[PREFERRED LIFE logo]
INSURANCE COMPANY OF NEW YORK
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This is a legal Contract between the Contract Owner (referred to in this
Contract as you and your) and Preferred Life Insurance Company of New York
(Preferred Life) (herein referred to as we, us and our). We will make Annuity
Payments as set forth in this Contract beginning on the Income Date.
This Contract is issued in consideration of the payment of the initial Purchase
Payment.
READ YOUR CONTRACT CAREFULLY
RIGHT TO EXAMINE. THIS CONTRACT MAY BE RETURNED WITHIN 10 DAYS AFTER YOU RECEIVE
IT. IT CAN BE MAILED OR DELIVERED TO EITHER US OR THE AGENT WHO SOLD IT. RETURN
OF THIS CONTRACT BY MAIL IS EFFECTIVE ON BEING POSTMARKED, PROPERLY ADDRESSED
AND POSTAGE PREPAID. THE RETURNED CONTRACT WILL BE TREATED AS IF WE HAD NEVER
ISSUED IT. WE WILL PROMPTLY REFUND THE CONTRACT VALUE AS OF THE DATE OF
SURRENDER. THIS MAY BE MORE OR LESS THAN THE PURCHASE PAYMENTS. WE HAVE THE
RIGHT TO ALLOCATE PAYMENTS TO THE MONEY MARKET FUND UNTIL THE EXPIRATION OF THE
RIGHT TO EXAMINE PERIOD. IF WE SO ALLOCATE PAYMENTS, WE WILL REFUND THE GREATER
OF THE PURCHASE PAYMENTS, LESS ANY SURRENDERS, OR THE CONTRACT VALUE.
This is a Variable Annuity Contract with Annuity Payments and Contract Values
increasing or decreasing depending on the experience of the Variable Account
which is set forth in the Contract Schedule.
Signed by the Company:
/s/ ▇▇▇▇ ▇. ▇▇▇▇▇ /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇
Secretary President
INDIVIDUAL FLEXIBLE PAYMENT VARIABLE ANNUITY
NONPARTICIPATING
Annuity payments will not decrease as long as the investment return of the
variable account assets equals or exceeds the Assumed Investment Return plus
1.34% plus the Administrative Expense Charge on an annual basis. Variable
Account expenses consist of a mortality and expense risk charge, an
administrative charge, a distribution expense charge, a contract maintenance
charge, and transfer fees. These are shown on the Contract Schedule Page.
The variable provisions can be found on pages 4, 5, 6, and 15 of this
contract.
TABLE OF CONTENTS
RIGHT TO EXAMINE
CONTRACT SCHEDULE
DEFINITIONS
PURCHASE PAYMENTS
PURCHASE PAYMENTS
CHANGE IN PURCHASE PAYMENTS
NO DEFAULT
ALLOCATION OF PURCHASE PAYMENTS
VARIABLE ACCOUNT
THE VARIABLE ACCOUNT
VALUATION OF ASSETS
ACCUMULATION UNITS
ACCUMULATION UNIT VALUE
NET INVESTMENT FACTOR
MORTALITY AND EXPENSE RISK CHARGE
ADMINISTRATIVE CHARGE
DISTRIBUTION EXPENSE CHARGE
MORTALITY AND EXPENSE GUARANTEE
CONTRACT VALUE
CONTRACT MAINTENANCE CHARGE
TRANSFERS
SURRENDER PROVISIONS
SURRENDERS
CONTINGENT DEFERRED SALES CHARGE
PROCEEDS PAYABLE ON DEATH
DEATH OF CONTRACT OWNER DURING THE ACCUMULATION PERIOD
DEATH BENEFIT AMOUNT DURING THE ACCUMULATION PERIOD
DEATH BENEFIT OPTIONS DURING THE ACCUMULATION PERIOD
DEATH OF CONTRACT OWNER DURING THE ANNUITY PERIOD
DEATH OF ANNUITANT
PAYMENT OF DEATH BENEFIT
BENEFICIARY
CHANGE OF BENEFICIARY
SUSPENSION OR DEFERRAL OF PAYMENTS PROVISION
CONTRACT OWNER, ANNUITANT, ASSIGNMENT PROVISIONS
CONTRACT OWNER
JOINT OWNER
ANNUITANT
ASSIGNMENT OF A CONTRACT
ANNUITY PROVISIONS
GENERAL
INCOME DATE
SELECTION OF AN ANNUITY OPTION
ANNUITY OPTIONS
OPTION 1 - LIFE ANNUITY
OPTION 2 - LIFE ANNUITY WITH 60, 120, 180, OR 240 MONTHLY ANNUITY
PAYMENTS GUARANTEED
OPTION 3 - JOINT AND LAST SURVIVOR ANNUITY
OPTION 4 - JOINT AND LAST SURVIVOR ANNUITY WITH 60, 120, 180, OR
240 MONTHLY ANNUITY PAYMENTS GUARANTEED
OPTION 5 - REFUND LIFE ANNUITY
ANNUITY
FIXED ANNUITY
VARIABLE ANNUITY
GENERAL PROVISIONS
THE CONTRACT
NON-PARTICIPATING IN SURPLUS
INCONTESTABILITY
MISSTATEMENT OF AGE OR SEX
CONTRACT SETTLEMENT
REPORTS
TAXES
EVIDENCE OF SURVIVAL
PROTECTION OF PROCEEDS
MODIFICATION OF CONTRACT
CONTRACT SCHEDULE
CONTRACT OWNER: [▇▇▇▇ ▇▇▇] CONTRACT NUMBER: [GA687456]
JOINT OWNER: [▇▇▇▇ ▇▇▇] ISSUE DATE: [04/15/96]
ANNUITANT: [▇▇▇▇ ▇▇▇] INCOME DATE: 04/15/06]
PURCHASE PAYMENTS:
INITIAL PURCHASE PAYMENT: [Non-Qualified: $5,000 or
$2,000 if you have selected AIP;
MINIMUM SUBSEQUENT
PURCHASE PAYMENT: [$250 or $100 if you have selected AIP]
MAXIMUM TOTAL
PURCHASE PAYMENTS: [$1 million; higher amounts may be accepted
with our prior approval]
ALLOCATION GUIDELINES:
[1. Currently, you can select all of the Funds and the Fixed
Account.
2. If allocations are made in percentages, whole numbers must
be used.
3. If the initial Purchase Payment and the forms required to
issue a Contract are in good order, the initial Purchase
Payment will be credited to your Contract within two (2)
business days after receipt at the Valuemark Service Center.
Additional Purchase Payments will be credited to your Contract
as of the Valuation Period when they are received in good
order.]
VARIABLE ACCOUNT: [Preferred Life Insurance Company
of New York Variable Account C]
ELIGIBLE INVESTMENTS:
[FRANKLIN VALUEMARK FUNDS ]
[CAPITAL GROWTH FUND]
[GROWTH AND INCOME FUND]
[HIGH INCOME FUND]
[INCOME SECURITIES FUND]
[MONEY MARKET FUND]
[PRECIOUS METALS FUND]
[REAL ESTATE SECURITIES FUND]
[RISING DIVIDENDS FUND]
[SMALL CAP FUND]
[▇▇▇▇▇▇▇▇▇ DEVELOPING MARKETS EQUITY FUND]
[TEMPLETON GLOBAL ASSET ALLOCATION FUND]
[▇▇▇▇▇▇▇▇▇ GLOBAL INCOME SECURITIES FUND]
[▇▇▇▇▇▇▇▇▇ GLOBAL GROWTH FUND]
[▇▇▇▇▇▇▇▇▇ INTERNATIONAL EQUITY FUND]
[▇▇▇▇▇▇▇▇▇ INTERNATIONAL SMALLER COMPANIES FUND]
[TEMPLETON PACIFIC GROWTH FUND]
[U.S. GOVERNMENT SECURITIES FUND]
[UTILITY EQUITY FUND]
[ZERO COUPON FUND 2000]
[ZERO COUPON FUND 2005]
[ZERO COUPON FUND 2010]
[PREFERRED LIFE INSURANCE COMPANY OF NEW YORK GENERAL ACCOUNT]
[PREFERRED LIFE FIXED ACCOUNT]
MORTALITY AND EXPENSE RISK CHARGE: During the Accumulation Period, the
Mortality and Expense Risk Charge is equal on an annual basis to [1.34%]
of the average daily net asset value of the Variable Account. During the
Annuity Period, the Mortality and Expense Risk is equal on an annual basis
to [1.25%] of the average daily net asset value of the Variable Account.
