Exhibit 4
FIRST ING LIFE
NEW YORK, NEW YORK
OWNER: ▇▇▇▇▇▇ ▇▇▇▇▇▇▇
CONTRACT DATE: January 1, 1996
CONTRACT NUMBER: 1000033
WE AGREE TO PAY the annuity benefit to the Annuitant beginning on the Annuity
Date, subject to the provisions of this Contract.
WE ALSO AGREE to provide the other rights and benefits of this Contract. These
agreements are subject to the provisions of this Contract.
10 DAY CONTRACT EXAMINATION PERIOD. You have the right to examine and return
this Contract within 10 days after receipt. It may be returned by delivering or
mailing it to us at our Customer Service Center. Immediately upon return, it
will be deemed void as of the Contract Date. Upon return of the Contract, we
will refund the Accumulation Value, in addition to any charges deducted, as of
the date the returned Contract is delivered to us at our Customer Service
Center, or, if mailed through the United States Postal Service, as of the date
the returned Contract is mailed to us. This 10 day period ends 15 days after
the Contract is mailed from our Customer Service Center.
In this Contract, "you" and "your" refer to the Owner of this Contract. "We",
"us" and "our" refer to First ING Life Insurance Company of New York.
/s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇ /s/ ▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇▇▇
Secretary President
THIS CONTRACT IS A FLEXIBLE PREMIUM DEFERRED COMBINATION FIXED AND VARIABLE
ANNUITY CONTRACT.
ANNUITY PAYOUTS AND OTHER VALUES PROVIDED BY THIS CONTRACT, WHEN BASED ON THE
INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE. THESE VALUES MAY
INCREASE OR DECREASE BASED ON INVESTMENT EXPERIENCE AND ARE NOT GUARANTEED AS TO
FIXED DOLLAR AMOUNT. ANNUITY PAYOUTS BEGIN AS OF THE ANNUITY DATE. PURCHASE
PAYMENTS ARE FLEXIBLE AND MAY BE MADE UNTIL THEAaNNUITY DATE. THE GUARANTEED
DEATH BENEFIT WILL BE PAID IF THE OWNER DIES PRIOR TO THE ANNUITY DATE.
FIRST ING LIFE INSURANCE COMPANY OF NEW YORK
A Stock Company
Customer Service Center
P.O. Box 173763, Denver, Colorado 80217-3763
Toll-free Telephone Number: ▇(▇▇▇)▇▇▇-▇▇▇▇
Form 1192 (VA)-NY
Page A
TABLE OF CONTENTS
This Contract is a legal Contract between you and us. READ IT CAREFULLY.
GUIDE TO KEY PROVISIONS
SCHEDULE.................................................... 5
CONTRACT EXPENSE PROVISIONS................................. 7
BENEFIT PROVISIONS.......................................... 8
EFFECTIVE DATE OF COVERAGE.................................. 8
ELECTION AND CHANGES OF ANNUITY DATE........................ 8
ELECTION AND CHANGES OF ANNUITY OPTION...................... 8
PAYOUT OF PROCEEDS.......................................... 8
As of the Annuity Date, to Provide Annuity Payouts......... 9
Upon Surrender of this Contract Prior to the Annuity Date.. 9
As a Death Benefit Prior to the Annuity Date............... 9
OWNERS AND DEATH OF THE OWNERS.............................. 9
REQUIRED DISTRIBUTIONS...................................... 10
GUARANTEED DEATH BENEFIT.................................... 10
ANNUITANTS AND DEATH OF ANNUITANTS.......................... 11
BENEFICIARIES AND DEATH OF BENEFICIARIES.................... 11
PURCHASE PAYMENT PROVISIONS................................. 12
PURCHASE PAYMENTS........................................... 12
PURCHASE PAYMENT ALLOCATION................................. 12
VARIABLE ACCOUNT PROVISIONS................................. 12
THE VARIABLE ACCOUNT........................................ 12
VARIABLE ACCOUNT DIVISIONS.................................. 12
CHANGES WITHIN THE VARIABLE ACCOUNT......................... 13
GENERAL ACCOUNT PROVISIONS.................................. 13
THE GENERAL ACCOUNT......................................... 13
GUARANTEED INTEREST DIVISION................................ 13
Form 1192(VA) - NY
Page 2
TRANSFER PROVISIONS.......................................... 14
TRANSFERS TO OR FROM THE GUARANTEED INTEREST DIVISION........ 14
EXCESS TRANSFER CHARGE....................................... 14
DOLLAR COST AVERAGING TRANSFER OPTION........................ 14
AUTOMATIC REBALANCING........................................ 15
ACCUMULATION VALUE PROVISIONS................................ 16
VALUATION DATE............................................... 16
VALUATION PERIOD............................................. 16
ACCUMULATION UNIT VALUE...................................... 16
ACCUMULATION EXPERIENCE FACTOR............................... 16
ACCUMULATION VALUE OF THE DIVISIONS OF THE VARIABLE ACCOUNT.. 17
ACCUMULATION VALUE OF THE GUARANTEED INTEREST DIVISION....... 17
PARTIAL WITHDRAWAL PROVISIONS................................ 18
DEMAND WITHDRAWAL OPTION..................................... 18
SYSTEMATIC INCOME PROGRAM.................................... 19
IRA INCOME PROGRAM........................................... 20
SURRENDER PROVISIONS......................................... 20
CASH SURRENDER VALUE......................................... 20
GENERAL CONTRACT PROVISIONS.................................. 20
THE CONTRACT................................................. 20
AGE.......................................................... 20
PROCEDURES................................................... 20
DEFERRAL OF PAYOUT........................................... 21
TAX QUALIFICATION............................................ 21
CONTRACT CHANGES............................................. 21
COLLATERAL ASSIGNMENT........................................ 22
INCONTESTABILITY............................................. 22
MISSTATEMENT OF AGE OR SEX................................... 22
PERIODIC REPORTS............................................. 22
BASIS OF COMPUTATIONS........................................ 22
TAXES........................................................ 22
NON PARTICIPATING............................................ 22
CUSTOMER SERVICE CENTER...................................... 23
Form 1192(VA) - NY
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ANNUITY OPTION PROVISIONS.................................... 23
SUPPLEMENTARY CONTRACT....................................... 23
PAYOUT OPTIONS............................................... 23
Variable Annuity Payout..................................... 23
Fixed Annuity Payout........................................ 25
Combination Annuity Payout.................................. 25
PAYOUT PERIOD OPTIONS........................................ 25
COMMUTING.................................................... 26
EXCESS INTEREST.............................................. 27
MINIMUM AMOUNTS.............................................. 27
INCOME PROTECTION............................................ 27
PAYOUTS OTHER THAN MONTHLY................................... 27
PAYOUT PERIOD OPTION TABLES.................................. 28
Additional benefits or riders, if any, will be shown in the Schedule. The
additional provisions will be inserted in this Contract.
Form 1192(VA) - NY
Page 4
SCHEDULE
Owner: ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ Age and Sex: 35, Male
Annuitant: ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ Age and Sex: 35, Male
Contract Date: January 1, 1996
Contract Number: 001-000028
Annuity Date: February 1, 2046
Initial Purchase Payment: $25,000.00
Minimum for Each Additional Purchase Payment: $500
Maximum Cumulative Net Purchase Payment: $1,500,000
Customer Service Center: P.O. Box 173763,
Denver, Colorado 80217-3763
Form 1192(VA) - NY
Page 5
SCHEDULE (CONTINUED)
ALLOCATION OF INITIAL PURCHASE PAYMENTS AS SHOWN ON APPLICATION
▇▇▇▇▇▇▇▇▇ & ▇▇▇▇▇▇ Limited Maturity Bond 0 %
▇▇▇▇▇▇▇▇▇ & ▇▇▇▇▇▇ Growth 0 %
▇▇▇▇▇▇▇▇▇ & ▇▇▇▇▇▇ Government Income 0 %
▇▇▇▇▇▇▇▇▇ & ▇▇▇▇▇▇ Partners 0 %
▇▇▇▇▇ American Small Capital 0 %
▇▇▇▇▇ American MidCap Growth 0 %
▇▇▇▇▇ American Growth Division 0 %
▇▇▇▇▇ American Leveraged AllCap Division 0 %
Fidelity Asset Manager 0 %
Fidelity Growth 0 %
Fidelity Overseas 0 %
Fidelity Money Market 50 %
Fidelity Index 500 0 %
INVESCO Total Return 0 %
INVESCO Industrial Income 0 %
INVESCO High Yield 0 %
INVESCO Utilities 0 %
▇▇▇ ▇▇▇ Worldwide Balanced 0 %
▇▇▇ ▇▇▇ Gold & Natural Resources 0 %
Guaranteed Interest Division 0 %
If you elect to invest in a particular Division, at least 1% of your Purchase
Payment must be allocated to that Division, provided that the allocation to each
Division is at least $100. All percentage allocations must be in whole numbers.
Form 1192(VA) - NY
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SCHEDULE (CONTINUED)
CONTRACT EXPENSE PROVISIONS
Owner Transaction Expenses (Deducted from the Accumulation Value)
1. Excess Transfer Charge: Refer to the Transfer Provisions section for
details.
2. Surrender Charge: This charge is deducted upon Surrender or Partial
Withdrawal of Purchase Payments held less than 5 full Contract Years
since the Contract Anniversary at the end of the Contract Year in which
the Purchase Payment was made. It is calculated as a percentage of the
Purchase Payments withdrawn or surrendered. The percentage is based on
the number of Contract Anniversaries since the Contract Year in which
each Purchase Payment was made.
-------------------------------------------------------------------------------
CONTRACT ANNIVERSARIES 0 1 2 3 4 5 6 and more
SINCE PURCHASE PAYMENT
WAS MADE:
-------------------------------------------------------------------------------
PERCENTAGE: 7% 6% 5% 4% 3% 2% 0%
-------------------------------------------------------------------------------
ANNUAL ADMINISTRATIVE CHARGE (Deducted from the Accumulation Value)
This charge is based on Net Purchase Payments. If Net Purchase Payments
received are:
less than $100,000: $ 30.00 per year
$100,000 or more: $ 0 per year
VARIABLE ACCOUNT ANNUAL EXPENSES (Based on the percentage of assets in each
Variable Account Division)
Mortality And Expense Risk Charge: 1.25%
Asset Based Administrative Charge: 0.15%
GUARANTEED INTEREST RATE
The Guaranteed Interest Rate for the Guaranteed Interest Division
is: 3.00%
per year
Form 1192(VA)-NY
Page 7
BENEFIT PROVISIONS
EFFECTIVE DATE OF COVERAGE
The Contract Date shown in the Schedule is the effective date for all coverage
provided under this Contract. This is subject to our receipt of the initial
Purchase Payment. The Contract Date is the date from which we measure Contract
Anniversaries. A Contract Anniversary occurs each Contract Year on the same
month and day as the Contract Date. If the Contract Date is February 29th, the
Contract Anniversary will be February 28th in Contract Years in which there is
not a February 29th.
