INDIVIDUAL FLEXIBLE PREMIUM
VARIABLE ANNUITY CONTRACT
ALPINE LIFE INSURANCE COMPANY
Hartford, Connecticut 06104-2999
(a stock life insurance company, herein called the "Company")
Unless otherwise directed by the Contract Owner, the Company agrees to pay the
named ▇▇▇▇▇▇▇▇▇, on the Annuity Commencement Date, if the Annuitant and Contract
Owner are then living, the first of a series of annuity payments the frequency,
period and dollar amounts of which shall be determined on the basis as set forth
herein, in accordance with the Annuity Option selected.
This contract is issued in consideration of the payment of the initial premium
payment.
This contract is subject to the laws of the jurisdiction where it is delivered.
The Contract Specifications on Page 3 and the conditions and provisions on this
and the following pages are part of the contract.
RIGHT TO EXAMINE CONTRACT
We want you to be satisfied with the contract you have purchased. We urge you
to closely examine its provisions. If for any reason you are not satisfied with
your purchase you may surrender the contract by returning the contract within
ten days after you receive it. A written request for cancellation must
accompany the contract. In such event, we will pay to the Contract Owner an
amount equal to the sum of (i) the difference between the premiums paid and the
amounts allocated to any Account under the contract and (ii) the Contract Value
on the date of surrender. The Contract Owner bears only the investment risk
during the period prior to the Company's receipt of request for cancellation.
Signed for the Company
/s/ ▇▇▇▇▇ ▇▇▇▇▇▇, SECRETARY /s/ ▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇, PRESIDENT
▇▇▇▇▇ ▇▇▇▇▇▇, SECRETARY ▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇, PRESIDENT
PREMIUM PAYMENTS ARE FLEXIBLE AS DESCRIBED HEREIN.
NONPARTICIPATING
ALL PAYMENTS AND VALUES PROVIDED BY THIS CONTRACT, WHEN BASED ON INVESTMENT
EXPERIENCE OF A SUB-ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED
DOLLAR AMOUNT. DETAILS OF THE VARIABLE PROVISIONS ARE DESCRIBED UNDER VALUATION
PROVISIONS, PAGES 9 AND 1O.
VA-APLINE SAMPLE Printed in U.S.A.
TABLE OF CONTENTS
PAGE
Contract Specifications 3
Definition of Certain Terms 4
Premium Payments Provision 5
Contract Control Provisions 6
General Provisions 7
Valuation Provisions 9
Termination Provisions 10
Settlement Provisions 12
Annuity Tables 15
VA-ALPINE SAMPLE Printed in U.S.A.
CONTRACT SPECIFICATIONS
CONTRACT NUMBER [SPECIMEN] CONTRACT DATE [FEBRUARY 8, 1994]
NAME OF ANNUITANT [▇▇▇▇▇ ▇▇▇▇▇] DATE OF ISSUE [FEBRUARY 8, 1994]
AGE OF ANNUITANT [35] ANNUITY COMMENCEMENT DATE [JANUARY 1, 2024]
SEX OF ANNUITANT [MALE] INITIAL PREMIUM PAYMENT [$20,000]
CONTINGENT ANNUITANT [▇▇▇▇ ▇▇▇▇▇] MINIMUM SUBSEQUENT PAYMENT $500
DESIGNATED BENEFICIARY [▇▇▇ ▇▇▇▇▇] MINIMUM FIXED ACCOUNT
INTEREST RATE 3%
CONTRACT OWNER [SAME]
(IF OTHER THAN ANNUITANT)
DESCRIPTION OF BENEFITS
INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY CONTRACT
ANNUAL WITHDRAWAL AMOUNT: CONTRACT YEARS 1-7
10% OF PREMIUM PAYMENTS.
AFTER CONTRACT YEAR 7
THE GREATER OF:
100% OF THE CONTRACT VALUE REDUCED BY
THE TOTAL OF ANY PREMIUM PAYMENTS MADE
DURING THE 7 YEARS PRIOR TO WITHDRAWAL;
AND
10% OF PREMIUM PAYMENTS MADE DURING THE
7 YEARS PRIOR TO WITHDRAWAL.
ANNUAL CONTRACT MAINTENANCE FEE: $0 IF THE CONTRACT VALUE IS $50,000 OR
MORE ON THE CONTRACT ANNIVERSARY.
$30 IF THE CONTRACT VALUE IS LESS THAN
$50,000 ON THE CONTRACT ANNIVERSARY.
MORTALITY AND EXPENSE RISK CHARGE: 1.25% PER ANNUM OF THE AVERAGE DAILY
CONTRACT VALUE.
ADMINISTRATION CHARGE: 0% PER ANNUM OF THE AVERAGE DAILY
CONTRACT VALUE.
VA-ALPINE SAMPLE Page 3 PRINTED IN U.S.A.
FUND OPTIONS:
THE INITIAL PREMIUM PAYMENT WILL BE ALLOCATED AS SPECIFIED IN YOUR APPLICATION.