We may decrease this charge, but we may not increase it.
ADMINISTRATIVE CHARGE: Equal on an annual basis to [.15%] of the average
daily net asset value of the Variable Account.
DISTRIBUTION EXPENSE CHARGE: [None]
CONTRACT MAINTENANCE CHARGE: The Contract Maintenance Charge is currently
[$30.00] each Contract Year. The Contract Maintenance Charge will be deducted
from the Contract Value on each Contract Anniversary while this Contract is
in force. However, during the Accumulation Period, if your Contract Value on
a Contract Anniversary is at least [$50,000], then no Contract Maintenance
Charge is deducted. If a total surrender is made on other than a Contract
Anniversary and your Contract Value for the Valuation Period during which the
total surrender is made is less than [$50,000], the full Contract Maintenance
Charge will be deducted at the time of the total surrender. The Contract
Maintenance Charge will be deducted from the Funds [and the Fixed Account] in
the same proportion that the amount of the Contract Value in each Fund [and/or
Fixed Account] bears to the total Contract Value. During the Annuity Period,
the Contract Maintenance Charge will be collected pro rata from each Annuity
Payment. In the event you own more than one Contract, we will determine the
total Contract Value for all of the Contracts. If the total Contract Value
is at least [$50,000], we will not assess the Contract Maintenance Charge.
If the Contract Owner is not a natural person, we will look to the Annuitant
in determining the foregoing.
TRANSFERS:
NUMBER OF FREE TRANSFERS PERMITTED: Currently, there are no limits on
the number of transfers that can be made. We reserve the right to
change this, but you will always be allowed at least 3 free transfers
in any Contract Year. [Currently, you are allowed 12 free transfers
each Contract Year. This applies to transfers prior to and after the
Income Date.]
TRANSFER FEE: For each transfer in excess of the Free Transfers
Permitted, the Transfer Fee is the lesser of [$25] or 2% of the amount
transferred. Transfers made at the end of the Right to Examine period
by us and any transfers made pursuant to a regularly scheduled transfer
will not be counted in determining the application of the Transfer Fee.
MINIMUM AMOUNT TO BE TRANSFERRED: [$1,000 (from any Fund or the Fixed
Account) or your entire interest in the Fund or the Fixed Account, if
less.] This requirement is waived if the transfer is pursuant to a
pre-scheduled transfer.
SURRENDERS:
CONTINGENT DEFERRED SALES CHARGE: A Contingent Deferred Sales Charge
is assessed against Purchase Payments withdrawn. The Charge is
calculated at the time of each surrender. For partial surrenders, the
Charge is deducted from the remaining Contract Value and is deducted
from the Funds [and the Fixed Account] in the same proportion that the
amount of surrender from the Fund [or Fixed Account] bears to the total
of the partial surrender. The Contingent Deferred Sales Charge is
based upon the length of the time from receipt of the Purchase Payment.
Surrenders are deemed to have come from the oldest Purchase Payments
first. Each Purchase Payment is tracked as to its date of receipt and
the Contingent Deferred Sales Charges are determined in accordance with
the following.
[CONTINGENT DEFERRED SALES CHARGE
Number of Years
from Receipt Charge
____________ ______
0 6%
1 6%
2 6%
3 5%
4 4%
5 3%
6 2%
7 years or more 0%]
[FREE SURRENDER AMOUNT: Each Contract Year after the first Contract
Year, on a non-cumulative basis, you can withdraw amounts from the
Contract Value without incurring a Contingent Deferred Sales Charge.
The amount not subject to the Contingent Deferred Sales Charge is 15%
of the Contract Value, less any previous Free Surrender Amount
withdrawn during that Contract Year.]
[If your Contract Value is $25,000 or more you can elect the Systematic
Withdrawal Option in lieu of the Free Surrender Option described above.
Systematic Withdrawals are available on a monthly or quarterly basis if
your Contract Value is $25,000 or more. The total of Systematic
Withdrawals in a Contract Year which can be made without incurring a
Contingent Deferred Sales Charge is limited to not more than 15% of the
Contract Value determined on the last Valuation Date prior to the
receipt of the Systematic Withdrawal Option request. There is no
limit to the amount or percentage of the Systematic Withdrawals if your
Purchase Payments are no longer subject to a Contingent Deferred Sales
Charge. If you have elected the Systematic Withdrawal Option, any
additional surrenders will be subject to any applicable Contingent
Deferred Sales Charge. We reserve the right to modify the eligibility
rules at any time, without notice.]
[If you have a Qualified Contract and your Contract Value is $25,000
or more, you can elect the Minimum Distribution Program with respect
to your Contract. Surrenders will be made on a monthly or quarterly
basis and will not be subject to a Contingent Deferred Sales Charge.
Such payments will be designed to meet the applicable minimum
distribution requirements imposed by the Internal Revenue Code on
Qualified Contracts. Withdrawals from your Qualified Contract
pursuant to the Minimum Distribution Program are in lieu of the Free
Surrender Amount described above. If you have elected the Minimum
Distribution Program, any additional surrenders will be subject to
any applicable Contingent Deferred Sales Charge.]
MINIMUM PARTIAL SURRENDER: [$500]
MINIMUM CONTRACT VALUE WHICH MUST REMAIN IN THE CONTRACT AFTER A
PARTIAL SURRENDER: [$2,000]
[FIXED ACCOUNT INITIAL RATE:] [X%]
We guarantee this rate for one year from the Issue Date.
RIDERS:
[Individual Retirement Annuity Endorsement]
[403 (b) Endorsement]
[Enhanced Death Benefit Endorsement]
[Unisex Endorsement]
[Declared Interest Rate Fixed Account Endorsement]
[Group Pension Plan Death Benefit Endorsement]
[Waiver of Contingent Deferred Sales Charge Endorsement]
SERVICE OFFICE: VALUEMARK SERVICE CENTER
[Lock Box Department - 3W
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DEFINITIONS
ACCUMULATION UNIT: An accounting unit of measure used to calculate the
Contract Value prior to the Income Date.
ACCUMULATION PERIOD: The period prior to the Income Date during which you
can make Purchase Payments.
ADJUSTED CONTRACT VALUE: The Contract Value less any applicable Premium Tax.
This amount is applied to the applicable Annuity Table to determine the
initial Annuity Payment.
AGE: Age last birthday unless otherwise specified.
ANNUITANT: The natural person upon whose continuation of life any Annuity
Payment involving life contingencies depends. You may change the Annuitant
at any time prior to the Income Date unless the Contract Owner is a
non-individual. On or after the Income Date, any reference to Annuitant
shall also include any Joint Annuitant.
ANNUITY OPTION: An arrangement under which Annuity Payments are made under
this Contract.
ANNUITY PAYMENTS: The series of payments made to you or any named payee
after the Income Date under the Annuity Option selected.
ANNUITY PERIOD: The period of time beginning on the Income Date during which
Annuity Payments are made.
ANNUITY RESERVE: The assets which support the Annuity Option you have
selected during the Annuity Period.
ANNUITY UNIT: An accounting unit of measure used to calculate Annuity
Payments after the Income Date.
ASSUMED INVESTMENT RETURN: The investment return upon which the Variable
Annuity Payments in the Contract are based.
AUTHORIZED REQUEST: A request, in a form satisfactory to the Company, which
is received by the Valuemark Service Center.
BENEFICIARY: The person(s) or entity(ies) who will receive any death
benefit payable under this Contract.
COMPANY: Preferred Life Insurance Company of New York.
CONTRACT ANNIVERSARY: An anniversary of the Issue Date of this Contract.
CONTRACT OWNER: The person(s) or entity(ies) entitled to the ownership
rights stated in this Contract. If Joint Owners are named, all references
to Contract Owner shall mean the Joint Owners.
CONTRACT SURRENDER VALUE: The Contract Value less any applicable Premium
Tax, less any Contingent Deferred Sales Charge and less any applicable
Contract Maintenance Charge.
