Providentmutual Life and Annuity Company of America A Stock Life Insurance Company Philadelphia, Pennsylvania
Providentmutual
Life and Annuity Company of America
A Stock
Life Insurance Company
Philadelphia,
Pennsylvania
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ANNUITANT
CONTRACT
NUMBER
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▇▇▇▇
▇▇▇
123456
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02-01-92
02-01-22
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ISSUE
DATE
MATURITY
DATE
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In this
Contract, Providentmutual Life and Annuity Company of America will be referred
to as "we," us" or "our." The Owner ("you," "your") is the Annuitant, unless
another person is named in the application or later becomes the Owner as allowed
by this Contract.
We agree
to pay the proceeds as described in this Contract, subject to its
provisions.
Annuity
payments and other values provided by this Contract, including any death benefit
that may be payable, when based on the investment experience of the Variable
Account may increase or decrease daily, depending upon the investment
performance of the Fund Portfolios in which your chosen Subaccounts are invested
and are not guaranteed as to fixed dollar amounts. No minimum
Contract Account Value is guaranteed, except for any amounts in the Guaranteed
Account.
PLEASE
READ THIS CONTRACT CAREFULLY
It
is a legal contract between you and us.
NOTICE
OF 10 DAY RIGHT TO EXAMINE CONTRACT
Please
examine this Contract closely. If for any reason you are not
satisfied with this Contract, you may return it to us for cancellation by
delivering or mailing it to:
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1.
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our
Home Office, ▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇.▇. Box 7326, Philadelphia,
Pennsylvania 19101;
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2.
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one
of our agency offices; or
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3.
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the
agent through whom it was
purchased.
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This
Contract must be returned to us no later than 10 days after you first receive
it. Upon such delivery or mailing, this Contract will be void as of
the date we receive your Contract and request. We will return the
greater of: (i) the amount of premiums you paid; (ii) the
Contract Account Value plus any charges we deducted, except the mortality and
expense risk charge and the advisory fees and expenses of the Fund.
Signed
for the Company in Philadelphia, Pennsylvania
///////////s///////////// ///////////s/////////////
Secretary President
FLEXIBLE
PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT
Flexible
premiums as stated in the Premiums Provision.
Policy
values are variable, except for amounts in the Guaranteed Account.
After the
Maturity Date, Payment Options are on a guaranteed basis.
Death
benefit payable upon death of Annuitant before Maturity Date.
Non-participating
– Policy does not pay dividends.
A
GUIDE TO THE PROVISIONS OF THIS CONTRACT
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Page
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Page
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Contract
Schedule……………………
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5
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Guaranteed
Account ………...
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8
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Description
of Subaccounts …………
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4
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Allocations
and Transfers……
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9
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Definitions…………………………..
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5
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Contract
Values……………...
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9-10
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General
Previsions …………………..
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5
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Payment
of Proceeds………..
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11
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Premiums…………………………….
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7
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Payment
Options………..……
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12-13
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Variable
Account ……………………
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7-8
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A
copy of the Application and any riders are included between pages 12 and
13
ENDORSEMENTS
(To
be made by the Company only)
CONTRACT
SCHEDULE
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ANNUITANT
CONTRACT
NUMBER
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▇▇▇▇ ▇▇▇
123456
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02-01-92
02-01-22
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ISSUE DATE
MATURITY DATE
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Initial
Premium Payment:
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$2,000
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Minimum
Additional Premium Amount
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$100
[
$50 for Qualified Contracts]
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Planned
Periodic Premium:
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$100
monthly
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Minimum
Withdrawal Amount:
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$500
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Minimum
Transfer Amount:
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$500
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Minimum
remaining Cash Surrender Value
After
Withdrawal:
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$2,000
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Charges and Fees
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||||
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Annual
Mortality and Expense Risk Charge:
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Current
–
Maximum
–
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1.10%
1.25%
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Annual
Administration Fee
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$30.00
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Transfer
Processing Fee:
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$25
after 1st
four in Contract Year
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Surrender
Charges*
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Contract Year
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Charge
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1
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6%
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|||
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2
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5%
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3
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4%
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4
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3%
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5
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2%
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6
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1%
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7
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0
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*
Applies to amount withdrawn or surrendered during Contract year in excess
of 10% of Contract Account Value as of the beginning of such Contract
Year. See "Surrender Charge" on page 10 for details and
restrictions.
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||||
Contract Schedule –
continued
Description
of Subaccounts of
Providentmutual
Variable Annuity Separate Account
Each
Subaccount listed invests in shares of its respective Portfolio of The Market
Street Fund, inc., a series type of mutual fund.
Growth
Subaccount. Investments of the Growth Portfolio will be,
primarily, common stocks of companies believed to offer above-average growth
potential over both the intermediate and long term.
Money Market
Subaccount. Investments of the money Market Portfolio will be,
primarily, money market instruments such as: United States (U.S.)
Government Securities; bank obligations and instruments secured thereby;
commercial paper and certain debt obligations; repurchase agreements; and
certain other obligations.
