Exhibit-B(4)(b)
The Northwestern Mutual Life Insurance Company agrees
to pay the benefits provided in this contract, subject
to its terms and conditions. Signed at Milwaukee,
Wisconsin on the Issue Date.
▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇ ▇▇▇▇ ▇. ▇▇▇▇▇▇▇
PRESIDENT AND C.E.O. SECRETARY
FLEXIBLE PAYMENT VARIABLE ANNUITY-Account A
Net Purchase Payments accumulated in a Separate Account,
assets of which are invested in shares of one or more
mutual funds, or Guaranteed Interest Fund.
Retirement benefit payable at maturity.
Payment at death before maturity.
Contract benefits payable in one sum or as variable or
guaranteed monthly income. Variable Payment Plan
benefits described in Section 11.
Participating.
AMOUNTS ALLOCATED TO THE SEPARATE ACCOUNT DIVISIONS AND
VARIABLE PAYMENTS PROVIDED BY THIS CONTRACT ARE NOT
GUARANTEED AS TO FIXED DOLLAR AMOUNT BUT ARE VARIABLE
AND MAY INCREASE OR DECREASE TO REFLECT THE INVESTMENT
EXPERIENCE OF THE SEPARATE ACCOUNT.
RIGHT TO RETURN CONTRACT -- Please read this contract
carefully. The Owner may return the contract for any
reason within ten days after receiving it. Return of the
contract is effective on the date written notice of the
return is delivered, mailed or sent by telegram to
either The Northwestern Mutual Life Insurance Company,
▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ or
the agent who sold the contract. If returned, the
contract will be cancelled and the Company will refund
the sum of (a) the difference between the Purchase
Payments paid and the amounts, if any, allocated to the
Separate Account plus (b) the value of the contract on
the effective date of return.
[NORTHWESTERN
MUTUAL LIFE LOGO]
CONTRACT NUMBER V12 345 678
ANNUITANT ▇▇▇▇ ▇. ▇▇▇
ISSUE DATE January 15, 1996
Sex Neutral
TABLE OF CONTENTS
PAGE
----
CONTRACT INFORMATION, SEPARATE ACCOUNT DIVISIONS 3
LOADS, FEES, AND CHARGES;
PURCHASE PAYMENTS, ACCUMULATION VALUE, PAYMENT PLANS 4
SECTION 1. GENERAL TERMS AND DEFINITIONS 5
SECTION 2. SEPARATE ACCOUNT 6
- Definition of Separate Account
- Accumulation Units
- Net Investment Factor
- Substitution and Change
SECTION 3. GUARANTEE INTEREST FUND 7
- Guaranteed Interest Fund
- Accumulation Value
- Transfer Restrictions
- Maximum Accumulation Value
SECTION 4. PURCHASE PAYMENTS, TRANSFERS AND WITHDRAWALS 7
- Payment of Purchase Payments
- Application of Purchase Payments
- Selection of Division for Purchase Payments
- Transfer of Accumulation Units
- Withdrawals and Full Surrender
- Effective Date
SECTION 5. BENEFITS 8
- Maturity Benefit
- Payment at Death
SECTION 6. BENEFICIARIES 9
- Definition of Beneficiaries
- Naming and Change of Beneficiaries
- Succession in Interest of Beneficiaries
- General
SECTION 7. LOADS, FEES, AND CHARGES 10
- Contract Fee
- Sales Load and Premium Taxes
- Withdrawal Charge
SECTION 8. OWNERSHIP 11
- The Owner
- Transfer of Ownership
- Collateral Assignment
- Reports to Owners
- Transferability Restrictions
1
PAGE
----
SECTION 9. THE CONTRACT 11
- Guarantees
- Valuation of Assets
- Determination of Values
- Deferment of Benefit Payments
- Dividends
- Incontestability
- Misstatement of Age or Sex
- Entire Contract; Changes
- Termination of Contract
SECTION 10. PAYMENT OF CONTRACT BENEFITS 12
- Payment of Benefits
- Payment at Death
- Effective Date for Payment Plan
- Payment Plan Elections
SECTION 11. PAYMENT PLANS 13
- Description of Payment Plans
- Allocation of Benefits
- Annuity Units under Variable Payment Plans
- Payments under Variable Payment Plans
- Transfers between Variable Payment Plans
- Withdrawal under Payment Plans
- Payment Plan Rates
ADDITIONAL BENEFITS (IF ANY) Following page
APPLICATION Attached to the contract
ENDORSEMENTS
TO BE MADE ONLY BY THE COMPANY AT THE HOME OFFICE
2
CONTRACT INFORMATION
CONTRACT NUMBER V12 345 678
PLAN Flexible Payment Variable Annuity
ADDITIONAL BENEFITS None
TAX REPORTING CATEGORY Personal Annuity
ANNUITANT ▇▇▇▇ ▇. ▇▇▇
AGE AND SEX 35 Male
OWNER ▇▇▇▇ ▇. ▇▇▇, the Annuitant
ISSUE DATE June 1, 1999
CONTRACT ANNIVERSARY June 1, 2000 and each June 1
thereafter
MATURITY DATE June 1, 2029
DIRECT BENEFICIARY ▇▇▇▇ ▇. ▇▇▇, Wife of the Annuitant
INVESTMENT DIVISIONS
On the Issue Date, Purchase Payments and contract values may be allocated among
the following Investment Accounts. Available Separate Account Divisions are
subject to change. See Section 2.1.
Divisions of Separate Account A:
Select Bond Division
International Equity Division
Money Market Division
Balanced Division
Index 500 Stock Division
Aggressive Growth Stock Division
High Yield Bond Division
Growth Stock Division
Growth and Income Stock Division
Index 400 Stock Division
Small Cap Growth Stock Division
▇▇▇▇▇▇▇ Multi-Style Equity Division
▇▇▇▇▇▇▇ Aggressive Equity Division
▇▇▇▇▇▇▇ Non-US Division
▇▇▇▇▇▇▇ Real Estate Securities Division
▇▇▇▇▇▇▇ Core Bond Division
Guaranteed Accounts:
Guaranteed Interest Fund
QQV.ACCT.A.(0599) Page 3
CONTRACT NUMBER V12 345 678
LOADS, FEES, AND CHARGES
DEDUCTION FROM PURCHASE PAYMENTS:
SALES LOAD: Not applicable.
PREMIUM TAX (See Section 7.2):
For the first Contract Year, Premium Taxes are not deducted
from Purchase payments. After the first Contract Year, the
Company may deduct Premium Taxes from Purchase Payments
received or benefits paid.
ANNUAL ANNUITY RATE AND EXPENSE GUARANTEE CHARGE (See Section 2.3):
1.25% at Issue; 1.50% Maximum
ANNUAL CONTRACT FEE (See Section 7.1):
$30 charged on the contract anniversary. The contract fee will be
waived if the Accumulation Value of the contract equals or exceeds
$50,000 on the contract anniversary.
TRANSFER FEE (See Sections 4.4 and 11.5):
$25 beginning with the thirteenth transfer in any Contract Year.
WITHDRAWAL CHARGE (See Section 7.3):
Total Purchase Payments Withdrawal Charge
Paid Under the Contract Starts at
First $100,000 8% of each Purchase Payment
Next $400,000 4% of each Purchase Payment
Next $500,000 2% of each Purchase Payment
Balance over $1,000,000 1% of each Purchase Payment
The Withdrawal Charge for each Purchase Payment is reduced by l% as of each
contract anniversary after the Purchase Payment is paid. The Withdrawal Charge
may be waived or deferred as described in the contract.
MINIMUM PURCHASE PAYMENTS, ACCUMULATION VALUE, PAYMENT PLANS
MINIMUM PURCHASE PAYMENT (See Section 4.1): $25
MINIMUM ACCUMULATION VALUE (See Section 9.9):
$2,000 after the first contract anniversary
MINIMUM PAYMENT UNDER PAYMENT PLAN (See Sections 9.9 and 10.4): $20
Page 4
GUARANTEED INTEREST FUND - TABLE OF GUARANTEED VALUES
The table shows minimum guaranteed values and assumes a $1,000 Purchase Payment
made at the time of issue and annually thereafter on each contract anniversary.
The values are based on the assumption that 100% of all net Purchase Payments
are allocated to, and remain in, the Guaranteed Interest Fund.
End of
Contract Accumulation Cash
Year October 1, Value Value
1 1996 $ 1,030 $ 960
2 1997 2,060 1,930
3 1998 3,121 2,941
4 1999 4,214 3,994
5 2000 5,339 5,089
6 2001 6,498 6,228
7 2002 7,692 7,412
8 2003 8,922 8,642
9 2004 10,189 9,909
10 2005 11,494 11,214
11 2006 12,838 12,558
12 2007 14,222 13,942
13 2008 15,648 15,368
14 2009 17,116 16,836
15 2010 18,629 18,349
16 2011 20,187 19,907
17 2012 21,792 21,512
18 2013 23,444 23,164
19 2014 25,147 24,867
20 2015 26,900 26,620
Age 60 2020 36,489 36,209
Age 65 2025 47,605 47,325
This table is based on the guaranteed annual interest rate of 3%. Higher
declared rates of interest will increase values. Values shown at the end of
contract years do not reflect any Purchase Payments paid on that contract
anniversary. The actual guaranteed values may differ from those shown above,
depending on the amount and frequency of Purchase Payments.
Page 4A
SECTION 1. GENERAL TERMS AND DEFINITIONS
ACCUMULATION UNIT. A unit of measure used to determine the value of the interest
of this contract in the Separate Account prior to the date on which amounts are
placed under a payment plan.
ACCUMULATION VALUE. The Accumulation Value of a Separate Account Division is the
total value of all Accumulation Units in that Division. The Accumulation value
of the Guaranteed Interest Fund is the sum of amounts applied to the fund, plus
credited interest, less amounts withdrawn or transferred from the fund. The
Accumulation Value of the contract is the sum of the Accumulation Values of all
Investment Accounts.
