Founded in 1867...Mutual Company...P.O. ▇▇▇ ▇▇▇▇▇,
▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇ ▇▇▇▇▇
ANNUITANT: ▇▇▇▇ ▇▇▇
OWNER: ▇▇▇▇ ▇▇▇
CONTRACT NUMBER: 0123456789
CONTRACT DATE: August 01, 2004
WE promise to pay the benefits of this contract in accordance
with its terms.
LOOK AT THE APPLICATION FORMS. This contract is issued based
on payment of the initial premium and the answers in the
application (see copy attached). If all answers are not true
and complete, this contract may be affected.
PLEASE READ THIS CONTRACT CAREFULLY. This is a legal
contract between you and Union Central.
RIGHT TO EXAMINE THE CONTRACT. IT IS IMPORTANT TO UNION
CENTRAL THAT YOU ARE SATISFIED WITH THIS CONTRACT. YOU HAVE
10 DAYS AFTER YOU RECEIVE IT TO REVIEW THE CONTRACT. IF THIS
CONTRACT IS A REPLACEMENT FOR AN EXISTING CONTRACT YOU HAVE
20 DAYS AFTER YOU RECEIVE IT TO REVIEW THE CONTRACT. IF YOU
ARE NOT SATISFIED, YOU MAY SEND IT BACK TO US OR GIVE IT TO
OUR AGENT. IN SUCH CASE, THIS CONTRACT WILL BE VOID FROM THE
BEGINNING. WE WILL REFUND, WITHIN 7 DAYS AFTER THIS CONTRACT
IS RETURNED, THE ACCUMULATION VALUE OF THE CONTRACT. IF THIS
CONTRACT IS ISSUED AS AN INDIVIDUAL RETIREMENT ACCOUNT, AND
YOU RETURN IT DURING THE RIGHT TO EXAMINE PERIOD WE WILL
REFUND, WITHIN 7 DAYS AFTER THIS CONTRACT IS RETURNED, ANY
PREMIUMS PAID.
ALL ACCUMULATION VALUES AND ANNUITY PAYMENTS PROVIDED BY THIS
CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A
SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO
FIXED DOLLAR AMOUNTS.
Signed for the Company at Cincinnati, Ohio
/s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇▇ /s/ ▇▇▇▇ ▇. ▇▇▇▇▇▇
Secretary President
Flexible Premium Deferred Variable Annuity
Participating
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Licensed Resident Agent
INTRODUCTION
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This is a flexible premium deferred variable annuity. This
annuity contract provides that the accumulation value will be
variable, and annuity payments may be either fixed or
variable, or a combination of fixed and variable.
You determine the investment allocation for this annuity.
You may allocate your premiums to the guaranteed account or
the variable account, or a combination of these accounts, in
amounts as shown on the schedule page. If you select the
guaranteed account, then your accumulation value and annuity
payments will be fixed and guaranteed. If you select the
variable account, your accumulation value and annuity
payments will vary with the investment performance of the
separate account's subaccounts. If you select both the
guaranteed and variable accounts, then your values and
payments will be fixed in part, and variable in part.
If you select the variable account, then you must allocate
premiums among one or more subaccounts of the variable
account. These subaccounts are identified in the contract
application and on the schedule page.
CONTRACT INDEX
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Page
Definitions. . . . . . . . . . . . . . . . . . . . . . . . 4
Ownership . . . . . . . . . . . . . . . . . . . . . . . . 5
Benefits . . . . . . . . . . . . . . . . . . . . . . . . . 5
Premiums . . . . . . . . . . . . . . . . . . . . . . . . . 7
Variable Account Provisions. . . . . . . . . . . . . . . . 7
Guaranteed Account Provisions. . . . . . . . . . . . . . . 9
Transfers. . . . . . . . . . . . . . . . . . . . . . . . .10
Surrender Provisions . . . . . . . . . . . . . . . . . . .10
Charges and Deductions . . . . . . . . . . . . . . . . . .11
General Provisions . . . . . . . . . . . . . . . . . . . .12
Payment of Contract Benefits . . . . . . . . . . . . . . .14
Schedule Page
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Initial Allocation of Net Premiums:
Separate Account: Carillon Account
SUBACCOUNTS:
[AIM VI BALANCED 25]%
[AIM VI BASIC VALUE 25]
[AIM VI CAPITAL APPRECIATION 0]
[▇▇▇▇▇ AMERICAN LEVERAGED ALLCAP 0]
[▇▇▇▇▇ ▇▇▇▇ MIDCAP GROWTH 0]
[AMERICAN CENTURY/VP INCOME & GROWTH 0]
[AMERICAN CENTURY/VP INTERNATIONAL 0]
[AMERICAN CENTURY/VP VALUE 0]
[FTVIPT ▇▇▇▇▇▇▇▇▇ FOREIGN SECURITIES 0]
[FTVIPT ▇▇▇▇▇▇▇▇▇ GROWTH SECURITIES 0]
[MFS VIT HIGH INCOME 0]