Bond
Subaccount. Investments of the bond Portfolio will be,
primarily, a diversified portfolio of marketable debt securities.
Managed
Subaccount. Investments of the Managed Portfolio will be those
types of securities that are permissible investments of other
portfolios. This portfolio may be invested solely in common stocks,
solely in money market instruments, solely in bonds, or in a combination of
these types of investments.
Aggressive Growth
Subaccount. Investments of the international Portfolio will
be, primarily, securities of non-United States companies selected primarily for
long-term capital growth.
DEFINITIONS
ANNUITANT. The
person whose life determines that annuity benefits payable under this contract
and whose death determines the death benefit.
BENEFICIARY. The
person to whom we will pay the proceeds payable on your death or on the death of
the Annuitant.
CASH SURRENDER
VALUE. The Contract Account Value less any applicable
surrender charge.
CONTRACT ACCOUNT VALUE.
The sum of the Variable Account Value and the guaranteed
Account Value.
CONTRACT YEARS, MONTHS,
ANNIVERSARIES. Are calculated from the Issue Date shown in
the Contract Schedule.
GUARANTEED
ACCOUNT. This account is part of our General Account and is
not part of nor depends upon investment performance of the Variable
Account.
HOME OFFICE. Our
office at ▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇.▇. Box 7326, Philadelphia,
Pennsylvania 19101.
MATURITY DATE. The
date when the Contract Account Value will be applied under a Payment Option,
unless you have elected to receive a lump sum payment of the Cash Surrender
Value. The (XXXX) Maturity Date is the later of: the
Contract Anniversary nearest Annuitant's age 85, or 10 years after the
Date of the Contract.
NET PREMIUM. The
premium paid less any premium tax levied for the year the premium is
paid.
OWNER. The person
entitled to exercise all rights and privileges provided in this
Contract.
SUBACCOUNT. The
Variable Account has Subaccounts; the assets of each Subaccount are invested in
a corresponding Portfolio of the Market Street Fund, Inc.
VALUATION DAY. Each
day on which valuation of the assets of a Subaccount is required by applicable
law.
VALUATION PERIOD.
The period that starts at the close of business on the Valuation Day and ends at
the close of business on the next succeeding Valuation Day.
VARIABLE
ACCOUNT. Providentmutual Variable Annuity Separate Account
which is not part of our general Account. The Variable Account has
Subaccounts each of which is invested in a corresponding Portfolio of the Market
Street Fund, Inc.
WRITTEN NOTICE. A
written request or notice in a form satisfactory to us which is signed by you
and received at our Home Office.
GENERAL
PROVISIONS
THE CONTRACT. We
have issued this Policy in consideration of your application and your payment of
the initial Premium. The entire contract is made up of this policy
and the attached copy of the application. The statements made in the
application are, in the absence of fraud, deemed representations and not
warranties. We cannot use any statement in defense to a claim or to
void this policy unless it is contained in the attached
application. Only our President, a Vice president, or Secretary may
modify this policy or waive any of our rights or requirements. No
agent may bind us by making any promise not contained in this
policy.
INCONTESTABILITY. We
will not contest this contract after it has been in force during the Annuitant's
lifetime for two years from the Issue Date.
OWNER. During the
Annuitant's lifetime and before the maturity Date, you have all the rights and
privileges granted by this Contract. During the Annuitant's lifetime
and before the Maturity Date, you may name a new Owner by giving us Written
Notice. If you are not the Annuitant and you die before the maturity
Date and before the Annuitant, ownership will pass:
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1.
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to
your designated beneficiary, if any (as defined in "Proceeds On Death of
Owner");
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2.
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to
your estate.
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BENEFICIARY. We
will pay the beneficiary any proceeds payable on your death or the death of the
Annuitant. During the Annuitant's lifetime and before the maturity
Date, you may change the named Beneficiary by giving us Written Notice of such
change.
We
will pay the proceeds under the beneficiary designation in effect at the date of
death. The proceeds will be paid to the surviving Beneficiaries
equally unless you have indicated otherwise. If no Beneficiary is
living when the Annuitant dies, or if none has been named, the proceeds will be
paid to you or your estate. If no Beneficiary is living when you die,
any proceeds will be paid to your estate.
CHANGE OF OWNER OR
BENEFICIARY. Written Notice must be signed by you, dated, and
of a form and content acceptable to us. Your Written notice will not
be effective until we receive and file it at our Home
office. However, the change provided in your Written notice will then
be effective as of the date you signed such notice:
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1.
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subject
to any payments mad or other action we take before we receive and file
your Written Notice; and
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2.
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whether
or not you or the Annuitant are alive when we receive and file your
Written Notice.
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ASSIGNMENT. You may
assign this policy or an interest in it at any time before the Maturity Date
during the lifetime of the Annuitant. An assignment must be in a
Written Notice acceptable to us. It will not be binding on us until
we receive and file it at our Home Office. We are not responsible for
the validity or sufficiency of any assignment. Your rights and the
rights of any beneficiary will be affected by an assignment.