CONTRACT VALUE: The dollar value as of any Valuation Date of all amounts
accumulated under this Contract.
CONTRACT YEAR: Any period of twelve (12) months commencing with the Issue
Date and each Contract Anniversary thereafter.
ELIGIBLE INVESTMENT(S): Those investments available under the Contract.
Current Eligible Investments are shown on the Contract Schedule.
FUND: A segment of an Eligible Investment which constitutes a separate
and distinct class of interests under an Eligible Investment.
GENERAL ACCOUNT: Our general investment account which contains all the
assets of the Company with the exception of the Variable Account and other
segregated asset accounts.
INCOME DATE: The date on which Annuity Payments are to begin.
ISSUE DATE: The date shown on the Contract Schedule on which the first
Contract Year begins.
JOINT OWNER: If there is more than one Contract Owner, each Contract Owner
shall be a Joint Owner of the Contract. Joint Owners have equal ownership
rights and must both authorize any exercising of those ownership rights unless
otherwise allowed by us. Any Joint Owner must be the spouse of the other
Contract Owner.
PREMIUM TAX: Any premium taxes owed to any governmental entity and assessed
against Purchase Payments or Contract Value.
PURCHASE PAYMENT: A payment made toward this Contract.
SUB-ACCOUNT: Variable Account assets are divided into Sub-Accounts. Assets
of each Sub-Account will be invested in shares of an Eligible Investment or
Fund. In this Contract, "Fund" may also refer to the Sub-Accounts from
which the Fund investment is made.
VALUATION DATE: The Variable Account will be valued each day that the New
York Stock Exchange is open for trading.
VALUATION PERIOD: The period commencing at the close of business of the
New York Stock Exchange on each Valuation Date and ending at the close of
business for the next succeeding Valuation Date.
VALUEMARK SERVICE CENTER: The office indicated on the Contract Schedule of
this Contract to which notices, requests and Purchase Payments must be sent.
All sums payable to us under the Contract are payable only at the Valuemark
Service Center.
VARIABLE ACCOUNT: A separate account maintained by us in which a portion of
our assets has been allocated for this and certain other contracts. It has
been designated on the Contract Schedule.
PURCHASE PAYMENTS
PURCHASE PAYMENTS: Purchase Payments are payable according to the frequency
and in the amount selected by you. The initial Purchase Payment is due on
the Issue Date. We reserve the right to decline any Purchase Payment. The
Minimum Subsequent Purchase Payment and the Maximum Total Purchase Payments
allowed are shown on the Contract Schedule.
CHANGE IN PURCHASE PAYMENTS: You may elect to increase or decrease or to
change the frequency of Purchase Payments.
NO DEFAULT: Unless surrendered, this Contract remains in force and will
not be in default if no additional Purchase Payments are made.
ALLOCATION OF PURCHASE PAYMENTS: Purchase Payments are allocated to one or
more of the Funds of the Variable Account [and/or the Fixed Account] in
accordance with your selection. The allocation of the initial Purchase
Payment is made in accordance with your selection made at the Issue Date.
Unless you inform us otherwise, subsequent Purchase Payments are allocated in
the same manner as the initial Purchase Payment. However, the Company has
reserved the right to allocate the initial Purchase Payment to the Money
Market Fund until the expiration of the Right to Examine period. All
allocations of Purchase Payments are subject to the Allocation Guidelines
shown on the Contract Schedule. We guarantee that you will be allowed to
select at least five Funds for allocation of Purchase Payments.
VARIABLE ACCOUNT
THE VARIABLE ACCOUNT: The Variable Account is designated on the Contract
Schedule. It consists of assets we have set aside and have kept separate
from the rest of our assets and those of our other separate accounts. The
assets of the Variable Account, equal to reserves and other liabilities of
your Contract and those of other Contract Owners, will not be charged with
liabilities arising out of any other business we may conduct.
The Variable Account assets are divided into Funds. The Funds which are
available under this Contract are listed on the Contract Schedule. The
assets of the Fund are allocated to the Eligible Investments (and/or the
Funds, if any, within an Eligible Investment) shown on the Contract Schedule.
We may add additional Eligible Investments or Funds to those shown. You may
be permitted to transfer your Contract Value or allocate Purchase Payments
to the additional Fund(s). However, the right to make such transfers or
allocations will be limited by any terms and conditions we may impose.
Should the shares of any Eligible Investment(s), or any Fund(s) within an
Eligible Investment, become unavailable for investment by the Variable
Account, or our Board of Directors deems further investment in the shares
inappropriate, we may limit further purchase of such shares or substitute
shares of another Eligible Investment or Fund for shares already purchased.
VALUATION OF ASSETS: Assets of Eligible Investments within each Fund will
be valued at their net asset value on each Valuation Date.
ACCUMULATION UNITS: Accumulation Units shall be used to account for all
amounts allocated to or withdrawn from the Funds of the Variable Account as
a result of Purchase Payments, surrenders, transfers, or fees and charges.
We will determine the number of Accumulation Units of a Sub-Account
purchased or canceled. This will be done by dividing the amount allocated to
(or the amount withdrawn from) the Sub-Account by the dollar value of one
Accumulation Unit of the Sub-Account as of the end of the Valuation Period
during which the transaction is processed at the Valuemark Service Center.
ACCUMULATION UNIT VALUE: The Accumulation Unit Value for each Fund was
arbitrarily set initially. Subsequent Accumulation Unit Values for each
Fund are determined by multiplying the Accumulation Unit Value for the
immediately preceding Valuation Period by the Net Investment Factor for the
Fund for the current period.
The Accumulation Unit value may increase or decrease from Valuation Period
to Valuation Period.
NET INVESTMENT FACTOR: The Net Investment Factor for each Fund is
determined by dividing A by B and multiplying by (1 - C) where:
A is (i) the net asset value per share of the Eligible Investment
or the Fund of an Eligible Investment held by the Fund at the
end of the current Valuation Period; plus
(ii) any dividend or capital gains per share declared on
behalf of such Eligible Investment or Fund that has an
ex-dividend date within the current Valuation Period.
B is the net asset value per share of the Eligible Investment or
Fund held by the Fund for the immediately preceding Valuation
Period.
C is (i) the Valuation Period equivalent of the daily Mortality and
Expense Risk Charge, for the Administrative Charge [and for the
Distribution Expense Charge, if any,] which are shown on the
Contract Schedule; plus
(ii) a charge factor, if any, for any taxes or any tax reserve
we have established as a result of the operation or maintenance
MORTALITY AND EXPENSE RISK CHARGE: Each Valuation Period, we deduct a
Mortality and Expense Risk Charge from the Variable Account which is equal,
on an annual basis, to the amount shown on the Contract Schedule. The
Mortality and Expense Risk Charge compensates us for assuming the mortality
and expense risks under this Contract.
ADMINISTRATIVE CHARGE: Each Valuation Period, we deduct an Administrative
Charge from the Variable Account which is equal, on an annual basis, to the
amount shown on the Contract Schedule. The Administrative Charge
compensates us for the costs associated with the administration of this
Contract and the Variable Account.
[DISTRIBUTION EXPENSE CHARGE: Each Valuation Period, we deduct a
Distribution Expense Charge from the Separate Account which is equal, on
an annual basis, to the amount shown on the Contract Schedule. The
Distribution Expense Charge compensates the Company for costs associated
with the distribution of Contracts.]
MORTALITY AND EXPENSE GUARANTEE: We guarantee that the dollar amount of
each annuity payment after the first will not be affected by variations in
mortality or expense experience.
CONTRACT VALUE
The Contract Value for any Valuation Period is equal to the total dollar
value accumulated under this Contract. The Contract Value in a Fund of the
Variable Account is determined by multiplying the number of Accumulation
Units allocated to the Contract Value for the Fund by the Accumulation Unit
Value. Purchase Payments, surrenders and transfers from or to a Fund will
result in the addition of or the cancellation of Accumulation Units in a
Fund.
CONTRACT MAINTENANCE CHARGE
We deduct an annual Contract Maintenance Charge shown on the Contract
Schedule. Prior to the Income Date, this will be deducted from the
Contract Value by canceling Accumulation Units to reimburse us for expenses
relating to maintenance of this Contract. The number of Accumulation Units
to be canceled will be from each applicable Fund is the ratio that the
value of each Fund bears to the total Contract Value.