ANNUITANT. The person upon whose life this contract is issued and contract
benefits depend.
ANNUITY UNIT. A unit of measure used to determine the amount of variable
payments under a variable payment plan and the value of the interest of a
variable payment plan in the Separate Account.
COMPANY. The Northwestern Mutual Life Insurance Company.
CONTRACT FEE. An annual charge for administrative expenses made on each contract
anniversary prior to the Maturity Date.
CONTRACT YEAR. The first Contract Year is the period of time ending on the first
contract anniversary. Subsequent Contract Years are the annual periods between
contract anniversaries.
DIVISION. A component of the Separate Account to which the Owner may allocate
Purchase Payments and contract values.
GUARANTEED INTEREST FUND. The portion of the contract that is credited with a
guaranteed interest rate and which is held as part of the general assets of the
Company.
HOME OFFICE. The office of the Northwestern Mutual Life Insurance Company
located at ▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇.
INVESTMENT ACCOUNT. The Guaranteed Interest Fund and Separate Account Divisions
available for allocation of Purchase Payments and contract values. The available
investment Accounts are listed on page 3.
ISSUE DATE. The date this contract is issued and becomes effective.
MATURITY DATE. The date upon which contract benefits will become payable. If the
contract is continued in force under the Optional Maturity Date provision, the
Optional Maturity Date will become the Maturity Date.
NET PURCHASE PAYMENT. A Purchase Payment less all applicable deductions.
Deductions may include the Sales Load and Premium Tax.
OPTIONAL MATURITY DATE. The contract anniversary nearest the Annuitant's 90th
birthday. Upon reaching the Maturity Date shown on page 3, the Owner may elect
to continue the contract in force until this Optional Maturity Date.
OWNER. The person possessing the ownership rights stated in this contract.
PREMIUM TAX. A tax imposed by a governmental entity when Purchase Payments and
charges for the Disability Waiver of Purchase Payment Benefit are received or
benefits are paid.
PURCHASE PAYMENT. A payment made by or on behalf of the Owner with respect to
this contract excluding any charge for the Disability Waiver of Purchase Payment
Benefit.
SALES LOAD. A deduction made from Purchase Payments received.
SEPARATE ACCOUNT. NML Variable Annuity Account A. The Separate Account consists
of assets set aside by the Company, the investment performance of which is kept
separate from that of the general assets and all other separate account assets
of the Company.
WITHDRAWAL CHARGE. A deduction that is made from maturity benefits and
withdrawal amounts.
WITHDRAWAL CHARGE FREE AMOUNT. For a withdrawal, the amount that can be
withdrawn without a Withdrawal Charge prior to the withdrawal of Net Purchase
Payments.
TRANSFER FEE. A deduction that is made from the amount transferred between
Investment Accounts.
VALUATION DATE. Any day on which the assets of the Separate Account are valued.
Assets are valued as of the close of trading on the New York Stock Exchange for
each day the Exchange is open.
5
SECTION 2. SEPARATE ACCOUNT
2.1 SEPARATE ACCOUNT
The Separate Account (NML Variable Annuity Account A) has been established
by the Company. The Separate Account consists of assets set aside by the
Company, the investment performance of which is kept separate from that of the
general assets and all other separate account assets of the Company. The assets
of the Separate Account will not be charged with liabilities arising out of any
other business the Company may conduct. Interests in the Separate Account are
represented by Accumulation Units and Annuity Units, described in Sections 2.2
and 11.3, respectively.
The Separate Account is comprised of the Divisions listed on page 3. The
assets allocated to these Divisions are invested in shares of corresponding
Portfolios of the Northwestern Mutual Series Fund, Inc. (the Series Fund). The
Series Fund is registered under the Investment Company Act of 1940 as an
open-end, diversified management investment company. Shares of the Series Fund
Portfolios are purchased for the Separate Account at their net asset value.
The Company reserves the right to eliminate or add additional Divisions
and Portfolios.
2.2 ACCUMULATION UNITS
The interest of this contract in the Separate Account, prior to the date
on which amounts become payable under a payment plan, is represented by
Accumulation Units. The dollar value of Accumulation Units for each Division
will increase or decrease to reflect the investment experience of the Division.
The value of an Accumulation Unit on any Valuation Date is determined by
multiplying:
- The value on the immediately preceding Valuation Date; by
- The Net Investment Factor for the period from the immediately
preceding Valuation Date up to and including the current Valuation
Date (the current period).
2.3 NET INVESTMENT FACTOR
For each Division of the Separate Account the Net Investment Factor for
the current period is one plus the net investment rate for the Division. The net
investment rate for the current period is equal to the gross investment rate for
the Division reduced on each Valuation Date by a charge for annuity rate and
expense guarantees. The charge for these guarantees on the Issue Date is shown
on page 4. The Company may increase or decrease the charge after the Issue Date,
but the Company may not increase the charge to exceed the maximum charge shown
on page 4.
The gross investment rate for the current period for each Division is equal to
a. divided by b. where:
a. is:
- the investment income of the Division for the current period; plus
- captial gains for the period, whether realized or unrealized, on the
assets of the Division; less
- capital losses for the period, whether realized or unrealized, on
the assets of the Division; less
- deduction for any tax liability paid or reserved for by the Company
resulting from the maintenance or operation of the Division; and
less
- any reasonable expenses paid or reserved for by the Company which
result from a substitution of other securities for shares of the
Portfolio(s) as set forth in Section 2.4 and
b. is the value of the assets in the Division on the immediately
preceding Valuation Date.
The gross investment rate may be positive or negative. The deduction for
any tax liability may be charged proportionately against those contracts to
which the liability is attributable by a reduction in the gross investment rate
for those contracts.
2.4 SUBSTITUTION AND CHANGE
Pursuant to the authority of the Board of Trustees of the Company:
- the assets of the Division may be invested in securities other than
shares of the Portfolio(s) as a substitute for those shares already
purchased or as the securities to be purchased in the future;
- the provision of the contracts may be modified to comply with any
other applicable federal or state laws.
In the event of a substitution or change, the Company may make appropriate
endorsement on this and other contracts having an interest in the Separate
Account and take other actions as may be necessary to effect the substitution or
change.
6
SECTION 3. GUARANTEED INTEREST FUND
3.1 GUARANTEED INTEREST FUND
Net Purchase Payments (see Section 4.2) and amounts transferred from other
investment Accounts under this contract (see Section 4.4) may be applied to the
Guaranteed Interest Fund. Contract benefits placed under a variable payment plan
may not be applied to the Guaranteed Interest Fund. Amounts applied to the
Guaranteed Interest Fund become part of the general assets of the Company.
3.2 ACCUMULATION VALUE
The Accumulation Value of the Guaranteed Interest Fund is the sum of the
amounts applied to it, plus credited interest, less any amounts withdrawn or
transferred from the fund. Interest begins to accrue on the effective date of
the Purchase Payment or transfer (see Section 4.6). Interest will be credited at
an annual effective interest rate of not less than 3%. A higher rate may be
declared by the Company from time to time for a period set by the Company.
3.3 TRANSFER RESTRICTIONS
Neither transfers of Accumulation Value into the Guaranteed Interest Fund
nor transfers of Accumulation Value from the Guaranteed Interest Fund will be
allowed for a period of 365 days following the most recent transfer of
Accumulation Value from the Guaranteed Interest Fund. The maximum amount of the
Accumulation Value that may be transferred from the Guaranteed Interest Fund in
one transfer is limited to the greater of:
- 20% of the Accumulation Value of the Guaranteed Interest Fund on the
last contract anniversary preceding the transfer, and
- the amount of the most recent transfer from the Guaranteed Interest
Fund.
However, in no event will this maximum transfer amount be less than $1,000
or greater than $50,000.
3.4 MAXIMUM GUARANTEED INTEREST FUND ACCUMULATION VALUE
The Accumulation Value of the Guaranteed interest Fund may not exceed
$1,000,000 without prior consent of the Company, except when the maximum is
exceeded because of interest accruing to the Guaranteed Interest Fund.
3.5 TABLE Of GUARANTEED VALUES
Accumulation and cash values are shown on page 4A for the end of the
contract years shown. Values for contract years not shown are calculated on the
same basis as those shown on page 4A. All values are at least as great as those
required by the state in which this contract is delivered.
SECTION 4. PURCHASE PAYMENTS TRANSFERS, WITHDRAWALS
4.1 PAYMENT Of PURCHASE PAYMENTS
All Purchase Payments are payable at the Home Office or to an authorized
agent. A receipt signed by an officer of the Company will be furnished on
request.
Purchase Payments may be made at any time prior to the Maturity Date. The
Owner may vary the amount of Purchase Payments, but no Purchase Payment may be
less than the minimum Purchase Payment shown on page 4. Total Purchase Payments
may not exceed $5,000,000 without the consent of the Company.
The Company will not accept any Purchase Payments under Section 4 unless
it is a contribution under a pension or profit sharing plan which meets the
requirements of Section 401 of the Internal Revenue Code of 1954, as amended, or
the requirements for deduction of the employer's contribution under Section
404(a)(2) of such code.
4.2 APPLICATION OF PURCHASE PAYMENTS
Each Purchase Payment, net of the Sales Load and Premium Tax, will be
applied to one or more Investment Accounts. Net Purchase Payments applied to the
Guaranteed Interest Fund will accrue interest from the effective date of the
Purchase Payment. Net Purchase Payments applied to the Separate Account will
provide Accumulation Units in one or more Divisions. Accumulation Units are
credited as of the effective date of the Purchase Payment.
The number of Accumulation Units will be determined by dividing the Net
Purchase Payment by the value of an Accumulation Unit on the effective date.
This number of Accumulation Units will not be changed by any subsequent change
in the dollar value of Accumulation Units.