MISSTATMENT OF AGE OR
SEX. If the age or sex off the Annuitant has been misstated,
we will pay the amount which the proceeds would have purchased at the correct
age and sex. If we make an overpayment because of an error in age or
sex, the overpayment plus interest at 3% compounded annually will be a debt
against this contract. If the debt is not repaid, future payments
will be reduced accordingly.
If we
make an underpayment because of an error in age or sex, any annuity payments
will be recalculated at the correct age and sex, and future payments will be
adjusted. The underpayment with interest at 3% compounded annually
will be paid in a single sum.
PERIODIC
REPORTS. We will mail you a report showing the following
items.
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1.
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the
number of units credited to this Contract and the dollar value of a
unit;
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2.
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the
Contract Account Value and Cash Surrender
Value.
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3.
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any
premiums paid, withdrawals, and charges made since the last report
and
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4.
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any
other information required by law.
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The
information in the report will be as of a date not more than two months before
the date of the mailing. We will mail the report to you;
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1.
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at
least annually, or more often as required by law;
and
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2.
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to
your last address known to us.
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MODIFICATION. Upon notice to
you, we may modify the contract, but only if such modification:
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1.
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is
necessary to make the Contract or the Variable Account comply with any law
or regulation issued by a governmental agency to which we are subject;
or
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2.
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is
necessary to assure continued qualification of the contract under the
Internal Revenue Code or other federal or state laws relating to
retirement annuities or variable annuity policies;
or
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3.
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is
necessary to reflect a change in the operation of the Variable Account;
or
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4.
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provides
additional variable account and or fixed accumulation
options.
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In
the event of any such modification, we may make appropriate endorsement to the
contract.
NON-PARTICIPATION. This
Contract is non-participating and does not share in our profits or surplus
earnings.
PROTECTION OFF
PROCEEDS. No beneficiary may commute, encumber or alienate any
payments under this Contract before they are due. No annuity payments
shall be subject to the debts, contract or engagements of any Beneficiary nor to
any judicial process to levy upon or attach the same for payment of such
debts.
CREDITOR CLAIMS. To
the extent permitted baby applicable laws, no right or benefit under this
Contract shall be subject to claims of creditors, except as may be provided by
an Assignment.
DISCHARGE OF
LIABILITY. We shall be discharged from all liability to the
extent of any withdrawal, surrender or death benefit paid. Any
payments made by us under any Payment Option shall discharge our liability to
the extent of each such payment.
PREMIUMS
INITIAL
PREMIUM. The Initial Premium is shown in the
Contract Schedule and is payable on or before the Contract Date.
ADDITIONAL
PREMIUMS. You may make additional premium payments at any time
during the Annuitant's lifetime and before the maturity date. The
amount of additional premium payments may vary. The minimum
additional premium that we will accept is shown in the Contract
Schedule.
NET
PREMIUM. The Net premium is the premium paid less
any premium tax levied on us relating to this Contract for the year the premium
is paid.
THE
VARIABLE ACCOUNT
VARIABLE
ACCOUNT. We have established the Providentmutual Variable
Annuity Separate Account (the "Variable Account"). The variable
Account is registered with the Securities and Exchange Commission as a unit
investment trust under the Investment Company Act of 1940. The
Variable Account is also subject to the laws of the Commonwealth of
Pennsylvania.
Although
we own the assets in the Variable Account, these assets are held separately from
our other assets and are not part of our General Account. The assets
in the Variable Account are used to support the operation of and provide the
variable values and benefits for this contract and similar
Contracts.
The
portion of the assets of the Variable Account equal to the reserves and other
contract liabilities of the Variable Account will not be charged with
liabilities that arise from any other business that we conduct. We
have the right to transfer to our General Account any assets of the Variable
Account which are in excess of such reserves and other liabilities.
SUBACCOUNTS. The
Variable Account currently consists of the Subaccount listed in the Contract
Schedule and in the current Prospectus you received. Each Subaccount
invests in shares of a corresponding series of The Market Street Fund, Inc (the
"Fund"). Shares of a series are purchased and redeemed for a Subaccount as their
net asset value. Any amounts of income, dividends and gains
distributed from the shares of a series will be reinvested in additional shares
of that series at its net asset value. The Fund prospectuses you
received define the net asset value and describe each portfolio of the
Fund.
The
dollar amounts of values and benefits of this policy provided by the Variable
Account depend on the investment performance of the portfolios of the Fund in
which your selected Subaccounts are invested. We do not guarantee the
investment performance of the portfolios. You bear the full
investment risk for amounts applied to the selected Subaccounts.
VARIABLE ACCOUNT
VALUE. This Contract's Variable Account Value for any
Valuation Period before
the Maturity Date is determined by multiplying:
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1.
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the
amount of units credited to this Contract for each Subaccount as of the
end of the Valuation Period; by
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2.
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the
current unit value for each
Subaccount.
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The
sum of these amounts equals the Variable Account Value.