THE SAME ALLOCATIONS WILL BE MADE FOR SUBSEQUENT PREMIUM PAYMENTS UNLESS YOU
CHANGE THE ALLOCATION OR, AT THE TIME OF A PREMIUM PAYMENT, YOU INSTRUCT US TO
ALLOCATE THAT PAYMENT DIFFERENTLY.
SEPARATE ACCOUNT: ALPINE LIFE INSURANCE COMPANY
SEPARATE ACCOUNT ONE
SUB-ACCOUNT BASED ON
ADVISERS FUND HARTFORD ADVISERS HLS FUND (IA), INC.
BOND FUND HARTFORD BOND HLS FUND (IA), INC.
CAPITAL APPRECIATION FUND HARTFORD CAPITAL APPRECIATION HLS FUND (IA),
INC.
DIVIDEND AND GROWTH FUND HARTFORD DIVIDEND AND GROWTH HLS FUND (IA),
INC.
GROWTH AND INCOME FUND HARTFORD GROWTH AND INCOME HLS FUND (IA),
INC.
INDEX FUND HARTFORD INDEX HLS FUND (IA), INC.
INTERNATIONAL ADVISERS FUND HARTFORD INTERNATIONAL ADVISERS HLS FUND
(IA), INC.
INTERNATIONAL OPPORTUNITIES FUND HARTFORD INTERNATIONAL OPPORTUNITIES HLS FUND
(IA), INC.
MIDCAP FUND HARTFORD MIDCAP HLS FUND (IA), INC.
MONEY MARKET FUND HARTFORD MONEY MARKET HLS FUND (IA), INC.
MORTGAGE SECURITIES FUND HARTFORD MORTGAGE SECURITIES HLS FUND (IA),
INC.
SMALL COMPANY FUND HARTFORD SMALL COMPANY HLS FUND (IA), INC.
STOCK FUND HARTFORD STOCK HLS FUND (IA), INC.
OR OTHER FUNDS AS MAY BE MADE AVAILABLE FROM TIME TO TIME.
VA-ALPINE SAMPLE Page 3 (Continued) PRINTED IN U.S.A.
CONTINGENT DEFERRED SALES CHARGES:
SUBJECT TO THE ANNUAL WITHDRAWAL AMOUNT, SURRENDERS OF CONTRACT VALUES
ATTRIBUTABLE TO PREMIUM PAYMENTS MAY BE SUBJECT TO A CONTINGENT DEFERRED SALES
CHARGE ("CHARGE"). THE LENGTH OF TIME FROM RECEIPT OF THE PREMIUM PAYMENT TO
THE TIME OF SURRENDER DETERMINES THE CHARGE.
DURING THE FIRST SEVEN CONTRACT YEARS, ALL SURRENDERS WILL BE FIRST FROM PREMIUM
PAYMENTS AND THEN FROM EARNINGS. IF AN AMOUNT EQUAL TO ALL PREMIUM PAYMENTS HAS
BEEN SURRENDERED, A CHARGE WILL NOT BE ASSESSED AGAINST THE SURRENDER OF THE
REMAINING CONTRACT VALUE.
AFTER THE SEVENTH CONTRACT YEAR, ALL SURRENDERS WILL BE FIRST FROM EARNINGS AND
THEN FROM PREMIUM PAYMENTS. A CHARGE WILL NOT BE ASSESSED AGAINST THE SURRENDER
OF EARNINGS. IF AN AMOUNT EQUAL TO ALL EARNINGS HAS BEEN SURRENDERED, A CHARGE
WILL NOT BE ASSESSED AGAINST PREMIUM PAYMENTS RECEIVED MORE THAN SEVEN YEARS
PRIOR TO SURRENDER, BUT WILL BE ASSESSED AGAINST PREMIUM PAYMENTS RECEIVED LESS
THAN SEVEN YEARS PRIOR TO SURRENDER. FOR THIS PURPOSE, PREMIUM PAYMENTS WILL BE
DEEMED TO BE SURRENDERED IN THE ORDER IN WHICH THEY WERE RECEIVED.
THE CHARGE IS A PERCENTAGE OF THE AMOUNT SURRENDERED (NOT TO EXCEED THE
AGGREGATE AMOUNT OF THE PREMIUM PAYMENTS MADE) AND EQUALS:
LENGTH OF TIME FROM PREMIUM PAYMENT
CHARGE (NUMBER OF YEARS)
6% 1
6% 2
5% 3
5% 4
4% 5
3% 6
2% 7
0% 8 AND THEREAFTER
NO CONTINGENT DEFERRED SALES CHARGES WILL BE ASSESSED IN THE EVENT THE CONTRACT
TERMINATES DUE TO THE DEATH OF THE ANNUITANT OR CONTRACT OWNER (AS APPLICABLE),
OR IF CONTRACT VALUES ARE APPLIED TO AN ANNUITY OPTION PROVIDED FOR UNDER THIS
CONTRACT (PROVIDED HOWEVER, ANY SURRENDER OUT OF OPTION 4 WILL BE SUBJECT TO
CONTINGENT DEFERRED SALES CHARGES, IF APPLICABLE), OR IF THE CONTRACT IS
SURRENDERED ON OR AFTER THE ANNUITANT'S 90TH BIRTHDAY, OR UPON THE EXERCISE OF
THE ANNUAL WITHDRAWAL AMOUNT.
