.
.
.
24(b)(4)(a)
THE ▇▇▇▇ ▇▇▇▇▇▇▇ LIFE INSURANCE
COMPANY OF NEW YORK (▇▇▇▇ ▇▇▇▇▇▇▇(R) LOGO)
OVERNIGHT MAILING ADDRESS: ANNUITY SERVICE OFFICE: HOME OFFICE
[▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ [P.O. Box 9506 [▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇
▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇] ▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-9506] Valhalla, NY 10595]
[▇-▇▇▇-▇▇▇-▇▇▇▇]
THIS IS A LEGAL CONTRACT - READ IT CAREFULLY.
WE AGREE to pay the benefits of this Contract in accordance with its terms.
THIS CONTRACT is issued in consideration of the Payments.
▇▇▇▇ ▇▇▇▇▇▇▇ Life Insurance Company (U.S.A.) will pay an annuity benefit
beginning on the Annuity Commencement Date to the Annuitant, if living, unless
otherwise directed by the Owner, in accordance with the Annuity Payments
provision of this Contract. If the Owner (Annuitant if Owner is not an
individual) dies while this Contract is in effect prior to the Annuity
Commencement Date, we will pay a Death Benefit to the Beneficiary upon receipt
of all required claim forms and proof of death of the Owner at the Annuity
Service Office.
The smallest annual rate of investment return which is required to be earned on
the assets of the separate account so that the dollar amount of variable annuity
payments will not decrease is [4.40%]. Explicit annual charges against the
assets of the separate account are as follows:
Contract Asset Fee Charge: No greater than [1.35%].
TEN DAY RIGHT TO REVIEW
YOU MAY CANCEL THE CONTRACT BY RETURNING IT TO OUR ANNUITY SERVICE OFFICE OR
REGISTERED REPRESENTATIVE WHO SOLD IT TO YOU AT ANY TIME WITHIN 10 DAYS AFTER
RECEIPT OF THE CONTRACT. WITHIN 7 DAYS OF DELIVERY OF THE CONTRACT TO US, WE
WILL PAY TO THE OWNER AN AMOUNT EQUAL TO THE SUM OF (I) AND (II), WHERE (I) IS
THE DIFFERENCE BETWEEN THE PAYMENTS MADE, INCLUDING ANY FEES AND DEDUCTIONS, AND
THE AMOUNTS ALLOCATED TO THE SEPARATE ACCOUNT UNDER THE CONTRACT. THE CONTRACT
VALUE WILL BE COMPUTED AT THE END OF THE VALUATION PERIOD DURING WHICH THE
CONTRACT IS DELIVERED TO US.
WHEN THE CONTRACT IS ISSUED AS AN INDIVIDUAL RETIREMENT ANNUITY, DURING THE
FIRST 7 DAYS OF THIS 10 DAY PERIOD, WE WILL RETURN THE GREATER OF (I) CONTRACT
VALUE COMPUTED AT THE END OF THE VALUATION PERIOD DURING WHICH THE CONTRACT IS
RECEIVED BY US PLUS THE SUM OF ALL FEES AND CHARGES DEDUCTED FROM THE GROSS
PAYMENTS OR (II) SUM OF ALL PAYMENTS.
SIGNED FOR THE COMPANY at its Home Office, Valhalla, New York, on the Contract
Date.
DETAILS OF VARIABLE ACCOUNT PROVISIONS ON PAGE 6.1
[/s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇] [/s/ ▇▇▇▇▇▇▇ ▇▇▇▇▇]
President Secretary
Flexible Payment Deferred Variable Annuity
Non-Participating
ANNUITY PAYMENTS, DEATH BENEFITS, SURRENDER VALUES AND OTHER VALUES PROVIDED BY
THIS CONTRACT WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT ARE
VARIABLE, MAY INCREASE OR DECREASE IN ACCORDANCE WITH THE FLUCTUATIONS IN THE
NET INVESTMENT FACTOR, AS APPLICABLE AND NOT GUARANTEED AS TO FIXED DOLLAR
AMOUNT.
VENTURE-VA.B.07-NY
SAMPLE
INTRODUCTION
This is a flexible payment deferred variable annuity contract. This Contract
provides that, prior to the Annuity Commencement Date, the Contract Value will
accumulate on a variable basis. Subject to the provisions of the Contract, you
may take withdrawal and transfer amounts among the Investment Options. After the
Annuity Commencement Date, Annuity Payments may be either fixed or variable, or
a combination of fixed and variable.
The Contract Value will vary with the investment performance of your Investment
Account.
If you select Annuity Payments on a variable basis, the payment amount will vary
with the investment performance of the Variable Account.
You must allocate Payments among one or more Investment Options. The Investment
Options are identified on the Specifications Page.
TABLE OF CONTENTS PAGE
----------------- ----
SPECIFICATIONS PAGES S.1
PART 1 - DEFINITIONS 1.1
PART 2 - GENERAL PROVISIONS 2.1
PART 3 - OWNER, BENEFICIARY 3.1
PART 4 - PAYMENTS 4.1
PART 5 - FEES AND DEDUCTIONS 5.1
PART 6 - VARIABLE ACCOUNT PROVISIONS 6.1
PART 7 - TRANSFERS 7.1
PART 8 - WITHDRAWAL PROVISIONS 8.1
PART 9 - LOAN PROVISIONS 9.1
PART 10 - DEATH BENEFITS 10.1
PART 11 - ANNUITY PAYMENTS 11.1
PART 12 - ANNUITY OPTIONS 12.1
SPECIFICATIONS PAGE
TYPE OF CONTRACT: [QUALIFIED] CONTRACT DATE: [10/25/2007]
INITIAL PAYMENT: [$5,000.00] CONTRACT NUMBER: [000000005]
GOVERNING LAW: NY
OWNER: [▇▇▇▇ ▇. ▇▇▇▇▇] OWNER'S AGE [45]
[CO-OWNER:] [_______________] [CO-OWNER'S AGE:] [__]
ANNUITANT: [▇▇▇▇ ▇. ▇▇▇▇▇] [CO-ANNUITANT:]
PLAN Venture Opportunity Series B
FEES AND CHARGES
CONTRACT ASSET FEE 1.35%
ANNUAL CONTRACT FEE $30.00(1)
(1) Prior to the Annuity Commencement Date, when the Annual Administration Fee
is to be assessed, if the sum of all your Investment Accounts equals or
exceeds $50,000, the Annual Administration Fee will be waived.