[MFS VIT NEW DISCOVERY 0]
[MFS VIT TOTAL RETURN 0]
[▇▇▇▇▇▇▇▇▇▇▇ CAPITAL APPRECIATION 0]
[▇▇▇▇▇▇▇▇▇▇▇ GLOBAL SECURITIES 0]
[▇▇▇▇▇▇▇▇▇▇▇ MAIN STREET 0]
[▇▇▇▇▇▇▇ VS I CAPITAL GROWTH 0]
[▇▇▇▇▇▇▇ VS I MONEY MARKET 0]
[▇▇▇▇▇▇▇▇ COMM & INFO 0]
[▇▇▇▇▇▇▇▇ SMALL-CAP VALUE 25]
[SUMMIT PINNACLE BALANCED INDEX 0]
[SUMMIT PINNACLE BOND 0]
[SUMMIT PINNACLE EAFE INTERNATIONAL INDEX 0]
[SUMMIT PINNACLE ▇▇▇▇▇▇ AGG BOND INDEX 0]
[SUMMIT PINNACLE NASDAQ 100 INDEX 0]
[SUMMIT PINNACLE ▇▇▇▇▇▇▇ 2000 INDEX 0]
[SUMMIT PINNACLE S&P MIDCAP 400 INDEX 0]
[SUMMIT PINNACLE S&P 500 INDEX 0]
[SUMMIT PINNACLE ZENITH 0]
[UIF CORE PLUS FIXED INCOME 0]
[UIF US REAL ESTATE 0]
GUARANTEED ACCOUNT [25%]
TOTAL: 100%
Transfer Charge:
Current: $[10.00]
Maximum: $15.00
Free Transfers. Notwithstanding the transfer charge
described above, 12 transfers may be made during each
contract year without a transfer charge being imposed.
Mortality and Expense Charge:
Current: [1.50%]
Maximum: 2.00%
Administration Fee:
Current: [0.25%]
Maximum: 0.25%
Contract Fee for any full or partial year: $50.00.
This fee is waived if, in any given contract year, the
contract value exceeds [$50,000]
Guaranteed Account Guaranteed Minimum Interest Rate: [1.5]%
Plan: [NonQualified]
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Annuitant: ▇▇▇▇ ▇▇▇ Contract Number: 0123456789
Owner: ▇▇▇▇ ▇▇▇ Maturity Date: June 01, 2050
Joint Owner: N/A Contract Date: August 01, 2004
UC 8138 3
Schedule Page
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Surrender Charge:
We impose a surrender charge on certain early surrenders.
The amount of the surrender charge is a percentage of the
amount withdrawn and is set forth below.
Contract Surrender Charge
Year Percentage
[ 1 8% ]
[ 2 7% ]
[ 3 6% ]
[ 4 5% ]
[ 5 AND ABOVE 0% ]
Partial surrenders totaling not more than 10% of the
accumulation value may be made each contract year without a
surrender charge being imposed. In no event will the
cumulative total of all surrender charges exceed 9% of
premiums.
Maximum transfer amount per contract year to the guaranteed
account:
After the first contract year, [30]% of the sum of the
amounts in all subaccounts as of the beginning of each
contract year, or $1,000, whichever is greater.
Maximum transfer amount per contract year from the guaranteed
account:
As of the beginning of any contract year, [20%] of the
amount in the guaranteed account or $1,000, whichever is
greater.
Maximum premium allocation to the guaranteed account:
[50%] of the net premium.
Minimum transfer amount: $[300.00]
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Annuitant: ▇▇▇▇ ▇▇▇ Contract Number: 0123456789
Owner: ▇▇▇▇ ▇▇▇ Maturity Date: June 01, 2050
Joint Owner: N/A Contract Date: August 01, 2004
UC 8138 3A
DEFINITION
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ACCUMULATION UNIT. Means a unit of measure that is used to
calculate the value of your interest in the separate account
(SA) before the maturity date.
ACCUMULATION VALUE. Means the sum of the values of the
guaranteed account and the variable account credited to this
contract.
ANNUITANT. Means the person(s) whose life is used to
determine the duration of any annuity payments involving life
contingencies. The annuitant is named in the application and
on the schedule page.
ANNUITY UNIT. Means a unit of measure that is used to
calculate variable annuity payments.
BENEFICIARY. Means the person(s) designated by you to
receive the death benefits from this contract upon your
death.
CALCULATION DATE. Means a date not more than 10 business
days prior to the maturity date.
CONTRACT DATE. Means the date we issue this contract. The
contract date is shown on the schedule page.
CONTRACT YEAR. Means a period of 12 consecutive months
beginning on the contract date or any anniversary thereafter.
DUE PROOF OF DEATH. Means one of the following: (1) a
certified copy of a death certificate; (2) a certified copy
of a decree of a court of competent jurisdiction as to the
finding of death; (3) a written statement by a medical doctor
who attended the deceased; and (4) any proof satisfactory to
us.
FIXED ANNUITY. Means an annuity with payments fixed
throughout the annuity payment period.