VA-ALPINE SAMPLE Page 3 (Continued) PRINTED IN U.S.A.
DEFINITION OF ACCOUNT - Any of the Sub-Accounts or the Fixed Account.
CERTAIN TERMS
ACCUMULATION UNIT - An accounting unit of measure used to
calculate the value of a Sub-Account of this contract before
annuity payments begin.
ANNUAL WITHDRAWAL AMOUNT - The amount that can be withdrawn
in any Contract Year prior to incurring surrender charges.
ANNUITANT - The person on whose life this contract is
issued.
ANNUITY COMMENCEMENT DATE - The date on which annuity
payments are to begin as described under Settlement
Provisions in this contract.
ANNUITY UNIT - An accounting unit of measure used to
calculate the amount of annuity payments under the variable
annuity option.
BENEFICIARY - The person entitled to receive benefits as per
the terms of the contract in case of the death of the
Contract Owner or Annuitant, as applicable.
COMPANY - The Company referred to on the first pages of the
Contract.
CONTINGENT ANNUITANT - The person so designated by the
Contract Owner who, upon the Annuitant's death, prior to the
Annuity Commencement Date, becomes the Annuitant.
CONTRACT ANNIVERSARY - An anniversary of the Contract Date.
Similarly, Contract Years are measured from the Contract
Date. The Contract Date is shown on Page 3.
CONTRACT MAINTENANCE FEE - An amount which is deducted from
the value of the contract at the end of the Contract Year or
on the date of surrender of this contract, if earlier.
CONTRACT OWNER - The owner(s) of the contract.
CONTRACT VALUE - The value of the Sub-Accounts plus the
value of the Fixed Account on any day.
DATE OF ISSUE - The date on which an Account is established
for the Contract Owner by the Company.
DOLLAR COST AVERAGING - Contract Owner initiated systematic
transfers from one or more Accounts to any other available
Sub-Accounts.
DUE PROOF OF DEATH - A certified copy of the death
certificate, an order of a court of competent jurisdiction,
a statement from a physician who attended the deceased, or
any other proof acceptable to the Company.
FIXED ACCOUNT - Part of the Company's General Account to
which all or a portion of the Contract Value may be
allocated.
VA-ALPINE SAMPLE Page 4 PRINTED IN U.S.A.
DEFINITION OF FUND(s) - Currently the Funds specified on Page 3 or any
CERTAIN TERMS other Fund(s) that may be added by the Company.
(CONTINUED)
GENERAL ACCOUNT - All assets of the Company other than those
allocated to the Separate Accounts of the Company.
MAXIMUM ANNIVERSARY VALUE - A value used in determining the
death benefit. It is based on a series of calculations of
Account Values on Contract Anniversaries, premium payments
and partial surrenders.
As of the date of death, the Company will calculate an
Anniversary Value for each Contract Anniversary prior to the
deceased's attained age 81. The Anniversary Value is equal
to the Account Value on a Contract Anniversary, increased by
the dollar amount of any premium payments made since that
anniversary and reduced by the dollar amount of any partial
surrenders since that anniversary. The Maximum Anniversary
Value is equal to the greatest Anniversary Value attained
from this series of calculations.
PREMIUM TAX - The amount of tax, if any, charged by a
federal, state or municipal entity on premium payments or
Contract Values.
SEPARATE ACCOUNT - An Account established by the Company to
separate the assets funding the variable benefits for the
class of contracts to which this contract belongs from the
other assets of the Company. The assets in the Separate
Account are not chargeable with liabilities arising out of
any other business the Company may conduct. The Separate
Account and the Funds, which are the underlying securities
of the Separate Account, are listed on the Contract
Specifications on Page 3 of this contract.
SUB-ACCOUNT - The subdivisions of the Separate Account which
are used to determine how the Contract Owner's Account is
allocated between the Funds.
TERMINATION VALUE - The value of the contract upon
termination, as described in the section of the contract
captioned "Termination Provisions."
VALUATION DAY - Every day the New York Stock Exchange is
open for trading.
PREMIUM PREMIUM PAYMENTS
PAYMENTS
Premium payments are payable to the Company. Payments may
be made by check payable to Us or by any other method which
the Company deems acceptable.
The Initial Premium Payment is shown on Page 3. This is a
flexible premium annuity. Additional payments may be
accepted by the Company. The additional payments must be at
least equal to the minimum subsequent premium payment shown
on Page 3.
ALLOCATION OF PREMIUM PAYMENTS
The Contract Owner shall specify that portion of any premium
payment to be allocated to each Account, provided, however,
that the minimum allocation to any Account may not be less
than the Company's minimum amount then in effect.
VA- ALPINE SAMPLE Page 5 PRINTED IN U.S.A.
PREMIUM The Contract Owner may transfer Contract Values held in the
PAYMENTS Accounts into other Accounts; however, the Company reserves the
(CONTINUED) right to limit the number of transfers to no more frequently than
12 per Contract Year with no two transfers being made on
consecutive Valuation Days. Subject to the following two
paragraphs, any such limitations will apply to all Contract
Owners.