UNITS. We credit
net Premiums in the form of units. We will credit units for the
initial net Premium on the issue date. The number of units of each
Subaccount credited under this contract is determined by dividing:
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1.
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the
net premium allocated to that Subaccount
by
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2.
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the
unit value for that Subaccount at the end of the Valuation Period during
which we receive and accept the premium at our Home
Office.
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We
will adjust the unit for any transfers (including any Transfer Fee) in or out of
a Subaccount. We will cancel the appropriate number of units based on
the unit value at the end of the Valuation Period in which any of the following
events occurs;
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1.
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the
Annual Administration Fee showing the Contract Schedule is
assessed;
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2.
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the
date we receive and file your Written Notice for a withdrawal or a cash
surrender;
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3.
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the
maturity Date occurs;
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4.
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the
date we receive due proof of the Annuitant's death;
or
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5.
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the
date the Contract Account Value is distributed upon your
death.
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UNIT VALUE. The
unit value for each Subaccount for the first Valuation period is set at
$1. The unit value for each subsequent Valuation period is determined
by multiplying.
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1.
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the
unit value at the end of the immediately preceding Valuation Period;
by
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2.
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the
net investment factor for the Valuation Period for which the value is
being determined.
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The
unit value for a Valuation Period applies to each day in that
period. The unit value may increase or decrease from one Valuation
Period to the next.
NET INVESTMENT
FACTOR. The net Investment Factor is an index that measures
the investment performance of a Subaccount from the one Valuation Period to the
next. Each Subaccount has a net investment Factor for each Valuation
period, which may be greater than or less than one.
The net investment Factor for each
Subaccount for a Valuation period equals 1 plus the fraction obtained by
dividing (a) by (b) where:
(a) is
the net result of:
1. the investment income,
dividends, and capital gains, realized or unrealized, credited during the
current Valuation period; plus
2. any amount credited or
released from reserves for taxes attributable to the operation of the Subaccount
minus
3. the capital losses,
realized or unrealized charged during the current Valuation Period;
minus
4. any amount charged for
taxes of any amount we set aside during the Valuation period as a reserve for
taxes attributable to the operation or maintenance of the Subaccount
minus
5. the amount charged for
mortality and expense risk for that Valuation Period. This charge
will not exceed the maximum annualized mortality and expense risk charge shown
in the Contract Schedule; and
(b)
is the value of the asset; in the Subaccount at the end of the preceding
Valuation period, adjusted for allocations and transfers to and withdrawals and
transfers from the Subaccount occurring during that preceding Valuation
Period.
RESERVED
RIGHTS. When permitted by law, we reserve the right
to:
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1.
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create
new variable accounts;
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2.
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combine
variable accounts, including the Providentmutual Variable Annuity Separate
Account;
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3.
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remove,
combine or add Subaccounts and make the new Subaccounts available to
contract owners at our discretion;
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4.
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substitute
shares of another portfolio of the Fund or shares of another investment
company for those of the fund
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5.
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add
new portfolios to the Fund;
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6.
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deregister
the Variable account under the Investment Company Act of 1940 if
registration is no longer required;
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7.
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make
any changes required by the investment Company Act of 1940
and
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8.
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operate
the Variable Account as a managed investment company under the Investment
Company Act of 1940 or any other form permitted by
law.
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If
a change is made, we will send you a revised prospectus and any notice required
by law.
CHANGE IN INVESTSMENT
POLICY. The investment policy of a Subaccount may not be
changed unless:
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1.
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the
change is approved, if required, by the Pennsylvania Insurance Department;
and
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2.
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a
statement of such approval is filed, if required, with the insurance
department of the state in which this contract is
delivered.
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THE
GUARANTEED ACCOUNT
GUARANTEED ACCOUNT. Amounts in
the Guaranteed Account are part of our General Account. The
Guaranteed Account is not part of and does not depend on the investment
performance of the Variable Account.
We
credit interest to amounts in the Guaranteed Account at rates we
determine. We guarantee that the effective annual interest rate will
not be less than 4%. We may credit a higher current interest
rate. For the amount in the Guaranteed Account at the beginning of a
calendar year, we will determine such inertest rates in advance off each
calendar year. Such rates will apply to the calendar year which
follows the date of determination. For amounts allocated or
transferred to the Guaranteed Account during a calendar year, we will determine
interest rates applicable to such amounts in advance of the date such amount is
received or transferred. Such rates will apply to the end of the
calendar year in which the payment is received or the transfer is
made.
GUARANTEED ACCOUNT VALUE. This
Contract's Guaranteed Account Value for any Valuation Period before the Maturity
Date is:
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1.
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the
sum of the net Premiums allocated to the Guaranteed Account;
plus
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2.
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any
amount transferred to the Guaranteed Account from a Subaccount of the
Variable Account; minus
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3.
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any
amounts withdrawn or transferred from the Guaranteed Account together with
any associated charges; minus
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4.
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any
Annual Administration Fee deducted from the amount in the Guaranteed
Account; plus
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5.
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interest
we credit to the amount in the Guaranteed
Account.