TRANSFERS
You may transfer all or a part of your interest in a Fund to another Fund.
We reserve the right to charge for transfers if there are more than the
number of free transfers shown on the Contract Schedule. All transfers are
subject to the following:
1. The deduction of any Transfer Fee that may be imposed as shown on the
Contract Schedule. The Transfer Fee will be deducted from the Fund from
which the transfer is made. If the entire amount in the Fund is
transferred, then the Transfer Fee will be deducted from the amount
transferred. If there are multiple source Funds, it will be treated as
a single transfer. Any Transfer Fee will be deducted proportionally
from the source Funds if less than the entire amount in the Fund is
transferred.
2. We reserve the right to limit transfers until the expiration of the
Right to Examine period.
3. The minimum amount which can be transferred is shown on the Contract
Schedule.
4. No transfer will be effective within seven calendar days prior to the
date on which the first Annuity Payment is due.
5. Any transfer direction must clearly specify:
a. the amount which is to be transferred; and
b. the Funds which are to be affected.
6. After the Income Date, transfers may not be made from a fixed annuity
option to a variable annuity option.
7. After the Income Date, you can make at least one transfer from a variable
annuity option to a fixed annuity option. The number of Annuity Units
canceled from the variable annuity option will be equal in value to the
amount of the Annuity Reserve transferred out of the Variable Account.
The amount transferred will purchase fixed annuity payments under the
Annuity Option in effect and based on the age and sex of the Annuitant
at the time of the transfer where allowed.
8. We reserve the right to establish policies that limit or discourage
excessive trading that may be disruptive to the Fund, which may result
in limitations being placed on the Contract Owner's right to make
transfers.
9. We reserve the right at any time and without prior notice to any party
to modify the transfer provisions described above. However, if we do
modify these provisions we guarantee that they will not be any more
restrictive than the above.
If you elect to use this transfer privilege, we will not be liable for
transfers made in accordance with your instructions. All amounts and
Accumulation Units will be determined as of the end of the Valuation Period
during which the request for transfer is received at the Valuemark Service
Center.
SURRENDER PROVISIONS
SURRENDERS: During the Accumulation Period, you may, upon Authorized
Request, make a total or partial surrender of the Contract Surrender Value.
Surrenders will result in the cancellation of Accumulation Units from each
Fund in the ratio that the value of each Fund bears to the total Contract
Value. You must specify, by Authorized Request, which Accumulation Units
are to be canceled if other than the above mentioned method of cancellation
is desired.
The Company will pay the amount of any surrender from the Variable Account
within seven (7) days of receipt of a request in good order unless the
Suspension or Deferral of Payments Provision is in effect.
Each partial surrender must be for an amount which is not less than the
amount shown on the Contract Schedule. The minimum Contract Value which
must remain in the Contract after a partial surrender is shown on the
Contract Schedule.
CONTINGENT DEFERRED SALES CHARGE: Upon a surrender of Contract Value a
Contingent Deferred Sales Charge as set forth on the Contract Schedule may
be assessed. Under certain circumstances, we allow surrenders without the
Contingent Deferred Sales Charge as set forth on the Contract Schedule.
PROCEEDS PAYABLE ON DEATH
DEATH OF CONTRACT OWNER DURING THE ACCUMULATION PERIOD: Upon the death of the
Contract Owner, or any Joint Owner, during the Accumulation Period, the death
benefit will be paid to the Beneficiary(ies) designated by the Contract Owner.
Upon the death of a Joint Owner, the surviving Joint Owner, if any, will be
treated as the primary Beneficiary. Any other Beneficiary designation on
record at the time of death will be treated as a contingent Beneficiary.
DEATH BENEFIT AMOUNT DURING THE ACCUMULATION PERIOD: The death benefit will
be the Adjusted Contract Value determined as of the end of the Valuation
Period during which the Company receives both due proof of death and an
election for the payment method.
DEATH BENEFIT OPTIONS DURING THE ACCUMULATION PERIOD: A Beneficiary may
request that the death benefit be paid under one of the Death Benefit Options
below. In addition, if the Beneficiary is the spouse of the Contract Owner,
he or she may elect to continue the Contract in his or her own name and
exercise all the Contract Owner's rights under the Contract. In this event,
the Contract Value for the Valuation Period during which this election is
implemented will be adjusted to equal the death benefit.
Option A - lump sum payment of the death benefit; or
Option B - the payment of the entire death benefit within 5 years of the
date of the death of the Contract Owner or any Joint Owner; or
Option C - payment of the death benefit under an Annuity Option over the
lifetime of the Beneficiary or over a period not extending beyond the
life expectancy of the Beneficiary with distribution beginning within
one year of the date of death of the Contract Owner or any Joint Owner.
Any portion of the death benefit not applied under Option C within one year
of the date of the Contract Owners' death, must be distributed within five
years of the date of death.
If a lump sum payment is requested, the amount will be paid within seven (7)
days of receipt of proof of death and the election, unless the Suspension or
Deferral of Payments Provision is in effect.
Payment to the Beneficiary, other than in a lump sum, may only be elected
during the sixty-day period beginning with the date of receipt of proof of
death.
DEATH OF CONTRACT OWNER DURING THE ANNUITY PERIOD: If you, or any Joint
Owner, dies during the Annuity Period, and you are not an Annuitant, any
remaining payments under the Annuity Option elected will continue at least
as rapidly as under the method of distribution in effect at such Contract
Owner's death. Upon your death during the Annuity Period, the Beneficiary
becomes the Contract Owner.
DEATH OF ANNUITANT: Upon the death of an Annuitant, who is not the Contract
Owner, during the Accumulation Period, you may designate a new Annuitant,
subject to our underwriting rules then in effect. If no designation is made
within 30 days of the death of the Annuitant, you will become the Annuitant.
If the Contract Owner is a non-individual, the death of the Annuitant will be
treated as the death of the Contract Owner and a new Annuitant may not be
designated.
Upon the death of the Annuitant during the Annuity Period, the death benefit,
if any, will be as specified in the Annuity Option elected. Death benefits
will be paid at least as rapidly as under the method of distribution in effect
at the Annuitant's death.
PAYMENT OF DEATH BENEFIT: The Company will require due proof of death before
any death benefit is paid. Due proof of death will be:
1. a certified death certificate; or
2. a certified decree of a court of competent jurisdiction as to the
finding of death; or
3. any other proof satisfactory to the Company.
All death benefits will be paid in accordance with applicable law or
regulations governing death benefit payments.
BENEFICIARY: The Beneficiary designation in effect on the Issue Date will
remain in effect until changed. The Beneficiary is entitled to receive the
benefits to be paid at your death.
Unless you provide otherwise, the death benefit will be paid in equal shares
to the survivor(s) as follows:
1. to the primary Beneficiary(ies) who survive you and/or the
Annuitant's death, as applicable; or if there are none
2. to the contingent Beneficiary(ies) who survive you and/or the
Annuitant's death, as applicable; or if there are none
3. to your estate.
CHANGE OF BENEFICIARY: Subject to the rights of any irrevocable
Beneficiary(ies), you may change the primary Beneficiary(ies) or contingent
Beneficiary(ies). A change may be made by Authorized Request. The change
will take effect as of the date the Authorized Request is signed. The Company
will not be liable for any payment made or action taken before it records the
change.
SUSPENSION OR DEFERRAL OF PAYMENTS PROVISION
The Company reserves the right to suspend or postpone payments from the
Variable Account for a surrender or transfer for any period when:
1. the New York Stock Exchange is closed (other than customary weekend
and holiday closings);
2. trading on the New York Stock Exchange is restricted;
3. an emergency exists as a result of which disposal of securities
held in the Variable Account is not reasonably practicable or it is
not reasonably practicable to determine the value of the Variable
Account's net assets; or
4. during any other period when the Securities and Exchange Commission,
by order, so permits for the protection of Contract Owners; provided
that applicable rules and regulations of the Securities and Exchange
Commission will govern as to whether the conditions described in
(2) and (3) exist.