The right to reallocate Contract Values between the Accounts is
subject to modification if the Company determines, in its sole
opinion, that the exercise of that right by one or more Contract
Owners is, or would be, to the disadvantage of other Contract
Owners. Any modification could be applied to transfers to or
from some or all of the Accounts and could include, but not be
limited to, the requirement of a minimum time period between each
transfer, not accepting transfer requests of an agent acting
under a power of attorney on behalf of more than one Contract
Owner, or limiting the dollar amount that may be transferred
between the Accounts by a Contract Owner at any one time. Such
restrictions may be applied in any manner reasonably designed to
prevent any use of the transfer right which is considered by the
Company to be to the disadvantage of other Contract Owners.
The maximum amount transferable from the Fixed Account during any
Contract Year is the greater of 30% of the Fixed Account balance
as of the last Contract Anniversary or the greatest of any prior
transfer from the Fixed Account. This limitation does not apply
to Dollar Cost Averaging. However, if any interest rate is
renewed at a rate at least one percentage point less than the
previous rate, the Contract Owner may elect to transfer up to
100% of the Funds receiving that reduced rate within 60 days of
notification of the interest rate decrease. Transfers may not be
made from the Sub-Accounts into the Fixed Account for the
six-month period following any transfer from the Fixed Account
into the other Sub-Accounts. The Company reserves the right to
defer transfers from the Fixed Account for up to six months from
the date of request.
CONTRACT ANNUITANT, CONTINGENT ANNUITANT, CONTRACT OWNER
CONTROL
PROVISIONS The Annuitant may not be changed.
The designations of Contract Owner and Contingent Annuitant will
remain in effect until changed by the Contract Owner. Changes in
the designation of the Contract Owner may be made during the
lifetime of the Annuitant by written notice to the Company.
Changes in the designation of Contingent Annuitant may be made at
any time prior to the Annuity Commencement Date by written notice
to the Company. Notwithstanding the foregoing, if no Contingent
Annuitant has been named and the Contract Owner/▇▇▇▇▇▇▇▇▇'s
spouse is the Beneficiary, it will be assumed that the Contract
Owner/Annuitant's spouse is the Contingent Annuitant.
The Contract Owner has the sole power to exercise all the rights,
options and privileges granted by this contract or permitted by
the Company and to agree with the Company to any change in or
amendment to the contract. The rights of the Contract Owner
shall be subject to the rights of any assignee of record with the
Company and of any irrevocably designated Beneficiary. In the
case of joint Contract Owners, each Contract Owner alone may
exercise all rights, options and privileges, except with respect
to the Termination and Partial Surrender/Annual Withdrawal Amount
Provisions and change of ownership.
VA-ALPINE SAMPLE Page 6 Printed in U.S.A.
CONTRACT BENEFICIARY
CONTROL
PROVISIONS The Designated Beneficiary will remain in effect until changed by
(CONTINUED) the Contract Owner. Changes in the Designated Beneficiary may be
made during the lifetime of the Annuitant by written notice to
the Company. If the Designated Beneficiary has been designated
irrevocably, however, such designation cannot be changed or
revoked without such Beneficiary's written consent. Upon receipt
of such notice and written consent, if required, the new
designation will take effect as of the date the notice is signed,
whether or not the Annuitant or Contract Owner is alive at the
time of receipt of such notice. The change will be subject to
any payments made or other action taken by the Company before the
receipt of the notice.
In the event of the death of the Annuitant when there is no
surviving Contingent Annuitant, the Beneficiary will be as
follows. If the death of the Annuitant occurs prior to the
Annuity Commencement Date, the Beneficiary shall be the surviving
Contract Owner, or joint Contract Owners, if applicable,
notwithstanding that the Designated Beneficiary may be different.
Otherwise, the Beneficiary will be the Designated Beneficiary
then in effect. If the Annuitant is the sole Contract Owner and
there is no Designated Beneficiary in effect, the Annuitant's
estate will be the Beneficiary.
In the event of the death of a Contract Owner prior to the
Annuity Commencement Date, the Beneficiary will be as follows.
If the owner was the sole Contract Owner, the Beneficiary shall
be the Designated Beneficiary then in effect. If no Beneficiary
designation is in effect or if the Designated Beneficiary has
predeceased the Contract Owner, the Contract Owner's estate shall
be the Beneficiary. At the first death of a joint Contract Owner
prior to the Annuity Commencement Date, the Beneficiary shall be
the surviving Contract Owner notwithstanding that the Designated
Beneficiary may be different.
GENERAL THE CONTRACT
PROVISIONS
This contract constitutes the entire contract.
MODIFICATION
No modification of this contract shall be made except over the
signature of the President, a Vice President, a Secretary or an
Assistant Secretary of the Company.
The Company reserves the right to modify the contract, but only
if such modification: (i) is necessary to make the contract or
the Separate Account comply with any law or regulation issued by
a governmental agency to which the Company is subject; (ii) is
necessary to assure continued qualification of the contract under
the Internal Revenue Code or other federal or state laws relating
to retirement annuities or annuity contracts; (iii) is necessary
to reflect a change in the operation of the Separate Account or
the Sub-Account(s); (iv) provides additional Account options; or
(v) withdraws Account options. In the event of any such
modification, the Company will provide notice to the Contract
Owner, or to the payee(s) during the annuity period. The Company
may also make appropriate endorsement in the Contract to reflect
such modification.