4.3 SELECTION OF INVESTMENT ACCOUNT FOR PURCHASE PAYMENTS
The Owner may at any time change the allocation of Net Purchase Payments
among the Investment Accounts by written notice to the Company. Net Purchase
Payments received at the Home Office on or after the date on which notice is
received will be applied to the designated Investment Accounts on the basis of
the new allocation.
4.4 TRANSFER OF ACCUMULATION VALUE
Before the Maturity Date the Owner may, on request satisfactory to the
Company, transfer amounts from one Investment Account to another, subject to the
transfer restrictions described in Section 3.3. For transfers among the Separate
Account Divisions, the number of Accumulation Units to be applied or deducted
will be adjusted to reflect the respective value of the Accumulation Units in
each of the Divisions on the date the transfer is effective. A Transfer Fee will
be deducted from the amount transferred. The amount of the Transfer Fee is shown
on page 4. The minimum amount which may be transferred is the lesser of $100 or
the entire Accumulation Value of the Investment Account from which the transfer
is being made.
For transfers from the Guaranteed Interest Fund, amounts closest to
expiration of an interest rate guarantee will be removed first. In the event
that two amounts are equally close to expiration, the one which was applied to
the Guaranteed Interest Fund earlier will be removed first.
7
4.5 WITHDRAWALS AND FULL SURRENDER
Before the Maturity Date the Owner may, on request satisfactory to the
Company, withdraw all or a portion of the Accumulation Value of the contract.
The Company may require that at least 100 Accumulation Units or $100 of
Accumulation Value of the Guaranteed Interest Fund remain after a partial
withdrawal. Withdrawal of the entire value of the contract constitutes a full
surrender, and receipt of the contract at the Home Office will terminate this
contract. Receipt of the contract may be waived by the Company.
The cash value of the amount withdrawn will be the Accumulation Value
withdrawn determined as of the date the withdrawal is effective, less any
applicable Withdrawal Charge. The Withdrawal Charge is described in Section 7.3.
The term "withdrawal amounts" as used in this contract includes amounts
paid as full surrenders and withdrawals of a portion of the Accumulation Value
of the contract.
For withdrawals from the Guaranteed Interest Fund, amounts closest to
expiration of an interest rate guarantee will be removed first. In the event
that two amounts are equally close to expiration, the one which was applied to
the Guaranteed Interest Fund earlier will be removed first.
4.6 EFFECTIVE DATE
The effective date of a Purchase Payment, transfer, or withdrawal is the
Valuation Date on which the Purchase Payment or the request for transfer or
withdrawal is received at the Home Office. However, the Purchase Payment,
transfer, or withdrawal will be effective on the following Valuation Date if the
Purchase Payment or request for transfer or withdrawal is received at the Home
Office either:
- on a Valuation Date after the close of trading on the New York Stock
Exchange; or
- on a day on which the New York Stock Exchange is closed.
SECTION 5. BENEFITS
5.1 MATURITY BENEFIT
MATURITY OPTIONS. If the Annuitant is living on the Maturity Date shown on page
3, and that Maturity Date is earlier than the contract anniversary nearest the
Annuitant's 90th birthday, the Owner may elect between the following maturity
options:
- payment of a monthly income to the Annuitant under a payment plan
chosen by the Owner; or
- deferral of the maturity benefit and continuation of this contract,
without any Disability Waiver of Purchase Payment Benefit, to the
Optional Maturity Date. The contract will continue under this option
if a written election for this purpose is received by the Company or
if on the Maturity Date shown on page 3, the Owner has not chosen a
payment plan.
If the Annuitant Is living on the Maturity Date and that Maturity Date is
on or after the contract anniversary nearest the Annuitant's 90th birthday, the
Company will pay a monthly income to the Annuitant under a payment form chosen
by the Owner.
PAYMENT OF MATURITY BENEFIT. The amount of the monthly income paid as the
maturity benefit will depend on the payment plan chosen (see Section 11) and the
maturity value. The maturity value of this contract will be the Accumulation
Value of the contract on the effective date of the maturity benefit, less any
applicable Withdrawal Charge (see Section 7.3). The maturity benefit will be
effective on the Maturity Date. However, if the New York Stock Exchange is
closed on the Maturity Date, the effective date will be the Valuation Date next
preceding the Maturity Date.
If no payment form is chosen at the time a monthly income becomes payable,
payments will be made to the Annuitant under he variable payment form of Life
Income Plan (Option C), with installments certain for ten years, as described in
Section 11.1.
OPTIONAL MATURITY DATE. The Optional Maturity Date is the contract anniversary
nearest the Annuitant's 90th birthday. If the contract is continued to the
Optional Maturity Date, all contract rights of the Owner will continue in effect
to the Optional Maturity Date except that the Disability Waiver of Purchase
Payment Benefit will not continue in force after the Maturity Date shown on page
3. The Optional Maturity Date will become the Maturity Date for all other
purposes of this contract.
5.2 PAYMENT AT DEATH
The Company will make a payment to the beneficiary upon receipt at its
Home Office of satisfactory proof of the death of the Annuitant before the
Maturity Date. The payment at death will be the Accumulation Value of the
contract determined on the effective date of the payment at death. The payment
at death will be effective on the Valuation Date on which proof of death is
received at the Home Office or, if later, the date on which a method of payment
is elected. However, payment at death will be effective on the next following
Valuation Date if the proof of death is received at the Home Office either:
- on a Valuation Date after the close of trading on the New York Stock
Exchange; or
- on a day on which the New York Stock Exchange is closed.
If the date of death is before the Annuitant's 65th birthday, the payment
at death will not be less than:
- total Purchase Payments paid under the contract; less
- any amounts withdrawn under Section 4.5.
The term "death benefits" as used in this contract refers to the payment
at death.
8
SECTION 6. BENEFICIARIES
6.1 DEFINITIONS
The term "beneficiaries" as used in this contract includes direct
beneficiaries, contingent beneficiaries and further payees.
6.2 NAMING AND CHANGE OF BENEFICIARIES
FOR MATURITY BENEFITS BY OWNER. The Owner may name and change the beneficiaries
of maturity benefits before the Maturity Date. If no direct beneficiary is named
by the Owner, the Annuitant will be the direct beneficiary.
FOR DEATH BENEFITS BY OWNER. The Owner may name and change the beneficiaries:
- while the Annuitant is living; or
- during the first 60 days after the date of death of the Annuitant,
if the Annuitant was not the Owner immediately prior to the
Annuitant's death. A change made during this 60 days cannot be
revoked.
FOR WITHDRAWAL AMOUNTS BY OWNER. The Owner may name the beneficiaries at the
time of withdrawal.
FOR DEATH BENEFITS BY DIRECT BENEFICIARY. A direct beneficiary may name and
change the contingent beneficiaries and further payees of the direct
beneficiary's share of the benefits:
- if the direct beneficiary is the Owner;
- if, at any time after the death of the Annuitant, no contingent
beneficiary or further payee of that share is living; or
- if, after the death of the Annuitant, the direct beneficiary elects
a payment plan. The interest of any other beneficiary in the share
of that direct beneficiary will end.
These direct beneficiary rights are subject to the Owner's rights during
the 60 days after the date of death of the Annuitant.
FOR MATURITY BENEFITS OR WITHDRAWAL AMOUNTS BY DIRECT BENEFICIARY. After a
withdrawal or the maturity of the contract, the direct beneficiary may name and
change the contingent beneficiaries and further payees of the direct
beneficiary's share of benefits that is under a payment plan.
FOR MATURITY OR DEATH BENEFITS OR WITHDRAWAL AMOUNTS BY SPOUSE (MARITAL
DEDUCTION PROVISION).
- POWER TO APPOINT. The spouse of the Annuitant will have the power
alone and in all events to appoint all amounts payable to the spouse
under the contract if:
a. just before the Annuitant's death, the Annuitant was the
Owner; and
b. the spouse is a direct beneficiary; and
c. the spouse survives the Annuitant.
- TO WHOM SPOUSE CAN APPOINT. Under this power, the spouse can
appoint:
a. to the estate of the spouse; or
b. to any other persons as contingent beneficiaries and further
payees.
- EFFECT OF EXERCISE. As to the amounts appointed, the exercise of
this power will:
a. revoke any other designation of beneficiaries;
b. revoke any election of payment plan as it applies to them; and
c. cause any provision to the contrary in Section 6 or 10 of this
contract to be of no effect.
EFFECTIVE DATE. A naming or change of a beneficiary will be made on receipt at
the Home Office of a written request that is acceptable to the Company. The
request will then take effect as of the date that it was signed. The Company is
not responsible for any payment or other action that is taken by it before the
receipt of the request. The Company may require that the contract be sent to it
to be endorsed to show the naming or change.
6.3 SUCCESSION IN INTEREST OF BENEFICIARIES
DIRECT BENEFICIARIES. The maturity or death benefits or withdrawal amounts will
be payable in equal shares to the direct beneficiaries who survive and receive
payment. If a direct beneficiary dies before receiving all or part of the direct
beneficiary's full share, the unpaid portion will be payable in equal shares to
the other direct beneficiaries who survive and receive payment.
CONTINGENT BENEFICIARIES. At the death of all of the direct beneficiaries, the
maturity or death benefits, the withdrawal amounts, or the present value of any
unpaid payments under a payment plan, will be payable in equal shares to the
contingent beneficiaries who survive and receive payment. If a contingent
beneficiary dies before receiving all or part of the contingent beneficiary's
full share, the unpaid portion will be payable in equal shares to the other
contingent beneficiaries who survive and receive payment.
FURTHER PAYEES. At the death of all the direct and contingent beneficiaries, the
maturity or death benefits, the withdrawal amounts, or the present value of any
unpaid payments under a payment plan, will be paid in one sum:
- in equal shares to the further payees who survive and receive
payment; or
- if no further payees survive and receive payment, to the estate of
the last to die of all beneficiaries who survive the Annuitant.
9
OWNER OR THE OWNER'S ESTATE. If no beneficiaries are alive when the Annuitant
dies, the benefits will be paid to the Owner or to the Owner's estate.