WITHDRAWAL CHARGES
Number of
Complete Years Withdrawal
Payment has Charge
been in Contract Percentage
---------------- ----------
0 6%
1 6%
2 5%
3 5%
4 4%
5 3%
6 2%
7+ 0%
FREE WITHDRAWAL AMOUNT The Free Withdrawal Amount is defined as the
greater of:
(a) the excess of the Contract Value on the
date of withdrawal over the unliquidated
Payments, or
(b) the excess of (i) over (ii), where:
(i) equals 10% times the total
Payments; and
(ii) equals 100% of all prior partial
withdrawals, in that Contract Year.
NY SAMPLE
S.1
RIDER FEE
RIDER FEES PERCENTAGE RIDER DATE
---------- ---------- ------------
[Guaranteed Minimum Withdrawal Benefit
Marketing Name] [0.40%] [10/25/2007]
[Enhanced Death Benefit Marketing Name] [0.20%] [10/25/2007]
LIMITS - PAYMENTS & TRANSFERS
PAYMENT LIMITS The initial Payment is shown above. Additional
Payments may be made at any time. However, each
additional Payment must be at least $30. If a
Payment would cause the Contract Value to exceed
$1,000,000, or the Contract Value already exceeds
$1,000,000, no additional Payments will be
accepted without our prior approval.
TRANSFER CHARGES AND We reserve the right to impose, upon notice, a
LIMITATIONS - BEFORE transaction charge for transfers. In the event a
MATURITY DATE charge is imposed, it will not exceed the lesser
of $25.00 or 2% of the amount of each transfer.
We reserve the right, upon notice, to limit the
amount of the transfer and the maximum number of
transfers that can be made.
You must transfer at least $300 or, if less, the
entire amount in the Investment Account each time
you make a transfer. If, after the transfer, the
amount remaining in the Investment Account from
which the transfer is made is less than $100, then
we will transfer the entire amount instead of the
requested amount.
Should we limit the maximum number of transfers
that can be made per Contract Year, that limit
will be no less than one per month or six at any
time within a Contract Year.
TRANSFER CHARGES AND We reserve the right, upon notice, to limit the
LIMITATIONS - ON OR AFTER maximum number of transfers you may make per
MATURITY DATE Contract Year after variable annuity payments have
begun.
If we limit the maximum number of transfers that
can be made after variable annuity payments have
begun, the maximum number of transfers you may
make per Contract Year shall be no less than 4.
LIMITATIONS ON AMOUNT OF Any withdrawal from an Investment Account must be
PARTIAL WITHDRAWALS at least $300 or the entire balance of the
Investment Account, if less. If after the
withdrawal, the amount remaining in that
Investment Account is less than $100, then we will
consider the withdrawal request to be a request
for withdrawal of the entire amount held in the
Investment Account. If a partial withdrawal would
reduce the Contract Value to less than $300, or if
the amount requested is greater than or equal to
the amount available as a total withdrawal, then
we will treat the partial withdrawal request as a
total withdrawal of the Contract Value.
S.2
ANNUITY BENEFITS
MATURITY DATE: [10/25/2057]
ANNUITY COMMENCEMENT DATE [10/25/2052]
ANNUITY OPTION: [Life 10-Year Certain]
ANNUITY PAYMENTS - GENERAL The rates for Annuity Payments determined are
INFORMATION based on:
- Mortality Table: Annuity 2000 Table
projected at Scale G to the terminal age
of the Table
- Fixed Annuity Payment Interest Rate:
3.00% interest per year
- Variable Annuity Payment Assumed
Interest Rate: 3:00%
The amount of each Annuity Payment will depend
upon the sex and age of the Annuitant, the
Co-Annuitant, if any, or other payee.
BENEFICIARY INFORMATION
[▇▇▇▇ ▇▇▇▇▇]
S.3
INITIAL ALLOCATION OF NET PAYMENT
(SEE FOLLOWING PAGE FOR ALL AVAILABLE OPTIONS)
[INITIAL [INITIAL GUARANTEE
[DCA ACCOUNT OPTIONS;] INTEREST RATE] PERIOD EXPIRES]
---------------------- -------------- ------------------
[6 month DCA] [25.00%] [1.00%] [04/25/2008]
[12 month DCA] [00.00%] [1.00%] [10/25/2008]
[THE INTEREST RATE FOR THE [6] [OR] [12] MONTH DCA ACCOUNT OPTION MAY CONTAIN AN
ENHANCEMENT THAT MAY NOT BE PROVIDED IN SUBSEQUENT GUARANTEE PERIODS.]
VARIABLE INVESTMENT OPTIONS:
[MID CAP STOCK] [50.00%]
[AMERICAN GROWTH] [25.00%]
TOTAL 100.00%
[THIS PLAN IS INTENDED TO QUALIFY UNDER THE INTERNAL REVENUE CODE FOR
TAX-FAVORED STATUS. LANGUAGE CONTAINED IN THIS CONTRACT REFERRING TO FEDERAL TAX
STATUS OR RULES IS INFORMATIONAL AND INSTRUCTIONAL. PLEASE SEEK THE ADVICE OF
YOUR OWN TAX ADVISOR REGARDING YOUR INDIVIDUAL TAX TREATMENT.]