VA-ALPINE SAMPLE Page 7 Printed in U.S.A.
GENERAL MINIMUM VALUE STATEMENT
PROVISIONS
(CONTINUED) Any Termination Values, death benefits or settlement provisions
available under this contract equal or exceed those required by
the state in which the contract is delivered.
NON-PARTICIPATION
This contract does not share in the surplus earnings of the
Company. That portion of the assets of the Separate Account
equal to the reserves and other contract liabilities of the
Separate Account shall not be chargeable with liabilities arising
out of any other business the Company may conduct.
MISSTATEMENT OF AGE AND SEX
If the age or sex of the Annuitant has been misstated, the amount
of the annuity payable by the Company shall be that provided by
that portion of the amounts allocated to effect such annuity on
the basis of the corrected information without changing the date
of the first payment of such annuity. Any underpayments by the
Company shall be made up immediately and any overpayments shall
be charged against future amounts becoming payable.
If the age of the Annuitant or Contract Owner has been misstated,
the amount of any death benefit payable shall be determined based
upon the correct age of the Annuitant or Contract Owner.
INCONTESTABILITY
We cannot contest this Contract.
REPORTS TO THE CONTRACT OWNER
There shall be furnished to each Contract Owner copies of any
shareholder reports of the Funds and of any other notices,
reports or documents required by law to be delivered to Contract
Owners. Annually, a statement of the Contract Value is sent to
the Contract Owner.
VOTING RIGHTS
The Company shall notify the Contract Owner of any Fund
shareholder's meetings at which the shares held for the Contract
Owner's Account may be voted and shall also send proxy materials
and a form of instruction by means of which the Contract Owner
can instruct the Company with respect to the voting of the shares
held for the Contract Owner's Account. In connection with the
voting of Fund shares held by it, the Company shall arrange for
the handling and tallying of proxies received from Contract
Owners. The Company will vote the Fund shares held by it in
accordance with the instructions received from the Contract
Owners having the right to give voting instructions. If a
Contract Owner desires to attend any meeting which shares held
for the Contract Owner's benefit may be voted, the Contract Owner
may request the Company to furnish a proxy or otherwise arrange
for the exercise of voting rights with respect to the Fund shares
held for such Contract Owner's Account.
VA-ALPINE SAMPLE Page 8 Printed in U.S.A.
GENERAL In the event that the Contract Owner gives no instructions or
PROVISIONS leaves the manner of voting discretionary, the Company will vote
(CONTINUED) such shares of the appropriate Fund in the same proportion as
shares of that Fund for which instructions have been received.
Also, the Company will vote the Fund Shares in this proportionate
manner which are held by the Company for its own Account. During
the annuity period under a contract the number of votes will
decrease as the assets held to fund annuity benefits decrease.
SUBSTITUTION
The Company reserves the right to substitute the shares of any
other registered investment company for the shares of any Fund
already purchased or to be purchased in the future by the
Separate Account provided that the substitution has been approved
by the Securities and Exchange Commission.
CHANGE IN THE OPERATION OF THE SEPARATE ACCOUNT
At the Company's election and subject to any necessary vote by
persons having the right to give instructions with respect to the
voting of the Fund shares held by the Sub-Accounts, the Variable
Account may be operated as a management company under the
Investment Company Act of 1940 or it may be deregistered under
the Investment Company Act of 1940 in the event registration is
no longer required. Deregistration of the Variable Account
requires an order by the Securities and Exchange Commission.
PROOF OF SURVIVAL
The payment of any annuity benefit will be subject to evidence
that the Annuitant is alive on the date such payment is otherwise
due.
VALUATION
PROVISIONS NET PREMIUM PAYMENTS
The net premium payment is equal to the premium payment minus any
applicable Premium Taxes. The net premium payment is applied to
provide Fixed Account values or Sub-Account Accumulation Units
with respect to the Sub-Account(s) selected by the Contract
Owner.
The number of Accumulation Units credited to each Sub-Account is
determined by dividing the net premium payment allocated to a
Sub-Account by the dollar value of one Accumulation Unit for such
Sub-Account, next computed after the receipt of a premium payment
by the Company. The number of Accumulation Units so determined
will not be affected by any subsequent change in the value of
such Accumulation Units. The Accumulation Unit value in any
Sub-Account may increase or decrease from day to day as described
below.
The Company will determine the value of the Fixed Account by
crediting interest to amounts allocated to the Fixed Account.
The minimum Fixed Account interest rate is the rate shown on Page
3, compounded annually. The Company, at its discretion, may
credit interest rates greater than the minimum Fixed Account
interest rate.
VA-ALPINE SAMPLE Page 9 Printed in U.S.A.