GUARANTEED ACCOUNT. Means this contract's value which is
held by The Union Central Life Insurance Company other than
those in its separate accounts (SA).
HOME OFFICE. Means the home office of The Union Central Life
Insurance Company which is:
▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇ (▇.▇. ▇▇▇ ▇▇▇▇▇), ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇ ▇▇▇▇▇.
MATURITY DATE. Means the date on which annuity payments will
begin. This date shall be the annuitant's 95th birthday
unless an earlier date is chosen by you.
NOTICE. Means information we have received at our home
office that is in a form acceptable to us.
PORTFOLIO OR FUND PORTFOLIO. Means a separate portfolio of
one of the mutual funds in which separate account (SA)
invests through its subaccounts, or its successors and
assigns.
SCHEDULE PAGE. Means the contract schedule page, or the
supplemental contract schedule page most recently sent to you
by us.
SEPARATE ACCOUNT ("SA"). Means the
Carillon Account of The
Union Central Life Insurance Company. The separate account
is divided into several subaccounts.
SUBACCOUNT(S). Means one or more of the subaccounts of the
SA. Each subaccount is invested in a different fund
portfolio.
VALUATION DATE. Means any date on which the New York Stock
Exchange is open for trading and we are open for business.
The assets of each subaccount will be valued on each
valuation date.
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UC 8138 4 07/04
VALUATION PERIOD. Means a period beginning with the close
of business on a valuation date and ending at the close of
business for the next valuation date.
VARIABLE ACCOUNT. Means this contract's value which is
invested in one or more subaccounts of the SA.
VARIABLE ANNUITY. Means an annuity with payments which: (1)
are not predetermined or guaranteed as to dollar amount; and
(2) vary in amount in relation to the investment experience
of one or more specified subaccounts.
WE AND YOU. "We," "us," or "our" means The Union Central
Life Insurance Company. "You" or "your" means the owner of
this contract.
OWNERSHIP
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GENERAL. The owner of this contract shall be as named in the
application or the latest change filed with us.
CHANGE OF OWNERSHIP. Prior to the maturity date, you may
assign the ownership of this contract. Such change must be
made by notice in a form acceptable to us and received at our
home office.
CHANGE OF ANNUITANT. Prior to the maturity date, you may
name a new annuitant. Such change must be made by notice in
a form acceptable to us and received at our home office.
BENEFITS
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ANNUITY BENEFITS. We will pay an annuity benefit to the
annuitant, if living, on the maturity date. Annuity benefits
will begin on the maturity date and continue while the
annuitant is living, with monthly payments guaranteed for 10
years, unless you elect a different annuity option at least
30 days before the maturity date. If you die after the
annuity benefits have begun, the entire remaining interest
will continue to be distributed to the annuitant at least as
rapidly as under the annuity option being used as of the date
of your death.
We may pay the accumulation value on the maturity date in one
lump sum if it is less than $5,000. We may change the
payment frequency to quarterly, semiannually or annually if
the first monthly annuity payment would be less than $50.
At least 30 days before the maturity date, you must select
how the accumulation value will be used to provide the
annuity benefit. Any election must be in a form satisfactory
to us and received at our home office. If you do not so
select how you wish settlement to be effected, we will
provide a fixed annuity.
If a variable annuity is used, subsequent annuity benefit
payments will vary based on the investment experience of the
subaccount(s) used to effect the annuity. The method used to
calculate the amount of subsequent payments is described in
the Variable Annuity Payment provision.
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UC 8138 5 07/04
DEATH BENEFITS. Notwithstanding any provision to the
contrary, death benefits shall always be made in accordance
with the distribution requirements of the Internal Revenue
Code. Different rules may apply if the beneficiary is not a
natural person.
If the death benefit is paid before the maturity date, the
death benefit will be the greater of:
(1) the accumulation value on the date that due proof of
death is received; or
(2) the adjusted sum of premiums determined as follows:
(a) as of the day a premium is received by us, the sum
is increased by the amount of that premium, and
(b) as of the day that a partial surrender is made,
the sum is decreased by the same proportion as
the accumulation value was decreased by that
surrender.
Death of Owner. If you are an owner and if you die before
the maturity date, the following will apply:
(1) If your spouse is not the beneficiary, the death benefit
will be paid to the named beneficiary:
(a) upon written request under any option listed in the
Payment of Contract Benefits section of this contract
over a period not exceeding the beneficiary's life
expectancy. If the death benefit is paid in
installments, the first installment payment must be
made no later than one year after the date of your
death; or
(b) in a single sum. The beneficiary has the option to
elect to receive the single sum any time within five
years after the date of your death.
(2) If your spouse is the solely named beneficiary, your
spouse may elect, by a written request to us, one of
the following options:
(a) to continue this contract as the owner; or
(b) to receive the death benefit under any option listed
in the Payment of Contract Benefits section of this
contract over a period not exceeding the
beneficiary's life expectancy. If the death benefit
is paid in installments, the first installment
payment must be made no later than one year after
the date of your death; or
(c) to receive the death benefit in a single sum. Your
spouse may elect to receive the single sum any time
within five years after the date of your death.