S.4
AVAILABLE INVESTMENT OPTIONS
VARIABLE ACCOUNT: ▇▇▇▇ ▇▇▇▇▇▇▇ LIFE INSURANCE COMPANY OF NEW YORK SEPARATE
ACCOUNT A
VARIABLE INVESTMENT OPTIONS
[All Cap Value]
[American Asset Allocation]
[American Blue Chip Income and Growth]
[American Bond]
[American Fundamental Holdings]
[American Global Growth]
[American Global Small Cap]
[American Growth]
[American Growth-Income]
[American High Income Bond]
[American International]
[American New World]
[Core Allocation Plus]
[Core Equity]
[▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ Founding Allocation]
[Fundamental Value]
[Global]
[Global Bond]
[International Core]
[International Small Cap]
[International Value]
[Investment Quality Bond]
[Lifestyle Balanced]
[Lifestyle Conservative]
[Lifestyle Growth]
Lifestyle Moderate]
[Mid Cap Intersection]
[Mid Cap Stock]
[Mid Cap Value]
[Money Market]
[Mutual Shares]
[Small Cap Growth]
[Small Cap Intrinsic Value]
[Small Cap Value]
[Total Return]
[Value]
DCA ACCOUNT OPTIONS:
6 month DCA
12 month DCA
S.5
PART 1 DEFINITIONS
------ -----------
WE AND YOU "We", "us" and "our" means the Company. "You" or
"your" means the Owner of this Contract.
ACCUMULATION UNIT A unit of measure that is used to calculate the
value of the Variable Account of this Contract
before the Annuity Commencement Date.
ANNUITANT Any individual person or persons whose life is
used to determine the duration of ▇▇▇▇▇▇▇ Payments
involving life contingencies. The Annuitant is as
designated on the Specifications Page, unless
changed.
ANNUITY COMMENCEMENT DATE The date Annuity Payments begin. It is the date
selected by you and specified on the
Specifications Page, unless changed. Annuity
Payments may not be scheduled under the Contract
to begin earlier than 12 months from the Contract
Date. This date may not be later than the Maturity
Date.
ANNUITY OPTION The method selected by you for Annuity Payments
made by us.
ANNUITY PAYMENT(S) Payment(s) by us to you, in accordance with the
Annuity Option elected under the terms of this
Contract.
ANNUITY SERVICE OFFICE Any office designated by us for the receipt of
Payments and processing of Owner requests.
ANNUITY UNIT A unit of measure that is used after the Annuity
Commencement Date to calculate Variable Annuity
payments.
BENEFICIARY The person, persons or entity to whom certain
benefits are payable following the death of an
Owner, or in certain circumstances, an Annuitant.
For purposes of section 72(s) of the Internal
Revenue Code, the "designated beneficiary" under
the Contract shall be the individual who is
entitled to receive the amounts payable on death
of an Owner, or if any Owner is not an individual,
on any change in, or death of, an Annuitant.
COMPANY The insurance company named on the first page of
this Contract (or any successor insurance company
named by endorsement to this Contract) that will
pay benefits in accordance with this Contract.
CONTRACT ANNIVERSARY The annual anniversary of the Contract beginning
twelve months from the Contract Date and each year
thereafter.
CONTRACT DATE The date of issue of this Contract as designated
on the Specifications Page.
CONTRACT VALUE The total of your Investment Account Values and,
if applicable, any amount in the Loan Account
attributable to your Contract.
CONTRACT YEAR The period of time measured twelve consecutive
months from the Contract Date or any Contract
Anniversary thereafter.
CONTINGENT BENEFICIARY The person, persons or entity who becomes entitled
to receive the Contract proceeds if all
Beneficiaries die before the Owner dies.
DEBT Any amounts you take as a loan under this Contract
plus any accrued and unpaid loan interest on that
amount. The loan provision is only available to
certain Qualified Contracts.
ENDORSEMENT An Endorsement modifies the contract to which it
is attached. Endorsements must be signed by an
officer of the Company in order to be effective.
FIXED ANNUITY An Annuity Option with payments which are
predetermined and guaranteed as to dollar amount.
1.1
GENERAL ACCOUNT All the assets of the Company other than assets in
separate accounts.
INTERNAL REVENUE CODE (IRC) The Internal Revenue Code of 1986, as amended from
time to time, and any successor statute of similar
purposes.
INVESTMENT ACCOUNT An account established by us which represents your
interest in an Investment Option prior to the
Annuity Commencement Date.
INVESTMENT ACCOUNT VALUE The value of your investment in an Investment
Account.
INVESTMENT OPTIONS The Sub-Account(s) of the Variable Account. The
Investment Options available under this Contract
are shown on the Specifications Page.
LOAN ACCOUNT The portion of the General Account that is used
for collateral when a loan is taken.
MATURITY DATE The latest date on which annuity benefits may
commence. It is the date specified on the
Specifications Page, unless changed. The maximum
Maturity Date will be the later of age 90 or the
end of the 10th Contract Year. Any extension of
the Maturity Date will be subject to the laws and
regulations then in effect and our prior approval.
NET PAYMENT The Payment less the amount of premium tax, if
any, deducted from the Payment.
NON-QUALIFIED CONTRACTS Contracts which are not issued under Qualified
Plans.
OWNER The person, persons or entity entitled to the
ownership rights under this Contract. The Owner is
as designated on the Specifications Page, unless
changed.
PORTFOLIO The investment choices available to the Variable
Account.
PAYMENT An amount paid to us by you as consideration for
the benefits provided by this Contract.
QUALIFIED CONTRACTS Contracts issued under Qualified Plans.
QUALIFIED PLANS Retirement plans which receive favorable tax
treatment under sections 401, 403, 408 or 457, of
the Internal Revenue Code of 1986, as amended.
RIDER A rider provides an optional benefit, which may
result in an additional charge to the Contract. A
rider supplements the contract to which it is
attached. Riders must be signed by an officer of
the Company in order to be effective.
SEPARATE ACCOUNT A segregated account of the Company that is not
commingled with our general assets and
obligations.
SUB-ACCOUNT(S) One or more of the Sub-Accounts of the Variable
Account. Each Sub-Account is invested in shares of
a different Portfolio.
SURRENDER VALUE The Contract Value on any Valuation Date, less, if
applicable, any contract fees, any rider charges,
any deduction for premium taxes or similar taxes,
any Debt and any Withdrawal Charge.