ELECTION AND CHANGES OF ANNUITY DATE
The Annuity Date is the date as of which Annuity Payouts begin. It may be
elected on your application, but may not be earlier than the second Contract
Anniversary. If no Annuity Date is elected in the application, the Annuity Date
will be the first day of the month following the Annuitant's 85th birthday. You
may change the Annuity Date at any time prior to 60 days before the Annuity Date
currently elected by sending written notice to our Customer Service Center.
ELECTION AND CHANGES OF ANNUITY OPTION
The Annuity Option is composed of both the Payout Option which specifies the
type of annuity to be paid and the Payout Period Option which determines how
long the annuity will be paid, the frequency and the amount of each payout. The
Owner elects the Annuity Option. The Owner may change the Annuity Option at any
time prior to the Annuity Date. The Beneficiary may select an Annuity Option
for any Payouts to be made pursuant to death Proceeds. Any death benefit
Proceeds to be applied under a Payout Option will be allocated to the Divisions
of the Variable Account or the Guaranteed Interest Division as instructed by the
Beneficiary. The available options are described in the Annuity Option
provisions section. Commutation rights are provided to an Annuitant or
Contingent Annuitant as described in the Commuting section of this Contract.
PAYOUT OF PROCEEDS
Proceeds are paid or applied under the following circumstances:
1. As of the Annuity Date, to provide Annuity Payouts;
2. Upon surrender of this Contract prior to the Annuity Date; or
3. As a death benefit prior to the Annuity Date.
The amount and method of payout under each circumstance is described below. The
payout of Proceeds is subject to the Required Distributions section in this
Contract. We may delay payout of the Proceeds for reasons listed in the
Deferral of Payout section.
Form 1192(VA)-NY
Page 8
As of the Annuity Date, to Provide Annuity Payouts
Proceeds applied as of the Annuity Date to provide an annuity under an
Annuity Option will be the Accumulation Value minus taxes incurred but not
deducted. This deduction will be allocated to each of the Divisions in the
same proportion that the Accumulation Value in each Division bears to the
Accumulation Value in all Divisions immediately prior to the Annuity Date.
We will provide an annuity under the Annuity Option then in effect. If no
Annuity Option is in effect, the Annuity Option default will be Payout Period
Option II for a Variable Annuity Payout, using a Benchmark Total Return of
3%, with a certain period of 20 years. The available options are described
in the Annuity Option Provisions section. The annuity benefits at the time
of their commencement will not be less than those that would be provided by
the application of the Proceeds to purchase any single premium immediate
annuity contract offered by us at that time to the same class of annuitants.
Contact our Customer Service Center or your agent for more information.
Upon Surrender of this Contract Prior to the Annuity Date
Proceeds payable upon the surrender of this Contract prior to the Annuity
Date will be the Cash Surrender Value. No Annuity Options are available upon
surrender; however, you may accelerate the Annuity Date under the Contract as
described in the Surrender Provisions section of this Contract.
As a Death Benefit Prior to the Annuity Date
Proceeds payable upon the death of the Owner prior to the Annuity Date will
be the Guaranteed Death Benefit and will be paid according to the provisions
in the Owners and Death of Owners and the Required Distributions sections. We
will pay the Proceeds in one lump sum unless the Beneficiary elects an
Annuity Option within 60 days after the determination of the Guaranteed Death
Benefit but prior to the date on which we pay the Proceeds. If a one sum
payout is elected, the Proceeds will usually be paid within 7 days of
determination of the amount of the Guaranteed Death Benefit. Interest will
be paid on the Proceeds from the date of determination of the Guaranteed
Death Benefit to the date of payout, or until an Annuity Option is selected.
Interest is at the rate we declare, or any higher rate required by law, but
not less than 3% per year. If the Proceeds are paid under an Annuity Option,
the Beneficiary becomes the Annuitant and the Contingent Beneficiary becomes
the Contingent Annuitant. The available options are described in the Annuity
Option Provisions section. The annuity benefits at the time of their
commencement will not be less than those that would be provided by the
application of the Proceeds to purchase any single premium immediate annuity
contract offered by us at that time to the same class of annuitants. Contact
our Customer Service Center or your agent for more information.
OWNERS AND DEATH OF THE OWNERS
The original Owner of this Contract is the person named as the Owner in the
application. Consistent with the terms of any Beneficiary designation and any
assignment, the Owner may, prior to the Annuity Date:
1. Assign this Contract or surrender it in whole or in part;
2. Amend or change this Contract with the consent of the Company;
3. Exercise any right and receive any benefit; or
4. Change the ownership.
Form 1192(VA)-NY
Page 9
Subject to the applicable provisions of the Required Distributions section, if
the Owner (or Deemed Owner as defined in the Required Distributions section)
dies prior to the Annuity Date, and:
1. If the Owner's spouse is the Joint Owner, then the spouse becomes the
new Owner and no death benefit is payable; or
2. If the Owner's spouse is the Beneficiary, then the spouse may elect to
become the Owner (in which case there is no death benefit payable) by
so electing within 60 days of the death and prior to the distribution
of Proceeds; if there is no such election, the Guaranteed Death Benefit
is payable to the Beneficiary; or
3. If the Owner's spouse is not the Joint Owner or the Beneficiary, then
the Guaranteed Death Benefit is payable to the Beneficiary.
REQUIRED DISTRIBUTIONS
The following required distribution rules shall apply if and to the extent
required under Section 72(s) of the Internal Revenue Code:
1. Subject to the alternative election or spouse beneficiary provisions in
subsection (2) or (3) below,
a) If any Owner dies on or after the annuity starting date and before
the entire interest in this Contract has been distributed, the
remaining portion of such interest shall be distributed at least as
rapidly as under the method of distribution being used as of the
date of such death;
b) If any Owner dies before the annuity starting date, the entire
interest in this Contract will be distributed within 5 years after
such death; and
c) If any Owner is not an individual, then for purposes of this
subsection (1), the primary Annuitant under this Contract shall be
treated as the Owner (the "Deemed Owner"), and any change in the
primary Annuitant shall be treated as the death of the Owner. The
primary Annuitant is the individual, the events in the life of whom
are of primary importance in affecting the timing or amount of the
payout under the Contract.
2. If any portion of the interest of an Owner (or a Deemed Owner) in
subsection (1) is payable to or for the benefit of a designated
beneficiary, and such beneficiary elects within 60 days after such
death but prior to the distribution of Proceeds to have such portion
distributed in an Annuity Option over a period that: A) does not extend
beyond such beneficiary's life or life expectancy and B) starts within
1 year after such death (a "Qualifying Distribution Period"); then for
purposes of satisfying the requirements of subsection (1), such portion
shall be treated as distributed entirely on the date such periodic
distributions begin. Such beneficiary may elect any Payout Period
Option for a Qualifying Distribution Period, subject to any
restrictions imposed by any regulations under Section 72(s) of the
Internal Revenue Code.
3. If any portion of the interest of an Owner (or a Deemed Owner)
described in subsection (1) is payable to or for the benefit of such
Owner's spouse, or is co-owned by such spouse, then such spouse shall
be treated as the Owner of such portion for purposes of the
requirements of subsection (1).
GUARANTEED DEATH BENEFIT
The Guaranteed Death Benefit is the greater of the following amounts. These
amounts are calculated as of the Valuation Date we receive due proof of death
and all information necessary to process the claim including the election of a
one sum payout or election under a Payout Option:
1. The Accumulation Value; or
Form 1192(VA)-NY
Page 10
2. The Step-Up Benefit, plus Net Purchase Payments since the last Step-Up
Anniversary. Net Purchase Payments are Purchase Payments made minus
Partial Withdrawals taken and associated charges. See detailed
definition in the Purchase Payment provisions section.
The Step-Up Benefit at issue is the initial Purchase Payment. As of each
Step-Up Anniversary, the current Accumulation Value is compared to the
prior Step-Up benefit increased by Net Purchase Payments since the last
Step-Up anniversary. The greater of these becomes the new Step-Up
benefit.
The Step-Up Anniversaries are every 6th Contract Anniversary for the
duration of the Contract (i.e., the 6th, 12th, 18th, etc.).
The Guaranteed Death Benefit payable to the Beneficiary is the Guaranteed Death
Benefit as calculated above minus taxes incurred but not deducted.
ANNUITANTS AND DEATH OF ANNUITANTS
The original Annuitant and any Contingent Annuitant are named in the
application. The Annuitant will receive the annuity benefits of the Contract
if, on the Annuity Date, the Annuitant is living and the Contract is then in
force. You may name a new Annuitant prior to the Annuity Date. Any Annuitant
or Contingent Annuitant must be younger than age 86 when named. Any Annuitant
or Contingent Annuitant that is not an individual may not be named without our
consent. If the Owner is not an individual, the Annuitant may not be changed
without our consent.
If the Annuitant dies before the Annuity Date, and a Contingent Annuitant has
been named, the Contingent Annuitant becomes the Annuitant. If no Contingent
Annuitant has been named, you must designate a new Annuitant. If no designation
is made within 30 days of the Annuitant's death, the Owner will become the
Annuitant.
If any Owner is not an individual, the death of the Annuitant will be treated as
the death of the Owner.
Upon the death of the Annuitant after the Annuity Date, any remaining Designated
Period payouts will be continued to any Contingent Annuitant. Upon the death of
both the Annuitant and all Contingent Annuitants, any remaining Designated
Period payouts will be paid to the estate of the last to die of the Annuitant
and Contingent Annuitants. Amounts may be released in one sum if the Owner's
election allows. See the Annuity Options provisions section.
BENEFICIARIES AND DEATH OF BENEFICIARIES
The original Beneficiary and any Contingent Beneficiaries are named in the
application. Surviving Contingent Beneficiaries are paid death Proceeds only if
no Beneficiary survives. If more than one Beneficiary in a class survives, they
will share the Proceeds equally, unless the Owner's designation provides
otherwise. If there is no designated Beneficiary or Contingent Beneficiary
surviving, we will pay the Proceeds to the Owner's estate. The Beneficiary
designation will be on file with us or at a location designated by us. We will
pay Proceeds to the most recent Beneficiary designation on file. The Owner may
name a new Beneficiary unless an irrevocable Beneficiary has been named. When
an irrevocable Beneficiary has been designated, the Owner and the irrevocable
Beneficiary must act together to make any Beneficiary changes.
Form 1192(VA) - NY
Page 11
PURCHASE PAYMENT PROVISIONS
PURCHASE PAYMENTS
This Contract will not be effective until the initial Purchase Payment is
received by us and accepted at our Customer Service Center. Any subsequent
Purchase Payments may be made at any time prior to the Annuity Date, subject to
the Minimum for Each Additional Purchase Payment amount. No Purchase Payment
will be allocated until it is received by us at our Customer Service Center. We
reserve the right to refuse to accept, without our prior approval, any Purchase
Payment when the sum of Net Purchase Payments to date exceeds the Maximum
Cumulative Net Purchase Payment shown in the Schedule. Net Purchase Payments are
Purchase Payments made minus Gross Partial Withdrawals taken. A Gross Partial
Withdrawal is a Partial Withdrawal plus any applicable Partial Withdrawal
Transaction Charge and any applicable Surrender Charge.