CONTRACT OWNER, ANNUITANT, ASSIGNMENT PROVISIONS
CONTRACT OWNER: As the Contract Owner you have all the interest and rights
under this Contract. The Contract Owner is the person designated as such on
the Issue Date, unless changed.
You may change Owners of the Contract at any time by Authorized Request. A
change of Contract Owner will automatically revoke any prior designation of
Contract Owner. The change will become effective as of the date the
Authorized Request is signed. We will not be liable for any payment made or
action taken before the change is recorded.
JOINT OWNER: A Contract may be owned by Joint Owners. If Joint Owners are
named, any Joint Owner must be the spouse of the other Contract Owner. Upon
the death of either Contract Owner, the surviving spouse will be the primary
Beneficiary. Any other Beneficiary designation will be treated as a
contingent Beneficiary unless otherwise indicated in an Authorized Request.
ANNUITANT: The Annuitant is the person on whose life Annuity Payments are
based. The Annuitant is the person designated by you subject to our
underwriting rules then in effect. The Annuitant may not be changed in a
Contract which is owned by a non-individual.
ASSIGNMENT OF A CONTRACT: An Authorized Request specifying the terms of an
assignment of a Contract must be provided to the Valuemark Service Center.
We will not be liable for any payment made or action taken before we record
the assignment.
We will not be responsible for the validity or tax consequences of any
assignment. Any assignment made after the death benefit has become payable
will be valid only with our consent.
If the Contract is assigned, your rights may only be exercised with the
consent of the assignee of record.
ANNUITY PROVISIONS
GENERAL: On the Income Date, the Adjusted Contract Value will be applied
under the Annuity Option you have selected. You may elect to have the
Adjusted Contract Value applied to provide a Fixed Annuity, a Variable
Annuity or a combination Fixed and Variable Annuity. If a combination is
elected, you must specify what part of the Adjusted Contract Value is to be
applied to the Fixed and Variable Annuity Options.
INCOME DATE: You select an Income Date at the time of issue. The Income
Date must always be the first day of a calendar month. The earliest Income
Date you can select is [two] years after the Issue Date. The latest Income
Date you can select is the later of the first day of the first calendar
month following the Annuitant's 90th birthday. You may, at any time prior
to the Income Date, change the Income Date by Authorized Request 30 days in
advance.
SELECTION OF AN ANNUITY OPTION: You can select an Annuity Option by
Authorized Request. If no Annuity Option is selected, Option 2, with 60
Monthly Payments Guaranteed, will automatically be applied. You may, at any
time prior to the Income Date, by Authorized Request 30 days in advance,
select and/or change the Annuity Option.
ANNUITY OPTIONS: This Contract provides for Annuity Payments under one of
the Annuity Options described below. Any other Annuity Option acceptable to
us may be selected.
OPTION 1 - LIFE ANNUITY. We will make monthly Annuity Payments during the
life of the Annuitant and ceasing with the last Annuity Payment due prior
to the Annuitant's death.
OPTION 2 - LIFE ANNUITY WITH 60, 120, 180, OR 240 MONTHLY ANNUITY PAYMENTS
GUARANTEED. We will make monthly Annuity Payments during the life of the
Annuitant with a guarantee that if at the Annuitant's death there have been
less than 60, 120, 180, or 240 monthly Annuity Payments made as selected,
monthly Annuity Payments will continue for the remainder of the guaranteed
period. You may elect to have the present value of the guaranteed monthly
Annuity Payments remaining, as of the date notice of the Annuitant's death
is received at the Valuemark Service Center, commuted at the Assumed
Investment Return selected for a Variable Annuity or for a Fixed Annuity
the Statutory Calendar Year Interest Rate based on the New York's Standard
Valuation Law for Single Premium Immediate Annuities corresponding to the
Income Date. We will require the return of this Contract and proof of death
prior to the payment of any commuted values.
OPTION 3 - JOINT AND LAST SURVIVOR ANNUITY. We will make monthly Annuity
Payments during the joint lifetime of the Annuitant and the Joint Annuitant.
Upon the death of the Annuitant, if the Joint Annuitant is then living,
Annuity Payments will continue to be paid during the remaining lifetime of
the Joint Annuitant at a level of 100%, 75% or 50% of the previous level, as
selected. Monthly Annuity Payments cease with the final Annuity Payment due
prior to the last survivor's death.
OPTION 4 - JOINT AND LAST SURVIVOR ANNUITY WITH 60, 120, 180, OR 240 MONTHLY
ANNUITY PAYMENTS GUARANTEED. We will make monthly Annuity Payments during
the joint lifetime of the Annuitant and the Joint Annuitant. Monthly Annuity
Payments will continue to be paid during the remaining lifetime of the Joint
Annuitant at 100% of the previous level, as selected. If at the last death
of the Annuitant and the Joint Annuitant, there have been less than 60, 120,
180, or 240 monthly Annuity Payments made as selected, monthly Annuity
Payments will continue to be made for the remainder of the guaranteed period.
You or your designated payee may elect to have the present value of the
guaranteed monthly Annuity Payments remaining, as of the date notice of the
Annuitant's death is received by us, commuted at the Assumed Investment
Return selected for a Variable Annuity or for a Fixed Annuity the Statutory
Calendar Year Interest Rate based on the New York's Standard Valuation Law
for Single Premium Immediate Annuities corresponding to the Income Date. We
will require the return of this Contract and proof of death prior to the
payment of any commuted values.
OPTION 5 - REFUND LIFE ANNUITY. We will make monthly Annuity Payments
during the lifetime of the Annuitant ceasing with the last Annuity Payment
due prior to the Annuitant's death with a guarantee that at the Annuitant's
death, you will receive a refund. For a Fixed Annuity the amount of the
refund will be any excess of the amount of the Adjusted Contract Value
applied under this Option over the total of all Annuity Payments made under
this Option. For a Variable Annuity the amount of the refund will be the
then dollar value of the number of Annuity Units equal to (1) the Adjusted
Contract Value applied to this Option divided by the Annuity Unit value used
to determine the first Annuity Payment, minus (2) the product of the number
of the Annuity Units represented by each monthly Annuity Payment and the
number of payments made. This calculation will be based upon the assumption
that the allocation of Annuity Units actually in-force at the time of the
Annuitant's death had been the allocation of Annuity Units at issue and at
all times thereafter. If the refund calculated above is not greater than
zero there will be no refund paid.
ANNUITY: If you select a Fixed Annuity, the Adjusted Contract Value is
allocated to the General Account and the Annuity is paid as a Fixed Annuity.
If you select a Variable Annuity, the Adjusted Contract Value will be
allocated to the Funds of the Variable Account in accordance with your
selection, and the Annuity will be paid as a Variable Annuity. Unless you
designate another payee, you will be the payee of the Annuity Payments. The
Adjusted Contract Value will be applied to the applicable Annuity Table
contained in this Contract based upon the Annuity Option you have selected.
We may offer more favorable rates than those guaranteed here at the time
your first annuity payment is calculated. Where permitted, Annuity
Payments will depend on the Age and sex of the Annuitant.
FIXED ANNUITY: You may elect to have the Adjusted Contract Value applied
to provide a Fixed Annuity. The dollar amount of each Fixed Annuity Payment
shall be determined in accordance with Annuity Tables contained in this
Contract which are based on the minimum guaranteed interest rate of 2 1/2%
per year.
