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Specifications Page
TYPE OF CONTRACT: [Qualified] CONTRACT DATE: [05/01/2011]
CONTRACT NUMBER: [000000005] ISSUE STATE: [YS]
OWNER: [▇▇▇▇ ▇. ▇▇▇] OWNER'S AGE & SEX: [55] [Male]
ANNUITANT: [▇▇▇▇ ▇. ▇▇▇] ANNUITANT'S AGE & SEX: [55] [Male]
[CO-OWNER:] [______] [CO-OWNER'S AGE & SEX:] [____][____]
[CO-ANNUITANT:] [______] [CO-ANNUITANT'S AGE & SEX:] [____][____]
PLAN [VENTURE Frontier with Flex Access Option]
[THE PURPOSE OF THE GUARANTEED MINIMUM WITHDRAWAL BENEFIT PROVIDED UNDER THIS
ANNUITY CONTRACT IS TO PROVIDE SECURITY THROUGH A STREAM OF INCOME PAYMENTS TO
THE OWNER. THE GUARANTEED MINIMUM WITHDRAWAL BENEFIT WILL TERMINATE UPON
ASSIGNMENT OR A CHANGE OF OWNERSHIP OF THE CONTRACT UNLESS THE NEW ASSIGNEE OR
OWNER MEETS THE QUALIFICATIONS SPECIFIED IN THE TERMINATION PROVISION OF THE
GUARANTEED MINIMUM WITHDRAWAL BENEFIT RIDER.]
THE PURPOSE OF THE GUARANTEED MINIMUM DEATH BENEFIT PROVIDED UNDER THIS ANNUITY
CONTRACT OR ANY DEATH BENEFIT RIDER ATTACHED TO THIS CONTRACT IS TO PROVIDE
SECURITY THROUGH A DEATH BENEFIT PAYMENT TO THE BENEFICIARY. THE GUARANTEED
MINIMUM DEATH BENEFIT WILL TERMINATE UPON ASSIGNMENT OR A CHANGE OF OWNERSHIP OF
THE CONTRACT UNLESS THE NEW ASSIGNEE OR OWNER MEETS THE QUALIFICATIONS SPECIFIED
IN THE TERMINATION PROVISION OF THE GUARANTEED MINIMUM DEATH BENEFIT RIDER OR
THE CHANGE OF OWNER, ANNUITANT, BENEFICIARY PROVISION OF THIS CONTRACT.
FEES AND CHARGES
CONTRACT ASSET FEE [1.65% years 1-4]
[1.15% years 5+]
ANNUAL CONTRACT FEE [Electronic-Delivery of Financial
[Owner Elects Electronic Delivery of Transaction Confirmations is
Financial Transaction Confirmations] Not Elected by Owner]
------------------------------------ ---------------------------------
[$0] [$50]
PAYMENT LIMITS
PAYMENT LIMITS - Minimum Additional Payment Amount: [$30]
- Maximum Amount: [$1,000,000]
- Flex Access Option: No additional Payment will be accepted without
our prior approval on or after the [first] Contract Anniversary
ICC11-SP.VENW-L.11 S.1 [SAMPLE]
LIMITS--TRANSFERS AND AMOUNT OF PARTIAL WITHDRAWALS
TRANSFER CHARGES AND LIMITATIONS-- - Minimum Transfer Amount: $300
BEFORE ANNUITY COMMENCEMENT DATE
- Minimum Investment Account Value: $100
- Minimum Number of Transfers Per Contract Year: one per month and no
more than six within the Contract Year
- Transfer Charge: the lesser of $25 or 2% of the amount of each
transfer in excess of 12 per Contract Year
TRANSFER LIMITATIONS - ON OR AFTER - Minimum Number of Transfers Per Contract Year: 4
ANNUITY COMMENCEMENT DATE
LIMITATIONS ON AMOUNT OF - Minimum Amount of Partial Withdrawal: [$300]
PARTIAL WITHDRAWALS
- Minimum Investment Account Balance: [$100]
- Minimum Remaining Contract Value: [$1,000]
WITHDRAWALS CHARGES
TABLE OF WITHDRAWAL CHARGES Number of Complete Years Withdrawal Charge
Payment has been in Contract Percentage
---------------------------- -----------------
[0] [8%]
[1] [7%]
[2] [6%]
[3] [5%]
[4+] [0%]
[Withdrawal Charges will be waived for any contract issued to an
employee of the Company, a registered representative or an employee of a
broker/dealer that has a selling agreement with the Company or such
person's spouse, parents, stepparents, in-laws, siblings, children and
stepchildren.]