VALUATION NET INVESTMENT FACTOR
PROVISIONS
(CONTINUED) The net investment factor for each of the Sub-Accounts is equal
to the net asset value per share of the corresponding Fund at the
end of the valuation period (plus the per share amount of any
unpaid dividends or capital gains by that Fund) divided by the
net asset value per share of the corresponding Fund at the
beginning of the valuation period and subtracting from that
amount the mortality and expense risk charge and the
administration charge shown on Page 3. The General Account net
investment factor is guaranteed to be equal to the Minimum Fixed
Account Interest Rate shown on Page 3.
ACCUMULATION UNIT VALUE
The Accumulation Unit Value for each Sub-Account will vary to
reflect the investment experience of the applicable Fund and will
be determined on each Valuation Day by multiplying the
Accumulation Unit Value of the particular Sub-Account on the
preceding Valuation Day by the net investment factor for that
Sub-Account for the valuation period then ended. The value of
the Sub-Account on each Valuation Day is then determined by
multiplying the number of Accumulation Units in that Sub-Account
by the Accumulation Unit Value on that Valuation Day.
ANNUITY UNIT VALUE
The value of an Annuity Unit for each Sub-Account of the Separate
Account will vary to reflect the investment experience of the
applicable Funds and will be determined by multiplying the value
of the Annuity Unit for that Sub-Account on the preceding day by
the product of (a) the net investment factor for that Sub-Account
for the day for which the Annuity Unit value is being calculated,
and (b) 0.999866, which is a factor that neutralizes an assumed
interest rate of 5%.
CONTRACT MAINTENANCE FEE
During each year that this contract is in force prior to the
Annuity Commencement Date, a fee will be deducted from the
contract at the end of the Contract Year or on the date of
surrender of this contract, if earlier. The fee will be charged
against the Contract Value by reducing the Fixed Account value
and, with respect to the Sub-Accounts, the number of Accumulation
Units held on that date on a pro-rata basis with respect to each
active Account.
The number of Accumulation Units deducted from the Sub-Account is
determined by dividing the pro-rata portion of the Contract
Maintenance Fee applicable to that Sub-Account, by the value of
an Accumulation Unit for the Sub-Account at the end of the
Contract Year, or on the date of surrender, as applicable.
TERMINATION TERMINATION PRIOR TO THE ANNUITY COMMENCEMENT DATE
PROVISIONS
FULL SURRENDER
At any time prior to the Annuity Commencement Date, the Contract
Owner has the right to terminate the contract by submitting a
written request to the Administrative Office of the Company. In
such event, the Termination Value of the contract may be taken in
the form of a cash settlement.
VA-ALPINE SAMPLE Page 10 Printed in U.S.A.
TERMINATIONS The Termination Value of the contract is equal to the Contract
PROVISIONS Value less:
(CONTINUED)
(a) any applicable Premium Taxes not previously deducted;
(b) the Contract Maintenance Fee as specified on Page 3; and
(c) any applicable contingent deferred sales charges as specified
on Page 3.
The Termination Value provided by the contract is not less than
the minimum values required by the insurance laws of the state in
which this contract is issued.
PARTIAL SURRENDERS/ANNUAL WITHDRAWAL AMOUNT
The Contract Owner may request, in writing, a partial surrender
of Contract Values at any time prior to the Annuity Commencement
Date provided the Contract Value remaining after the surrender is
at least equal to the Company's minimum amount rules then in
effect. If the remaining Contract Value following such surrender
is less than the Company's minimum amount rules, the Company will
terminate the contract and pay the Termination Value.
The contingent deferred sales charge will be assessed against any
Contract Values surrendered as described on Page 3. However, on
a noncumulative basis, the Contract Owner may make partial
surrenders during any Contract Year, up to the Annual Withdrawal
Amount shown on Page 3 and the contingent deferred sales charge
will not be assessed against such amounts. Surrender of Contract
Values in excess of the Withdrawal Amount and additional
surrenders made in any Contract Year will be subject to the
contingent deferred sales charge, as described on Page 3, if
applicable.
For Federal tax purposes, any surrenders will be deemed to be
first from earnings, to the extent that they exist, and then from
the premium payments.
TERMINATION AFTER THE ANNUITY COMMENCEMENT DATE
This contract may not be surrendered for its Termination Value
after the commencement of annuity payments, except with respect
to Options Four and Five.
PAYMENT ON SURRENDER - DEFERRAL OF PAYMENT
Payment on any request for surrender will be made as soon as
possible and, with respect to the Contract Values in the
Sub-Accounts, no later than seven days after the written request
is received by the Company. However, such payment may be subject
to postponement:
(a) for any period during which the New York Stock Exchange is
closed or during which trading on the New York Stock Exchange is
restricted;
(b) for any period during which an emergency exists as a result
of which (i) disposal of the securities held in the Sub-Accounts
is not reasonably practicable, or (ii) it is not reasonably
practicable for the value of the net assets of the Separate
Account to be fairly determined; and
(c) for such other periods as the Securities and Exchange
Commission may, by order, permit for the protection of the
Contract Owners. The conditions under which trading shall be
deemed to be restricted or any emergency shall be deemed to exist
shall be determined by rules and regulations of the Securities
and Exchange Commission.
VA-ALPINE SAMPLE Page 11 Printed in U.S.A.