PURCHASE PAYMENT ALLOCATION
The initial Purchase Payment will be allocated to the Guaranteed Interest
Division and the Divisions of the Variable Account as you directed in the
application. Any Purchase Payments thereafter will be allocated to each Division
in the same proportion that the Accumulation Value in each Division bears to the
total Accumulation Value as of the date we receive that additional Purchase
Payment at our Customer Service Center, or as otherwise instructed by you. You
may designate a different allocation with respect to any Purchase Payments by
sending us a written notice with the Purchase Payment.
VARIABLE ACCOUNT PROVISIONS
THE VARIABLE ACCOUNT
The Variable Account is an account established by us, pursuant to the laws of
the State of New York, to separate the assets funding the variable benefits for
the class of policies to which this Contract belongs from the other assets of
First ING Life of New York.
The Variable Account is registered as a unit investment trust under the
Investment Company Act of 1940. All income, gains and losses, whether or not
realized, from assets allocated to the Variable Account are credited to or
charged against the Variable Account without regard to income, gains or losses
of our General Account. The assets of the Variable Account are our property,
but are separate from our General Account and our other Variable Accounts. That
portion of the assets of the Variable Account which is equal to the reserves and
other contract liabilities with respect to the Variable Account is not subject
to creditor claims against us.
VARIABLE ACCOUNT DIVISIONS
The Variable Account is divided into Divisions, each of which invests in a
series fund Portfolio designed to meet the objectives of the Division. The
current eligible Divisions are shown in the Schedule. We may, from time to
time, add additional Divisions. If we do, you may be permitted to select from
these other Divisions subject to the terms and conditions we may impose on those
allocations.
We reserve the right to limit the number of Divisions in which you may invest.
Form 1192(VA) - NY
Page 12
CHANGES WITHIN THE VARIABLE ACCOUNT
When permitted by law, and subject to any required notice to you and approval of
the Securities and Exchange Commission ("SEC"), state regulatory authorities or
Contract Owners, we may from time to time make the following changes to the
Variable Account:
. Make additional Divisions available. These Divisions will invest in
investment Portfolios we find suitable for the Contract.
. Eliminate Divisions from the Variable Account, combine 2 or more Divisions, or
substitute a new Portfolio for the Portfolio in which a Division invests. A
substitution may become necessary if, in our judgment, a Portfolio no longer
suits the purposes of the Contract. This may happen due to a change in laws or
regulations, or a change in a Portfolio's investment objectives or
restrictions. This may also happen if the Portfolio is no longer available for
investment, or for some other reason, such as a declining asset base.
. Transfer assets of the Variable Account, which we determine to be associated
with the class of contracts to which your Contract belongs, to another
Variable Account.
. Withdraw the Variable Account from registration under the Investment Company
Act of 1940.
. Operate the Variable Account as a management investment company under the
Investment Company Act of 1940.
. Cause one or more Divisions to invest in a mutual fund other than or in
addition to the Portfolios.
. Discontinue the sale of Contracts and certificates.
. Terminate any employer or plan trustee agreement with us pursuant to its
terms.
. Restrict or eliminate any voting rights as to the Variable Account.
. Make any changes required by the Investment Company Act of 1940 or the rules
or regulations thereunder.
GENERAL ACCOUNT PROVISIONS
THE GENERAL ACCOUNT
The General Account holds all of our assets other than those held in the
Variable Account or our other separate accounts. The Guaranteed Interest
Division is a part of our General Account.
GUARANTEED INTEREST DIVISION
The Guaranteed Interest Division is another Division to which you may allocate
Purchase Payments or make transfers. The Accumulation Value of the Guaranteed
Interest Division is equal to the Net Purchase Payments allocated to this
Division plus any earned interest minus deductions taken from this Division.
Interest is credited at the guaranteed rate shown in the schedule or may be
credited at a higher rate. Any higher rate is guaranteed to be in effect for at
least 12-months.
Form 1192(VA) - NY
Page 13
TRANSFER PROVISIONS
After the Contract Examination Period, the Accumulation Value in each Division
may be transferred, upon request, to any other Division subject to the
limitations on transfers involving the Guaranteed Interest Division as detailed
in the following section. Any transfers made due to the operation of Dollar
Cost Averaging or Automatic Rebalancing will not count toward the limit on the
number of transfers allowed free of charge. The minimum amount that may be
transferred from each Division is the lesser of $100 or the balance of a
Division.
---------------------------------------------
Accumulation Period Annuity Period
--------------------------------------------------------------------------------
Free Transfers 12 4
--------------------------------------------------------------------------------
Total Number of
Transfers Permitted Unlimited 4
--------------------------------------------------------------------------------
Excess Transfer Charge $25 for each transfer in Not Applicable
excess of 12 during any
Contract Year
--------------------------------------------------------------------------------
We reserve the right to limit the number of transfers per Contract Year to 12
and to limit excessive trading activity.
TRANSFERS TO OR FROM THE GUARANTEED INTEREST DIVISION
Once during the first 30 days of each Contract Year, you may transfer amounts to
or from the Guaranteed Interest Division. Transfer requests received within 30
days prior to the Contract Anniversary will be deemed to occur as of the
Contract Anniversary. Transfer requests received on the Contract Anniversary or
during the next 30 days will be processed. Transfer requests received at any
other time will not be processed.
The maximum transfer amount from the Guaranteed Interest Division in any
Contract Year is the greatest of:
1. 25% of the Accumulation Value in the Guaranteed Interest Division at the
time of the first transfer or withdrawal in a Contract Year;
2. The minimum transfer amount; or
3. The amount transferred and withdrawn from the Guaranteed Interest Division
in the prior Contract Year.
For purposes of calculating the maximum transfer from the Guaranteed
Interest Division, all withdrawals (including Systematic Income Partial
Withdrawals) and transfers from the Guaranteed Interest Division in a
Contract Year are summed.
EXCESS TRANSFER CHARGE
If you exceed the number of free transfers allowed, you will be assessed an
Excess Transfer Charge. This charge will be deducted from each of the Divisions
in which you are invested in the same proportion that the amount of Accumulation
Value in that Division bears to the total Accumulation Value immediately after
the transfer.
DOLLAR COST AVERAGING TRANSFER OPTION
During the Accumulation Period only, if you have at least $10,000 of
Accumulation Value in either the Fidelity Investments Money Market Division or
the ▇▇▇▇▇▇▇▇▇ & ▇▇▇▇▇▇ Limited Maturity Bond Division, you may choose to
transfer a specified dollar amount each month from one of these
Form 1192(VA) - NY
Page 14
Divisions to other Divisions of the Variable Account. Dollar Cost Averaging
transfers may not be made to the Guaranteed Interest Division. You may elect the
Dollar Cost Averaging transfer option at any time prior to the Annuity Date.
The minimum amount that you may elect to transfer each month is $100. The
maximum amount that you may transfer is equal to the Accumulation Value in the
Division from which the transfer is taken when the election is made, divided by
12.
Dollar Cost Averaging may be elected to end on a specified date or when a
specific balance remains in the Fidelity Investments Money Market Division or
the ▇▇▇▇▇▇▇▇▇ & ▇▇▇▇▇▇ Limited Maturity Bond Division.
Allocations of the transfer amount must be designated as whole number
percentages; no specific dollar designation may be made to the Divisions of the
Variable Account. If you elect to transfer to a particular Division, the
minimum percentage that may be transferred to that Division is 5% of the total
amount transferred. The transfer date will be the same calendar day each month
as the Contract Date. If this calendar day is not a Valuation Date, the next
Valuation Date will be used. If, on any transfer date, the Accumulation Value
in the selected Division is equal to or less than the amount you have elected to
have transferred, the entire amount will be transferred, and this option will
end. Dollar Cost Averaging will end as of the Valuation Date immediately
preceding the Annuity Date.
You may change the transfer amount or the Divisions to which transfers are to be
made once each Contract Year. You may cancel this election by sending us
written notice at our Customer Service Center at least 7 days before the next
transfer date. Any transfer under this option will not be included for purposes
of the Excess Transfer Charge.
If you elect both Dollar Cost Averaging and Automatic Rebalancing, Dollar Cost
Averaging will occur first. On the first Valuation Date of the next calendar
quarter after Dollar Cost Averaging has terminated, Automatic Rebalancing will
begin.
AUTOMATIC REBALANCING
Automatic Rebalancing allows you to match your Accumulation Value in each
Division to your allocation percentages. Automatic Rebalancing can be elected
in your application or by completing the client service application and
returning it to our Customer Service Center. As of the first Valuation Date of
each calendar quarter thereafter we will reallocate your Accumulation Value so
that the amount in each Division matches your allocation percentages. Automatic
Rebalancing may not begin until the end of the Contract Examination Period.
When you request a change in your allocation percentages, your Accumulation
Value will be reallocated as of the Valuation Date that we receive your written
allocation instructions.
You may not transfer among Divisions while the Automatic Rebalancing feature is
in effect. If you elect both Dollar Cost Averaging and Automatic Rebalancing,
Dollar Cost Averaging will occur first. On the first Valuation Date of the next
calendar quarter after Dollar Cost Averaging has terminated, Automatic
Rebalancing will begin.
Form 1192(VA) - NY
Page 15
ACCUMULATION VALUE PROVISIONS
The Accumulation Value of this Contract is the sum of the Accumulation Values of
all the Divisions of the Variable Account in which your Contract is invested,
plus any Accumulation Value of the Guaranteed Interest Division.
The Accumulation Values are based on the Purchase Payments and transfers made,
Partial Withdrawals, the Contract charges, earned interest of the Guaranteed
Interest Division and the investment experience of the Division(s) of the
Variable Account.
All Contract processing occurs as of a Valuation Date. If a transaction occurs
on a day other than a Valuation Date, the transaction will be processed as of
the next Valuation Date.
VALUATION DATE
A Valuation Date is any day:
1. The New York Stock Exchange ("NYSE") is open for trading and on which
First ING Life's Customer Service Center is open; or
2. As may be required by law.
VALUATION PERIOD
A Valuation Period begins at 4 p.m. Eastern time on a Valuation Date. It ends
at 4 p.m. Eastern time on the next succeeding Valuation Date.
All Contract processing for a Valuation Period takes place as of the end of the
Valuation Period.
ACCUMULATION UNIT VALUE
The investment experience of a Division of the Variable Account is determined as
of each Valuation Date. We use an Accumulation Unit Value to measure the
experience of each of the Variable Account Divisions during a Valuation Period.
The Accumulation Unit Value for a Valuation Period equals the Accumulation Unit
Value for the preceding Valuation Period multiplied by the Accumulation
Experience Factor for the Valuation Period.
The number of units for a given transaction related to a Division of the
Variable Account as of a Valuation Date is determined by dividing the dollar
value of that transaction by that Division's Accumulation Unit Value for that
date.
ACCUMULATION EXPERIENCE FACTOR
For each Division of the Variable Account, the Accumulation Experience Factor
reflects the investment experience of the Portfolio in which that Division
invests and the charges assessed against that Division for a Valuation Period.
The Accumulation Experience Factor is calculated as follows:
1. The net asset value of the Portfolio in which that Division invests as of
the end of the current Valuation Period; plus
2. The amount of any dividend or capital gains distribution declared and
reinvested in the Portfolio during the current Valuation Period; minus
Form 1192(VA) - NY
Page 16
3. A charge for taxes, if any.
4. The result of (1), (2) and (3) divided by the net asset value of the
Portfolio as of the end of the preceding Valuation Period; minus
5. The daily equivalent of the Variable Account Annual Expenses shown in
the Schedule for each day in the current Valuation Period.