If none of these options are elected by your spouse within 45
days after we receive due proof of death, option (a) above
shall apply. If your spouse is the beneficiary of a trust,
which is named beneficiary, see (1) above.
(3) If no beneficiary is living, or if no beneficiary has
been named at the date of your death, the death benefit
will be paid in a single sum to the executor or
administrator of your estate within five years after
the date of your death.
Joint Owners. If this contract is owned jointly, the death
of the first joint owner shall be treated as the death of the
owner.
Death of Annuitant before the Maturity Date. If you, the
owner, are a different person from the annuitant, and the
annuitant dies during your lifetime and before the maturity
date, you will be treated as the annuitant until you choose a
new annuitant. If you are not a natural person, and the
annuitant dies before the maturity date, we will pay the
death benefit to you in a single sum. You have the option to
elect to receive the single sum any time within five years of
the death of the annuitant.
Death of Annuitant on or after the Maturity Date. If the
annuitant dies on or after the maturity date, the death
benefit, if any, will depend on the annuity option in effect
on the date of the annuitant's death.
Death of Beneficiary. Unless otherwise provided, if any
beneficiary dies before, at the same time as, or within 30
days after your death, that beneficiary will be treated as if
their death occurred before yours.
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UC 8138 6 07/04
PREMIUMS
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GENERAL. All premiums under this contract are payable at our
home office or such other place as we may designate.
No premium may be paid under this contract unless it is at
least $50. Premiums may be paid at any time. The amount of
the premium may be increased or decreased any time subject to
the $50 minimum.
NET PREMIUM. The net premium is the premium less any premium
tax.
ALLOCATION OF NET PREMIUM. You determine the allocation of
the net premiums between the guaranteed account and the
variable account. Net premiums may be allocated totally to
the variable account, or partially to both the variable
account and the guaranteed account. The minimum amount of
any net premium that you can allocate to the guaranteed
account or any subaccount of the variable account is $10.
The maximum amount of any net premium that can be allocated
to the guaranteed account is shown on the schedule page.
Your variable account allocation will be further allocated
among one or more subaccounts of the variable account. Your
variable account accumulation value will be subject to the
investment experience of the SA.
Premiums that you allocate to the guaranteed account will be
guaranteed a minimum value. We will credit interest to
amounts allocated to the guaranteed account at a rate of at
least the guaranteed interest rate as shown on the schedule
page, compounded annually. We may credit a higher rate of
interest to such amounts, but we are not required to do so.
When we receive the premiums, the net premiums will be
allocated in accordance with the net premium allocation
percentages shown in the application or as of the most recent
change of allocation received from you. No allocation will be
made prior to the contract date. You may change the
allocation of subsequent premiums at any time, without
charge, by giving us notice.
VARIABLE ACCOUNT PROVISIONS
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SEPARATE ACCOUNT. The separate account is shown on the
schedule page. It is a unit investment trust registered with
the Securities and Exchange Commission under the Investment
Company Act of 1940. It is established under the laws of
Ohio. The assets in the separate account are kept separate
from our general assets and assets of other separate
accounts.
CREDITING OF ACCUMULATION UNITS. We will credit net premiums
allocated in the form of accumulation units. The number of
accumulation units to be credited to this contract for each
subaccount will be determined by dividing the net premium
allocated by the accumulation unit value for the
corresponding subaccount as of the end of the valuation
period during which the premium is received. In the case of
the initial premium, accumulation units will be credited on
the later of these dates: (1) the contract date; or (2) the
date we receive the premium.
Accumulation units are credited when amounts are transferred
into a subaccount. Accumulation units are deducted when the
charges and deductions are assessed or when amounts are
partially surrendered or transferred, including transfer
charges, out of a subaccount.
ACCUMULATION VALUE. At any time prior to the maturity date,
the accumulation value of this contract equals the guaranteed
account plus the sum in all subaccounts of (1) times (2)
where: (1) equals the number of accumulation units credited
to a subaccount; and (2) equals the value of the appropriate
accumulation unit.
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UC 8138 7 07/04
ACCUMULATION UNIT. The value of an accumulation unit for
each subaccount was arbitrarily set at $10 when funds were
first credited to the respective subaccount. The
accumulation unit value for any subsequent valuation period
is determined by multiplying the accumulation unit value for
the immediately preceding valuation period by the "net
investment factor" for the valuation period for which the
value is being determined. The value of an accumulation unit
may increase or decrease from one valuation period to the
next.