TERMINATION The Company may defer payment of any amounts from the Fixed
PROVISIONS Account for up to six months from the date of the request to
(CONTINUED) surrender. If the Company defers payment for more than 30 days,
the Company will pay interest of at least 3% per annum on the
amount deferred.
DEATH BENEFIT
If the Annuitant dies before the Annuity Commencement Date and
there is no designated Contingent Annuitant surviving, or if the
Contract Owner dies before the Annuity Commencement Date, the
Death Benefit will be payable as determined under the Contract
Control Provisions. The Death Benefit is calculated as of the
date the Company receives written notification of Due Proof of
Death at the Administrative Office of the Company.
The Death Benefit will be the greatest of:
(a) The Contract Value on the date of receipt by the Company of
Due Proof of Death; or
(b) The Maximum Anniversary Value as described on Page 5 of this
Contract; or
(c) 100% of all premium payments made under the Contract,
reduced by the dollar amount of any partial surrenders since
the Date of Issue.
The Death Benefit may be taken in one sum or under any of the
settlement options then being offered by the Company provided,
however, that, in the event of a Contract Owner's death, any
settlement option must provide that any amount payable as a death
benefit will commence upon notification of Due Proof of Death and
be completed within five years of the date of death or, if the
benefit is payable over a period not extending beyond the life
expectancy of the Beneficiary or over the life of the
Beneficiary, such distribution must commence within one year of
the date of death. Notwithstanding the foregoing, in the event
of the Contract Owner's death where the sole Beneficiary is the
spouse of the Contract Owner and the Annuitant or Contingent
Annuitant is living, such spouse may elect, in lieu of receiving
the death benefit, to be treated as the Contract Owner.
When payment is taken in one sum, payment will be made within 7
days after the date Due Proof of Death is received, except when
the Company is permitted to defer such payment under the
Investment Company Act of 1940.
ANNUITY COMMENCEMENT DATE
The Annuity Commencement Date is shown on Page 3. This date may
be changed by the Contract Owner with 30 days advance written
notification, and may be the fifteenth day of any month before or
including the month of the Annuitant's 90th birthday. In the
event the Contingent ▇▇▇▇▇▇▇▇▇ becomes the Annuitant and in the
absence of a written election to the contrary, the Annuity
Commencement Date will be the fifteenth day of the month
coincident with or next following the Annuitant's 90th birthday.
VA-ALPINE SAMPLE Page 12 Printed in U.S.A.
SETTLEMENT ELECTION OF ANNUITY OPTION
PROVISIONS
(CONTINUED) The Contract Owner may elect to have the Termination Value,
without deduction for any contingent deferred sales charge,
applied on the Annuity Commencement Date under any one of the
annuity options described below except the fifth option or under
any of the settlement options then being offered by the Company.
The Termination Value is determined on the basis of the
Accumulation Unit value of each Sub-Account and the value of the
Fixed Account no later than the fifth Valuation Day preceding the
date annuity payments are to commence.
DATE OF PAYMENT
The first payment under any option shall be made on the fifteenth
day of the month immediately following approval of claim for
settlement. Subsequent payments shall be made on the fifteenth
day of each subsequent month in accordance with the manner of
payment selected.
DEATH OF THE ANNUITANT
In the event of the death of the Annuitant while receiving
annuity payments, the present value of any remaining payments
will be paid in one sum to the Beneficiary unless other
provisions shall have been made and approved by the Company. If
the Annuitant was also the Contract Owner, any method of
distribution must provide that any amount payable as a death
benefit will be distributed at least as rapidly as under the
method of distribution in effect at the Contract Owner's death.
In the case of the Separate Account calculations, for such
present value of the remaining payments the Company will assume a
net investment rate of 5% per annum. The Annuity Unit value on
the date of receipt of Due Proof of Death shall be used for the
purpose of determining such present value. In the case of the
General Account the net investment rate assumed will be the rate
used by the Company to determine the amount of each certain
payment.
ALLOCATION OF ANNUITY
The person electing an annuity option may further elect to have
the value of the contract applied to provide a variable annuity,
a fixed dollar annuity or a combination of both. Once every 3
months, following the commencement of annuity payments, the
Contract Owner may elect, in writing, to transfer among any
Sub-Account(s) on which variable annuity payments are based. No
transfers may be made between the Sub-Accounts and the General
Account.
If no election is made to the contrary, the value of each
Sub-Account shall be applied to provide a variable annuity based
thereon, and the value of the Fixed Account shall be applied to
provide a fixed dollar annuity.
VARIABLE ANNUITY AND FIXED DOLLAR ANNUITY
Variable Annuity - A variable annuity is an annuity with payments
increasing or decreasing in amount in accordance with the net
investment results of the Sub-Account(s) of the Separate Account
(as described in the Valuation Provisions). After the first
monthly payment for a variable annuity has been determined in
accordance with the provisions of this contract, a number of
Sub-Account Annuity Units is determined by dividing that first
monthly payment by the appropriate Sub-Account Annuity Unit value
on the effective date of the annuity payments.
VA-ALPINE SAMPLE Page 13 Printed in U.S.A.