GUARANTEED MONTHLY PAYMENT PER $1,000 OF PROCEEDS
Fixed Payouts
Age of Annt. Option 2 Option 2 Option 2 Option 2
Nearest BDay ____________ ____________ ____________ ____________ ____________
When 1st Pmt Option 1 5 Years 10 Years 15 Years 20 Years
is Made Minimum Minimum Minimum Minimum
Male Female Male Female Male Female Male Female Male Female
____________ ____________ ____________ ____________ ____________ ____________
30 2.84 2.71 2.84 2.71 2.84 2.71 2.84 2.71 2.83 2.71
31 2.87 2.74 2.87 2.73 2.87 2.73 2.86 2.73 2.86 2.73
32 2.90 2.76 2.90 2.76 2.89 2.76 2.89 2.75 2.88 2.75
33 2.92 2.78 2.92 2.78 2.92 2.78 2.92 2.78 2.91 2.77
34 2.95 2.80 2.95 2.80 2.95 2.80 2.95 2.80 2.94 2.80
35 2.98 2.83 2.98 2.83 2.98 2.83 2.98 2.82 2.97 2.82
36 3.02 2.85 3.02 2.85 3.01 2.85 3.01 2.85 3.00 2.85
37 3.05 2.88 3.05 2.88 3.05 2.88 3.04 2.88 3.03 2.87
38 3.09 2.91 3.09 2.91 3.08 2.91 3.08 2.91 3.06 2.90
39 3.12 2.94 3.12 2.94 3.12 2.94 3.11 2.93 3.10 2.93
40 3.16 2.97 3.16 2.97 3.16 2.97 3.15 2.96 3.13 2.96
41 3.20 3.00 3.20 3.00 3.20 3.00 3.19 3.00 3.17 2.99
42 3.25 3.04 3.24 3.04 3.24 3.03 3.23 3.03 3.21 3.02
43 3.29 3.07 3.29 3.07 3.28 3.07 3.27 3.06 3.25 3.06
44 3.34 3.11 3.33 3.11 3.33 3.10 3.31 3.10 3.29 3.09
45 3.39 3.15 3.38 3.15 3.37 3.14 3.36 3.14 3.33 3.13
46 3.44 3.19 3.43 3.19 3.42 3.18 3.41 3.18 3.38 3.16
47 3.49 3.23 3.49 3.23 3.48 3.22 3.45 3.22 3.42 3.20
48 3.55 3.27 3.54 3.27 3.53 3.27 3.51 3.26 3.47 3.24
49 3.60 3.32 3.60 3.32 3.58 3.31 3.56 3.30 3.52 3.29
50 3.66 3.37 3.66 3.37 3.64 3.36 3.62 3.35 3.57 3.33
51 3.73 3.42 3.72 3.42 3.71 3.41 3.67 3.40 3.62 3.38
52 3.80 3.47 3.79 3.47 3.77 3.46 3.73 3.45 3.68 3.42
53 3.87 3.53 3.86 3.53 3.84 3.52 3.80 3.50 3.74 3.48
54 3.94 3.59 3.93 3.59 3.91 3.58 3.86 3.56 3.79 3.53
55 4.02 3.65 4.01 3.65 3.98 3.64 3.93 3.62 3.85 3.58
56 4.10 3.72 4.09 3.71 4.06 3.70 4.00 3.68 3.91 3.64
57 4.19 3.79 4.18 3.78 4.14 3.77 4.08 3.74 3.98 3.70
58 4.28 3.86 4.27 3.86 4.23 3.84 4.16 3.81 4.04 3.76
59 4.38 3.94 4.37 3.93 4.32 3.91 4.24 3.88 4.11 3.82
60 4.49 4.02 4.47 4.02 4.42 3.99 4.32 3.95 4.17 3.88
61 4.60 4.11 4.58 4.10 4.52 4.08 4.41 4.03 4.24 3.95
62 4.72 4.20 4.69 4.19 4.63 4.16 4.50 4.11 4.31 4.02
63 4.84 4.30 4.82 4.29 4.74 4.26 4.59 4.19 4.38 4.09
64 4.98 4.41 4.95 4.39 4.86 4.36 4.69 4.28 4.44 4.16
65 5.12 4.52 5.09 4.50 4.98 4.46 4.79 4.37 4.51 4.23
66 5.28 4.64 5.24 4.62 5.11 4.57 4.89 4.47 4.58 4.31
67 5.44 4.76 5.39 4.75 5.24 4.69 4.99 4.57 4.64 4.38
68 5.61 4.90 5.56 4.88 5.38 4.81 5.09 4.67 4.70 4.45
69 5.80 5.04 5.73 5.02 5.53 4.94 5.19 4.78 4.76 4.53
70 6.00 5.20 5.92 5.17 5.68 5.07 5.30 4.88 4.82 4.60
71 6.21 5.37 6.12 5.34 5.84 5.22 5.40 4.99 4.88 4.67
72 6.43 5.55 6.32 5.51 6.00 5.37 5.50 5.11 4.93 4.74
73 6.66 5.75 6.54 5.70 6.16 5.53 5.60 5.22 4.97 4.80
74 6.91 5.96 6.77 5.90 6.33 5.69 5.70 5.34 5.02 4.86
75 7.18 6.18 7.01 6.11 6.50 5.87 5.79 5.45 5.06 4.92
76 7.49 6.43 7.28 6.34 6.69 6.05 5.89 5.56 5.09 4.97
77 7.80 6.69 7.55 6.58 6.86 6.23 5.97 5.67 5.12 5.01
78 8.13 6.97 7.83 6.84 7.04 6.42 6.05 5.78 5.15 5.06
79 8.49 7.27 8.13 7.11 7.22 6.61 6.13 5.88 5.17 5.09
80 8.87 7.60 8.44 7.40 7.39 6.81 6.20 5.97 5.20 5.13
81 9.27 7.95 8.77 7.71 7.57 7.01 6.26 6.06 5.21 5.15
82 9.70 8.33 9.10 8.03 7.73 7.21 6.32 6.14 5.23 5.18
83 10.16 8.74 9.45 8.38 7.90 7.40 6.37 6.21 5.24 5.20
84 10.65 9.18 9.81 8.74 8.05 7.59 6.42 6.28 5.25 5.22
85 11.18 9.66 10.19 9.12 8.20 7.77 6.46 6.34 5.26 5.23
GUARANTEED MONTHLY PAYMENT PER $1,000 OF PROCEEDS - cont'd.
Fixed Payouts
Option 5
Male Female
____ ________
2.82 2.71
2.84 2.73
2.87 2.75
2.89 2.77
2.92 2.79
2.95 2.81
2.98 2.84
3.01 2.86
3.04 2.89
3.07 2.92
3.10 2.95
3.14 2.97
3.17 3.01
3.21 3.04
3.25 3.07
3.29 3.10
3.33 3.14
3.38 3.18
3.42 3.22
3.47 3.26
3.52 3.30
3.57 3.34
3.62 3.39
3.68 3.44
3.74 3.49
3.80 3.54
3.86 3.60
3.93 3.65
4.00 3.71
4.07 3.78
4.14 3.84
4.23 3.91
4.31 3.99
4.39 4.06
4.49 4.14
4.58 4.23
4.68 4.31
4.78 4.41
4.89 4.50
5.01 4.60
5.13 4.72
5.25 4.83
5.38 4.95
5.51 5.07
5.66 5.20
5.82 5.35
5.97 5.49
6.14 5.65
6.31 5.81
6.50 5.97
6.69 6.15
6.89 6.34
7.10 6.53
7.32 6.74
7.55 6.95
7.80 7.17
GUARANTEED MONTHLY PAYMENT PER $1,000 OF PROCEEDS
FIXED PAYOUT
OPTION 3
FEMALE AGE 30 40 50 60 70 80
MALE AGE ____________ ____________ ____________ ____________ ____________ ____________
30 2.61 2.70 2.77 2.81 2.83 2.84
40 2.66 2.82 2.96 3.06 3.12 3.15
50 2.69 2.89 3.14 3.36 3.52 3.61
60 2.70 2.94 3.26 3.65 4.03 4.30
70 2.71 2.96 3.32 3.86 4.56 5.27
80 2.71 2.97 3.35 3.96 4.94 6.32
OPTION 4
5 YEARS MINIMUM
FEMALE AGE 30 40 50 60 70 80
MALE AGE ____________ ____________ ____________ ____________ ____________ ____________
30 2.61 2.70 2.77 2.81 2.83 2.84
40 2.66 2.82 2.96 3.06 3.12 3.15
50 2.69 2.89 3.14 3.36 3.52 3.61
60 2.70 2.94 3.26 3.65 4.03 4.30
70 2.71 2.96 3.32 3.86 4.56 5.26
80 2.71 2.97 3.35 3.96 4.93 6.30
OPTION 4
10 YEARS MINIMUM
FEMALE AGE 30 40 50 60 70 80
MALE AGE ____________ ____________ ____________ ____________ ____________ ____________
30 2.61 2.70 2.77 2.81 2.83 2.84
40 2.66 2.82 2.96 3.06 3.12 3.14
50 2.69 2.89 3.14 3.36 3.52 3.60
60 2.70 2.94 3.26 3.65 4.03 4.29
70 2.71 2.96 3.32 3.86 4.55 5.22
80 2.71 2.96 3.35 3.95 4.90 6.13
OPTION 4
15 YEARS MINIMUM
FEMALE AGE 30 40 50 60 70 80
MALE AGE ____________ ____________ ____________ ____________ ____________ ____________
30 2.61 2.70 2.77 2.81 2.83 2.84
40 2.66 2.82 2.96 3.06 3.12 3.14
50 2.69 2.89 3.13 3.36 3.52 3.59
60 2.70 2.94 3.26 3.65 4.01 4.24
70 2.71 2.96 3.32 3.84 4.50 5.05
80 2.71 2.96 3.34 3.93 4.79 5.70
OPTION 4
20 YEARS MINIMUM
FEMALE AGE 30 40 50 60 70 80
MALE AGE ____________ ____________ ____________ ____________ ____________ ____________
30 2.61 2.70 2.77 2.81 2.83 2.83
40 2.66 2.82 2.96 3.06 3.11 3.13
50 2.69 2.89 3.13 3.35 3.50 3.56
60 2.70 2.94 3.25 3.63 3.97 4.14
70 2.71 2.95 3.31 3.81 4.38 4.74
80 2.71 2.96 3.33 3.87 4.57 5.06
VARIABLE ANNUITY: You may elect to have the Adjusted Contract Value applied
to provide a Variable Annuity. Variable Annuity Payments reflect the
investment performance of the Variable Account in accordance with the
allocation of the Adjusted Contract Value to the Funds during the Annuity
Period. Variable Annuity Payments are not guaranteed as to dollar amount.