VALUATION DATE Any date on which the New York Stock Exchange is
open for business and the net asset value of a
Portfolio is determined.
VALUATION PERIOD Any period from one Valuation Date to the next,
measured from the time on each such date that the
net asset value of each Portfolio is determined.
VARIABLE ACCOUNT The Company's Separate Account as shown in the
Specifications Page.
VARIABLE ANNUITY An Annuity Option with payments which: (1) are not
predetermined or guaranteed as to dollar amount;
and (2) vary in relation to the investment
experience of one or more specified variable
Sub-Accounts.
1.2
WITHDRAWAL AMOUNT The amount deducted from the Contract Value when
you request a withdrawal. This amount is the total
of the amount paid to you plus the following, if
applicable: any contract fees, any rider charges,
any deduction for premium taxes or similar taxes,
any income taxes resulting from the withdrawal and
withheld by us, any Debt and any Withdrawal
Charges. The Withdrawal Amount may not exceed the
Contract Value.
1.3
PART 2 GENERAL PROVISIONS
------ ------------------
ENTIRE CONTRACT The entire Contract consists of this Contract,
Endorsements and Riders, if any, and the
application, if one is attached to this Contract.
The benefits and values available under this
Contract are not less than the minimum required by
any statute of the state in which this Contract is
delivered. We have filed a detailed statement of
the method used to calculate the benefits and
values with the Department of Insurance in the
state in which this Contract is delivered, if
required by law.
MODIFICATION Only the President, a Vice President, or the
Secretary of the Company has authority to agree on
our behalf to any alteration of the Contract or to
any waiver of our rights or requirements. The
change or waiver must be in writing. We will not
change or modify this Contract without your
consent except as may be required to make it
conform to any applicable law or regulation or any
ruling issued by a government agency.
CHANGE IN ANNUITY Prior to the Annuity Commencement Date, an Owner
COMMENCEMENT DATE may request in writing a change of the Annuity
Commencement Date. Any extension of the Annuity
Commencement Date beyond the Maturity Date will be
subject to our prior approval and any applicable
law or regulation then in effect.
ASSIGNMENT You may assign this Contract, except as otherwise
provided, at any time prior to the Annuity
Commencement Date. No assignment will be binding
on us unless it is written in a form acceptable to
us and received at our Annuity Service Office. We
will not be liable for any payments made or
actions we take before the assignment is accepted
by us. An absolute assignment will revoke the
interest of any revocable Beneficiary. We will not
be responsible for the validity of any assignment.
If this Contract is issued in a Qualified Plan,
this Contract is subject to assignment
restrictions for Federal Income Tax purposes. In
such event, this Contract shall not be sold,
assigned, discounted, or pledged as collateral for
a loan or as security for the performance of an
obligation or for any other purpose, to any person
other than us.
CLAIMS OF CREDITORS All benefits and payments under this Contract
shall be exempt from the claims of creditors to
the extent permitted by law.
MISSTATEMENT AND PROOF OF We may require proof of age, sex or survival of
AGE, SEX OR SURVIVAL any person upon whose age, sex or survival any
Annuity Payments or other benefits provided by
this Contract or any Rider attached thereof
depend. If the age or sex of the Annuitant has
been misstated, the benefits will be those which
would have been provided for the correct age and
sex. If we have made incorrect benefit payments,
we will immediately pay the amount of any
underpayment adjusted with interest at 3% per
annum. We will deduct the amount of any
overpayment from future benefit payments without
adjustment for interest.
2.1
ADDITION, DELETION OR We reserve the right, subject to prior approval of
SUBSTITUTION OF INVESTMENT the New York Superintendent of Insurance and in
OPTIONS compliance with applicable law, to make additions
to, deletions from, or substitutions for the
Portfolio shares that are held by the Variable
Account or that the Variable Account may purchase.
We reserve the right to eliminate the shares of
any of the eligible Portfolios and to substitute
shares of another Portfolio. We will not
substitute any shares attributable to your
interest in a Sub-Account without notice to you
and prior approval of the Securities and Exchange
Commission to the extent required by the
Investment Company Act of 1940. Nothing contained
herein shall prevent the Variable Account from
purchasing other securities for other series or
classes of contracts, or from effecting a
conversion between shares of another open-end
investment company.
We reserve the right, subject to prior approval of
the New York Superintendent of Insurance and in
compliance with applicable law, to establish
additional Sub-Accounts which would invest in
shares of a new Portfolio. We also reserve the
right to eliminate existing Sub-Accounts, to
combine Sub-Accounts or to transfer assets in a
Sub-Account to another Separate Account
established by us or an affiliated company. In the
event of any such substitution or change, we may,
by appropriate endorsement, make such changes in
this and other Contracts as may be necessary or
appropriate to reflect such substitutions or
change. If deemed by us to be in the best
interests of persons having voting rights under
the Contracts, the Variable Account may be
operated as a management company under the
Investment Company Act of 1940 or it may be
de-registered under such Act in the event such
registration is no longer required.
NON-PARTICIPATING Your Contract is non-participating and will not
share in our profits or surplus earnings. We will
pay no dividends on your Contract.
REPORTS We will send you reports containing information
required by the Investment Company Act of 1940 and
applicable state law at least annually without
charge.
CANCELLATION FOR NONPAYMENT If, prior to the Annuity Commencement Date, no
& MINIMUM ACCOUNT VALUE Payments have been made for three consecutive
Contract Years, and if both:
(a) the total Payments made, less any partial
withdrawals, are less then $2,000; and
(b) the Contract Value at the end of such three
year period is less than $2,000;
We may cancel this Contract and pay you the
Contract Value (measured as of the Valuation
Period during which the cancellation occurs), less
the Debt and Annual Contract Fee. We will provide
you with 31 days prior written notice before
canceling the Contract.