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For the
purpose off crediting interest, amounts deducted, transferred, and withdrawn
form the Guaranteed Account will be accounted for on a lasting, first-out
basis.
ALLOCATIONS
AND TRANSFERS
NET PREMIUM
ALLOCATION. In your application you selected how you wanted
your Initial Net Premium to be allocate among the Subaccounts and the guaranteed
Account.
We will
allocate that portion of the Initial net premium which is to be allocated to the
Variable Account to the Money market Subaccount for a 15-day
period. At the end of such period, we will allocate the amount in the
monetary market Subaccount to each of the chosen Subaccounts based on the
proportion that the allocation percentage for such Subaccount bears to the sum
of the Subaccount premium allocation percentages. You may change the
allocation schedule by Written notice. Any additional net Premiums
will be allocated in accordance with the allocation schedule in effect when such
premium is received, unless at the time of payment we receive Written notice to
the contrary. The portion of a Net Premium too be applied to each
elected Subaccount and the guaranteed account must be a whole
percentage.
TRANSFER PRIVILEGE. Before the
Maturity Date, you may transfer all or part of the amount in the Subaccount(s)
to another Subaccount(s) or to the Guaranteed Account, or transfer a part of an
amount in the Guaranteed Account to the Subaccount(s), subject to the
availability of a Subaccount or shares of a portfolio and subject to these
general restrictions and the additional restrictions below:
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1.
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the
minimum transfer amount is shown in the Policy Schedule (or the entire
amount in the Subaccount or the Guaranteed Account, if less);
and
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2.
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a
transfer request that would reduce the amount in that Subaccount or the
Guaranteed Account below $500 will be treated as a transfer request for
the entire amount in that Subaccount or the Guaranteed
Account.
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RESTRICTIONS ON TANSFERS FROM A
GUARANTEED ACCOUNT. You may transfer a pert of the amount in
the Guaranteed Account to the Subaccount(s) of the Variable Account, subject to
these additional restrictions.
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1.
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we
allow only one transfer each year and this transfer must be within the
period that is 30 days after the contract Anniversary. An
unused transfer option does not carry over to the next year;
and
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2.
|
the
maximum transfer amount is 25% of the Contract's Guaranteed Account Value
on the date of the transfer unless the balance after the transfer is less
than $500.
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We will
make the transfer on the Contract Anniversary if your written request is
received prior to the Contract Anniversary; if your written request is received
after the Contract Anniversary, we will make the transfer as of the date we
receive your request at our Home Office.
TRANSFER PROCESSING
FEE. There is no limit to the number of transfers that you can
make between the Subaccounts or to the Guaranteed Account. However,
we only allow one transfer each year from the guarnat3eeed Account (See
"Restrictions on Transfers from Guaranteed Account"). The first four
transfers during each Contract Year are free. We will assess a
transfer fee for each additional transfer during that Contract
Year. The amount of this fee is shown in the Contract
Schedule. For the purposes of assessing the fee, each Written notice
of transfer is considered to be one transfer, regardless of the number of
Subaccounts or the Guaranteed Account deduced from the amount being
transferred.
CONTRACT
VALUES
CONTRAT ACCOUNT VALUE.
The Contract Account Value is the sum of the Variable Account
Value and the Guaranteed Account Value.
CASH SURRENDER
VALUE. The Cash Surrender Value is the Contract Account Value,
less any applicable Surrender Charge. The Cash Surrender Value will be
determined on the date we receive your Written Notice for surrender and this
Contract at our Home office.
You
may surrender this Contract for its Cash Surrender Value at any time before the
earlier of the death of the Annuitant or the maturity Date. You may
elect to have the Cash Surrender Value (less any applicable deduction for
premium tax) paid in a single sum or under a Payment option. This
Contract ends when we pay the Cash Surrender Value or apply such sum under a
Payment Option.
WITHDRAWALS. You
may withdraw part of the Cash Surrender Value at any time before the earlier of
the death of the annuitant or the Maturity Date, subject to these
limits:
|
1.
|
withdrawals
may not be made before the end of the first Contract
year;
|
|
2.
|
the
minimum withdrawal amount is shown in the Contract
Schedule;
|
|
3.
|
the
maximum withdrawal is the amount that would leave a minimum Cash Surrender
Value of the amount shown in the Contract Schedule;
and
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|
4.
|
a
withdrawal request which would reduce the amount in a Subaccount or the
guaranteed Account below $500 will be treated as a request for a full
withdrawal of the amount in that Subaccount or Guaranteed
Account.
|
On the
date we receive your Written notice for a withdrawal at our Home Office, we will
withdraw the amount of the withdrawal from the Contract Account
Value. We will then deduct any applicable Surrender Charge from the
remaining Contract Account Value. No surrender charge will be applied
to a withdrawal if such is the first or second withdrawal during a Contract year
and the amount of the first withdrawal or the total amount of the first and
second withdrawals is not in excess of 10% of the contract Account Value as of
the beginning of such Contract year.