INITIAL ALLOCATION OF NET PAYMENT (See Following Page for All Available Investment Options)
INITIAL PAYMENT [$100,000.00]
[DCA ACCOUNT OPTIONS:] [INITIAL INTEREST RATE] [INITIAL GUARANTEE PERIOD EXPIRES]
[6 Month DCA Account] [25.00%] [1.00%] [11/01/2011]
VARIABLE INVESTMENT OPTIONS:
[Lifestyle Balanced PS] [75.00%]
TOTAL 100.00%
ICC11-SP.VENW-L.11 S.2 [SAMPLE]
AVAILABLE INVESTMENT OPTIONS
VARIABLE ACCOUNT: [▇▇▇▇ ▇▇▇▇▇▇▇ LIFE INSURANCE COMPANY (U.S.A.) SEPARATE ACCOUNT H]
VARIABLE INVESTMENT OPTIONS:
[Lifestyle Balanced]
[Lifestyle Balanced PS]
[Lifestyle Conservative]
[Lifestyle Conservative PS]
[Lifestyle Growth]
[Lifestyle Growth PS]
[Lifestyle Moderate]
[Lifestyle Moderate PS]
[Ultra Short Term Bond]
[Money Market]
[DOLLAR COST AVERAGING (DCA) ACCOUNT INVESTMENT OPTIONS:]
[6 Month DCA Account]
[12 Month DCA Account]
OPTIONAL RIDERS
[ENHANCED DEATH BENEFIT RIDER: MARKETING NAME]
- [Rider Date:] [05/01/2011]
- [Rider Fee Percentage:] [0.30%]
- [Total asset Fee Percentage [1.95% years 1-4]
(Contract Asset Fee + Rider Fee):] [1.45% years 5+]
[GUARANTEED MINIMUM WITHDRAWAL BENEFIT RIDER: MARKETING NAME]
- [Rider Date:] [05/01/2011]
- [Maximum Rider Fee Percentage:] [1.50%]
ICC11-SP.VENW-L.11 S.3 [SAMPLE]
ANNUITY BENEFITS
MATURITY DATE: [10/25/2051]
ANNUITY OPTION: Life 10-Year Certain
ANNUITY PAYMENTS -- GENERAL The rates for Annuity Payments are determined based on:
INFORMATION
- Mortality Table: Annuity 2000 Table projected at Scale G, 100%
female blend
- Fixed Annuity Payment Interest Rate: 1.00% interest per year
- Variable Annuity Payment Assumed Interest Rate: 1.00%
The amount of each Annuity Payment will depend upon the age of the
Annuitant, the Co-Annuitant, if any, or other payee.
For variable annuity payments, the smallest annual rate of investment
return which is required to be earned on the assets of the Separate
Account so that the dollar amount of such payments will not decrease is
[2.78%].
BENEFICIARY INFORMATION
[▇▇▇▇ ▇▇▇]
[DISCLOSURES]
[PURSUANT TO SECTION 3 OF THE FEDERAL DEFENSE OF MARRIAGE ACT ("DOMA"), SAME SEX-MARRIAGES, DOMESTIC
PARTNERSHIPS AND CIVIL UNIONS CURRENTLY ARE NOT RECOGNIZED FOR PURPOSES OF FEDERAL LAW. THEREFORE, THE
FAVORABLE INCOME-DEFERRAL OPTIONS AFFORDED BY FEDERAL TAX LAW TO AN OPPOSITE-SEX SPOUSE UNDER INTERNAL
REVENUE CODE SECTIONS 72(S) AND 401(A)(9) ARE CURRENTLY NOT AVAILABLE TO A SAME-SEX SPOUSE, DOMESTIC PARTNER
OR CIVIL UNION PARTNER. SAME-SEX SPOUSES, DOMESTIC PARTNERS OR CIVIL UNION PARTNERS WHO OWN OR ARE
CONSIDERING THE PURCHASE OF ANNUITY PRODUCTS THAT PROVIDE BENEFITS BASED UPON STATUS AS A SPOUSE SHOULD
CONSULT A TAX ADVISOR. TO THE EXTENT THAT AN ANNUITY CONTRACT ACCORDS TO SPOUSES OTHER RIGHTS OR BENEFITS
THAT ARE NOT AFFECTED BY DOMA, SAME-SEX SPOUSES, DOMESTIC PARTNERS AND CIVIL UNION PARTNERS RECOGNIZED BY THE
ISSUE STATE REMAIN ENTITLED TO SUCH RIGHTS OR BENEFITS TO THE SAME EXTENT AS ANY ANNUITY HOLDER'S SPOUSE.]
[THIS PLAN IS INTENDED TO QUALIFY UNDER THE INTERNAL REVENUE CODE FOR TAX-FAVORED STATUS. LANGUAGE CONTAINED
IN THIS CONTRACT REFERRING TO FEDERAL TAX STATUS OR RULES IS INFORMATIONAL AND INSTRUCTIONAL AND THIS
LANGUAGE IS NOT SUBJECT TO APPROVAL OR DISAPPROVAL BY THE ISSUE STATE. PLEASE SEEK THE ADVICE OF YOUR OWN TAX
ADVISOR REGARDING YOUR INDIVIDUAL TAX TREATMENT.]
ICC11-SP.VENW-L.11 S.4 [SAMPLE]