INSULATION The portion of the assets of the Variable Account
equal to the reserves and other contract
liabilities with respect to such account are not
chargeable with liabilities arising out of any
other business we may conduct. Moreover, the
income, gains and losses, realized or unrealized,
from assets allocated to the Variable Account
shall be credited to or charged against such
account without regard to our other income, gains
or losses.
2.2
SEPARATE ACCOUNT ASSETS We will maintain, in the Separate Account, assets
with a value at least equal to the amounts
accumulated in accordance with the terms of the
applicable agreements with respect to the Separate
Account, and the reserves for annuities, in the
course of payment that vary with the investment
experience of the Separate Account.
CURRENCY AND PLACE OF All payments made to or by us shall be made in the
PAYMENTS lawful currency of the United States of America at
the Annuity Service Office or elsewhere if we
consent.
NOTICES AND ELECTIONS To be effective, all notices and elections you
make under this Contract must be in writing,
signed by you and received by us at the Annuity
Service Office. Unless otherwise provided in this
Contract, all notices, requests and elections will
be effective when received by us at our Annuity
Service Office, complete with all necessary
information and your signature.
GOVERNING LAW This Contract will be governed by the laws of the
jurisdiction indicated on the Specifications Page.
SECTION 72(S) The provisions of this Contract shall be
interpreted so as to comply with the requirements
of Section 72(s) of the Internal Revenue Code.
2.3
PART 3 OWNER, BENEFICIARY
------ ------------------
OWNER Before the Annuity Commencement Date, the Owner of
this Contract shall be the person, persons or
entity designated on the Specifications Page or
the latest change filed with us. On the Annuity
Commencement Date the Annuitant becomes the Owner
of this Contract. If amounts become payable to the
Beneficiary under this Contract, the Beneficiary
becomes the Owner of this Contract.
BENEFICIARY The Beneficiary is as designated on the
Specifications Page, unless changed. However, if
there is a surviving Owner, that person will be
treated as the Beneficiary. If no such Beneficiary
is living, the Beneficiary is the Contingent
Beneficiary. If no Beneficiary or Contingent
Beneficiary is living, the Beneficiary is the
estate of the deceased Owner.
CHANGE OF OWNER, ANNUITANT, Subject to the rights of an irrevocable
BENEFICIARY Beneficiary, you may change the Owner, Annuitant,
or Beneficiary by written request in a form
acceptable to us and which is received at our
Annuity Service Office. The Annuitant may not be
changed after the Annuity Commencement Date. You
need not send us the Contract unless we request
it. Any change must be approved by us. If
approved, any change of Owner, Annuitant or
Beneficiary will take effect on the date the
request is signed. We will not be liable for any
payments or actions we take before the change is
approved.
The substitution or addition of any Owner may
result in the resetting of the Death Benefit to an
amount equal to the Contract Value as of the date
of such change. For purposes of subsequent
calculations of the Death Benefit, described in
Part 10, Death Benefits, Death Benefit Before
Maturity Date, we will treat the Contract Value on
the date of the change as a Payment made on that
date. In addition, all anniversary values, all
Payments made and all amounts deducted in
connection with partial withdrawals prior to the
date of the change of Owner will not be considered
in the determination of the Death Benefit. This
paragraph will not apply if (a) the individual
whose death will cause the Death Benefit to be
paid is the same after the change of Owner, or (b)
if Ownership is transferred to the Owner's spouse.
If any Annuitant is changed and any Owner is not
an individual, the entire interest in the Contract
must be distributed to the Owner within five years
of the change.
3.1
PART 4 PAYMENTS
------ --------
GENERAL The Contract is not effective until Payment is
received by us at our Annuity Service Office or
such other place designated by us. All Payments
under this Contract are payable at our Annuity
Service Office or such other place as we may
designate. Payment Limits are identified on the
Specifications Page.
ALLOCATION OF NET PAYMENTS When we receive Payments, the Net Payments will be
allocated among Investment Options in accordance
with the allocation percentages shown on the
Specifications Page. You may change the allocation
of subsequent Net Payments at any time, without
charge, by giving us written notice in a form
acceptable to us.
4.1
PART 5 FEES AND DEDUCTIONS
------ -------------------
CONTRACT ASSET FEE To compensate us for assuming mortality and
expense risks, and certain administration
expenses, we deduct from each variable Investment
Option a fee each Valuation Period at an annual
rate set forth on the Specifications Page. A
portion of this Asset Fee may also be used to
reimburse us for distribution expenses. This fee
is reflected in the Net Investment Factor used to
determine the value of Accumulation Units and
Annuity Units of the Contract.
ANNUAL CONTRACT FEE To compensate us for assuming certain
administrative expenses, we charge an Annual
Contract Fee as set forth on the Specifications
Page. Prior to the Annuity Commencement Date, the
Annual Contract Fee is deducted on each Contract
Anniversary. We withdraw the Annual Contract Fee
from each Investment Option in the same proportion
that the value of the Investment Accounts of each
Investment Option bears to the Contract Value. If
the Contract Value is totally withdrawn on any
date other than the Contract Anniversary, we will
deduct the total amount of the Annual Contract Fee
from the amount paid. After the Annuity
Commencement Date, we deduct the Annual Contract
Fee on a pro rata basis from each Annuity Payment.
However, the Annual Contract Fee will not reduce
the Fixed Annuity payments below the amount
determined according to the mortality and interest
factors in the Annuity Benefits section of the
Specifications Page.
TAXES We reserve the right to charge certain taxes
against your Payments (either at the time of
payment or liquidation), Contract Value, payment
of Death Benefit, or Annuity Payments, as
appropriate. Such taxes may include premium taxes
or other taxes levied by any government entity
which we, in our sole discretion, determine have
resulted from the establishment or maintenance of
the Variable Account, or from the receipt by us of
Payments, or from the issuance of this Contract,
or from the commencement or continuance of Annuity
Payments under this Contract.
5.1
PART 6 VARIABLE ACCOUNT PROVISIONS
------ ---------------------------
INVESTMENT ACCOUNT We will establish a separate Investment Account
for you for each variable Investment Option to
which you allocate amounts. The Investment Account
represents the number of your Accumulation Units
in an Investment Option.