You
may specify the amount to be withdrawn from certain Subaccounts or the
guaranteed Account for your partial withdrawal. If you do not specify this
information to us, or the amount in the designated Subaccounts or Guaranteed
Account is inadequate to comply with your request, we will make the withdrawal
based on the proportion that your Subaccount Values and the Guaranteed Account
Value bear to the Contract Account Value prior to the withdrawal.
SURRENDER
CHARGE. The applicable percentage from the Surrender Charge
Table in the Contract Schedule will be deducted upon any withdrawal or surrender
and will be applies as follows:
|
a.
|
to
the entire withdrawal amount if such withdrawal is the third or subsequent
withdrawal in any one Contract
Year;
|
|
b.
|
to
that portion of the total amount of the first and second withdrawals
during a Contract year which is in excess of 10% of the contract Account
Value as of the beginning of the contract
year;
|
|
c.
|
to
the amount of a surrender paid in a single sum which is in excess of 10%
of the Contract Account Value as of the beginning of the Contract year,
less the amount withdrawn during the contract Year without imposition of
the Surrender Charge.
|
Any
Surrender Charge will be deducted from the Subaccount(s) and the Guaranteed
Account based on the proportion that your subaccount Values and the Guaranteed
Account Value immediately after the withdrawal or surrender. In no
event will the surrender Charge exceed 89.5% of the total premiums received
under the contract.
ANNUAL ADMINISTRATION
FEE. We will assess the Annual Administration Fee shown in the
Policy Schedule:
|
1.
|
for
the prior contract year, on the contract Anniversary;
or
|
|
2.
|
for
the current Contract year on the date this Contract is surrendered for its
Cash Surrender Value or on the maturity Date (unless the Contract is
surrendered on a Contract Anniversary or the Maturity Date is a Contract
anniversary and the fee is assessed under 1
above).
|
The
fee will be assessed against the Subaccount(s) and Guaranteed Account based on
the proportion and the guaranteed Account based on the proportion that your
Subaccount Values and the Guaranteed Account Value bear to the Contract Account
Value.
If
the fee is obtained from the Subaccounts, we will cancel the appropriate number
of units credited to this policy based on the Unit Value at the end of the
Valuation Period when the fee is assessed. If the fee is obtained
from the guaranteed Account, we will reduce this Contract's Guaranteed Account
Value by the amount of the fee.
MATURITY DATE. No
Surrender Charge will be applied to the Contract Account Value on the maturity
Date if the proceeds are applied under a Payment option. If the
proceeds are paid in a lump sum on the Maturity Date, the proceeds will equal
the Cash Surrender Value on such date.
You
may change the Maturity Date, subject to these imitations:
|
1.
|
we
must receive your Written Notice at our Home Office at least 30 days after
we receive your Written Notice; and
|
|
2.
|
the
requested maturity Date must be a date that is at least 30 days after we
receive your Written notice; and
|
|
3.
|
the
requested maturity date must not be later than the first day of the month
after the Annuitant's 90th
birthday, or any earlier date required by
law.
|
TERMINATION. We may
pay you the Cash Surrender Value and end this policy if, before the Maturity
Date, all of these events simultaneously exist:
|
1.
|
you
have not paid any premiums for at least two
years;
|
|
2.
|
the
Contract Account Value is less than 42,000;
and
|
|
3.
|
the
total premium paid, less any partial withdrawals, is less than
$2,000.
|
We
will mail you a notice of our intention to end this contract at least six months
in advance. This Contract will automatically terminate on the date
specified in the notice, unless we receive an additional premium payment before
the termination date specified in the contract Schedule.
BASIS OF
VALUES. Any paid-up annuity, cash surrender or death benefits
that may be available are at least equal to the minimum required by law in the
state in which this Contract is delivered. A detailed statement of the method
used to compute the minimum values has been filed, where required, with the
insurance officials of the jurisdiction in which this Contract is
delivered.
PAYMENT
OF PROCEEDS
PROCEEDS. Proceeds
means the amount we will pay when the first of the following events
occurs: the maturity Date; the Contract is surrendered; or we receive
due proof of death of the Annuitant or the owner. This Contract ends
when we pay the proceeds.
"Due
Proof of Death" is proof of death that is satisfactory to us. Such
proof may consist of:
|
1.
|
a
certified copy of the death certificate;
and/or
|
|
2.
|
a
certified copy of the decree of a court of competent jurisdiction as to
the finding of death.
|
We
will deduct any applicable premium tax form the proceeds described below, unless
we already deducted the tax from the premiums when paid. (See "Net
Premium" provision)
PROCEEDS ON MATURITY DATE
.. If you have not elected to receive the proceeds in a lump
sum, the proceeds we pay is the contract Account Value, which we will apply
under a Payment Option on the Maturity date. (See the "Maturity Date" provision
and the "Payment Options" section.) If the proceeds are paid in a
lump sum, we will pay the Cash Surrender Value.
PROCEEDS ON
SURRENDER. If you surrender this policy before the earlier of
the death of the Annuitant or the Maturity Date, the proceeds we will pay is the
Cash Surrender Value. (See the "Maturity Date" provision concerning changing the
Maturity Date and having the Contract Account Value applied under a Payment
Option.)