NET INVESTMENT FACTOR. The net investment factor is an index
that measures the investment performance of a subaccount from
one valuation period to the next. The net investment factor
for each subaccount for any valuation period is determined by
dividing (1) by (2) and subtracting (3) from the result,
where:
(1) is the net result of:
(a) the net asset value per share of a portfolio share
held in the subaccount determined as of the end of
the current valuation period, plus
(b) the per share amount of any dividend or capital gain
distributions made by the portfolio on shares held
in the subaccount if the "ex-dividend" date occurs
during the current valuation period, plus or minus
(c) a per share charge or credit for any taxes incurred
by or reserved for in the subaccount, which is
determined by us to have resulted from the
maintenance of the subaccount; and
(2) is the net result of:
(a) the net asset value per share of a portfolio share
held in the subaccount determined as of the end of
the immediately preceding valuation period (adjusted
for an "ex-dividend"), plus or minus
(b) the per share charge or credit for any taxes reserved
for the immediately preceding valuation period; and
(3) is a factor representing the charges deducted from the
subaccounts on a daily basis for administration expenses
and mortality and expense risks. Such factor is equal
on an annual basis to the amount shown on the schedule
page for administration fee and mortality and expense
charges.
VARIABLE ANNUITY PAYMENT. The amount of the first variable
annuity payment is determined by applying the accumulation
value of your contract, measured as of the calculation date
(minus any applicable premium taxes), to the appropriate
Option Table contained in this contract. This is done
separately for each subaccount. We will determine subsequent
payments by dividing the first payment derived from each
subaccount by the annuity unit value determined as of the
calculation date. This number of annuity units is then
multiplied by the annuity unit value for each subsequent
determination date which is a uniformly applied date not more
than 10 business days before payment is due.
ANNUITY UNIT VALUE. The value of an annuity unit for each
subaccount was arbitrarily set at $10 when funds were first
credited to the respective subaccount. Subsequently, the
value of an annuity unit in each subaccount for any valuation
period is determined as follows:
(1) the net investment factor for each subaccount for the
valuation period for which the annuity unit value is
being calculated is multiplied by the value of the
annuity unit on the preceding valuation date; and
(2) the result is adjusted to compensate for the interest
rate assumed in the Option Tables used to determine the
first variable annuity payment.
The dollar value of annuity units may change from one
valuation period to the next.
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UC 8138 8 07/04
ADDITION, DELETION, OR SUBSTITUTION OF INVESTMENTS. We
reserve the right, subject to compliance with applicable law,
to make additions to, deletions from, or substitution for the
portfolio shares that are held by the separate account or
that the separate account may purchase. We reserve the right
to eliminate the shares of any of the eligible portfolios and
to substitute shares of another portfolio, or of another
open-end, registered investment company, if the shares of an
eligible portfolio are no longer available for investment, or
if in our judgment further investment in any eligible
portfolio should become inappropriate in view of the purposes
of the separate account. We will not substitute any shares
attributable to your interest in a subaccount without notice
to you and prior approval of the Securities and Exchange
Commission, to the extent required by the Investment Company
Act of 1940. Nothing contained herein shall prevent the
separate account from purchasing other securities for other
series or classes of contracts, or from effecting a
conversion between series or classes of contracts on the
basis of requests made by owners.
We reserve the right to establish additional subaccounts,
each of which would invest in a new portfolio, or in shares
of another open-end, registered investment company. We also
reserve the right to eliminate existing subaccounts.
In the event of any such substitution or change, we may, by
appropriate endorsement, make such changes in this and other
contracts as may be necessary or appropriate to reflect such
substitution or change. If deemed by us to be in the best
interest of persons having voting rights under the contracts,
the separate account may be operated as a management company
under the Investment Company Act of 1940 or it may be
deregistered under such Act in the event such registration is
no longer required.
The investment contract of the separate account will not be
changed without the approval of the Insurance Commissioner of
the State of Ohio. If required, the approval process is on
file with the Commissioner of the state in which this
contract is issued.
GUARANTEED ACCOUNT PROVISIONS
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The guaranteed account of your contract at any time equals:
(1) the total of all net premiums allocated to the
guaranteed account; plus
(2) the total of all amounts transferred to the
guaranteed account from the variable account; minus
(3) the total of all amounts transferred from the
guaranteed account to the variable account (including
the transfer fee); minus
(4) the total of all partial surrenders from the
guaranteed account (including any surrender charges);
plus
(5) interest.
GUARANTEED ACCOUNT INTEREST RATE. The guaranteed interest
rate used in the calculation of the guaranteed account is
found on the schedule page. Interest in excess of the
guaranteed rate may be used in the calculation of the
guaranteed account at such increased rates and in such a
manner as we may determine.
FIXED ANNUITY PAYMENTS. We guarantee the amount of fixed
annuity payments. The payment amount depends only on the
annuity option elected, the age (and possibly sex) of the
annuitant, and the amount, (minus any applicable premium
taxes), applied to purchase the fixed annuity, in accordance
with the Option Tables contained in the contract.
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UC 8138 9 07/04
TRANSFERS
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TRANSFERS BEFORE MATURITY DATE. Before the maturity date,
you may transfer amounts between the guaranteed account and
the subaccounts of the variable account or among subaccounts.