ACCUMULATION VALUE OF THE DIVISIONS OF THE VARIABLE ACCOUNT
The Accumulation Value of each Division of the Variable Account as of the
Contract Date is equal to the amount of the initial Purchase Payment allocated
to that Division.
On subsequent Valuation Dates, the Accumulation Value of each Division of the
Variable Account is calculated as follows:
1. The number of Accumulation Units in that Division as of the end of the
preceding Valuation Period multiplied by that Division's Accumulation
Unit Value for the current Valuation Period; plus
2. Any additional Purchase Payments allocated to that Division during the
current Valuation Period; plus
3. Any Accumulation Value transferred to such Division during the current
Valuation Period; minus
4. Any Accumulation Value transferred from such Division during the current
Valuation Period; minus
5. Any Excess Transfer Charge allocated to such Division during the current
Valuation Period; minus
6. Any Gross Partial Withdrawals allocated to that Division during the
current Valuation Period; minus
7. The portion of the Administrative Charge applicable to that Division if
a Contract Anniversary occurs during the Valuation Period.
The Administrative Charge is allocated to each of the Divisions of the Variable
Account and the Guaranteed Interest Division in the same proportion that the
Accumulation Value in that Division bears to the Accumulation Value in all of
the Divisions.
ACCUMULATION VALUE OF THE GUARANTEED INTEREST DIVISION
The Accumulation Value in the Guaranteed Interest Division as of the Contract
Date is equal to the amount of the initial Purchase Payment allocated to that
Division.
On subsequent Valuation Dates, the Accumulation Value of the Guaranteed Interest
Division is calculated as follows:
1. The Accumulation Value of the Guaranteed Interest Division as of the end
of the preceding Valuation Period plus any earned interest during the
Valuation Period; plus
2. Any additional Purchase Payments allocated to the Guaranteed Interest
Division during the current Valuation Period; plus
3. Any Accumulation Value transferred to the Guaranteed Interest Division
during the current Valuation Period; minus
4. Any Accumulation Value transferred from the Guaranteed Interest Division
during the current Valuation Period; minus
5. Any Excess Transfer Charge allocated to the Guaranteed Interest Division
during the current Valuation Period; minus
6. Any Gross Partial Withdrawals allocated to the Guaranteed Interest
Division during the current Valuation Period; minus
7. The portion of the Administrative Charge applicable to the Guaranteed
Interest Division if a Contract Anniversary occurs during the current
Valuation Period.
Form 1192(VA) - NY
Page 17
The Administrative Charge is allocated to each of the Divisions of the Variable
Account and the Guaranteed Interest Division in the same proportion that the
Accumulation Value in that Division bears to the Accumulation Value in all of
the Divisions.
PARTIAL WITHDRAWAL PROVISIONS
After the Contract Examination Period and prior to the Annuity Date, you may
withdraw, in cash, all or part of the Cash Surrender Value of this Contract. A
Partial Withdrawal may incur Surrender Charges. Withdrawals may be subject to a
10% penalty tax. A Gross Partial Withdrawal is a Partial Withdrawal plus any
applicable Surrender Charges.
In no case will you be allowed to withdraw more than your Cash Surrender Value.
A Partial Withdrawal will result in a decrease in the Accumulation Value of this
Contract. The decrease is equal to the amount of the Gross Partial Withdrawal.
Partial Withdrawals from the Divisions of the Variable Account will be made by
redeeming Accumulation Units in the affected Divisions at their value as next
computed after we receive your written request at our Customer Service Center.
Any applicable Surrender Charge will reduce the Accumulation Value of each
Division in the same proportion that the Accumulation Value in each Division
bears to the total Accumulation Value immediately after the withdrawal.
There are 3 Partial Withdrawal options available:
1. Demand Withdrawal Option
2. Systematic Income Program
3. IRA Income Program.
DEMAND WITHDRAWAL OPTION
After the Contract Examination Period and prior to the Annuity Date, you may
make a Demand Withdrawal. The minimum Demand Withdrawal amount is $100. The
maximum Demand Withdrawal amount is the Cash Surrender Value minus $500. If the
amount of Demand Withdrawal you specify exceeds the maximum level, the amount of
the withdrawal will automatically be adjusted.
Demand Withdrawals are deemed to be withdrawn in the following order:
1. Earnings in the Contract;
2. Purchase Payments held more than 5 full Contract Years since the Contract
Anniversary immediately following the end of the Contract Year in which
the Purchase Payment was made;
3. The amount by which 15% of the Accumulation Value as of the last Contract
Anniversary (minus any Gross Partial Withdrawals already made during the
Contract Year which are not considered withdrawals of Purchase Payments)
exceeds earnings, if any;
4. Purchase Payments held less than 5 full Contract Years since the Contract
Anniversary at the end of the Contract Year in which the Purchase Payment
was made, withdrawn on a first-in, first-out basis.
Unless you specify otherwise, the amount of the Partial Withdrawal will be taken
from each Division in the same proportion that the amount of Accumulation Value
in that Division bears to the Accumulation Value in all of the Divisions
immediately prior to the withdrawal. You may not
Form 1192(VA) - NY
Page 18
withdraw from the Guaranteed Interest Division an amount that is greater than
the total withdrawal multiplied by the ratio of the Accumulation Value in the
Guaranteed Interest Division to the total Accumulation Value immediately prior
to the withdrawal.
Earnings in the contract, for the purpose of calculating Surrender Charges,
equal the current Accumulation Value minus any Purchase Payments not previously
withdrawn.
SYSTEMATIC INCOME PROGRAM
You may elect this option at any time prior to the Annuity Date. You may choose
to receive Systematic Income Partial Withdrawals on a monthly or quarterly basis
from the Accumulation Value. Withdrawals will be taken from each Division of
the Variable Account and the Guaranteed Interest Division in the same proportion
that the Accumulation Value of that Division bears to the total Accumulation
Value. The payouts under this option may not start sooner than one month after
the Contract Date. You may select the day of the month when the withdrawals
will be made. If no day is selected, the withdrawals will be made on the same
calendar day of the month as the Contract Date. If this calendar day is not a
Valuation Date, the next Valuation Date will be used. You may select a dollar
amount or a percentage amount for your withdrawal subject to the following
maximums:
MONTHLY: 1.25% of the Accumulation Value
QUARTERLY: 3.75% of the Accumulation Value
Except as described in the following sections, in no event will a payout be less
than $100.
If a dollar amount is selected and the amount to be systematically withdrawn
would exceed the applicable maximum percentage listed above on the withdrawal
date, the amount withdrawn will be reduced to equal such percentage. If the
amount to be withdrawn is then less than $100, the withdrawal will be made and
the Systematic Income Program will be canceled.
If a percentage is selected and the amount to be systematically withdrawn based
on that percentage would be less than $100, the amount will be increased to the
lesser of $100 or the maximum percentage. If the amount to be withdrawn is then
less than $100, the withdrawal will be made and the Systematic Income Program
will be canceled.
If the Systematic Income Program is canceled due to an insufficient Accumulation
Value, any remaining Cash Surrender Value will be paid to you. This will result
in the termination of the Contract.
You may change the amount or percentage of your Systematic Income Partial
Withdrawal once each Contract Year. You may cancel your election at any time by
sending written notice to us at our Customer Service Center at least 7 days
prior to the next scheduled withdrawal date.
During any Contract Year, if a Demand Withdrawal is made while the Systematic
Income Program is in effect, the remaining payouts to be made under the
Systematic Income Program for that Contract Year will be considered Demand
Withdrawals for purposes of calculating Partial Withdrawal Transaction Charges
and any applicable Surrender Charges. If a Demand Withdrawal is not made in the
same Contract Year, Systematic Income Partial Withdrawals will not be assessed a
Surrender Charge. However, the amount available for Systematic Income Partial
Withdrawals is never greater than the Cash Surrender Value.
Form 1192(VA) - NY
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IRA INCOME PROGRAM
If you have an IRA contract, we will send you Partial Withdrawals to accommodate
IRS required minimum distribution rules. These Partial Withdrawals will begin
automatically if the minimum distributions are not otherwise satisfied.
SURRENDER PROVISIONS
CASH SURRENDER VALUE
The Cash Surrender Value of this Contract is the Accumulation Value minus any
Surrender Charges, taxes incurred but not deducted and the Administrative
Charge, if any, due at the end of the Contract Year. The applicable Surrender
and Administrative Charges are shown in the Schedule.
Surrenders may be subject to a 10% penalty tax.
You may surrender this Contract for its Cash Surrender Value at any time prior
to the Annuity Date. The Surrender Charge shown in the Schedule will be
deducted on surrender. A Surrender Charge is applicable only to the Surrender
or Partial Withdrawal of Purchase Payments held less than 5 full Contract Years
since the Contract Anniversary at the end of the Contract Year in which the
Purchase Payment was made.
If you do not wish to receive your Cash Surrender Value in a one sum payout and
you are also the Annuitant, you may avoid a Surrender Charge by applying the
Proceeds to Payout Period Options II or III by accelerating the Annuity Date
under the Contract, subject to the limitations in the Election and Changes of
Annuity Date section. No surrender may be made on or after the Annuity Date or
with respect to any amounts applied under an Annuity Option.
GENERAL CONTRACT PROVISIONS
THE CONTRACT
This Contract, including any applications, riders and endorsements, makes up the
entire Contract between you and us. A copy of the initial application will be
attached to this Contract at issue. All statements made in an application will
be considered representations and not warranties. No statement will be used to
deny a claim unless it is in an application.
AGE
This Contract is issued at the Owner's Age shown in the Schedule. This is the
Owner's Age as of last birthday on the Contract Date. The Annuitant's attained
age on any date for which age is to be determined is the Annuitant's age as of
last birthday.
PROCEDURES
We must receive any election, designation, assignment or any other change
request you make in writing, except those specified on the application. We may
require a return of this Contract for any Contract change or for paying its Cash
Surrender Value. The effective date of any change in
Form 1192(VA) - NY
Page 20
provisions of the Contract will be the date the request was signed. Any change
will not affect payouts made or action taken by us before the change is recorded
at our Customer Service Center.
We may require due proof of age, death or survival of an Annuitant or any
Beneficiary when such proof is relevant to the payout of a benefit, claim, or
settlement under the Contract.
In the event of the Owner's death before the Annuity Date, we should be informed
as soon as possible. Claim procedure instructions will be sent to your
Beneficiary immediately. We require a certified copy of the death certificate
and may require proof of the Owner's Age. We may require the Beneficiary and
the Owner's next of kin to sign authorizations as part of due proof.
DEFERRAL OF PAYOUT
Partial Withdrawals or payout of Proceeds from Divisions of the Variable Account
will usually be processed within 7 days of receipt of the request at our
Customer Service Center. However, we may postpone the processing of any such
transactions for any of the following reasons:
1. When the NYSE is closed for trading;
2. When trading on the NYSE is restricted by the SEC;
3. When an emergency exists such that it is not reasonably practical to
dispose of securities in the applicable Division of the Variable Account
or to determine the value of its assets; or
4. When a governmental body having jurisdiction over the Variable Account
permits such suspension by order.