6.4 TRUSTEE AS BENEFICIARY
If a trustee is named as a beneficiary and no qualified trustee makes
claim to the proceeds, or to the present value of any unpaid payments under a
payment plan, within one year after payment becomes due to the trustee, or if
satisfactory evidence is furnished to the Company within that year showing that
no trustee can qualify to receive payment, payment will be made as though the
trustee had not been named.
The Company will be fully discharged of liability for any action taken by
the trustee and for all amounts paid to, or at the direction of, the trustee and
will have no obligation as to the use of the amounts. In all dealings with the
trustee the Company will be fully protected against the claims of every other
person. The Company will not be charged with notice of a change of trustee
unless written evidence of the change is received at the Home Office.
6.5 GENERAL
TRANSFER OF OWNERSHIP. A transfer of ownership of itself will not change the
interest of a beneficiary.
CLAIMS OF CREDITORS. So far as allowed by law, no amount payable under this
contract will be subject to the claims of creditors of a beneficiary.
SUCCESSION UNDER PAYMENT PLANS. A direct or contingent beneficiary who succeeds
to an interest in a payment plan will continue under the terms of the plan.
SECTION 7. FEES AND CHARGES
7.1 CONTRACT FEE
On each contract anniversary prior to the Maturity Date, a Contract Fee
will be charged for administrative expenses. The amount of the Contract Fee is
shown on page 4. The Contract Fee will be deducted from the Investment Accounts
in proportion to the Accumulation Value of the Investment Accounts. The
effective date of the Contract Fee will be the contract anniversary. However, if
the New York Stock Exchange is closed the contract anniversary, the effective
date will be the next following Valuation Date.
7.2 SALES LOAD AND PREMIUM TAXES
The Company will deduct from Purchase Payments received the Sales Load
shown on page 4. The Company may also deduct from Purchase Payments received any
Premium Taxes incurred.
7.3 WITHDRAWAL CHARGE
CONDITIONS. Maturity benefits and withdrawals are subject to a Withdrawal Charge
described on page 4. There is no Withdrawal Charge on benefits that are paid
under a variable Installment Income or variable Life Income Payment Plan.
However, the withdrawal of the present value of any unpaid installments under a
variable Installment Income Plan (Option B) will be subject to a withdrawal
charge if the withdrawal is made less than five years after the date that the
payment plan takes effect.
CALCULATIONS. The amount of the Withdrawal Charge on the contract is equal to
the sum of the Withdrawal Charges on all Net Purchase Payments. The Withdrawal
Charge on a Net Purchase Payment is equal to the Withdrawal Charge percentage on
the date the Withdrawal Charge is determined, multiplied by the amount of the
Net Purchase Payment. The Withdrawal Charge percentages are shown on page 4. The
excess of the Accumulation Value of the contract over the total of Net Purchase
Payments paid is not subject to a Withdrawal Charge.
Withdrawal Charges are determined:
- for maturity benefits, as of the Maturity Date.
- for withdrawals under Section 4.5, as of the effective date of the
withdrawal.
- for withdrawals from payment plans, as of the effective date of the
withdrawal.
WITHDRAWAL CHARGE FREE AMOUNT. If the Accumulation Value of the contract is at
least $10,000 on the most recent contract anniversary preceding a withdrawal
under Section 4.5, then the amount withdrawn will be taken first from any
eligible portion of the Accumulation Value of the contract that exceeds the
total of Net Purchase Payments paid. For each Contract Year, the amount eligible
for the Withdrawal Charge Free Amount is the lesser of the following:
- the excess of the Accumulation Value of the contract on the
effective date of the withdrawal over the total of Net Purchase
Payments paid up to the effective date of the withdrawal; and
- 10% of the Accumulation Value of the contract on the most recent
contract anniversary preceding the withdrawal.
ORDER OF WITHDRAWAL. A withdrawal will be taken from the contract in the
following order:
- first, from the Withdrawal Charge Free Amount, if any;
- next, from the Net Purchase Payments in the order that produces the
lowest Withdrawal Charge; and
- last, from any remaining amount by which the Accumulation Value of
the contract exceeds the total of Net Purchase Payments.
10
SECTION 8. OWNERSHIP
8.1 THE OWNER
The Owner is named on page 3. All contract rights may be exercised by the
Owner, the Owner's successor, or the Owner's transferee without the consent of
any beneficiary. After the Annuitant's death, contract rights may be exercised
only as provided in Sections 6 and 10.
If the contract has more than one Owner, contract rights may be exercised
only by authorization of all Owners.
8.2 TRANSFER Of OWNERSHIP
The Owner may transfer the ownership of this contract. Written proof of
transfer satisfactory to the Company must be received at its Home Office. The
transfer will then take effect as of the date it was signed. The Company may
require that the contract be sent to it for endorsement to show the transfer.
The Company will not be responsible to a transferee Owner for any payment or
other action taken by the Company before receipt of the proof of transfer at its
Home Office.
8.3 COLLATERAL ASSIGNMENT
The Owner may assign this contract as collateral security. The Company is
not responsible for the validity or effect of a collateral assignment. The
Company will not be responsible to an assignee for any payment or other action
taken by the Company before receipt of the assignment in writing at its Home
Office.
The interest of any beneficiary will be subject to any collateral
assignment made either before or after the beneficiary is named.
A collateral assignee is not an Owner. A collateral assignment is not a
transfer of ownership. Ownership can be transferred only by complying with
Section 8.2.
8.4 REPORTS TO OWNERS
At least once each Contract Year, the Company will also send to the Owner
or payee a statement of the Accumulation Values of the Investment Accounts, the
number of units credited to the contract, the dollar value of a unit as of a
date not more than two months previous to the date of mailing, and a statement
of the investments held by the Separate Account.
8.5 TRANSFERABILITY RESTRICTIONS
Notwithstanding any other provisions of this contract, the Owner may not:
- change the ownership of the contract; or
- sell the contract, or assign or pledge the contract as collateral
for a loan or as security for the performance of an obligation or
for any other purpose, to any person other than the Company.
These restrictions will not apply if the Owner is:
- the trustee of an employee trust that is qualified under the
Internal Revenue Code; or
- the custodian of a custodial account treated as an employee trust
that is qualified under the Internal Revenue Code.
The restrictions do not preclude the employer under a non-trusteed plan
from transferring ownership of this contract to the Annuitant or to the employer
or trustee under another plan or trust when required by the plan.
SECTION 9. THE CONTRACT
9.1 GUARANTEES
The Company guarantees that mortality and expense results will not
adversely affect the amount of variable payments.
9.2 VALUATION OF SEPARATE ACCOUNT ASSETS
The value of the shares of each Portfolio held in the Separate Account on
each Valuation Date will be the redemption value of the shares on that date. If
the right to redeem shares of a Portfolio has been suspended, or payment of the
redemption value has been postponed, the shares held in the Separate Account
(and Annuity Units) may be valued at fair value as determined in good faith by
the Board of Trustees of the Company for the sole purpose of computing annuity
payments.
9.3 DETERMINATION OF SEPARATE ACCOUNT VALUES
The method of determination by the Company of the Net Investment Factor,
and the number and value of Accumulation Units and Annuity Units, will be
conclusive upon the Owner, any assignee, the Annuitant, and any beneficiary.
9.4 DEFERMENT OF BENEFIT PAYMENTS
SEPARATE ACCOUNT DIVISIONS. The Company reserves the right to defer
determination of the contract values of the Separate Account portion of this
contract, or the payment of benefits under a variable payment plan, until after
the end of any period during which the right to redeem shares of a Portfolio is
suspended, or payment of the redemption value is postponed. Any deferment would
be in accordance with the provisions of the Investment Company Act of 1940 by
reason of closing of, or restriction of trading on, the New York Stock Exchange,
or other emergency, or as otherwise permitted by the Act. In addition, the
Company reserves the right to defer payment of contract values until seven days
after the end of any deferment in the determination of contract values.
GUARANTEED INTEREST FUND. The Company may defer paying contract values of the
Guaranteed Interest Fund for up to six months from the effective date of the
withdrawal or full surrender. If payment is deferred for 30 days or more,
interest will be paid on the withdrawal amounts at an annual effective rate of
3% from the effective date of the withdrawal or surrender to the date of the
payment.
11
9.5 DIVIDENDS
This contract will share in the divisible surplus of the Company, except
while payments are being made under a variable payment plan. This surplus will
be determined each year, and the dividend, if any, will be credited on the
contract anniversary. Any dividend credited prior to the Maturity Date will be
applied on the effective date as a Net Purchase Payment unless the Owner elects
to have the dividend paid in cash. The effective date of the dividend will be
the contract anniversary. However, if the New York Stock Exchange is closed on
the contract anniversary, the effective date will be the next following
Valuation Date.
9.6 INCONTESTABILITY
The Company will not contest this contract after it has been in force
during the lifetime of the Annuitant for two years from the Issue Date. This
Issue Date is shown on page 3.
9.7 MISSTATEMENT OF AGE OR SEX
If the age or sex of the Annuitant has been misstated, the amount payable
will be the amount which the Purchase Payments paid would have purchased at the
correct age and sex.
9.8 ENTIRE CONTRACT; CHANGES
This contract with the attached application is the entire contract.
Statements in the application are representations and not warranties. A change
in the contract is valid only if it is approved by an officer of the Company.
The Company may require that the contract be sent to it for endorsement to show
a change. No agent has the authority to change the contract or to waive any of
its terms.
All payments by the Company under this contract are payable at its Home Office.
Assets of the Separate Account are owned by the Company and the Company is
not a trustee with respect thereto. The Company may from time to time adjust the
amount of assets contained in the Separate Account, by periodic withdrawals or
additions, to reflect the contract deductions and the Company's reserves for
this and other similar contracts.
This contract is subject to the laws of the state in which it is
delivered. All benefits are at least as great as those required by that state.
