter una 

queja: 

Usted puede ilamar al numero de telefono gratis 

de State Farm's para inforniacion o para someter 

una queja aL 

1-800-252-1932 

Puede comunicarse con el Departamento de 

Seguros de Texas para obtener inforinacion acerca de companias, coberturas, derechos o quejas 

aL 

1-800-252-3439 

Puede esribir al Departamento de Seguros de 

Texas 

Consumer Services (111-1A 

P.O. Box 149091 

Austin, TX 78714-9091 

FAX# (512) 475-1771 

DISPUTAS SOBRE PRIMAS 0 RECLAMOS: 

Si tiene mm disputa concernieiite a su prima o a 

un reclamo, debe comunicarse con la compania 

primero. Si no se resuelve la disputa, puede 

entonces comunicarse con el departamento ITDI). 

UNA ESTE AVISO A SU POLIZA: Este 

aviso es solo para proposito de informacion y no se 

convierte en parte o condicion del documento 

adjunto. 

FORM 8636375 920401 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 63 of 64
BASIC PLAN DESCRIPTION 

Flexible premium adjustable life insurance, A death benefit is payable if the Insured dies 

before the maturity date. The cash surrender value is payable if the Insured is alive on the maturity date, Flexible premiums are payable while the Insured is alive until the maturity date. Coverage may terminate prior to the maturity date. The basic plan is eligible for 

annual dividends. 

FORM 94030-42 931215 

Case 5:20-cv-00617-FB-ESC Document 71-1 Filed 03/01/21 Page 64 of 64