Rules and regulations of the SEC are applicable and will govern as to whether
conditions described in (2), (3), or (4) exist.
We may defer up to 6 months the payout of any Partial Withdrawal or Proceeds
other than death benefits from the Guaranteed Interest Division.
TAX QUALIFICATION
This Contract is intended to qualify as an annuity contract under the Internal
Revenue Code. To that end, all terms and provisions of the Contract shall be
interpreted to ensure or maintain such qualification. Payouts and distributions
under this Contract shall be made in the time and manner necessary to maintain
such qualification under the applicable provisions of the Internal Revenue Code
in existence at the time this Contact is issued. We reserve the right to amend
this Contract, to reflect any clarifications or changes that may be needed or
are appropriate, or to conform it to any applicable changes in the tax
requirements. Such changes will apply uniformly to all Contracts that are
affected. We will send you written notice of any such changes.
CONTRACT CHANGES
All changes made by us must be signed by our president or an officer and by our
secretary or an assistant secretary. No other person can change any of this
Contract's terms and conditions.
Form 1192(VA) - NY
Page 21
COLLATERAL ASSIGNMENT
The Owner may assign this Contract as collateral security upon written notice to
us. Once it is recorded with us, the rights of the Owner and Beneficiary are
subject to the assignment. It is your responsibility to make sure the
assignment is valid.
INCONTESTABILITY
We will not contest the statements in an application for this Contract after the
Contract Date.
MISSTATEMENT OF AGE OR SEX
If the Age or sex has been misstated in an application, the amounts payable or
benefits provided by this Contract will be those that the Purchase Payouts made
would have purchased at the actual Age or sex, with interest at 6% per year on
any overpayments or underpayments previously made.
PERIODIC REPORTS
During the Accumulation Period, we will send you a report within 90 days after
the end of each calendar quarter. This report will show the current
Accumulation Value, Cash Surrender Value, Guaranteed Death Benefit and activity
under the Contract since the last report. During the Annuity Period, we will
send you a report within 90 days after the end of each calendar year showing any
information required by law. The reports will also include any other
information that may be required by the SEC or the insurance supervisory
official of the jurisdiction in which this Contract is delivered.
BASIS OF COMPUTATIONS
The Cash Surrender Values under this Contract are not less than the minimums
required on the Contract Date by the state in which this Contract was delivered.
A detailed statement of the method of computation of Accumulation Values under
this Contract has been filed with the insurance department of the state in which
this Contract was delivered, if requested by that state.
TAXES
Taxes relating to this Contract paid by us to any governmental entity will be
deducted from the Purchase Payments or Accumulation Value. We will, at our sole
discretion, determine when taxes have resulted from: the investment experience
of the Divisions of the Variable Account; receipt by us of the Purchase
Payments; Surrenders and Partial Withdrawals; or the start of an Annuity Option.
We may, at our sole discretion, pay taxes when incurred and deduct that amount
from the Accumulation Value at a later date. Payment at an earlier date does
not waive any right we may have to deduct amounts at this later date. We will
deduct any withholding taxes required by applicable law.
NON PARTICIPATING
This Contract does not participate in our surplus earnings.
Form 1192(VA) - NY
Page 22
CUSTOMER SERVICE CENTER
Our Customer Service Center is at the address shown in the Schedule. Unless you
are otherwise notified:
1. All requests and payments should be sent to us at our Customer Service
Center; and
2. All transactions are effective as of the date the required information is
received at our Customer Service Center.
ANNUITY OPTION PROVISIONS
The Annuity Option is composed of both the Payout Option which specifies the
type of annuity to be paid and the Payout Period Option which determines how
long the annuity will be paid, the frequency and the amount of the first payout.
SUPPLEMENTARY CONTRACT
When an Annuity Option becomes effective, this Contract will be amended to
include a Supplementary Contract. The Supplementary Contract will provide for
the manner of settlement and rights of the Annuitant. The Supplementary
Contract Effective Date will be the Annuity Date or the date of other
settlement, whenever the Annuity Option becomes effective. The first payout
will be payable as of the Supplementary Contract Effective Date.
PAYOUT OPTIONS
Annuity Payouts can be made under a Variable Annuity Payout, a Fixed Annuity
Payout, or a Combination Annuity Payout, each under various Payout Period
Options. Each of these options is described below.
VARIABLE ANNUITY PAYOUT
A Variable Annuity is an annuity with payouts which:
1. Are not pre-determined or guaranteed as to dollar amount; and
2. Vary in amount with the investment experience of the Divisions of the
Variable Account in which you invest.
As of the Annuity Date, any Accumulation Value invested in the Guaranteed
Interest Division will be allocated among the Divisions of the Variable Account
in the same proportion that the Accumulation Value of each Division bears to the
total Accumulation Value of all the Divisions of the Variable Account.
The first Variable Annuity Payout for each Division of the Variable Account will
be the amount that the Proceeds will provide as of the close of business on the
Valuation Date immediately preceding the Supplementary Contract Effective Date
at the Benchmark Total Return elected. If you have elected to have payouts made
less frequently than monthly, the payout amount is then adjusted according to
the factors in the Payouts Other Than Monthly section. The initial number of
Annuity Units for a Division of the Variable Account is calculated by dividing
the payout amount of that Division of the Variable Account by the Annuity Unit
Value of that Division as of the Supplementary Contract Date. The total
Variable Annuity Payout is the sum of the Variable Annuity Payouts from all
Divisions of the Variable Account.
Form 1192(VA) - NY
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Variable Annuity Payouts, after the first payout, vary in amount with the
investment experience of the Divisions of the Variable Account. The dollar
amount of each Variable Annuity Payout after the first payout is calculated by
adding the amount due for each Division of the Variable Account. The amount due
for each Division equals:
1. The number of Annuity Units for that Division; multiplied by,
2. The Annuity Unit Value for that Division as of the Valuation Date for
which each payout is due.
The dollar amount of each Annuity Payout after the first will not be affected by
variations in our expenses or mortality experience.
Benchmark Total Return
You must elect either a 3% or 5% Benchmark Total Return. Your election may
not be changed after the Annuity Date. Electing the 5% Benchmark Total
Return would mean a higher initial payout but more slowly rising or more
rapidly falling subsequent payouts if actual investment experience varied
from 5%. The 3% Benchmark Total Return assumption would have the opposite
effect. If the actual investment rate is at the annual rate of 3% or 5%, the
Annuity Payouts will be level if you elected either the 3% or 5%
respectively.
Annuity Unit Value
We use an Annuity Unit Value to calculate the value of Variable Annuity
Payouts. The Annuity Unit Value for a Valuation Period is:
a) The Annuity Unit Value for each Division as of the last prior
Valuation Period multiplied by the Annuity Experience Factor for
that Division for the Valuation Period for which the Annuity Unit
Value is being calculated; divided by
b) An interest factor based on the Benchmark Total Return selected.
(This is done to neutralize the Benchmark Total Return.)
Annuity Experience Factor
For each Division of the Variable Account, the Annuity Experience Factor
reflects the investment experience of the Portfolio in which that Division
invests and the charges assessed against that Division for a Valuation
Period. The Annuity Experience Factor is calculated as follows:
a) The net asset value of the Portfolio as of the end of the current
Valuation Period; plus
b) The amount of any dividend or capital gains distribution declared
and reinvested in such Portfolio during the current Valuation
Period; minus
c) A charge for taxes, if any.
d) The result of (a), (b) and (c), divided by the net asset value of
the Portfolio as of the end of the preceding Valuation Period; minus
e) The daily equivalent of the Variable Account Annual Expenses shown
in the Schedule for each day in the current Valuation Period.
Form 1192(VA)-NY
Page 24
Transfer of Annuity Units
The Annuitant may transfer all or a portion of the Annuity Units in a
Division of the Variable Account to another Division of the Variable
Account. The limit on transfers is shown in the table in the Transfer
provisions section. After the transfer, the number of Annuity Units in the
Division of the Variable Account from which you are transferring will be
reduced by the number of Annuity Units transferred. The number of Annuity
Units in the Division to which the transfer is made will be increased by the
number of Annuity Units transferred multiplied by:
a) The value of an Annuity Unit in the Division of the Variable Account
from which the transfer is made, divided by
b) The value of an Annuity Unit in the Division of the Variable Account
to which the transfer is made.
Fixed Annuity Payout
A Fixed Annuity Payout is an annuity with payouts which remain fixed as to
dollar amount throughout the Payout Period. As of the Supplementary Contract
Effective Date, any Proceeds invested in the Divisions of the Variable Account
will be allocated to the Guaranteed Interest Division. The Fixed Annuity Payout
will be that amount that the Proceeds will provide as of the Supplementary
Contract Effective Date at the guaranteed Benchmark Total Return of 3%. If the
Fixed Annuity Payout is credited at an interest rate above the guaranteed
minimum, the installment dollar amount will be greater than the determined
installment dollar amount for the time period that the higher rate is declared.
If you have elected to have payouts made less frequently than monthly, the
payout amount is adjusted according to the factors in Payouts Other Than Monthly
section.
Combination Annuity Payout
A Combination Annuity Payout is an annuity where a portion of the payout is
variable and a portion of the payout is fixed as to dollar amount throughout the
Payout Period. At least 25% of the Proceeds must be allocated to each selected
option as of the Supplementary Contract Effective Date. As of the Supplementary
Contract Effective Date, we will allocate Accumulation Value between the
Guaranteed Interest Division and the Divisions of the Variable Account to meet
the proportions selected. Any amount of Proceeds to be transferred to or from
the Guaranteed Interest Division will be split among the Divisions of the
Variable Account in the same proportion that the Accumulation Value of each of
the Divisions of the Variable Account bears to the total Accumulation Value of
the Divisions of the Variable Account. Any Death Proceeds to be applied under a
Combination Annuity Payout will be allocated to the Divisions of the Variable
Account as instructed by the Beneficiary. Once a Combination Annuity Payout is
selected, the Annuitant may subsequently increase the allocation to a Fixed
Annuity Payout, but may not increase the allocation to the Variable Annuity
Payout.
PAYOUT PERIOD OPTIONS
Under each Payout Option, the Payout Period is elected from one of the
following:
Form 1192(VA)-NY
Page 25
OPTION I. Payouts for a Designated period. Payouts will be made in 1, 2, 4,
or 12 installments per year as elected for a designated period, which may be 5
to 30 years. If a Fixed Annuity Payout is elected, the installment dollar
amounts will be equal except for any Excess Interest as described below. If a
Variable Annuity Payout is elected, the number of Annuity Units of each
installment will be equal, but the dollar amount of each installment will vary
based on the Annuity Unit Values of the Divisions elected. If the Annuitant dies
before the end of the designated period, payouts will be continued to the
Contingent Annuitant, if one has been named, until the end of the designated
period. The amount of each payout will depend upon the designated period
elected, and if a Variable Annuity Payout is elected, the investment experience
of the Divisions of the Variable Account selected. The amount of the first
monthly payout for each $1,000 of Accumulation Value applied is shown in Payout
Option Table I.