PROCEEDS ON DEATH OF ANNUITANT BEFORE
MATURITY DATE. If the Annuitant dies before the Maturity Date,
the proceeds we will pay to the beneficiary is the death benefit, which is the
greater of:
|
1.
|
the
premiums paid, less any partial withdrawals including applicable surrender
charges; or
|
|
2.
|
the
Contract Account Value on the date we receive due proof of the Annuitant's
death.
|
The
proceeds will be paid in a lump sum or under a payment Option. No
death benefit is payable if this Policy is surrendered before the Annuitant's
death.
PROCEEDS ON DEATH OF OWNER.
If you die before the Maturity Date, Federal tax law requires
that the contract Account Value be distributed to your beneficiary within five
years after the date of your death.
If
you die on or after the maturity Date, any remaining payments must be
distributed at least as rapidly as under the Payment Option in effect on the
date of your death.
These
distribution requirements will be considered satisfied as to any portion of the
proceeds:
|
1.
|
payable
to or for the benefit of a designated beneficiary;
and
|
|
2.
|
which
is distributed over the life (or period not exceeding the life expectancy)
of that beneficiary, provided that such distribution begin within one year
of your death.
|
Your
designated beneficiary is the person designated by you as beneficiary and to
whom the ownership of the policy passes by reason of your death and must be a
natural person. However, if your spouse is the designated
beneficiary, the contract may be continued with your surviving spouse as the new
Owner.
PAYMENTS. We will
usually pay any proceeds, withdrawals, or cash surrenders within seven business
days after;
|
1.
|
we
receive and file your Written notice for withdrawal or a cash surrender;
or
|
|
2.
|
we
receive and file due proof of death of the owner or
Annuitant.
|
However,
we can postpone the payment of proceeds, withdrawals, or cash surrenders or the
transfer of amounts between Subaccounts if:
|
1.
|
the
New York Stock Exchange is closed, other than customary weekend and
holiday closings, or trading on the exchange is restricted as determined
by the Securities and Exchange Commission;
or
|
|
2.
|
the
Securities and Exchange commission permits by an order the postponement
for the protection of policy owners;
or
|
|
3.
|
the
Securities and Exchange Commission determines that an emergency exists
that would make the disposal of securities held in the Variable account or
the determination of their value not reasonably practicable;
or
|
|
4.
|
the
Fund is permitted by law or regulation to postpone payment of
proceeds.
|
If
a recent check or draft has been submitted, we have the right to defer payment
of the contract Account Value, Cash Surrender Value or Death Benefit until such
check or draft has been honored.
We
have the right to defer payment of any withdrawal, transfer or Cash Surrender
Value from the Guaranteed Account for up to six months from the date we receive
your Written Notice for a withdrawal or surrender.
INTEREST ON PROCEEDS. We will
pay interest on proceeds if we do not pay the proceeds in a single sum or begin
paying the proceeds under a Payment option:
|
1.
|
within
30 days after the proceeds become payable;
or
|
|
2.
|
within
the time required by the applicable jurisdiction, if less than 30
days.
|
This
interest will accrue from the date the proceeds become payable to the date of
payment, but not for more than one year, at an annual rate of 3% or the rate and
time required by law, if greater.
CONFORMITY WITH
LAWS. To the extend this Contract conflicts with any
applicable laws or the requirements of the internal Revenue Service concerning
distributions on death, this policy shall be considered to be amended to conform
with such requirements.
PAYMENT
OPTIONS
ELECTION OF
OPTION. The following options are available to you
during your lifetime. They are also available to the
Beneficiary after your death, if you have not selected an option for
such Beneficiary.
You
may elect to have the cash surrender Value, Contract Account Value or Death
Benefit paid in accordance with any one of the options described below or in any
other manner acceptable to us. If no election has been made, the
automatic option shall be Option B. The amount paid under these
options if fixed and dies not depend on the investment performance of the
variable Account.
OTPION A – Life
Annuity: An income payable during the lifetime or the Payee,
ceasing with the last payment due prior to the death of the Payee, according to
Option Table, Life Only column.
OPTION
B – Life Annuity with 10 years Guaranteed:
An
income payable during the lifetime of the Payee with the guaranteed that
payments shall be made for a period of not less than 10 years according to the
Option Table, 10 year Period Certain column.
Under
Option B, if any beneficiary dies while receiving payment, the present value off
the current dollar amount on the date of death or any remaining guaranteed
payments shall be paid in one sum to the executors or administrators of the
beneficiary unless otherwise provided in writing. Calculation of such
present value shall be at 3%, which is the rate of interest assumed in computing
the amount of annuity payments.
ALTERNATE INCOME
OPTION. In lieu of one of the above options you may elect to
settle the Cash Surrender Value, Contract Account Value or Death Benefit under
an alternate income option based on our single premium immediate annuity rates
in effect at the time of settlement. Such rates will be adjusted to a
due basis and the income thus produced will be increased by 4%. In no
case will the resulting income be less than which would be payable if the amount
were used to purchase a single premium immediate annuity adjusted to a due
basis.