9.9 TERMINATION OF CONTRACT
At any time after the first contract anniversary, the Company may
terminate the contract and pay the Owner the Accumulation Value of the contract
and be released of any further obligation if:
- prior to the Maturity Date no Purchase Payments have been received
under the contract for a period of two full years and each of the
following is less than the Minimum Accumulation Value shown on page
4:
a. the Accumulation Value of the contract; and
b. total Purchase Payments paid under the contract, less any
amounts withdrawn under Section 4.5; or
- on the Maturity Date the Accumulation Value of the contract is less
than the Minimum Accumulation Value shown on page 4 or would provide
a monthly income the initial amount of which is less than the
minimum payment amount shown on page 4.
SECTION 10. PAYMENT OF CONTRACT BENEFITS
10.1 PAYMENT OF BENEFITS
All or part of the contract benefits may be paid under one or more of the
following:
- a variable payment plan;
- a fixed payment plan; or
- in cash.
The provisions and rate for variable and fixed payment plans are described
in Section 11. Contract benefits may not be placed under a payment plan unless
the plan would provide to each beneficiary a monthly income the initial amount
of which is at least the minimum payment amount shown on page 4. A Withdrawal
Charge will be deducted from contract benefits before their payment under
certain conditions described in Section 7.3.
10.2 PAYMENT AT DEATH
Upon the death of the Annuitant prior to the Maturity Date, the payment at
death will be made under any payment plan previously elected. If no payment plan
has been elected, the payment at death will be made under a payment plan or in
cash as elected by the Owner or beneficiary.
12
10.3 EFFECTIVE DATE FOR PAYMENT PLAN
A payment plan that is elected for maturity benefits will take effect on
the Maturity Date.
A payment plan that is elected for death benefits will take effect on the
date proof of death of the Annuitant is received at the Home Office if:
- the plan is elected by the Owner; and
- the election is received at the Home Office while the Annuitant is
living.
In all other cases, a payment plan that is elected will take effect:
- On the date the election is received at the Home Office; or
- on a later date, if requested.
10.4 PAYMENT PLAN ELECTIONS
FOR DEATH BENEFITS BY OWNER. The Owner may elect payment plans for death
benefits:
- while the Annuitant is living; or
- during the first 60 days after the date of death of the Annuitant,
if the Annuitant was not the Owner immediately prior to the
Annuitant's death. An election made during the 60 days cannot be
changed.
FOR DEATH BENEFITS BY DIRECT OR CONTINGENT BENEFICIARY. A direct or contingent
beneficiary may elect payment plans for death benefits payable to the direct or
contingent beneficiary if no payment plan that has been elected is in effect.
This right is subject to the Owner's rights during the above 60 days.
FOR MATURITY BENEFITS OR WITHDRAWAL AMOUNTS. The Owner may elect payment plans
for maturity benefits or withdrawal amounts.
TRANSFER BETWEEN PAYMENT PLANS. A beneficiary who is receiving payment under a
payment plan which includes the right to withdraw may transfer the amount
withdrawable to any other payment plan that is available.
SECTION 11. PAYMENT PLANS
11.1 DESCRIPTION OF PAYMENT PLANS
INSTALLMENT INCOME FOR SPECIFIED PERIOD (OPTION B)
The Company will make monthly installment income payments providing for
payment of benefits over a specified period of 5 to 30 years.
LIFE INCOME PLANS
- SINGLE LIFE INCOME (OPTION C). The Company will make monthly
payments for the selected certain period, if any, and thereafter
during the remaining lifetime of the individual upon whose life
income payments depend. The selections available are: (a) no certain
period; or (b) a certain period of 10 or 20 years.
- JOINT AND SURVIVOR LIFE INCOME (OPTION E). The Company will make
monthly payments for a 10-year certain period and thereafter during
the joint lifetime of the two individuals upon whose lives income
payments depend and continuing during the remaining lifetime of the
survivor.
- OTHER SELECTIONS. The Company may offer other selections under the
Life Income Plans.
- LIMITATIONS. A direct or contingent beneficiary who is a natural
person may be paid under a Life Income Plan only if the payments
depend on that beneficiary's life. A corporation may be paid under a
Life Income Plan only if the payments depend on the life of the
Annuitant or, after the death of the Annuitant, on the life of the
Annuitant's spouse or dependent.
These payment plans are available on either a fixed or variable basis.
Under a fixed payment plan the payment remains level. Under a variable payment
plan the payment will increase or decrease as described in Section 11.4.
11.2 ALLOCATION OF BENEFITS
Upon election of a variable payment plan, the Owner or direct or
contingent beneficiary may select the allocation of variable benefits among the
Divisions.
If no selection is made, the allocation of benefits will be as follows:
- for amounts in the Separate Account Divisions, benefits will be
allocated in proportion to the Accumulation Value of each Division
on the effective date of the variable payment plan, and
- for amounts in the Guaranteed Interest Fund, benefits will be
allocated 100% to the Money Market Division.
11.3 ANNUITY UNITS UNDER VARIABLE PAYMENT PLANS
The interest of this contract in the Separate Account after the effective
date of a variable payment plan is represented by Annuity Units. The dollar
value of Annuity Units for each Division will increase or decrease to reflect
the investment experience of the Division. The value of an Annuity Unit on any
Valuation Date is the product of:
- the Annuity Unit value on the, immediately preceding Valuation Date;
- the Net Investment Factor for the period from the immediately
preceding Valuation Date up to and including the current Valuation
Date (the current period); and
- the Daily Adjustment Factor of .99990575 raised to a power equal to
the number of days in the current period to reflect the Assumed
Investment Rate of 3 1/2% used in calculating the monthly payment
rate.
13
11.4 PAYMENTS UNDER VARIABLE PAYMENT PLANS
FIRST PAYMENT. The first payment under a variable payment plan will be due as of
the effective date of the payment plan.
The amount of the first payment is the sum of payments from each Division,
each determined by multiplying the benefits allocated to the Division under the
variable payment plan by the applicable monthly variable payment rate per $1,000
of benefits.
NUMBER OF ANNUITY UNITS. The number of Annuity Units in each Division under a
variable payment plan is determined by dividing the amount of the first payment
payable from the Division by the Annuity Unit value for the Division at the
close of business on the Valuation Date on which the variable payment plan
becomes effective. The number of Annuity Units will not be changed by any
subsequent change in the dollar value of Annuity Units.
SUBSEQUENT VARIABLE PAYMENTS. The amount of each subsequent payment from each
Division under a variable payment plan will increase or decrease in accord with
the increase or decrease in the value of an Annuity Unit which reflects the
investment experience of that Division of the Separate Account.
The amount of subsequent variable payments is the sum of payments from
each Division, each determined by multiplying the fixed number of Annuity Units
for the Division by the value of an Annuity Unit for the Division on:
- the fifth Valuation Date prior to the payment due date if the
payment due date is a Valuation Date; or
- the sixth Valuation Date prior to the payment due date if the
payment due date is not a Valuation Date.
11.5 TRANSFER BETWEEN VARIABLE PAYMENT PLANS
A payee or joint payees receiving payments under a variable payment plan
may:
- transfer Annuity Units from one Division to another. The number of
Annuity Units in each Division will be adjusted to reflect the
respective value of the Annuity Units in the Divisions on the date
the transfer is effective. A Transfer Fee will be deducted from the
amount transferred. The amount of the Transfer Fee is shown on page
4. Transfers from the Money Market Division may be made at any time.
No transfer from the other Divisions may be made within 90 days of
the effective date of the variable payment plan or within 90 days
from the effective date of the last transfer.
- transfer from an Installment Income Plan (Option B) to either form
of the Life Income Plan (Option C or E).
Other transfers may be permitted subject to conditions set by the Company.
A transfer will be effective on the Valuation Date on which a satisfactory
transfer request is received in the Home Office, or a later date if requested.
However, the transfer will be effective on the following Valuation Date if the
request is received at the Home Office either:
- on a Valuation Date after the close of trading on the New York Stock
Exchange; or
- on a day on which the New York Stock Exchange is closed.
11.6 WITHDRAWAL UNDER PAYMENT PLANS
Withdrawal of the present value of any unpaid income payments may be
elected at any time by the beneficiary, except that withdrawal may not be
elected under a Life Income Plan (Option C or E) until the death of all
individuals upon whose lives income payments depend.
The withdrawal value under the Installment Income Plan (Option B) will be
the present value of any unpaid payments, less any applicable Withdrawal Charge
under Section 7.3. The withdrawal value under a Life Income Plan (Option C or E)
will be the present value of any unpaid payments for the certain period with no
Withdrawal Charge.
For a fixed payment plan, the present value of any unpaid income payments
will be based on the rate of interest used to determine the amount of the
payments. For a variable payment plan, the present value of any unpaid income
payments will be based on interest at the Assumed Investment Rate used in
calculating the amount of the variable payments. The amount of variable payments
used in calculating the present value of unpaid payments will be determined by
multiplying the number of Annuity Units by the value of an Annuity Unit on the
effective date of the withdrawal.
A withdrawal will be effective on the Valuation Date on which the request
is received in the Home Office. However, the withdrawal will be effective on the
following Valuation Date if the request is received at the Home Office either:
- on a Valuation Date after the close of trading on the New York Stock
Exchange; or,
- on a day on which the New York Stock Exchange is closed.
14
11.7 PAYMENT PLAN RATES
PAYMENT RATE TABLES. The guaranteed monthly payment rates for both a fixed
payment plan and the first payment under a variable payment plan are shown in
the Payment Rate Tables. The tables show rates for the Installment Income Plan
for a Specified Period (Option B) and Life Income Plans (Options C and E). Life
Income Plan (Option C or E) rates are based on the sex and adjusted age of any
individual upon whose life payments depend. The adjusted age is:
- the age on the birthday that is nearest to the date on which the
payment plan takes effect; plus
- the age adjustment shown below for the number of Contract Years that
have elapsed from the Issue Date to the date that the payment plan
takes effect. A part of a Contract Year is counted as a full year.