OPTION II. Life Income With Payouts for a Designated period. Payouts will be
made in 1, 2, 4, or 12 installments per year throughout the Annuitant's
lifetime, or if longer, for a period of 5, 10, 15 or 20 years as elected. If a
Fixed Annuity Payout is elected, the installment dollar amounts will be equal
except for any Excess Interest, as described below. If a Variable Annuity Payout
is elected, the number of Annuity Units of each installment will be equal, but
the dollar amounts of each installment will vary based on the Annuity Unit
Values of the selected Divisions. If the Annuitant dies before the end of the
designated period, payouts will be continued to the Contingent Annuitant, if one
has been named, until the end of the designated period. The amount of each
payout will depend upon the Annuitant's sex, age at the time the first payout is
due, the designated period elected and, if a Variable Annuity Payout is elected,
the investment experience of the Divisions of the Variable Account selected. The
amount of the first monthly payout for each $1,000 of Accumulation Value applied
is shown in Payout Period Option Table II. This option is only available for
ages shown in these Tables.
OPTION III. Joint and Last Survivor. Payouts will be made in 1, 2, 4, or 12
installments per year as elected while both Annuitants are living. Upon the
death of one ▇▇▇▇▇▇▇▇▇, the Survivor's Annuity Payout will be paid throughout
the lifetime of the Surviving Annuitant.
If a ▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ is elected, the installment dollar amount will be
level while both Annuitants are living and upon the death of one Annuitant will
be reduced to 2/3rds of the installment dollar amount (excluding any Excess
Interest paid) while both Annuitants were living.
If a Variable Annuity Payout is elected, the number of Annuity Units applied to
each installment will be level while both Annuitants are living and upon the
death of one Annuitant will be reduced to 2/3rds of the number of Annuity Units
applied to each installment while both Annuitants were living. The dollar
amounts of each installment will vary based on the Annuity Unit Values of the
selected Divisions.
The amount of each payout will depend upon the age last birthday and sex of each
Annuitant at the time the first payout is due and, if a Variable Annuity Payout
is elected, the investment experience of the Divisions of the Variable Account
selected.
Payouts for Payout Period Option III will be determined by using the 1983A
Individual Annuity Mortality Table. Contact our Customer Service Center to
determine the amount of the first monthly installment for each $1,000 of
Accumulation Value applied.
OPTION IV. Other. Payouts will be made in any other manner as agreed upon in
writing between you or the Beneficiary and us.
COMMUTING
The Annuitant may commute remaining designated period installments under Payout
Period Option I. The Contingent Annuitant may commute remaining designated
period installments after the death of the Annuitant. If no Contingent Annuitant
is named, any remaining designated period
Form 1192(VA)-NY
Page 26
installments after the death of the Annuitant may be commuted by the estate. Any
computation shall be at the appropriate Benchmark Total Return rate.
EXCESS INTEREST
We may declare that Fixed Annuity Payouts will be credited at an interest rate
above the guaranteed minimum. We guarantee that any higher rate will not be
reduced more than once during a 12-month period.
MINIMUM AMOUNTS
The minimum amount that may be applied under any Annuity Option is $2,000. If
the Proceeds to be applied are less than $2,000, or if the payouts to the
Annuitant are ever less than $20, we may change the frequency of payouts to
result in payouts of at least that amount or require a one sum payout.
INCOME PROTECTION
Unless otherwise provided in the Annuity Option election, an Annuitant or
Contingent Annuitant has the right to assign, transfer to a third party or
encumber amounts held or installments to become payable pursuant to this
Contract. To the extent provided by law, the Proceeds, amount retained, and
installments are not subject to any Annuitant's debts, contracts, or
engagements.
PAYOUTS OTHER THAN MONTHLY
The following tables show initial monthly installments for Payout Period Options
I and II. To arrive at annual, semiannual, or quarterly payouts, multiply the
appropriate figures by 11.839, 5.963, or 2.993 if the Benchmark Total Return is
3%, and by 11.736, 5.939 or 2.988 if the Benchmark Total Return is 5%,
respectively. Factors for other designated periods or for other options that may
be provided by mutual agreement will be provided upon reasonable request.
Form 1192(VA)-NY
Page 27
PAYOUT PERIOD OPTION TABLES
PAYOUT PERIOD OPTION TABLE I
(Benchmark Total Return is 3% -- Per $1,000 of Net Proceeds)
No. of Years Monthly No. of Years Monthly
Payable Installments Payable Installments
----------------------------------------------------------------------
5 $17.92 20 $5.53
6 15.16 21 5.34
7 13.18 22 5.17
8 11.70 23 5.01
9 10.55 24 4.86
10 9.63 25 4.73
11 8.88 26 4.61
12 8.26 27 4.50
13 7.73 28 4.39
14 7.28 29 4.30
15 6.89 30 4.21
16 6.55
17 6.25
18 5.98
19 5.75
----------------------------------------------------------------------
Form 1192(VA)-NY
Page 28
PAYOUT PERIOD OPTION TABLE I -- VARIABLE ANNUITY ONLY
(Benchmark Total Return is 5% -- Per $1,000 of Net Proceeds)
No. of Years Monthly No. of Years Monthly
Payable Installments Payable Installments
----------------------------------------------------------------------
5 $18.79 20 $6.57
6 16.04 21 6.39
7 14.08 22 6.23
8 12.61 23 6.08
9 11.47 24 5.94
10 10.56 25 5.82
11 9.82 26 5.71
12 9.21 27 5.61
13 8.69 28 5.51
14 8.25 29 5.43
15 7.88 30 5.35
16 7.55
17 7.26
18 7.00
19 6.77
----------------------------------------------------------------------
Form 1192(VA)-NY
Page 29
PAYOUT PERIOD OPTION TABLE II
(Benchmark Total Return is 3% -- Per $1,000 of Net Proceeds)
------------------------------------------------------------------------------------------------------------------------------------
Age of Annuitant Age of Annuitant
Last Birthday When Last Birthday When
First Installment is First Installment is
Payable Monthly Installment Payable Monthly Installment
------------------------------------------------------------------------------------------------------------------------------------
5 Years 10 Years 15 Years 20 Years 5 Years 10 Years 15 Years 20 Years
Male Certain Certain Certain Certain Male Certain Certain Certain Certain
------------------------------------------------------------------------------------------------------------------------------------
15 2.94 2.94 2.94 2.93 40 3.63 3.62 3.61 3.58
16 2.96 2.95 2.95 2.95 41 3.68 3.67 3.65 3.62
17 2.97 2.97 2.97 2.96 42 3.73 3.72 3.70 3.66
18 2.99 2.99 2.99 2.98 43 3.78 3.77 3.74 3.71
19 3.01 3.01 3.00 3.00 44 3.84 3.82 3.79 3.75
20 3.03 3.02 3.02 3.02 45 3.89 3.88 3.84 3.80
21 3.05 3.04 3.04 3.04 46 3.95 3.93 3.90 3.85
22 3.07 3.06 3.06 3.06 47 4.01 3.99 3.95 3.90
23 3.09 3.08 3.08 3.08 48 4.08 4.05 4.01 3.95
24 3.11 3.11 3.10 3.10 49 4.15 4.12 4.07 4.00
25 3.13 3.13 3.13 3.12 50 4.22 4.19 4.13 4.06
26 3.16 3.15 3.15 3.14 51 4.29 4.26 4.20 4.11
27 3.18 3.18 3.17 3.17 52 4.37 4.33 4.27 4.17
28 3.21 3.20 3.20 3.19 53 4.45 4.41 4.34 4.23
29 3.23 3.23 3.23 3.22 54 4.54 4.49 4.41 4.29
30 3.26 3.26 3.25 3.25 55 4.63 4.58 4.49 4.36
31 3.29 3.29 3.28 3.27 56 4.73 4.67 4.57 4.42
32 3.32 3.32 3.31 3.30 57 4.83 4.76 4.65 4.48
33 3.36 3.35 3.34 3.33 58 4.94 4.87 4.74 4.55
34 3.39 3.39 3.38 3.36 59 5.05 4.97 4.82 4.61
35 3.43 3.42 3.41 3.40 60 5.18 5.08 4.92 4.68
36 3.46 3.46 3.45 3.43 61 5.31 5.20 5.01 4.75
37 3.50 3.50 3.48 3.47 62 5.45 5.32 5.11 4.81
38 3.54 3.54 3.52 3.50 63 5.60 5.45 5.21 4.87
39 3.59 3.58 3.56 3.54 64 5.76 5.59 5.31 4.94
------------------------------------------------------------------------------------------------------------------------------------
Form 1192(VA)-NY
Page 30
PAYOUT PERIOD OPTION TABLE II
(Benchmark Total Return is 3% -- Per $1,000 of Net Proceeds)
------------------------------------------------------------------------------------------------------------------------------------
Age of Annuitant Age of Annuitant
Last Birthday When Last Birthday When
First Installment is First Installment is
Payable Monthly Installment Payable Monthly Installment
------------------------------------------------------------------------------------------------------------------------------------
5 Years 10 Years 15 Years 20 Years 5 Years 10 Years 15 Years 20 Years
Male Certain Certain Certain Certain Male Certain Certain Certain Certain
------------------------------------------------------------------------------------------------------------------------------------
65 5.92 5.73 5.41 5.00 75 8.24 7.39 6.34 5.41
66 6.10 5.88 5.51 5.05 76 8.55 7.57 6.42 5.43
67 6.29 6.03 5.61 5.11 77 8.87 7.74 6.48 5.45
68 6.49 6.19 5.71 5.16 78 9.20 7.91 6.54 5.46
69 6.70 6.35 5.81 5.21 79 9.54 8.08 6.59 5.47
70 6.93 6.52 5.91 5.25 80 9.90 8.24 6.64 5.48