INVESTMENT ACCOUNT VALUE The Investment Account Value of an Investment
Account is determined by (a) times (b) where:
(a) equals the number of Accumulation Units
credited to the Investment Account; and,
(b) equals the value of the appropriate
Accumulation Unit.
ACCUMULATION UNITS We will credit Net Payments to your Investment
Accounts in the form of Accumulation Units. The
number of Accumulation Units we will credit to
each Investment Account of the Contract will be
determined by dividing the Net Payment allocated
to that Investment Account by the Accumulation
Unit value for that Investment Account.
Accumulation Units will be adjusted for any
transfers and will be canceled on payment of a
death benefit, withdrawal, maturity or assessment
of certain charges based on their value for the
Valuation Period in which such transaction occurs.
VALUE OF ACCUMULATION UNIT We will determine the Accumulation Unit value for
a particular Investment Account for any Valuation
Period by multiplying the Accumulation Unit value
for the immediately preceding Valuation Period by
the net investment factor for the Valuation Period
for which the value is being determined. The value
of an Accumulation Unit may increase, decrease or
remain the same from one Valuation Period to the
next.
NET INVESTMENT FACTOR The net investment factor is an index that
measures the investment performance of a
Sub-Account from one Valuation Period to the next.
The net investment factor for any Valuation Period
is determined by dividing (a) by (b) and
subtracting (c) from the result where:
(a) is the net result of:
1) the net asset value per share of a
Portfolio share held in the Sub-Account
determined as of the end of the current
Valuation Period, plus:
2) the per share amount of any dividend or
capital gain distributions made by the
Portfolio on shares held in the
Sub-Account if the ex-dividend date
occurs during the current Valuation
Period, and
(b) is the net asset value per share of a
Portfolio share held in the Sub-Account
determined as of the end of the immediately
preceding Valuation Period, and
(c) is the Contract Asset Fee shown on the
Specifications Page.
The net investment factor may be greater or less
than, or equal to, one.
6.1
PART 7 TRANSFERS
------ ---------
TRANSFERS BEFORE MATURITY Before the Maturity Date or the Annuity
DATE Commencement Date, if earlier, you may transfer
amounts among Investment Accounts of the Contract.
Amounts will be canceled from the Investment
Accounts from which amounts are transferred and
credited to the Investment Account to which
amounts are transferred. We will effect such
transfers so that the Contract Value on the date
of transfer will not be affected by the transfer.
TRANSFERS ON OR AFTER Once variable Annuity Payments have begun, you may
MATURITY DATE transfer all or part of the investment upon which
your variable Annuity Payments are based from one
Sub-Account to another. To do this, we will
convert the number of variable Annuity Units you
hold in the Sub-Account from which you are
transferring to a number of variable Annuity Units
of the Sub-Account to which you are transferring
so that the next Annuity Payment, if it were made
at that time, would be the same amount that it
would have been without the transfer. After the
transfer, the variable Annuity Payments will
reflect changes in the values of your new variable
Annuity Units. You must give us notice at least 30
days before the due date of the first variable
Annuity Payment to which the transfer will apply.
Transfer charges and limitations are identified on
the Specifications Page.
After the Annuity Commencement Date, transfers
will not be allowed from a fixed to a variable
Annuity Option, or from a variable to a fixed
Annuity Option.
DEFERRAL, MODIFICATION OR We reserve the right to defer, modify or terminate
TERMINATION OF TRANSFER the transfer privilege at any time. Other transfer
PRIVILEGE charges and limitations are identified on the
Specifications Page and in the Suspension of
Payments provision in the Withdrawals Provisions
section.
7.1
PART 8 WITHDRAWAL PROVISIONS
------ ---------------------
PAYMENTS OF WITHDRAWALS You may withdraw part or all of the Surrender
Value, at any time before the earlier of the death
of an Owner, the Annuity Commencement Date or the
Maturity Date, by sending us a written request. We
will pay all withdrawals within seven days of
receipt at the Annuity Service Office subject to
postponement in certain circumstances, as
specified below.
SUSPENSION OF PAYMENTS We may defer the right of withdrawal from, or
postpone the date of payments from, the variable
Investment Accounts 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) the
Securities and Exchange Commission, by order, so
permits for the protection of security holders;
provided that applicable rules and regulations of
the Securities and Exchange Commission shall
govern as to whether the conditions described in
(2) and (3) exist.
TOTAL WITHDRAWAL Upon receipt of your request to withdraw the
entire Contract Value, we will terminate the
Contract and pay you the Surrender Value.
PARTIAL WITHDRAWAL If you request to withdraw an amount less than the
Surrender Value, we will pay you the amount
requested and deduct the Withdrawal Amount from
the Contract Value. Unless you specify the amount
to be withdrawn from each Investment Option, the
Withdrawal Amount will be withdrawn from each
Investment Option on a pro rata basis.
Partial withdrawals will reduce the Death Benefit,
as described in the Death Benefit section.
WITHDRAWAL CHARGE If a withdrawal is made from the Contract we may
assess a Withdrawal Charge (contingent deferred
sales charge) against Payments. The amount of the
Withdrawal Charge and when it is assessed is
discussed below:
(a) The Free Withdrawal Amount defined on
the Specifications Page may be withdrawn
free of a Withdrawal Charge.
(b) Payments are liquidated when the
Withdrawal Amount exceeds the Free
Withdrawal Amount. The amount of
Payments liquidated equals
(i) the lesser of the Withdrawal Amount
or the total unliquidated Payments;
minus
(ii) The Free Withdrawal Amount.
A total withdrawal will liquidate all
unliquidated Payments. Payments will be
liquidated on a first-in-first-out
basis. We will liquidate Payments in the
order such Payments were made: the
oldest unliquidated Payment first, the
next Payment second, etc. until all
Payments have been liquidated.
(c) Any Payments liquidated may be subject
to a Withdrawal Charge based on the
length of time the Payment has been in
the Contract. The Withdrawal Charge is
determined by multiplying the amount of
the Payment being liquidated by the
applicable Withdrawal Charge percentage
obtained from the table shown on the
Specifications Page.