CONTRACT CONTRACT
YEARS AGE YEARS AGE
ELAPSED ADJUSTMENT ELAPSED ADJUSTMENT
1 to 8 0 33 to 40 -4
9 to 16 -1 41 to 48 -5
17 to 24 -2 49 or more -6
25 to 32 -3
CURRENT FIXED PAYMENT PLAN RATES
- INSTALLMENT INCOME FOR SPECIFIED PERIOD (OPTION 6). The Company may
offer fixed payment plan rates higher than those guaranteed in this
contract with conditions on withdrawal.
- LIFE INCOME PLANS (OPTION C OR E). Payments will be based on rates
declared by the Company which will not be less than the rates
guaranteed in this contract. The declared rates will provide at
least as much income as would the Company's rates, on the date that
the payment plan takes effect, for a single premium immediate
annuity contract.
ALTERNATE VARIABLE RATE BASIS. The Company may from time to time publish higher
initial rates for variable payment plans under this contract. These higher rates
will not be available to increase payments under payment plans already in
effect.
When a variable payment plan is effective on an alternate rate basis, the
Daily Adjustment Factor described in Section 11.3 will be determined based on
the Assumed Investment Rate used in calculating the alternate payment rate.
PAYMENT RATE TABLES
MONTHLY INCOME PAYMENTS PER $1,000 BENEFITS
FIRST PAYMENT UNDER VARIABLE PAYMENT PLAN
INSTALLMENT INCOME PLAN (OPTION B)
PERIOD MONTHLY PERIOD MONTHLY PERIOD MONTHLY
(YEARS) PAYMENT (YEARS) PAYMENT (YEARS) PAYMENT
Years 1-4 11 $ 9.09 21 $ 5.56
Not Available 12 8.46 22 5.39
13 7.94 23 5.24
14 7.49 24 5.09
5 $ 18.12 15 7.10 25 4.96
6 15.35 16 6.76 26 4.84
7 13.38 17 6.47 27 4.73
8 11.90 18 6.20 28 4.63
9 10.75 19 5.97 29 4.53
10 9.83 20 5.75 30 4.45
GUARANTEED FIXED PAYMENT PLANS
INSTALLMENT INCOME PLAN (OPTION B)
PERIOD MONTHLY PERIOD MONTHLY PERIOD MONTHLY
(YEARS) PAYMENT (YEARS) PAYMENT (YEARS) PAYMENT
Years 1-4 11 $ 8.42 21 $ 4.85
Not Available 12 7.80 22 4.67
13 7.26 23 4.51
14 6.81 24 4.36
5 $ 17.49 15 6.42 25 4.22
6 14.72 16 6.07 26 4.10
7 12.74 17 5.77 27 3.98
8 11.25 18 5.50 28 3.87
9 10.10 19 5.26 29 3.77
10 9.18 20 5.04 30 3.68
15
PAYMENT RATE TABLES
MONTHLY INCOME PAYMENTS PER $1,000 BENEFITS
LIFE INCOME PLAN (OPTION C)
SINGLE LIFE MONTHLY PAYMENTS
CHOSEN PERIOD (YEARS)
ADJUSTED
AGE* ZERO 10 20
55 $ 4.17 $ 4.14 $ 4.06
56 4.23 4.20 4.11
57 4.31 4.28 4.17
58 4.39 4.35 4.23
59 4.47 4.43 4.29
60 4.56 4.51 4.35
61 4.65 4.59 4.42
62 4.76 4.69 4.49
63 4.87 4.79 4.56
64 4.98 4.90 4.63
65 5.10 5.00 4.70
66 5.24 5.12 4.77
67 5.38 5.24 4.84
68 5.54 5.37 4.91
69 5.70 5.51 4.98
70 5.88 5.66 5.05
71 6.07 5.81 5.12
72 6.27 5.96 5.19
73 6.49 6.13 5.24
74 6.73 6.30 5.30
75 6.99 6.48 5.36
76 7.27 6.67 5.40
77 7.58 6.86 5.45
78 7.91 7.05 5.49
79 8.26 7.25 5.52
80 8.64 7.45 5.55
81 9.05 7.65 5.58
82 9.50 7.84 5.60
83 9.98 8.02 5.62
84 10.50 8.20 5.63
85 and over. 11.06 8.38 5.64
LIFE INCOME PLAN (OPTION E)
JOINT AND SURVIVOR MONTHLY PAYMENTS
OLDER LIFE YOUNGER LIFE ADJUSTED AGE*
ADJUSTED
AGE* 55 60 65 70 75 80 85 and over
55 $ 3.79
60 3.87 $ 4.07
65 3.94 4.18 $ 4.45
70 3.99 4.27 4.61 $ 4.99
75 4.02 4.34 4.73 5.20 $ 5.72
80 4.05 4.38 4.81 5.35 6.00 $ 6.67
85 and over 4.06 4.40 4.86 5.45 6.18 7.00 $ 7.75
*See Section 10.7.
The amount of the payment for any other combination of ages will be furnished by
the Company on request. The maximum initial monthly income per $l,000 will be
$7.75.
Monthly payment rates are based on an Assumed Investment Rate of 3 1/2% and the
1983 Table a with Projection Scale G.
16
AMENDMENT TO SECTION 2
FOR FLEXIBLE PAYMENT VARIABLE ANNUITY
ACCOUNT A
AS OF THE ISSUE DATE, THE SECOND PARAGRAPH OF SECTION 2.1 IS AMENDED TO READ
AS FOLLOWS:
The Separate Account is comprised of the Divisions listed on page 3. The
assets allocated to these Divisions are invested in shares of corresponding
mutual funds or portfolios of mutual funds, both of which are referred to in
this policy as Portfolios. Shares of the Portfolios are purchased for the
Separate Account at their net asset value.
Secretary
NORTHWESTERN MUTUAL LIFE
INSURANCE COMPANY
QQVA.FUNDS.(0599)
AMENDMENT TO SEPARATE ACCOUNT DIVISIONS
AS OF APRIL 30, 1999, THE SECOND AND THIRD PARAGRAPHS OF THE SEPARATE
ACCOUNT SECTION OF THE CONTRACT RELATING TO THE DIVISIONS OF THE SEPARATE
ACCOUNT AND THE ASSETS ALLOCATED TO THESE DIVISIONS ARE AMENDED TO READ AS
FOLLOWS:
The Separate Account is comprised of the Select Bond, International Equity,
Money Market, Balanced, Index 500 Stock, Aggressive Growth Stock, High Yield
Bond, Growth Stock, Growth and Income Stock, Index 400 Stock, Small Cap Growth
Stock, ▇▇▇▇▇▇▇ Multi-Style Equity, ▇▇▇▇▇▇▇ Aggressive Equity, ▇▇▇▇▇▇▇ Non-US,
▇▇▇▇▇▇▇ Real Estate Securities, and ▇▇▇▇▇▇▇ Core Bond Divisions. Assets
allocated to these Divisions are invested in shares of corresponding mutual
funds or portfolios of mutual funds, both of which are referred to in this
policy as Portfolios. Shares of the Portfolios are purchased for the Separate
Account at their net asset value.
The Company may make available additional Divisions and Portfolios.
Secretary
NORTHWESTERN MUTUAL LIFE
INSURANCE COMPANY
VA.FUNDS.(0599)
A
THE NORTHWESTERN MUTUAL LIFE
INSURANCE COMPANY
MILWAUKEE, WISCONSIN
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CONTRACT NUMBER
_______________________
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DEFERRED ANNUITY APPLICATION
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1. Has a Northwestern Mutual policy ever been issued on the annuitant's life? / / Yes / / No
If yes, the last policy number is
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2. ANNUITANT
/X/ Mr. / / Mrs. / / Ms. / / Dr. / / Other___________________________ /X/ Male / / Female
-----------------------------------------------------------------------------------------------------------------------------
NAME BIRTHDATE (MONTH, DAY, YEAR)
/J/O/H/N/ /J/ /D/O/E/ /0/1/ - /1/5/ - /1/9/6/1/
-----------------------------------------------------------------------------------------------------------------------------
STATE OF BIRTH (OR FOREIGN COUNTRY) TAXPAYER IDENTIFICATION NUMBER
Wisconsin /4/4/4/ - /4/4/ - /4/4/4/4/
-----------------------------------------------------------------------------------------------------------------------------
PRIMARY RESIDENCE
STREET OR PO BOX 1234 Main Street
-----------------------------------------------------------------------------------------------------------------------------
CITY, STATE, ZIP (COUNTRY IF OTHER THAN U.S.)
Milwaukee, WI 53200
-----------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
3. MARKET CATEGORY (SELECT ONE)
NON-TAX QUALIFIED
/ / Personal
/ / Estate or Business
/ / Eligible 457 Deferred Compensation Plan
GO TO QUESTION 4.
TAX QUALIFIED
/ / IRA Individual
/ / IRA Simplified Employee Pension Plan (SEPP)
/ / TDA Employee salary reduction only
/ / TDA Employer matching or non-elective contributions included
/ / 401(g) Non-transferable annuity
THE OWNER IS THE ANNUITANT. GO TO QUESTION 5.
/x/ Pension and Profit Sharing
-------------------------
If new trust, attach
Trust Number / 0 / 0 / 0 / 1 / 2 / 3 / Declaration of Employer (31-3344)
-------------------------
-------------------
MONTH DAY
Contract Anniversary Date / / / - / / / Complete only if required by plan.
-------------------
THE OWNER AND BENEFICIARY ARE THE TRUSTEE(S) OF THE PLAN. GO TO QUESTION 6.