Transfers from subaccounts will be made based on the
accumulation unit values at the end of the valuation period
during which we receive the request for transfer. Transfers
will be effected such that the account value on the date of
transfer will not be affected by the transfer, except for the
deduction of the transfer charge. The minimum transfer
amount is shown on the schedule page. The transfer must be
at least for the minimum amount, or, if less, the entire
amount in the guaranteed account or a subaccount each time
that a transfer is made. If, after the transfer, the amount
remaining in the guaranteed account or any subaccount from
which the transfer is made is less than $25, then the entire
amount will be transferred instead of the requested amount.
A transfer charge shown on the schedule page will be imposed
for each transfer. The charge will be deducted from the
account(s) from which the transfer is made. You are subject
to the terms and conditions stated by each portfolio in its
prospectus. These terms and conditions may contain
restrictions on how often you may move in or out of the
subaccount in a given period. We will help the portfolios
enforce such restrictions by notifying you if you violate a
portfolio's transfer restrictions and, if necessary,
requiring you to submit transfer requests via regular United
States mail. We reserve the right to charge back to your
contract any related costs allocated by a portfolio due to
your excessive trading.
TRANSFERS AFTER MATURITY DATE. After annuity payments have
been made for at least 12 months, you may, no more than once
each 12 months, change all or part of the investment upon
which your annuity payments are based from one subaccount to
another. After your death, the annuitant assumes this right.
To do this, we will convert the number of annuity units being
changed to the number of annuity units of the subaccount to
which you are changing so as to result in the next annuity
payment being of the same amount that it would have been
without the change. After that, annuity payments will
reflect changes in the values of your new annuity units. You
must give us notice at least 30 days before the due date of
the first annuity payment to which the change will apply.
No transfers may be made with respect to fixed annuity
payments.
LIMITATIONS ON TRANSFERS FROM THE GUARANTEED ACCOUNT.
Transfers from the guaranteed account are limited in total
for any contract year to no more than the amount shown on the
schedule page.
LIMITATIONS ON TRANSFERS TO THE GUARANTEED ACCOUNT.
Transfers to the guaranteed account are not allowed during
the first contract year, and are limited in total for any
contract year to no more than the amount shown on the
schedule page.
SURRENDER PROVISIONS
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PAYMENT OF SURRENDERS. You may totally or partially
surrender this contract and receive all of the accumulation
value any time at or before the earlier of the death of the
annuitant or the maturity date, by sending us a written
request. We will pay all surrenders from the variable
account within seven days of receipt of the written request,
subject to postponement for any period during which the New
York Stock Exchange is closed for trading (except for normal
holiday closing) or when the Securities and Exchange
Commission has determined that a state of emergency exists or
when required to withhold the surrender by any other
applicable law or regulation. We reserve the right to
postpone surrenders from the guaranteed account for up to six
months after we receive the request.
TOTAL SURRENDER. If you are totally surrendering the
contract, we will deduct the surrender charge, if applicable,
and the contract fee from the amount paid.
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PARTIAL SURRENDER. If you are partially surrendering this
contract, you should specify the amounts that should be
withdrawn from the guaranteed account or each subaccount. If
you do not so specify, the requested amount will be withdrawn
from the guaranteed account and each subaccount in which you
have an interest, in the same proportion that your interest
therein bears to the accumulation value. You may
preauthorize periodic surrenders by entering into a separate
agreement with us. Under this agreement, you may withdraw
part of your accumulation value at a regular interval chosen
by you. You may choose to withdraw a level dollar amount or
a percentage of your accumulation value. If you choose the
latter, the accumulation value for the first year you choose
to make these withdrawals is set on the date we approve your
request. In later years, the accumulation value is set on
the first day of the contract year. These surrenders may be
subject to the 10% federal tax on early withdrawals. We will
deduct the surrender charge, if applicable, from the
accumulation value remaining after the payment of the
requested amount.
DOLLAR COST AVERAGING. You have the option to elect the
Dollar Cost Averaging Plan. This Plan enables you to
automatically transfer specified dollar amounts from a
subaccount we specify to other subaccounts. You must specify
a fixed dollar amount in the subaccount from which transfers
will be made. The minimum amount of this type of transfer is
$100.00 and a $25.00 minimum to each subaccount.
Once elected, transfers from the subaccount will be processed
monthly until the number of designated transfers has been
completed, or the value of the subaccount is completely
depleted, or you send us notice instructing us to cancel the
transfers.
We also reserve the right to alter the terms or suspend or
eliminate the availability of this option at any time. Any
transfers made under this plan will not count towards the
number of free transfers permitted in a contract year.
PORTFOLIO REBALANCING. If you have at least $5,000 in your
variable annuity, you may elect to have the accumulated
balance of each subaccount periodically redistributed to
equal the allocation percentages you specified in the
election form. Transfers pursuant to this provision will
continue until you send us notice to stop or this contract
terminates. This option is not available if Dollar Cost
Averaging Plan or Interest Sweep Plan is in effect.
We also reserve the right to alter the terms or suspend or
eliminate the availability of this option at any time. Any
transfers made under this plan will not count towards the
number of free transfers permitted in a contract year.