The total Withdrawal Charge will be the
sum of the Withdrawal Charges for the
Payments being liquidated.
8.1
(d) A Withdrawal Charge is not applied if
the withdrawal is
(i) payment of the Death Benefit; or
(ii) due to the application of the
Contract Value to an Annuity
Option; or
(iii) taken at the Maturity Date of the
Contract; or
(iv) a distribution required to satisfy
Federal Income Tax minimum
distribution requirements that
apply to this annuity; or
(v) a withdrawal guaranteed under any
rider attached to the Contract.
FREQUENCY AND AMOUNT OF You may make as many partial withdrawals as you
PARTIAL WITHDRAWALS wish. Limitations on the amount of partial
withdrawals are set forth on the Specifications
Page.
8.2
PART 9 LOAN PROVISIONS (CERTAIN QUALIFIED CONTRACTS ONLY)
------ --------------------------------------------------
GENERAL This loan provision applies only to certain
Qualified Contracts. All provisions and terms of a
loan are included in the Qualified Plan
Endorsement, if attached.
9.1
PART 10 DEATH BENEFITS
------- --------------
DEATH BENEFIT BEFORE Prior to the Maturity Date or Annuity Commencement
MATURITY DATE Date, if earlier, we will determine the Death
Benefit as of the date on which written notice and
proof of death and all required claim forms are
received at the Company's Annuity Service Office
as follows:
The Death Benefit will be determined as the
greater of the Contract Value or the sum of all
Payments made, less any amount deducted in
connection with partial withdrawals.
For purposes of calculating the Death Benefit, the
amount deducted in connection with partial
withdrawals will be equal to (i) times (ii), where
(i) is equal to the Death Benefit prior to the
withdrawal, and (ii) is equal to the amount of the
partial withdrawal divided by the Contract Value
prior to the partial withdrawal
If there is any Debt, the Death Benefit equals the
amount described above less the Debt under the
Contract.
We will permit the Owner to limit the Death
Benefit option(s) to be offered any named
Beneficiary, if the Owner provides written notice
to the Company prior to death and the desired
option(s) is one provided for in this Contract.
DEATH OF ANNUITANT: On the death of the last
surviving Annuitant, the Owner becomes the new
Annuitant, if the Owner is an individual. If any
Owner is not an individual the death of any
Annuitant is treated as the death of an Owner and
the Death Benefit will be determined by
substituting the Annuitant for the Owner as
described below.
DEATH OF OWNER: We will pay the Death Benefit to
the Beneficiary if any Owner dies prior to the
Maturity Date or Annuity Commencement Date, if
earlier. The Death Benefit may be taken in one sum
immediately, in which case the Contract will
terminate. If the Death Benefit is not taken in
one sum immediately, the Contract will continue
subject to the following provisions:
(a) The Beneficiary becomes the Owner.
(b) The excess, if any, of the Death Benefit over
the Contract Value will be allocated to and
among the Investment Accounts in proportion
to their values as of the date on which the
Death Benefit is determined.
(c) No additional Payments may be applied to the
Contract.
(d) If the Beneficiary is not the deceased
Owner's spouse, the entire interest in the
Contract must be distributed under one of the
following options:
(i) The entire interest in the Contract must
be distributed over the life of the
Beneficiary, or over a period not
extending beyond the life expectancy of
the Beneficiary, with distributions
beginning within one year of the Owner's
death; or
10.1
(ii) the entire interest in the Contract must
be distributed within 5 years of the
Owner's Death, or
(iii) as Annuity Payments under one of the
options described in the Annuity Options
section.
If the Beneficiary dies before the
distributions required by (i) or (ii) are
complete, the entire remaining Contract Value
must be distributed in a lump sum
immediately.
(e) If the Beneficiary is the deceased Owner's
spouse, the Contract will continue with the
surviving spouse as the new Owner. The
surviving spouse may name a new Beneficiary
(and, if no Beneficiary is so named, the
surviving spouse's estate will be the
Beneficiary).
The spouse may also elect distributions under
one of the following options:
(i) the entire interest in the Contract may
be distributed over the life of the
Beneficiary, or over a period not
extending beyond the life expectancy of
the Beneficiary, with distributions
beginning within one year of the Owner's
death; or
(ii) as Annuity Payments under one of the
options described in the Annuity Options
section.
(f) We will waive Withdrawal Charges on any
withdrawals.
If there is more than one Beneficiary, the
foregoing provisions will independently apply to
each Beneficiary, to the extent of that
Beneficiary's share.
DEATH BENEFIT ON OR AFTER If Annuity Payments have been selected based on an
MATURITY DATE Annuity Option providing for payments for a
guaranteed period, and the Annuitant dies on or
after the Annuity Commencement Date, we will make
the remaining guaranteed payments to the
Beneficiary. Any remaining payments will be made
at least as rapidly as under the method of
distribution being used as of the date of the
Annuitant's death. If no Beneficiary is living, we
will commute any unpaid guaranteed payments to a
single sum (on the basis of the interest rate used
in determining the payments) and pay that single
sum to the estate of the last to die of the
Annuitant and the Beneficiary.
PROOF OF DEATH We will require Proof of death upon the death of
the Annuitant or the Owner. Proof of death is one
of the following received at the Annuity Service
Office:
(a) A certified copy of a death certificate.
(b) A certified copy of a decree of a court of
competent jurisdiction as to the finding of
death.
(c) Any other proof satisfactory to us.
10.2
PART 11 ANNUITY PAYMENTS
------- ----------------
GENERAL Benefits payable under this Contract may be
applied in accordance with one or more of the
Annuity Options described below, subject to any
restrictions of Internal Revenue Code section
72(s). Once Annuity Payments commence, the Annuity
Option may not be changed. The "Life 10-year
certain" Annuity Option described under Part 12,
Option 1(b) is the default Annuity Option unless
you request another option prior to the Annuity
Commencement Date or unless otherwise required by
the Internal Revenue Code. If you are receiving
distributions that comply with the minimum
distribution requirements of the Internal Revenue
Code, you do not need to annuitize the Contract
Value.