----------------------------------------------------------------------------------------------------------------------------------
90-1900 (0196)
4. OWNER (NOTE: A minor owner limits future contract actions.)
/ / Annuitant / / See attached information / / Other: (Complete A, B, C below)
-----------------------------------------------------------------------------------------------------------------------
A. / / Mr. / / Mrs. / / Ms. / / Dr. / / Other____________________________________ / / Male / / Female
-----------------------------------------------------------------------------------------------------------------------
PERSONAL NAME BIRTHDATE (MONTH, DAY, YEAR)
/ / / / / / / / / / / / / / / / / / / / / / / / / / / / - / / / - / / / /
-----------------------------------------------------------------------------------------------------------------------
OR
-----------------------------------------------------------------------------------------------------------------------
BUSINESS/TRUST NAME
-----------------------------------------------------------------------------------------------------------------------
B. RELATIONSHIP TO ANNUITANT TAXPAYER IDENTIFICATION NUMBER
/ / / - / / / - / / / / /
-----------------------------------------------------------------------------------------------------------------------
C. ADDRESS - ANNUITANT'S ADDRESS, OR
STREET OR PO BOX
-----------------------------------------------------------------------------------------------------------------------
CITY, STATE, ZIP (COUNTRY IF OTHER THAN US)
-----------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
BENEFICIARY (NOTE: Cannot be annuitant unless "Estate of Annuitant" named.)
5. A. Direct Beneficiary of payment at DEATH:
/ / Owner / / Other
-----------------------------------------------------------------------------------------------------------------------
FIRST MIDDLE INITIAL LAST RELATIONSHIP TO ANNUITANT
-----------------------------------------------------------------------------------------------------------------------
FIRST MIDDLE INITIAL LAST RELATIONSHIP TO ANNUITANT
-----------------------------------------------------------------------------------------------------------------------
FIRST MIDDLE INITIAL LAST RELATIONSHIP TO ANNUITANT
-----------------------------------------------------------------------------------------------------------------------
FIRST MIDDLE INITIAL LAST RELATIONSHIP TO ANNUITANT
-----------------------------------------------------------------------------------------------------------------------
B. Contingent Beneficiary of payment at DEATH:
-----------------------------------------------------------------------------------------------------------------------
FIRST MIDDLE INITIAL LAST RELATIONSHIP TO ANNUITANT
-----------------------------------------------------------------------------------------------------------------------
FIRST MIDDLE INITIAL LAST RELATIONSHIP TO ANNUITANT
-----------------------------------------------------------------------------------------------------------------------
Box (1) or (2) may be selected to include all children or brothers and sisters without naming them, or to add to the
contingent beneficiaries named. Box (3) may be selected to provide for children of a deceased contingent beneficiary; use
only if contingent beneficiaries are named and/or box (1) or (2) is checked. NOTE: The word "children" includes child and
any legally adopted child.
/ / (1) and all (other) children of the Annuitant.
/ / (2) and all (other) brothers and sisters of the Annuitant born of the marriage of or legally adopted by __________
and ______________ before the Annuitant's death.
/ / (3) any amount that would have been paid to a deceased contingent beneficiary, if living, will be paid in one sum
and in equal shares to the children of that contingent beneficiary who survive and receive payment.
C. Further Payee of payment at DEATH:
-----------------------------------------------------------------------------------------------------------------------
FIRST MIDDLE INITIAL LAST RELATIONSHIP TO ANNUITANT
-----------------------------------------------------------------------------------------------------------------------
D. / / See attached information form (Use in place of 5A, 5B, 5C)
---------------------------------------------------------------------------------------------------------------------------------
6. Will the policy applied for replace any Northwestern Mutual Life insurance or annuities? / /Yes /X/ No
---------------------------------------------------------------------------------------------------------------------------------
7. Will the policy applied for replace insurance or annuities from another insurance company? / / Yes /X/ No
---------------------------------------------------------------------------------------------------------------------------------
8. PLAN (Select One)
/X/ VARIABLE ANNUITY. Complete Variable Annuity Section (Pages 3-4)
/ / FLEXIBLE PREMIUM ANNUITY. Complete Fixed Rate Annuity Supplement (Page 5)
/ / SINGLE PREMIUM RETIREMENT ANNUITY. Complete Fixed Rate Annuity Supplement (Page 5)
----------------------------------------------------------------------------------------------------------------------------------
90-1900 (0196)
----------------------------------------------------------------------------------------------------------------------------------
V1 / / Back-end Design
TYPE /X/ Front-end Design ($10,000 minimum initial purchase payment)
----------------------------------------------------------------------------------------------------------------------------------
V2
------------ ----------------------------------------
(MONTH, DAY, YEAR) If neither specified,
MATURITY AGE / / / OR MATURITY DATE / / / - / / / - / / / / / defaults to age 85.
------------ ----------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
V3 A. COMPLETE IN ALL CASES TO INDICATE ALLOCATION OF NET PUR- B. COMPLETE ONLY IF THE ALLOCATION OF THE ATTACHED INITIAL
CHASE PAYMENTS. PAYMENT IS TO BE DIFFERENT THAN INDICATED IN A.
----------------------------------------------------------------------------------------------------------------------------------
(Use whole %. Total must equal 100%) (Use whole %. Total must equal 100%)
VARIABLE FUNDS VARIABLE FUNDS
10 Select Bond Select Bond
----------- -----------
10 International Equity International Equity
----------- -----------
10 Money Market Money Market
----------- -----------
10 Balanced Balanced
----------- -----------
10 Index 500 Stock Index 500 Stock
----------- -----------
10 Aggressive Growth Stock Aggressive Growth Stock
----------- -----------
10 High Yield Bond High Yield Bond
----------- -----------
10 Growth Stock Growth Stock
----------- -----------
10 Growth and Income Stock Growth and Income Stock
----------- -----------
FIXED FUNDS FIXED FUNDS
10 Guaranteed Interest Guaranteed Interest
----------- -----------
100% Total 100% Total
---------------------------------------------------------------------------------------------------------------------------------
V4 INITIAL PURCHASE PAYMENT
/X/ PREPAID A purchase payment for the contract applied for has been paid to the agent in exchange for the receipt
with the same number as this application. NOTE: ALL PURCHASE PAYMENT CHECKS MUST BE MADE PAYABLE TO
NORTHWESTERN MUTUAL LIFE. DO NOT MAKE CHECK PAYABLE TO AGENT OR LEAVE PAYEE BLANK.
------------------------
AMOUNT
$ 5,000.00
------------------------
For IRA and SEPP only, indicate how initial purchase payment is to be applied. Total must equal amount above.
------------------------
$ Current (19 ) tax year
------------------------
$ Prior (19 ) tax year
------------------------
$ Rollover distribution received by Annuitant in last 60 days.
------------------------
$ Direct transfer of / / IRA / / TDA / / Pension from another
institution or plan
trustee
/ / NON-PREPAID (NOTE: Contract will not be issued until initial purchase payment is received.)
/ / Collected via Multiple Contract ▇▇▇▇ (MCB).
/ / Automatic withdrawal from checking account (ISA/EFT). -----------------------------
/ / Check coming from another financial institution. Estimated Amount $
-----------------------------
----------------------------------------------------------------------------------------------------------------------------------
V5 Waiver of Purchase Payment Benefit requested? / / Yes /X/ No (If yes, send evidence of insurability).
If waiver not approved, issue contract without benefit? / /Yes /X/ No
----------------------------------------------------------------------------------------------------------------------------------
90-1900 (0196)
----------------------------------------------------------------------------------------------------------------------------------
V6 SUBSEQUENT PURCHASE PAYMENTS (Select One) -----------------
/ / None Anticipated. ISA NUMBER
/X/ Send Investment Reminders to Owner with Confirmations and Quarterly Summary Statements.
------------------------- ----------------
ANTICIPATED ANNUAL AMOUNT
$ 2,000.00
-------------------------
/ / Automatic Withdrawal from Checking Account (ISA/EFT).
-------------------------------------------------------------------------------------------------------------------------
AMOUNT DATE OF FIRST DRAFT (MONTH, DAY, YEAR) FREQUENCY
$ / / - / / / - / / / / / / / Monthly / / Quarterly / / Semiannual / / Annual
-------------------------------------------------------------------------------------------------------------------------
NOTE: Subsequent withdrawals will be on the same day of the month (1-28 ONLY) as the initial draft. ATTACH VOID CHECK
IF ONGOING DRAFT DRAWN ON DIFFERENT ACCOUNT THAN INITIAL PAYMENT CHECK OR IF CHECK NOT ATTACHED.
ISA/EFT Payer / / Annuitant at annuitant address / / Other:
-------------------------------------------------------------------------------------------------------------------------
A. / / Mr. / / Mrs. / / Ms. / / Dr. / / Other:_______________________________ / / Male / / Female
-------------------------------------------------------------------------------------------------------------------------
PERSONAL NAME BIRTHDATE (MONTH, DAY, YEAR)
/ / / / / / / / / / / / / / / / / / / / / / / / / / / - / / / - / / / / /
-------------------------------------------------------------------------------------------------------------------------
OR
-------------------------------------------------------------------------------------------------------------------------
BUSINESS/TRUST NAME
-------------------------------------------------------------------------------------------------------------------------
B. TAXPAYER IDENTIFICATION NUMBER DAYTIME TELEPHONE NUMBER
/ / / / / / / / / / / ( )
-------------------------------------------------------------------------------------------------------------------------
C. ADDRESS
STREET OR PO BOX
-------------------------------------------------------------------------------------------------------------------------
CITY, STATE, ZIP (COUNTRY IF OTHER THAN US)
-------------------------------------------------------------------------------------------------------------------------
Payer signature below is authorization to the depository institution named on the attached check to pay and charge named
account electronic funds transfers, or other form of pre-authorized check or withdrawal order transfers, initiated
by the Northwestern Mutual Life Insurance Company to its own order. This authorization will remain in effect until
revoked in writing.
X
----------------------------------------------------------
ISA/EFT PAYER SIGNATURE
/ / Add to Multiple Contract Bill.