INTEREST SWEEP. If you have at least $5,000 in the
guaranteed account, you may elect to have the interest
credited to the guaranteed account periodically transferred
into specified subaccounts. Transfers made pursuant to this
provision will continue until you send us notice to stop or
the contract terminates.
We also reserve the right to alter the terms or suspend or
eliminate the availability of this option at any time. Any
transfers made under this plan will not count towards the
number of free transfers permitted in a contract year.
FREQUENCY AND AMOUNT OF SURRENDERS. You may make as many
partial surrenders as you wish. Any surrender from the
guaranteed account or a subaccount must be at least $100 or
the entire balance of the guaranteed account or subaccount.
If, after the surrender (and deduction of any surrender
charge), the amount remaining in the guaranteed account or
subaccount is less than $25, then we may consider the
surrender request to be a request for surrender of the entire
amount held in the guaranteed account or subaccount. If,
after a partial surrender, the accumulation value is reduced
to less than $100, then we may pay that accumulation value to
you as a total surrender of the contract.
CHARGES AND DEDUCTIONS
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MORTALITY AND EXPENSE RISK CHARGE. To compensate us for
assuming the mortality and expense risks, we deduct a charge
each valuation period. The current charge is shown on the
schedule page, as is the maximum charge that can be charged.
We will deduct the charge from each subaccount in the same
proportion that the value of each subaccount bears to the
accumulation value.
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SURRENDER CHARGE. A surrender charge is imposed on total and
partial surrenders other than those made pursuant to the
death of the owner, or the annuitant if the owner is not a
natural person, or upon annuitization under the contract.
The amount of the charge and the period for which it will be
assessed are shown on the schedule page.
ADMINISTRATION FEE. We deduct an administration charge each
valuation period to partially defray the expenses of
maintaining the contract. During the accumulation period we
also deduct an annual contract fee as shown on the schedule
page as partial compensation for the cost of providing and/or
purchasing certain administrative services. The contract fee
is waived if the contract year end account balance exceeds
the amount shown on the schedule page. The contract fee is
not imposed during the annuity period.
The administration fee is deducted daily and the contract fee
is deducted on the anniversary of the contract date. They
are withdrawn from the guaranteed account or any subaccount
in which you have an interest, in proportion to their value.
If the contract is totally surrendered, we will deduct the
full amount of the contract fee from the amount paid. The
current charges are shown on the schedule page, as is the
maximum charge that can be charged.
TAXES. We will charge certain taxes against your premiums,
accumulation value, or annuity payments, when incurred.
These taxes include any premium taxes or other taxes levied
by any government entity which we, in our sole discretion,
determine have resulted from:
(1) the establishment or maintenance of the accumulation
value; or
(2) the investment experience of the accumulation value;
or
(3) the receipt by us of the premium; or
(4) the issuance of this contract, or
(5) the commencement or continuance of annuity payments
under this contract.
GENERAL PROVISIONS
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ENTIRE CONTRACT. This contract is a legal contract that you
have entered into with us. The entire contract consists of
this contract, any endorsements, schedule pages, amendments,
and the attached copy of the application and supplemental
applications. Any change in this contract must be written
and signed by our President, one of our Vice Presidents, our
Secretary or Assistant Secretary. No agent or person other
than the above-named has the authority to change or modify
this contract or waive any of its provisions. Words that can
be interpreted as singular or plural shall mean both singular
and plural.
BENEFICIARY. The primary and any contingent beneficiaries of
this contract are named in the application. If changed, the
beneficiary is as shown in the latest change. Unless the
beneficiary designation provides otherwise, any death
benefits will be divided equally among beneficiaries of the
same class. The contingent beneficiary will receive the
death benefits if no primary beneficiary is living at the
time of the event giving rise to the benefit payment. Prior
to the maturity date, if no beneficiary survives you, your
estate will be the beneficiary. The interest of any
beneficiary is subject to that of any assignee.
CHANGE OF BENEFICIARY. You may change the beneficiary,
unless an irrevocable designation has been made. Any
such change must be made by notice in a form acceptable to us
and received at our home office. If you die after the
maturity date, the annuitant may change the beneficiary
unless an irrevocable designation has been made.
CHANGE IN MATURITY DATE. Prior to the maturity date, you may
change the maturity date by notice at least 30 days before
the previously specified maturity date. After the election,
the new maturity date will become the maturity date.
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ASSIGNMENT. You may assign this contract. No assignment
will be binding on us unless it is in a form acceptable to us
and received at our home office. We will not be responsible
for the validity of any assignment. We will not be liable
for any payments we make or actions we take before we receive
notice of an assignment.
CLAIMS OF CREDITORS. Any accumulation value, before paid,
under this contract, will not be subject to the claims of a
beneficiary's creditors, except as required by law.
MISSTATEMENT AND PROOF OF AGE, SEX OR SURVIVAL. We may
require proof of age, sex, or survival of any person upon
whose age, sex, or survival any payments depend.
If the age or sex of the annuitant has been misstated, the
benefits will be those that the premiums would have provided
for the correct age and sex. If we have made incorrect
annuity payments, we will adjust future payments. The
adjustments will reflect any overpayment or underpayment.