71 7.16 6.69 6.01 5.29 81 10.27 8.39 6.68 5.49
72 7.41 6.86 6.10 5.33 82 10.64 8.53 6.72 5.50
73 7.67 7.04 6.19 5.36 83 11.02 8.66 6.75 5.50
74 7.95 7.22 6.27 5.38 84 11.41 8.79 6.77 5.51
85 11.79 8.90 6.80 5.51
------------------------------------------------------------------------------------------------------------------------------------
Form 1192(VA)-NY
Page 31
PAYOUT PERIOD OPTION TABLE II -- VARIABLE ANNUITY ONLY
(Benchmark Total Return is 5% -- Per $1,000 of Net Proceeds)
-----------------------------------------------------------------------------------------------------------------------------------
Age of Annuitant Age of Anuitant
Last Birthday When Last Birthday When
First Installment is First Installment is
Payable Monthly Installment Payable Monthly Installment
-----------------------------------------------------------------------------------------------------------------------------------
5 Years 10 Years 15 Years 20 Years 5 Years 10 Years 15 Years 20 Years
Male Certain Certain Certain Certain Male Certain Certain Certain Certain
------------------------------------------------------------------------------------------------------------------------------------
15 4.31 4.30 4.30 4.30 40 4.88 4.87 4.84 4.81
16 4.32 4.32 4.31 4.31 41 4.92 4.91 4.88 4.84
17 4.33 4.33 4.32 4.32 42 4.97 4.95 4.92 4.88
18 4.34 4.34 4.34 4.33 43 5.02 5.00 4.96 4.92
19 4.36 4.35 4.35 4.34 44 5.07 5.04 5.01 4.95
20 4.37 4.37 4.36 4.36 45 5.12 5.09 5.05 5.00
21 4.38 4.38 4.38 4.37 46 5.17 5.15 5.10 5.04
22 4.40 4.40 4.39 4.39 47 5.23 5.20 5.15 5.08
23 4.42 4.41 4.41 4.40 48 5.29 5.26 5.20 5.13
24 4.43 4.43 4.42 4.42 49 5.35 5.32 5.25 5.17
25 4.45 4.45 4.44 4.43 50 5.42 5.38 5.31 5.22
26 4.47 4.47 4.46 4.45 51 5.49 5.44 5.37 5.27
27 4.49 4.49 4.48 4.47 52 5.57 5.51 5.43 5.32
28 4.51 4.51 4.50 4.49 53 5.64 5.59 5.49 5.37
29 4.53 4.53 4.52 4.51 54 5.73 5.66 5.56 5.43
30 4.56 4.55 4.54 4.53 55 5.81 5.74 5.63 5.48
31 4.58 4.58 4.57 4.55 56 5.91 5.83 5.71 5.54
32 4.61 4.60 4.59 4.58 57 6.01 5.92 5.78 5.60
33 4.64 4.63 4.62 4.60 58 6.11 6.01 5.86 5.65
34 4.67 4.66 4.65 4.63 59 6.22 6.12 5.94 5.71
35 4.70 4.69 4.68 4.65 60 6.34 6.22 6.03 5.77
36 4.73 4.72 4.71 4.68 61 6.47 6.33 6.11 5.83
37 4.76 4.75 4.74 4.71 62 6.61 6.45 6.20 5.89
38 4.80 4.79 4.77 4.74 63 6.76 6.58 6.29 5.94
39 4.84 4.83 4.81 4.77 64 6.91 6.70 6.38 6.00
------------------------------------------------------------------------------------------------------------------------------------
Form 1192(VA)-NY
Page 32
PAYOUT PERIOD OPTION TABLE II -- VARIABLE ANNUITY ONLY
(Benchmark Total Return is 5% -- Per $1,000 of Net Proceeds)
-----------------------------------------------------------------------------------------------------------------------------------
Age of Annuitant Age of Anuitant
Last Birthday When Last Birthday When
First Installment is First Installment is
Payable Monthly Installment Payable Monthly Installment
-----------------------------------------------------------------------------------------------------------------------------------
5 Years 10 Years 15 Years 20 Years 5 Years 10 Years 15 Years 20 Years
Male Certain Certain Certain Certain Male Certain Certain Certain Certain
65 7.08 6.84 6.48 6.05 75 9.37 8.42 7.34 6.42
66 7.25 6.98 6.57 6.10 76 9.67 8.59 7.40 6.44
67 7.44 7.13 6.67 6.15 77 9.98 8.75 7.46 6.45
68 7.64 7.28 6.76 6.19 78 10.31 8.91 7.51 6.47
69 7.85 7.43 6.85 6.24 79 10.65 9.06 7.56 6.48
70 8.07 7.59 6.94 6.28 80 11.00 9.21 7.61 6.49
71 8.30 7.75 7.03 6.31 81 11.36 9.35 7.64 6.49
72 8.55 7.92 7.11 6.34 82 11.72 9.49 7.68 6.50
73 8.81 8.08 7.19 6.37 83 12.09 9.61 7.71 6.50
74 9.08 8.25 7.27 6.40 84 12.47 9.73 7.73 6.51
85 12.84 9.83 7.75 6.51
------------------------------------------------------------------------------------------------------------------------------------
Form 1192(VA)-NY
Page 33
PAYOUT PERIOD OPTION TABLE II
(Benchmark Total Return is 3% -- Per $1,000 of Net Proceeds)
-----------------------------------------------------------------------------------------------------------------------------------
Age of Annuitant Age of Anuitant
Last Birthday When Last Birthday When
First Installment is First Installment is
Payable Monthly Installment Payable Monthly Installment
------------------------------------------------------------------------------------------------------------------------------------
5 Years 10 Years 15 Years 20 Years 5 Years 10 Years 15 Years 20 Years
Female Certain Certain Certain Certain Female Certain Certain Certain Certain
15 2.85 2.85 2.85 2.85 40 3.41 3.40 3.40 3.38
16 2.87 2.87 2.86 2.86 41 3.44 3.44 3.43 3.42
17 2.88 2.88 2.88 2.88 42 3.48 3.48 3.47 3.45
18 2.89 2.89 2.89 2.89 43 3.52 3.52 3.51 3.49
19 2.91 2.91 2.91 2.91 44 3.57 3.56 3.55 3.53
20 2.92 2.92 2.92 2.92 45 3.61 3.60 3.59 3.57
21 2.94 2.94 2.94 2.94 46 3.66 3.65 3.64 3.61
22 2.96 2.96 2.95 2.95 47 3.71 3.70 3.68 3.66
23 2.97 2.97 2.97 2.97 48 3.76 3.75 3.73 3.70
24 2.99 2.99 2.99 2.99 49 3.81 3.80 3.78 3.75
25 3.01 3.01 3.01 3.00 50 3.87 3.86 3.84 3.80
26 3.03 3.03 3.03 3.02 51 3.93 3.92 3.89 3.85
27 3.05 3.05 3.05 3.04 52 4.00 3.98 3.95 3.90
28 3.07 3.07 3.07 3.06 53 4.06 4.04 4.01 3.96
29 3.09 3.09 3.09 3.08 54 4.13 4.11 4.08 4.02
30 3.12 3.11 3.11 3.11 55 4.21 4.18 4.14 4.08
31 3.14 3.14 3.13 3.13 56 4.29 4.26 4.21 4.14
32 3.16 3.16 3.16 3.15 57 4.37 4.34 4.29 4.20
33 3.19 3.19 3.18 3.18 58 4.46 4.42 4.36 4.27
34 3.22 3.21 3.21 3.20 59 4.55 4.51 4.44 4.33
35 3.24 3.24 3.24 3.23 60 4.65 4.61 4.53 4.40
36 3.27 3.27 3.27 3.26 61 4.76 4.71 4.61 4.47
37 3.30 3.30 3.30 3.29 62 4.87 4.81 4.71 4.54
38 3.34 3.33 3.33 3.32 63 4.99 4.92 4.80 4.62
39 3.37 3.37 3.36 3.35 64 5.11 5.04 4.90 4.69
------------------------------------------------------------------------------------------------------------------------------------
Form 1192(VA)-NY
Page 34
PAYOUT PERIOD OPTION TABLE II
(Benchmark Total Return is 3% -- Per $1,000 of Net Proceeds)
------------------------------------------------------------------------------------------------------------------------------------
Age of Annuitant Age of Anuitant
Last Birthday When Last Birthday When
First Installment is First Installment is
Payable Monthly Installment Payable Monthly Installment
------------------------------------------------------------------------------------------------------------------------------------
5 Years 10 Years 15 Years 20 Years 5 Years 10 Years 15 Years 20 Years
Female Certain Certain Certain Certain Female Certain Certain Certain Certain
------------------------------------------------------------------------------------------------------------------------------------
65 5.25 5.16 5.00 4.76 75 7.23 6.78 6.09 5.34
66 5.39 5.29 5.10 4.83 76 7.52 6.98 6.19 5.37
67 5.54 5.43 5.21 4.90 77 7.82 7.18 6.29 5.40
68 5.71 5.57 5.32 4.97 78 8.14 7.38 6.37 5.42
69 5.88 5.72 5.43 5.03 79 8.48 7.58 6.45 5.44
70 6.07 5.88 5.55 5.10 80 8.83 7.78 6.52 5.46
71 6.27 6.05 5.66 5.15 81 9.21 7.98 6.58 5.47
72 6.49 6.22 5.77 5.21 82 9.61 8.16 6.63 5.48
73 6.72 6.40 5.88 5.26 83 10.02 8.34 6.68 5.49
74 6.97 6.59 5.99 5.30 84 10.44 8.50 6.72 5.50
85 10.88 8.65 6.75 5.50
------------------------------------------------------------------------------------------------------------------------------------
Form 1192(VA)-NY
Page 35
PAYOUT PERIOD OPTION TABLE II -- VARIABLE ANNUITY ONLY
(Benchmark Total Return is 5% -- Per $1,000 of Net Proceeds)
------------------------------------------------------------------------------------------------------------------------------------
Age of Annuitant Age of Anuitant
Last Birthday When Last Birthday When
First Installment is First Installment is
Payable Monthly Installment Payable Monthly Installment
-----------------------------------------------------------------------------------------------------------------------------------
5 Years 10 Years 15 Years 20 Years 5 Years 10 Years 15 Years 20 Years
Female Certain Certain Certain Certain Female Certain Certain Certain Certain
------------------------------------------------------------------------------------------------------------------------------------
15 4.24 4.24 4.24 4.24 40 4.67 4.66 4.65 4.64
16 4.25 4.25 4.25 4.24 41 4.70 4.69 4.68 4.66
17 4.26 4.26 4.26 4.25 42 4.73 4.73 4.71 4.69
18 4.27 4.27 4.26 4.26 43 4.77 4.76 4.75 4.73
19 4.28 4.28 4.27 4.27 44 4.81 4.80 4.78 4.76
20 4.29 4.29 4.28 4.28 45 4.85 4.84 4.82 4.79
21 4.30 4.30 4.30 4.29 46 4.89 4.88 4.86 4.83
22 4.31 4.31 4.31 4.30 47 4.93 4.92 4.90 4.87
23 4.32 4.32 4.32 4.32 48 4.98 4.97 4.94 4.90
24 4.34 4.34 4.33 4.33 49 5.03 5.01 4.99 4.95
25 4.35 4.35 4.35 4.34 50 5.08 5.06 5.03 4.99
26 4.37 4.36 4.36 4.35 51 5.14 5.12 5.08 5.03
27 4.38 4.38 4.37 4.37 52 5.20 5.17 5.13 5.08
28 4.40 4.39 4.39 4.38 53 5.26 5.23 5.19 5.13
29 4.41 4.41 4.41 4.40 54 5.32 5.30 5.25 5.18
30 4.43 4.43 4.42 4.42 55 5.39 5.36 5.31 5.23
31 4.45 4.45 4.44 4.43 56 5.47 5.43 5.37 5.28
32 4.47 4.46 4.46 4.45 57 5.55 5.51 5.44 5.34
33 4.49 4.49 4.48 4.47 58 5.63 5.58 5.51 5.40
34 4.51 4.51 4.50 4.49 59 5.72 5.67 5.58 5.46
35 4.53 4.53 4.52 4.51 60 5.81 5.76 5.66 5.52
36 4.56 4.55 4.55 4.54 61 5.92 5.85 5.74 5.58