-------------------------------------------------------------------------------------------------------------------------
AMOUNT MCB NUMBER MCB PAYER
$
-------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
V7
ANNUITANT'S PURPOSE FOR CONTRACT CURRENT FINANCIAL STATUS
/X/ Fund tax-qualified retirement plan Total Annual Income (all sources) $__________________________
/ / Personal retirement planning Total Net Worth $__________________________
/ / Other. Specify __________________________________ ANTICIPATED NUMBER OF YEARS CONTRACT WILL BE IN FORCE__________
INVESTMENT OBJECTIVES FOR THIS CONTRACT
/ / Preservation of principal / / Moderate risk, moderate return potential
/ / Lower risk, lower return potential / / Higher risk, higher return potential
THE COMPANY IS REQUIRED TO MAKE THE ABOVE INQUIRIES FOR PURPOSES OF DETERMINING SUITABILITY OF THIS SALE. ALL RESPONSES WILL
BE KEPT STRICTLY CONFIDENTIAL. CHECK ONE: / / The answers to V7 accurately describe my current financial status and
objectives.
/x/ I have been asked these questions and decline to answer.
ON (date of delivery: ___-___-___) THE FOLLOWING PROSPECTUS OR OFFERING CIRCULAR AND REPORT WAS DELIVERED:
/ / Account A Offering Circular dated __-__-__ and Report dated ___-___-___ (Corporate Pension Plans)
/X/ Account A Prospectus dated 01-15-96 (Partnership or Sole Proprietorship Pension Plans)
/ / Account B Prospectus dated ___-___-___ (all others)
I ACKNOWLEDGE RECEIPT OF THE PROSPECTUS OR OFFERING CIRCULAR AND REPORT AND I UNDERSTAND THAT ALL PAYMENTS AND VALUES
PROVIDED BY THIS CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT
GUARANTEED AS TO AMOUNT.
X X (SIGNED) ▇▇▇▇ ▇. ▇▇▇
------------------------------------------------------------- -----------------------------------------------------------
ANNUITANT SIGNATURE (IF OTHER THAN APPLICANT) APPLICANT SIGNATURE
----------------------------------------------------------------------------------------------------------------------------------
90-1900 (0196)
FIXED RATE ANNUITY SUPPLEMENT
----------------------------------------------------------------------------------------------------------------------------------
F1 Single Premium Retirement Annuity Guarantee Period: / / One Year / / Three Year
----------------------------------------------------------------------------------------------------------------------------------
F2 Maturity Age ______. If not specified, defaults to age 85.
----------------------------------------------------------------------------------------------------------------------------------
F3 Initial Premium:
A. Has the initial premium for the policy been paid to the agent
in exchange for the receipt with the same number as this application?
/ / Yes. Check attached. NOTE: ALL PREMIUM CHECKS MUST BE MADE PAYABLE
TO NORTHWESTERN MUTUAL LIFE. DO NOT MAKE
CHECK PAYABLE TO AGENT OR LEAVE PAYEE
BLANK.
/ / Non-prepaid TDA or 457 Deferred Compensation.
/ / Check coming from another financial institution.
B. Amount $__________ (Can be estimated amount if check coming from another financial institution)
C. For IRA and SEPP only, indicate how premium to be applied. Total must equal amount above.
$__________ Current (19__) tax year
$__________ Prior (19__) tax year
$__________ Rollover/Transfer from another institution (Always credited as of current year)
----------------------------------------------------------------------------------------------------------------------------------
F4 Waiver of Premium Benefit requested? / / Yes / / No (If yes, send evidence of insurability).
If waiver not approved, issue contract without benefit? / / Yes / / No
----------------------------------------------------------------------------------------------------------------------------------
F5 Subsequent Premiums: (Flexible Premium Annuity only)
A. Periodic Billing Amount $_________________ or Monthly Retirement Life Income $___________________________
DEFINED BENEFIT POLICY ONLY
B. Billing Frequency / / Monthly / / Quarterly / / Semiannual / / Annual
C. Billing Method: / / Send Billing Notices
/ / TDA Policy. Payer #__________
/ / Add to Multiple Contract Bill: -------------- -----------------------------
(MCB NUMBER) (MCB PAYER)
/ / Automatic Withdrawal from DATE OF FIRST DRAFT (MONTH, DAY, YEAR)
Checking Account (ISA/EFT). / / / - / / / - / / / / /
NOTE: SUBSEQUENT WITHDRAWALS WILL BE ON THE SAME DAY OF THE MONTH (1-28 ONLY) AS THE INITIAL
DRAFT. ATTACH VOID CHECK IF ONGOING DRAFT DRAWN ON DIFFERENT ACCOUNT THAN INITIAL PAYMENT
CHECK OR IF CHECK NOT ATTACHED.
▇. ▇▇▇▇ Billing To: / / Annuitant at Annuitant's Address / / Owner at address shown below:
/ / Annuitant at address shown below: / / MCB Payer
/ / Owner at Owner's address (Pension and Profit Sharing only) / / Other/TDA Payer:
----------------------------------------------------------------------------------------------------------------------------------
/ / Mr. / / Mrs. / / Ms. / / Dr. / / Other: ________________ / / Male / / Female
----------------------------------------------------------------------------------------------------------------------------------
PERSONAL NAME BIRTHDATE (MONTH, DAY, YEAR)
/ / / / / / / / / / / / / / / / / / / / / / / / / / / / - / / / - / / / / /
----------------------------------------------------------------------------------------------------------------------------------
OR
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
BUSINESS/TRUST NAME
----------------------------------------------------------------------------------------------------------------------------------
TAXPAYER IDENTIFICATION NUMBER DAYTIME TELEPHONE NUMBER ISA NUMBER
/ / / / / / / / / / ( )
----------------------------------------------------------------------------------------------------------------------------------
ADDRESS
STREET OR PO BOX
----------------------------------------------------------------------------------------------------------------------------------
CITY, STATE, ZIP (COUNTRY IF OTHER THAN US)
----------------------------------------------------------------------------------------------------------------------------------
Payer signature below is authorization to the depository institution named
on the attached check to pay and charge named account electronic funds
transfers, or other form of pre-authorized check or withdrawal order
transfers, initiated by the Northwestern Mutual Life Insurance Company to
its own order. This authorization will remain in effect until revoked in
writing.
X
--------------------------------------------------------------------------------
ISA/EFT PAYER SIGNATURE
----------------------------------------------------------------------------------------------------------------------------------
90-1900 (0196)
THE ANNUITANT CONSENTS TO THIS APPLICATION.
EACH PERSON SIGNING THIS APPLICATION DECLARES THAT THE ANSWERS AND STATEMENTS
MADE ON PAGES 1, 2, (3 AND 4, OR 5) AND 6 ARE CORRECTLY RECORDED, COMPLETE AND
TRUE TO THE BEST OF HIS OR HER KNOWLEDGE AND BELIEF.
IT IS UNDERSTOOD AND AGREED THAT:
For the purposes of this application, if a Variable Annuity is applied for, the
word "policy" means contract and the word "premium" means purchase payment.
If the Owner is a Trustee or successor Trustee under a tax qualified plan or the
employer under a tax qualified non-trusteed plan, Northwestern Mutual Life will
be fully discharged of liability for any action taken by the Owner in the
exercise of any policy right and for all amounts paid to, or at the direction
of, the Owner and will have no obligation as to the use of the amounts. In all
dealings with the Owner, Northwestern Mutual Life will be fully protected
against the claims of every other person.
If paid at the time of application, the first premium will be credited the date
it is received at the Home Office, if this is a Flexible Premium or Single
Premium Retirement Annuity, or the valuation date coincident with or next
following the date it is received at the Home Office, if this is a Variable
Annuity.
If a Tax Qualified Employee Plan, an IRA or TDA is applied for, the Applicant
and/or Annuitant have received and reviewed the appropriate ERISA, IRA or TDA
disclosure statements.
FIXED RATE ANNUITY AND BACK LOADED VARIABLE ANNUITY POLICIES HAVE PROVISIONS FOR
THE ASSESSMENT OF SURRENDER CHARGES ON CASH WITHDRAWAL.
No agent is authorized to make or alter contracts or to waive the rights or
requirements of Northwestern Mutual Life.
X X (signed) ▇▇▇▇ ▇. ▇▇▇
-------------------------------------- ---------------------------------------
SIGNATURE OF ANNUITANT SIGNATURE OF APPLICANT
(If Other Than Applicant) (Indicate relationship below if
applicable)
/ / TRUSTEE / / EMPLOYER
SIGNED at Milwaukee Milwaukee WI Date / 0 / 1 / - / 1/ 5 / - / 1/9/9/6
---------------------------- ----------------------------------
CITY COUNTY STATE MONTH DAY YEAR
X (signed) ▇▇▇▇ ▇ Western
------------------------------------------
SIGNATURE OF LICENSED AGENT
IT IS RECOMMENDED THAT YOU ...
read your contract.
notify your Northwestern Mutual agent or the Company at
▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇, ▇▇▇. 53202, of an
address change.
call your Northwestern Mutual agent for information
-- particularly on a suggestion to terminate or exchange
this contract for another contract or plan.
ELECTION OF TRUSTEES
The members of The Northwestern Mutual Life Insurance
Company are its policyholders of insurance policies and
deferred annuity contracts. The members exercise control
through a Board of Trustees. Elections to the Board are
held each year at the annual meeting of members. Members
are entitled to vote in person or by proxy.
FLEXIBLE PAYMENT VARIABLE ANNUITY-ACCOUNT B
AMOUNTS ALLOCATED TO THE SEPARATE ACCOUNT DIVISIONS AND
VARIABLE PAYMENTS PROVIDED BY THIS CONTRACT ARE NOT
GUARANTEED AS TO FIXED DOLLAR AMOUNT BUT ARE VARIABLE
AND MAY INCREASE OR DECREASE TO REFLECT THE INVESTMENT
EXPERIENCE OF THE SEPARATE ACCOUNT.
QQV.ACCT.A.(0196)
[NORTHWESTERN
MUTUAL LIFE(R) LOGO]