DIVIDEND. As long as this contract is in force, you will
receive any dividends declared by us. It is anticipated that
no dividends will be declared.
You have these options:
(1) take the dividends in cash; or
(2) use the dividends to be credited as additional
accumulation units with respect to the variable
account; or
(3) add the dividends to the guaranteed account.
You may choose either option or change options by notice to
us. If none is chosen, the second option will be used.
REPORTS. At least once a year we will send you a report
showing:
(1) the accumulation unit value as of the beginning date
of the report;
(2) the accumulation unit value as of the ending date of
the report;
(3) the total number of accumulation units as of the
ending date of the report;
(4) the value of the guaranteed account and/or each
subaccount on the beginning date of the report;
(5) the value of the guaranteed account and/or each
subaccount on the ending date of the report; and
(6) the change in value for the guaranteed account
and/or each subaccount.
For the column headings within the report, the accumulation
unit is referred to as "unit."
INSULATION. The assets of SA are not chargeable with
liabilities arising out of any other business we may conduct.
OWNERSHIP OF ASSETS. We shall have exclusive and absolute
ownership and control of our assets, including the assets of
SA.
MODIFICATION OF CONTRACT. This contract may not be modified
by us without your consent except as may be required by
applicable law.
INCONTESTABILITY. We cannot contest this contract after it
has been in force during the lifetime of the annuitant for a
period of two years from the contract date.
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WAIVER OF SURRENDER CHARGES. Notwithstanding the surrender
charge described on the contract schedule page, the surrender
charge will be waived in the event of (1) or (2) below:
(1) You become confined in a qualified institution for a
period of at least 30 consecutive days after the contract
date, subject to the following:
(a) You must be a natural person (not a Trust,
Corporation, or other legal entity).
(b) You must have been an owner of this contract
continuously since the contract date.
(c) You were not confined in a qualified institution
at any time during the 60 day period just prior
to the contract date.
(d) We receive a written request for a full or partial
surrender along with due proof of confinement
within 12 months following such confinement.
(e) A "qualified institution" means any licensed
hospital or licensed skilled or intermediate care
nursing facility at which:
(i) medical treatment is available on a daily
basis; and
(ii) daily medical records are kept for each
patient.
(2) You acquire a terminal illness after the contract date,
subject to the following:
(a) You must be a natural person (not a Trust,
Corporation, or other legal entity).
(b) You must have been an owner of this contract
continuously since the contract date.
(c) You must have less than 12 months to live.
(d) We must receive a written statement for full
or partial surrender together with a certificate
from your attending physician stating your life
expectancy and any other proof we may require.
(e) "Physician" means a medical doctor licensed in
the United States who:
(i) is operating within the scope of that
license; and
(ii) is not the owner and is not related to
the owner.
PAYMENT OF CONTRACT BENEFITS
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GENERAL. Annuity benefits under this contract are payable in
accordance with the Option Tables given within or under such
other annuity options to which we may agree.
ALTERNATE ANNUITY OPTIONS. Instead of an annuity in
accordance with the Option Tables given within, you may
choose an alternate type of fixed annuity payment. Such
alternate annuity option shall be based on rates at least as
favorable as those for fixed dollar single premium immediate
annuities being issued by us on the maturity date. Such
election may only be made within 30 days before that date.
DESCRIPTION OF ANNUITY OPTIONS.
Option 1: Life Annuity
(1) Nonrefund. We will make payments during the lifetime
of the annuitant. No payments are due after the death
of the annuitant.
(2) 5-Years Certain. We will make payments for 5 years
and after that during the lifetime of the annuitant.
No payments are due after the death of the annuitant
or, if later, the end of the 5-year period certain.
(3) 10-Years Certain. We will make payments for 10 years
and after that during the lifetime of the annuitant.
No payments are due after the death of the annuitant
or, if later, the end of the 10-year period certain.
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(4) Installment Refund. We will make payments for a period
certain and after that during the lifetime of the
annuitant. No payments are due after the death of the
annuitant or, if later, the end of the period certain.
The number of period certain payments is equal to the
amount applied under this Installment Refund Option
divided by the amount of the first annuity payment;
provided, however, that the amount of the final period
certain payment shall be multiplied by that part of
the preceding quotient which is not a whole number.
Option 2: Joint and Survivor Life Annuity
(1) Joint and Survivor Nonrefund. We will make payments
during the joint lifetime of the annuitant and
contingent annuitant. Payments will then continue
during the remaining lifetime of the survivor of them.
No payments are due after the death of the last survivor
of the annuitant and contingent annuitant.
(2) Joint and Survivor with 10-Years Certain. We will
make payments for 10 years and after that during the
joint lifetime of the annuitant and contingent
annuitant. Payments will then continue during the
remaining lifetime of the survivor of them. No
payments are due after the death of the survivor of
the annuitant and contingent annuitant or, if later,
the end of the 10-year period certain.
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Flexible Premium Deferred Variable Annuity
Participating
UC 8138 07/04