37 4.58 4.58 4.57 4.56 62 6.02 5.95 5.82 5.64
38 4.61 4.60 4.60 4.58 63 6.14 6.05 5.91 5.71
39 4.64 4.63 4.62 4.61 64 6.26 6.16 6.00 5.77
------------------------------------------------------------------------------------------------------------------------------------
PAYOUT PERIOD OPTION TABLE II -- VARIABLE ANNUITY ONLY
(Benchmark Total Return is 5% -- Per $1,000 of Net Proceeds)
------------------------------------------------------------------------------------------------------------------------------------
Age of Annuitant Age of Anuitant
Last Birthday When Last Birthday When
First Installment is First Installment is
Payable Monthly Installment Payable Monthly Installment
------------------------------------------------------------------------------------------------------------------------------------
5 Years 10 Years 15 Years 20 Years 5 Years 10 Years 15 Years 20 Years
Female Certain Certain Certain Certain Female Certain Certain Certain Certain
------------------------------------------------------------------------------------------------------------------------------------
65 6.39 6.28 6.09 5.84 75 8.35 7.83 7.10 6.35
66 6.53 6.40 6.19 5.90 76 8.63 8.02 7.19 6.38
67 6.68 6.53 6.29 5.96 77 8.92 8.21 7.28 6.41
68 6.84 6.67 6.39 6.02 78 9.24 8.40 7.36 6.43
69 7.01 6.81 6.49 6.08 79 9.58 8.59 7.43 6.45
70 7.20 6.97 6.60 6.14 80 9.93 8.78 7.49 6.46
71 7.40 7.13 6.70 6.19 81 10.30 8.96 7.55 6.48
72 7.61 7.29 6.81 6.24 82 10.69 9.14 7.60 6.49
73 7.84 7.47 6.91 6.28 83 11.10 9.31 7.64 6.49
74 8.08 7.65 7.01 6.32 84 11.52 9.46 7.68 6.50
85 11.95 9.60 7.71 6.50
------------------------------------------------------------------------------------------------------------------------------------
Form 1192(VA)-NY
Page 37
PAYOUT PERIOD OPTION TABLE II
(Benchmark Total Return is 3% -- Per $1,000 of Net Proceeds)
------------------------------------------------------------------------------------------------------------------------------------
Age of Annuitant Age of Anuitant
Last Birthday When Last Birthday When
First Installment is First Installment is
Payable Monthly Installment Payable Monthly Installment
------------------------------------------------------------------------------------------------------------------------------------
5 Years 10 Years 15 Years 20 Years 5 Years 10 Years 15 Years 20 Years
Unisex Certain Certain Certain Certain Unisex Certain Certain Certain Certain
------------------------------------------------------------------------------------------------------------------------------------
20 2.98 2.98 2.97 2.97 45 3.75 3.74 3.72 3.69
21 2.99 2.99 2.99 2.99 46 3.81 3.79 3.77 3.73
22 3.01 3.01 3.01 3.01 47 3.86 3.85 3.82 3.78
23 3.03 3.03 3.03 3.02 48 3.92 3.91 3.88 3.83
24 3.05 3.05 3.05 3.04 49 3.98 3.96 3.93 3.88
25 3.07 3.07 3.07 3.06 50 4.05 4.03 3.99 3.93
26 3.09 3.09 3.09 3.09 51 4.11 4.09 4.05 3.99
27 3.12 3.12 3.11 3.11 52 4.19 4.16 4.11 4.04
28 3.14 3.14 3.14 3.13 53 4.26 4.23 4.18 4.10
29 3.17 3.16 3.16 3.15 54 4.34 4.31 4.25 4.16
30 3.19 3.19 3.18 3.18 55 4.42 4.39 4.32 4.22
31 3.22 3.22 3.21 3.20 56 4.51 4.47 4.40 4.29
32 3.25 3.24 3.24 3.23 57 4.60 4.56 4.47 4.35
33 3.27 3.27 3.27 3.26 58 4.70 4.65 4.56 4.42
34 3.31 3.30 3.30 3.29 59 4.81 4.75 4.64 4.48
35 3.34 3.33 3.33 3.32 60 4.92 4.85 4.73 4.55
36 3.37 3.37 3.36 3.35 61 5.04 4.96 4.82 4.62
37 3.41 3.40 1.39 3.38 62 5.16 5.07 4.91 4.69
38 3.44 3.44 3.43 3.41 63 5.30 5.19 5.01 4.75
39 3.48 3.48 3.47 3.45 64 5.44 5.32 5.11 4.82
40 3.52 3.52 3.50 3.49 65 5.59 5.45 5.21 4.89
41 3.56 3.56 3.54 3.52 66 5.75 5.59 5.32 4.95
42 3.61 3.60 3.59 3.56 67 5.92 5.73 5.42 5.01
43 3.66 3.65 3.63 3 60 68 6.10 5.89 5.53 5.07
44 3.70 3.69 3.67 3.65 69 6.29 6.04 5.63 5.13
------------------------------------------------------------------------------------------------------------------------------------
Form 1192(VA)-NY
Page 38
PAYOUT PERIOD OPTION TABLE II
(Benchmark Total Return is 3% -- Per $1,000 of Net Proceeds)
------------------------------------------------------------------------------------------------------------------------------------
Age of Annuitant Age of Anuitant
Last Birthday When Last Birthday When
First Installment is First Installment is
Payable Monthly Installment Payable Monthly Installment
-----------------------------------------------------------------------------------------------------------------------------------
5 Years 10 Years 15 Years 20 Years 5 Years 10 Years 15 Years 20 Years
Unisex Certain Certain Certain Certain Unisex Certain Certain Certain Certain
------------------------------------------------------------------------------------------------------------------------------------
70 6.50 6.21 5.74 5.18 80 9.37 8.02 6.59 5.47
71 6.72 6.38 5.84 5.23 81 9.74 8.19 6.64 5.48
72 6.95 6.55 5.95 5.27 82 10.12 8.35 6.68 5.49
73 7.20 6.73 6.04 5.31 83 10.52 8.51 6.72 5.50
74 7.46 6.91 6.14 5.35 84 10.92 8.65 6.75 5.50
75 7.74 7.10 6.23 5.38 85 11.33 8.78 6.78 5.51
76 8.03 7.29 6.31 5.40
77 8.34 7.47 6.39 5.43
78 8.67 7.66 6.46 5.45
79 9.01 7.84 6.53 5.46
------------------------------------------------------------------------------------------------------------------------------------
Form 1192(VA)-NY
Page 39
PAYOUT PERIOD OPTION TABLE II -- VARIABLE ANNUITY ONLY
(Benchmark Total Return is 5% -- Per $1,000 of Net Proceeds)
------------------------------------------------------------------------------------------------------------------------------------
Age of Annuitant Age of Anuitant
Last Birthday When Last Birthday When
First Installment is First Installment is
Payable Monthly Installment Payable Monthly Installment
-----------------------------------------------------------------------------------------------------------------------------------
5 Years 10 Years 15 Years 20 Years 5 Years 10 Years 15 Years 20 Years
Unisex Certain Certain Certain Certain Unisex Certain Certain Certain Certain
------------------------------------------------------------------------------------------------------------------------------------
20 4.33 4.33 4.32 4.32 45 4.98 4.97 4.93 4.89
21 4.34 4.34 4.34 4.33 46 5.03 5.01 4.98 4.93
22 4.36 4.35 4.35 4.34 47 5.08 5.06 5.02 4.97
23 4.37 4.37 4.36 4.36 48 5.14 5.11 5.07 5.02
24 4.39 4.38 4.38 4.37 49 5.19 5.16 5.12 5.06
25 4.40 4.40 4.39 4.39 50 5.25 5.22 5.17 5.10
26 4.42 4.41 4.41 4.40 51 5.31 5.28 5.23 5.15
27 4.44 4.43 4.43 4.42 52 5.38 5.34 5.28 5.20
28 4.45 4.45 4.44 4.44 53 5.45 5.41 5.34 5.25
29 4.47 4.47 4.46 4.46 54 5.52 5.48 5.40 5.30
30 4.49 4.49 4.48 4.47 55 5.60 5.55 5.47 5.36
31 4.52 4.51 4.50 4.49 56 5.69 5.63 5.54 5.41
32 4.54 4.53 4.53 4.52 57 5.78 5.71 5.61 5.47
33 4.56 4.56 4.55 4.54 58 5.87 5.80 5.68 5.53
34 4.59 4.58 4.57 4.56 59 5.97 5.89 5.76 5.58
35 4.61 4.61 4.60 4.58 60 6.08 5.99 5.84 5.64
36 4.64 4.64 4.63 4.61 61 6.19 6.09 5.92 5.70
37 4.67 4.67 4.65 4.64 62 6.32 6.20 6.01 5.77
38 4.71 4.70 4.68 4.66 63 6.45 6.31 6.10 5.83
39 4.74 4.73 4.71 4.69 64 6.59 6.43 6.19 5.89
40 4.77 4.76 4.75 4.72 65 6.73 6.56 6.28 5.94
41 4.81 4.80 4.78 4.75 66 6.89 6.69 6.38 6.00
42 4.85 4.84 4.82 4.79 67 7.06 6.83 6.48 6.06
43 4.89 4.88 4.85 4.82 68 7.24 6.97 6.57 6.11
44 4.94 4.92 4.89 4.86 69 7.43 7.12 6.67 6.16
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Form 1192(VA)-NY
Page 40
PAYOUT PERIOD OPTION TABLE II -- VARIABLE ANNUITY ONLY
(Benchmark Total Return is 5% -- Per $1,000 of Net Proceeds)
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Age of Annuitant Age of Anuitant
Last Birthday When Last Birthday When
First Installment is First Installment is
Payable Monthly Installment Payable Monthly Installment
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5 Years 10 Years 15 Years 20 Years 5 Years 10 Years 15 Years 20 Years
Unisex Certain Certain Certain Certain Unisex Certain Certain Certain Certain
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70 7.63 7.28 6.77 6.21 80 10.47 9.00 7.55 6.47
71 7.85 7.44 6.86 6.25 81 10.83 9.16 7.60 6.48
72 8.08 7.60 6.96 6.29 82 11.21 9.31 7.64 6.49
73 8.32 7.78 7.05 6.33 83 11.60 9.46 7.67 6.50
74 8.58 7.95 7.14 6.36 84 11.99 9.59 7.70 6.50
75 8.86 8.13 7.22 6.39 85 12.39 9.72 7.73 6.51
76 9.15 8.30 7.30 6.41
77 9.45 8.48 7.37 6.43
78 9.78 8.66 7.44 6.45
79 10.11 8.83 7.50 6.46
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Form 1192(VA)-NY
Page 41
This Contract is a FLEXIBLE PREMIUM DEFERRED COMBINATION FIXED AND VARIABLE
ANNUITY CONTRACT.
Annuity Payouts and other values provided by this Contract, when based on the
Investment experience of a separate account, are variable. These values may
increase or decrease based on investment experience and are not guaranteed as to
fixed dollar amount. ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ begin as of the Annuity Date. Purchase
Payments are flexible and may be made until the Annuity Date. The Guaranteed
Death Benefit will be paid if the Owner dies prior to the Annuity Date.
FIRST ING LIFE INSURANCE COMPANY OF NEW YORK
A Stock Company
Customer Service Center
P.O. Box 173763, Denver, Colorado 80217
Toll-free Telephone Number: ▇ (▇▇▇) ▇▇▇-▇▇▇▇
Form 1192(VUL) - NY