On the Income Date a fixed number of Annuity Units will be purchased as
follows:
The first Annuity Payment is equal to the Adjusted Contract Value, divided
first by $1000 and then multiplied by the appropriate Annuity Payment amount
for each $1000 of value for the Annuity Option selected. In each Fund the
fixed number of Annuity Units is determined by dividing the amount of the
initial Annuity Payment determined for each Fund by the Annuity Unit value on
the Income Date. Thereafter, the number of Annuity Units in each Fund remains
unchanged unless you elect to transfer between Funds. All calculations will
appropriately reflect the Annuity Payment frequency selected.
On each subsequent Annuity Payment date, the total Annuity Payment is the sum
of the Annuity Payments for each Fund. The Annuity Payment in each Fund is
determined by multiplying the number of Annuity Units then allocated to such
Fund by the Annuity Unit value for that Fund.
On each subsequent Valuation Date, the value of an Annuity Unit is determined
in the following way:
First: The Net Investment Factor is determined as described under "Variable
Account - Net Investment Factor" above.
Second: The value of an Annuity Unit for a Valuation Period is equal to:
a. the value of the Annuity Unit for the immediately preceding
Valuation Period;
b. multiplied by the Net Investment Factor for the current Valuation
Period;
c. divided by the Assumed Net Investment Factor (see below) for the
Valuation Period.
The Assumed Net Investment Factor is equal to one plus the Assumed Investment
Return which is used in determining the basis for the purchase of an Annuity,
adjusted to reflect the particular Valuation Period. The Assumed Investment
Return that we will use is 5%. However, we may agree with you to use a
different value.
GUARANTEED INITIAL MONTHLY PAYMENT PER $1,000 OF PROCEEDS
Variable Payouts Based on 5% AIR
Age of Annt. Option 2 Option 2 Option 2 Option 2
Nearest BDay ____________ ____________ ____________ ____________ ____________
When 1st Pmt Option 1 5 Years 10 Years 15 Years 20 Years
is Made Minimum Minimum Minimum Minimum
Male Female Male Female Male Female Male Female Male Female
____________ ____________ ____________ ____________ ____________ ____________
30 4.46 4.36 4.46 4.36 4.46 4.35 4.45 4.35 4.44 4.35
31 4.48 4.37 4.48 4.37 4.48 4.37 4.47 4.37 4.46 4.36
32 4.50 4.39 4.50 4.39 4.50 4.38 4.49 4.38 4.48 4.38
33 4.52 4.40 4.52 4.40 4.52 4.40 4.51 4.40 4.50 4.39
34 4.55 4.42 4.55 4.42 4.54 4.42 4.53 4.41 4.52 4.41
35 4.57 4.44 4.57 4.44 4.57 4.44 4.56 4.43 4.55 4.43
36 4.60 4.46 4.60 4.46 4.59 4.45 4.58 4.45 4.57 4.45
37 4.63 4.48 4.63 4.48 4.62 4.48 4.61 4.47 4.60 4.46
38 4.66 4.50 4.66 4.50 4.65 4.50 4.64 4.49 4.62 4.49
39 4.69 4.52 4.69 4.52 4.68 4.52 4.67 4.51 4.65 4.51
40 4.72 4.55 4.72 4.55 4.71 4.54 4.70 4.54 4.68 4.53
41 4.76 4.57 4.75 4.57 4.75 4.57 4.73 4.56 4.71 4.55
42 4.79 4.60 4.79 4.60 4.78 4.60 4.76 4.59 4.74 4.58
43 4.83 4.63 4.83 4.63 4.82 4.62 4.80 4.62 4.77 4.60
44 4.88 4.66 4.87 4.66 4.86 4.65 4.84 4.64 4.80 4.63
45 4.92 4.69 4.91 4.69 4.90 4.69 4.87 4.68 4.84 4.66
46 4.97 4.73 4.96 4.73 4.94 4.72 4.91 4.71 4.88 4.69
47 5.01 4.76 5.01 4.76 4.99 4.75 4.96 4.74 4.92 4.72
48 5.06 4.80 5.06 4.80 5.04 4.79 5.00 4.78 4.96 4.76
49 5.12 4.84 5.11 4.84 5.09 4.83 5.05 4.81 5.00 4.79
50 5.17 4.88 5.16 4.88 5.14 4.87 5.10 4.85 5.04 4.83
51 5.23 4.93 5.22 4.93 5.19 4.91 5.15 4.89 5.09 4.87
52 5.30 4.98 5.28 4.97 5.25 4.96 5.20 4.94 5.13 4.91
53 5.36 5.03 5.35 5.02 5.31 5.01 5.26 4.98 5.18 4.95
54 5.43 5.08 5.42 5.08 5.38 5.06 5.32 5.03 5.23 4.99
55 5.51 5.14 5.49 5.13 5.45 5.11 5.38 5.08 5.28 5.04
56 5.58 5.20 5.57 5.19 5.52 5.17 5.44 5.14 5.33 5.09
57 5.67 5.26 5.65 5.26 5.60 5.23 5.51 5.19 5.39 5.14
58 5.76 5.33 5.74 5.32 5.68 5.30 5.58 5.25 5.44 5.19
59 5.85 5.41 5.83 5.40 5.76 5.37 5.65 5.32 5.50 5.24
60 5.95 5.48 5.93 5.47 5.85 5.44 5.73 5.38 5.56 5.30
61 6.06 5.57 6.03 5.55 5.95 5.52 5.81 5.45 5.62 5.36
62 6.18 5.65 6.15 5.64 6.05 5.60 5.89 5.52 5.67 5.42
63 6.30 5.75 6.27 5.73 6.16 5.68 5.97 5.60 5.73 5.48
64 6.44 5.85 6.40 5.83 6.27 5.78 6.06 5.68 5.79 5.54
65 6.58 5.96 6.53 5.94 6.38 5.87 6.15 5.76 5.85 5.60
66 6.74 6.07 6.68 6.05 6.51 5.98 6.24 5.85 5.91 5.67
67 6.90 6.20 6.83 6.17 6.63 6.09 6.33 5.94 5.96 5.73
68 7.08 6.33 7.00 6.30 6.77 6.20 6.42 6.03 6.02 5.80
69 7.27 6.47 7.17 6.44 6.91 6.32 6.52 6.13 6.07 5.86
70 7.46 6.63 7.35 6.59 7.05 6.45 6.61 6.23 6.12 5.92
71 7.68 6.80 7.55 6.75 7.20 6.59 6.70 6.33 6.17 5.98
72 7.90 6.98 7.75 6.92 7.35 6.74 6.79 6.43 6.21 6.04
73 8.14 7.18 7.97 7.11 7.50 6.89 6.88 6.54 6.25 6.10
74 8.39 7.39 8.19 7.30 7.66 7.05 6.97 6.64 6.29 6.15
75 8.66 7.62 8.43 7.52 7.82 7.21 7.06 6.74 6.32 6.20
76 8.99 7.87 8.70 7.74 8.00 7.38 7.14 6.85 6.35 6.24
77 9.30 8.13 8.97 7.98 8.16 7.56 7.22 6.94 6.38 6.28
78 9.64 8.42 9.25 8.24 8.33 7.74 7.29 7.04 6.40 6.32
79 9.99 8.72 9.54 8.51 8.49 7.92 7.36 7.13 6.42 6.35
80 10.38 9.06 9.84 8.80 8.65 8.11 7.42 7.21 6.44 6.38
81 10.79 9.41 10.16 9.10 8.82 8.29 7.48 7.29 6.46 6.41
82 11.23 9.80 10.49 9.43 8.97 8.48 7.53 7.36 6.47 6.43
83 11.69 10.22 10.83 9.77 9.12 8.66 7.58 7.43 6.48 6.45
84 12.19 10.68 11.19 10.13 9.27 8.83 7.62 7.49 6.49 6.46
85 12.73 11.17 11.55 10.50 9.41 9.00 7.66 7.54 6.50 6.47
GUARANTEED INITIAL MONTHLY PAYMENT PER $1,000 OF PROCEEDS - cont'
Variable Payouts Based on 5% AIR
Option 5
Male Female
____ ________
4.46 4.36