SETTLEMENT Once variable annuity payments have begun, the number of Annuity
PROVISIONS Units remains fixed with respect to a particular Sub-Account. If
(CONTINUED) the Contract Owner elects that continuing annuity payments be
based on a different Sub-Account, the number will change
effective with that election but will remain fixed in number
following such election. The method of calculating the unit
value is described under Valuation Provisions.
The dollar amount of the second and subsequent variable annuity
payments is not predetermined and may increase or decrease from
month to month. The actual amount of each variable annuity
payment after the first is determined by multiplying the number
of Sub-Account Annuity Units by the Sub-Account Annuity Unit
value as described in the Valuation Provisions. The Sub-Account
Annuity Unit value will be determined no earlier than the fifth
Valuation Day preceding the date the annuity payment is due.
The Company guarantees that the dollar amount of variable annuity
payments will not be adversely affected by variations in the
expense results and in the actual mortality experience of payees
from the mortality assumptions, including any age adjustment,
used in determining the first monthly payment.
Fixed Dollar Annuity - A fixed dollar annuity is an annuity with
payments which remain fixed as to dollar amount throughout the
payment period.
ANNUITY OPTIONS
FIRST OPTION - Life Annuity - An annuity payable monthly during
the lifetime of the payee, ceasing with the last payment due
prior to the death of the payee.
SECOND OPTION - Life Annuity with 120, 180 or 240 Monthly
Payments Certain - An annuity providing monthly income to the
payee for a fixed period of 120 months, 180 months, or 240 months
(as selected), and for as long thereafter as the payee shall
live.
THIRD OPTION - Joint and Last Survivor Life Annuity - An annuity
payable monthly during the joint lifetime of the payee and a
secondary payee, and thereafter during the remaining lifetime of
the survivor, ceasing with the last payment prior to the death of
the survivor.
FOURTH OPTION - Payment for a Designated Period - An amount
payable monthly for the number of years selected which may be
from 5 to 30 years. The remaining balance of proceeds in the
General Account or the Separate Account for any day is equal to
the balance on the previous day decreased by the amount of any
installment paid on that day and the remainder multiplied by the
applicable net investment factor for the day as described in the
valuation provisions. Any surrender out of this option will be
subject to contingent deferred sales charges, as described on
Page 3.
If this contract is issued to qualify under Section 401, 403, or
408 of the Internal Revenue Code of 1954 as amended, the fourth
option shall be available only if the guaranteed payment period
is less than the life expectancy of the Annuitant at the time the
option becomes effective. Such life expectancy will be computed
under the mortality table then in use by the Company.
VA-ALPINE SAMPLE Page 14 Printed in U.S.A.
SETTLEMENT FIFTH OPTION - Death Benefit Remaining with the Company -
PROVISIONS Proceeds from the Death Benefit left with the Company for a
(CONTINUED) period not to exceed five years from the date of the Contract
Owner's death prior to the Annuity Commencement Date. The
proceeds will remain in the Sub-Account(s) to which they were
allocated at the time of death unless the Beneficiary elects to
reallocate them. Full or partial withdrawals may be made at any
time. In the event of withdrawals, the remaining value will
equal the Contract Value of the proceeds left with the Company,
minus any withdrawals.
In the absence of an election by the Contract Owner, the
Termination Value, without deduction for any contingent deferred
sales charge, will be applied on the Annuity Commencement Date
under the second option to provide a life annuity with 120
monthly payments certain.
ANNUITY TABLES DESCRIPTION OF TABLES
The attached tables show the minimum dollar amount of the first
monthly payments for each $1,000 applied under the options.
Under the First or Second Options, the amount of each payment
will depend upon the age and sex of the payee at the time the
first payment is due. Under the Third Option, the amount of each
payment will depend upon the sex of both payees and their ages at
the time the first payment is due.
The variable payment annuity tables for the First, Second and
Third Options are based on the 1983a Individual Annuity Mortality
Table with ages set back one year and an interest rate of 5% per
annum. The table for the Fourth Option is based on an interest
rate of 5% per annum.
The fixed annuity payment tables for the First, Second and Third
Options are based on the 1983a Individual Annuity Mortality Table
with ages set back one year and an interest rate of 3% per annum.
The table for the Fourth Option is based on an interest rate of
3% per annum.
Once the Contract Owner has elected an annuity option, that
election may not be changed with respect to any Annuitant
following the commencement of annuity payments.
MINIMUM PAYMENT
No election of any options or combination of options may be made
under this contract unless the first payment for each affected
Account would be at least equal to the minimum payment amount
according to Company rules then in effect. If at any time,
payments to be made to any payee from each Account are or become
less than the minimum payment amount, the Company shall have the
right to change the frequency of payment to such intervals as
will result in a payment at least equal to the minimum. If any
amount due would be less than the minimum payment amount per
annum, the Company may make such other settlement as may be
equitable to the payee.
VA-ALPINE SAMPLE Page 15 Printed in U.S.A.
INDIVIDUAL FLEXIBLE PREMIUM
VARIABLE ANNUITY CONTRACT
ALPINE LIFE INSURANCE COMPANY
HARTFORD, CONNECTICUT 06104-2999
VA-ALPINE SAMPLE PRINTED IN U.S.A.