We will send you information about Annuity Options
before the Annuity Commencement Date. If by the
Maturity Date, you do not choose an Annuity
Option, make a total Withdrawal of the Surrender
Value, or ask us to change the Maturity Date, we
will automatically pay you Annuity Payments under
the Annuity Option shown in the Specifications
Page and the Annuity Commencement Date is
considered to be the Maturity Date. You can change
the Annuity Option at any time before Annuity
Payments commence.
You may select a Fixed or Variable Annuity. We
will provide variable Annuity Payments unless
otherwise elected. Once Annuity Payments commence,
the Annuity Option may not be changed.
The method used to calculate the amount of the
initial and subsequent Annuity Payments is
described below.
We may pay the Contract Value, less Debt, on the
Annuity Commencement Date in one lump sum if the
monthly income is less than $20.
VARIABLE ANNUITY PAYMENTS We will determine the amount of the first Variable
Annuity Payment by applying the portion of the
Contract Value used to effect a Variable Annuity
(minus any applicable premium taxes) to the
Annuity Option elected based on the mortality
table and assumed interest rate shown in the
Specifications Page. We will provide a table of
the annuity factors upon request. If the current
rates in use by us on the Annuity Commencement
Date are more favorable to you, we will use the
current rates. The portion of the Contract Value
used to effect a Variable Annuity will be measured
as of a date not more than 10 business days prior
to the Annuity Commencement Date.
Subsequent payments will be based on the
investment performance of one or more Sub-Accounts
as you select. The amount of such payments is
determined by the number of Annuity Units credited
for each Sub-Account. Such number is determined by
dividing the portion of the first payment
allocated to that Sub-Account by the Annuity Unit
value for that Sub-Account determined as of the
same date that the Contract Value used to effect
Annuity Payments was determined. We then multiply
this number of Annuity Units for each Sub-Account
by the appropriate Annuity Unit value for each
subsequent determination date, which is a
uniformly applied date not more than 10 business
days before the payment is due.
Variable Annuity payments, at the time of their
commencement will not be less than those that
would be provided by the application of an amount
to purchase any single consideration immediate
annuity contract offered at the time, to the same
class of annuitants. Since no such annuity
contract current exists, a comparable contract in
an affiliated company will be used. Such an amount
would be equal to the greater of:
(a) the Contract Value less applicable Withdrawal
Charges; or
(b) 95% of the Contract Value.
11.1
MORTALITY AND EXPENSE We guarantee that the dollar amount of each
GUARANTEE Variable Annuity payment will not be affected by
changes in mortality and expense experience.
ANNUITY UNIT VALUE The value of an Annuity Unit for each Sub-Account
for any Valuation Period is determined as follows:
(a) The net investment factor for the Sub-Account
for the Valuation Period for which the
Annuity Unit value is being calculated is
multiplied by the value of the Annuity Unit
for the preceding Valuation Period; and
(b) The result is adjusted to compensate for the
interest rate used to determine the first
Variable Annuity payment.
The dollar value of Annuity Units may increase,
decrease or remain the same from one Valuation
Period to the next.
FIXED ANNUITY PAYMENTS We will determine the amount of each Fixed Annuity
payment by applying the portion of the Contract
Value used to effect a Fixed Annuity measured as
of a date not more than 10 business days prior to
the Annuity Commencement Date (minus any
applicable premium taxes) to the Annuity Option
elected based on the mortality table and interest
rate shown on the Specifications Page. The Fixed
Annuity payment will not be less than that
available by applying the Contract Value to
purchase a single premium immediate annuity then
offered to the same class of annuitants by us or a
company affiliated with us.
Fixed Annuity payments, at the time of their
commencement will not be less than those that
would be provided by the application of an amount
to purchase any single consideration immediate
annuity contract offered at the time, to the same
class of annuitants. Since no such annuity
contract current exists, a comparable contract in
an affiliated company will be used. Such an amount
would be equal to the greater of:
(a) the Contract Value less applicable Withdrawal
Charges; or
(b) 95% of the Contract Value.
We guarantee the dollar amount of Fixed Annuity
payments.
11.2
PART 12 ANNUITY OPTIONS
------- ---------------
DESCRIPTION OF ANNUITY Option 1: Life Annuity
OPTIONS
a) Life Non-Refund. We will make Annuity
Payments during the lifetime of the
Annuitant. No payments are due after the
death of the Annuitant.
b) Life 10-Year Certain. We will make Annuity
Payments for 10 years and after that during
the lifetime of the Annuitant. No payments
are due after the death of the Annuitant or,
if later, the end of the 10-year period.
Option 2: Joint and Survivor Life Annuity
The second Annuitant named shall be referred to as
the Co-Annuitant.
a) Joint and Survivor Non-Refund. We will make
Annuity Payments during the joint lifetime of
the Annuitant and Co-Annuitant. Payments will
then continue during the remaining lifetime
of the survivor. No payments are due after
the death of the last survivor of the
Annuitant and Co-Annuitant.
b) Joint and Survivor with 10-Year Certain. We
will make Annuity Payments for 10 years and
after that during the joint lifetime of the
Annuitant and Co-Annuitant. Payments will
then continue during the remaining lifetime
of the survivor. No payments are due after
the death of the survivor of the Annuitant
and Co-Annuitant or, if later, the end of the
10-year period.
ALTERNATE ANNUITY OPTIONS Instead of settlement in accordance with the
Annuity Options described above, you may choose an
alternate form of settlement acceptable to us.
Once Annuity Payments commence, the form of
settlement may not be changed.
12.1
--------------------------------------------------------------------------------
THE ▇▇▇▇ ▇▇▇▇▇▇▇ LIFE INSURANCE COMPANY
OF NEW YORK (▇▇▇▇ ▇▇▇▇▇▇▇(R) LOGO)
--------------------------------------------------------------------------------