4.48 4.38
4.50 4.39
4.52 4.41
4.54 4.43
4.57 4.44
4.59 4.46
4.62 4.48
4.64 4.50
4.67 4.52
4.70 4.55
4.73 4.57
4.76 4.60
4.80 4.62
4.83 4.65
4.87 4.68
4.91 4.71
4.95 4.75
4.99 4.78
5.04 4.82
5.08 4.85
5.13 4.89
5.19 4.94
5.24 4.98
5.30 5.03
5.37 5.08
5.43 5.13
5.50 5.19
5.57 5.25
5.65 5.31
5.73 5.38
5.81 5.45
5.90 5.52
6.00 5.60
6.10 5.69
6.20 5.77
6.31 5.87
6.43 5.97
6.55 6.07
6.67 6.18
6.81 6.30
6.95 6.43
7.10 6.56
7.26 6.70
7.42 6.85
7.60 7.01
7.78 7.18
7.97 7.35
8.18 7.54
8.39 7.74
8.61 7.95
8.85 8.17
9.09 8.40
9.36 8.65
9.63 8.91
9.92 9.17
GUARANTEED INITIAL MONTHLY PAYMENT PER $1,000 OF PROCEEDS
VARIABLE PAYOUT BASED ON 5% AIR
OPTION 3
FEMALE AGE 30 40 50 60 70 80
MALE AGE ____________ ____________ ____________ ____________ ____________ ____________
30 4.26 4.33 4.38 4.41 4.44 4.45
40 4.30 4.40 4.51 4.60 4.66 4.70
50 4.32 4.47 4.65 4.84 4.99 5.09
60 4.34 4.51 4.76 5.09 5.44 5.72
70 4.35 4.53 4.82 5.29 5.93 6.63
80 4.35 4.54 4.86 5.40 6.31 7.65
OPTION 4
5 YEARS MINIMUM
FEMALE AGE 30 40 50 60 70 80
MALE AGE ____________ ____________ ____________ ____________ ____________ ____________
30 4.26 4.33 4.38 4.41 4.44 4.45
40 4.30 4.40 4.51 4.60 4.66 4.70
50 4.32 4.47 4.65 4.84 4.99 5.09
60 4.34 4.51 4.76 5.09 5.44 5.72
70 4.35 4.53 4.82 5.29 5.93 6.62
80 4.35 4.54 4.86 5.40 6.31 7.63
OPTION 4
10 YEARS MINIMUM
FEMALE AGE 30 40 50 60 70 80
MALE AGE ____________ ____________ ____________ ____________ ____________ ____________
30 4.26 4.33 4.38 4.41 4.44 4.45
40 4.30 4.40 4.51 4.60 4.66 4.69
50 4.32 4.47 4.65 4.84 4.99 5.09
60 4.34 4.50 4.76 5.09 5.43 5.70
70 4.35 4.53 4.82 5.28 5.91 6.56
80 4.35 4.54 4.86 5.39 6.26 7.43
OPTION 4
15 YEARS MINIMUM
FEMALE AGE 30 40 50 60 70 80
MALE AGE ____________ ____________ ____________ ____________ ____________ ____________
30 4.26 4.33 4.38 4.41 4.44 4.45
40 4.30 4.40 4.51 4.60 4.66 4.69
50 4.32 4.47 4.65 4.83 4.98 5.07
60 4.34 4.50 4.75 5.08 5.42 5.64
70 4.35 4.53 4.82 5.27 5.86 6.37
80 4.35 4.54 4.84 5.36 6.13 6.96
OPTION 4
20 YEARS MINIMUM
FEMALE AGE 30 40 50 60 70 80
MALE AGE ____________ ____________ ____________ ____________ ____________ ____________
30 4.26 4.33 4.38 4.41 4.43 4.44
40 4.30 4.40 4.51 4.60 4.65 4.67
50 4.32 4.46 4.64 4.83 4.97 5.03
60 4.34 4.50 4.75 5.06 5.36 5.52
70 4.34 4.52 4.80 5.23 5.72 6.04
80 4.35 4.53 4.82 5.29 5.89 6.32
GENERAL PROVISIONS
THE CONTRACT: The entire Contract consists of this Contract, and any
attached application endorsements or riders. This Contract may be changed
or altered only by our President or Secretary. Any change, modification or
waiver must be made in writing.
NON-PARTICIPATING IN SURPLUS: This Contract does not share in any
distribution of our profits or surplus.
INCONTESTABILITY: We will not contest this Contract from its Issue Date.
MISSTATEMENT OF AGE OR SEX: We may require proof of Age of the Annuitant
before making any life contingent Annuity Payment provided for by this
Contract. If the Age or sex of the Annuitant has been misstated the amount
payable will be the amount that the Contract Value would have provided at the
true Age or sex.
Once Annuity Payments have begun, any underpayments will be made up in one sum
with the next Annuity Payment, and overpayments will be deducted from the
future Annuity Payments until the total is repaid.
CONTRACT SETTLEMENT: This Contract must be returned to us upon any
settlement.
Prior to any settlement as a death claim, due proof of death must be submitted
to us. Any paid-up annuity, cash surrender or death benefits that may be
available are not less than the minimum benefits required by statute.
REPORTS: We will furnish you with a report showing the Contract Value at
least once each calendar year. This report will be sent to your last known
address.
TAXES: Any taxes paid to any governmental entity will be charged against the
Contract Value. We will, in our sole discretion, determine when taxes have
resulted from: the investment experience of the Variable Account; receipt by
us of the Purchase Payment(s); or commencement of Annuity Payments. We may,
at our discretion, pay taxes when due and deduct that amount from the Contract
Value at a later date. Payment at an earlier date does not waive any right we
may have to deduct amounts at a later date. We reserve the right to establish
a provision for federal income taxes if we determine, in our sole discretion,
that we will incur a tax as a result of the operation of the Variable Account.
We will deduct for any income taxes incurred by it as a result of the
operation
of the Variable Account whether or not there was a provision for taxes and
whether or not it was sufficient. The Company will deduct any withholding
taxes required by applicable law.
EVIDENCE OF SURVIVAL: Where any benefits under this Contract are contingent
upon the recipient being alive on a given date, we may require proof
satisfactory to us that the condition has been met.
PROTECTION OF PROCEEDS: No Beneficiary may commute, encumber, alienate or
assign any payments under this Contract before they are due. To the extent
permitted by law, no payments will be subject to the debts, contracts or
engagements of any Beneficiary or to any judicial process to levy upon or
attach the same for payment thereof.
MODIFICATION OF CONTRACT: This Contract may not be modified by us without
your consent except as may be required by applicable law.