GENERAL
PROVISION. Annuity payments shall commence and continue
subject to the following provisions:
|
A.
|
This
Contract shall be surrendered to us at our office. We shall
issue a Supplementary Contract stating the terms of payment under the
option elected.
|
|
B.
|
Proof
satisfactory to us of the identity, birth date and sex of any person on
whose life an annuity depends shall be provided to us before any annuity
payments will be made.
|
|
C.
|
We
shall make each annuity payment by check which shall be personally
endorsed by the person upon whose life the annuity depends or other
evidence must be furnished that such person is
alive.
|
|
D.
|
No
election of any option may be made under this Contract for any Payee
unless such election would produce a periodic payment of at least $50 to
that Payee. If at any time, payments to be made become less
than 450 each, we shall have the right to change the frequency of payments
to such interval as shall result in the payment of at least
$50. Subject to this condition, payments may be made annually,
semi-annually, quarterly or
monthly.
|
|
E.
|
If
the Payee is other than you, the electron of a Payment Option shall
require our consent.
|
|
F.
|
We
shall deduct from the Cash Surrender Value or the contract Account Value
any premium Tax at the time income payments
commence.
|
Option
table
GUARANTEED
AMOUNT OF MONTHLY PAYMENT FOR EACH $1,000 OF
ANNUITY
VALUE APPLIED
|
GUARANTEED
MONTHLY PAYMENTS
|
|||||||
|
Age
of Payee
|
10
Year Period Certain (Option B)
|
Age
of Payee
|
10
Year Period Certain (Option B)
|
||||
|
Male
|
Female
|
Life
Only (Option A)
|
Male
|
Female
|
Life
Only (Option A)
|
||
|
5
|
$2.79
|
$2.79
|
45
|
50
|
$4.08
|
$4.05
|
|
|
6
|
2.80
|
2.80
|
46
|
51
|
4.15
|
4.12
|
|
|
7
|
2.81
|
2.81
|
47
|
52
|
4.23
|
4.19
|
|
|
8
|
2.82
|
2.82
|
48
|
53
|
4.31
|
4.27
|
|
|
9
|
2.83
|
2.83
|
49
|
54
|
4.40
|
4.34
|
|
|
5
|
10
|
2.84
|
2.84
|
50
|
55
|
4.48
|
4.43
|
|
6
|
11
|
2.85
|
2.85
|
51
|
56
|
4.57
|
4.51
|
|
7
|
12
|
2.87
|
2.87
|
52
|
57
|
4.67
|
4.60
|
|
8
|
13
|
2.88
|
2.88
|
53
|
58
|
4.77
|
4.70
|
|
9
|
14
|
2.89
|
2.89
|
54
|
59
|
4.89
|
4.80
|
|
10
|
15
|
2.91
|
2.91
|
55
|
60
|
5.00
|
4.90
|
|
11
|
16
|
2.92
|
2.92
|
56
|
61
|
5.13
|
5.01
|
|
12
|
17
|
2.94
|
2.94
|
57
|
62
|
5.26
|
5.13
|
|
13
|
18
|
2.95
|
2.95
|
58
|
63
|
5.41
|
5.25
|
|
14
|
19
|
2.97
|
2.97
|
59
|
64
|
5.56
|
5.37
|
|
15
|
20
|
2.99
|
2.99
|
60
|
65
|
5.72
|
5.50
|
|
16
|
21
|
3.01
|
3.01
|
61
|
66
|
5.89
|
5.64
|
|
17
|
22
|
3.02
|
3.02
|
62
|
67
|
6.07
|
5.77
|
|
18
|
23
|
3.04
|
3.04
|
63
|
68
|
6.26
|
5.92
|
|
19
|
24
|
3.06
|
3.06
|
64
|
69
|
6.47
|
6.07
|
|
20
|
25
|
3.08
|
3.08
|
65
|
70
|
6.68
|
6.22
|
|
21
|
26
|
3.11
|
3.11
|
66
|
71
|
6.91
|
6.38
|
|
22
|
27
|
3.13
|
3.13
|
67
|
72
|
7.15
|
6.54
|
|
23
|
28
|
3.15
|
3.15
|
68
|
73
|
7.41
|
6.70
|
|
24
|
29
|
3.18
|
3.18
|
69
|
74
|
7.69
|
6.86
|
|
25
|
30
|
3.20
|
3.20
|
70
|
75
|
7.98
|
7.03
|
|
26
|
31
|
3.23
|
3.23
|
71
|
76
|
8.29
|
7.20
|
|
27
|
32
|
3.26
|
3.26
|
72
|
77
|
8.62
|
7.37
|
|
28
|
33
|
3.29
|
3.29
|
73
|
78
|
8.98
|
7.54
|
|
29
|
34
|
3.32
|
3.32
|
74
|
79
|
9.35
|
7.71
|
|
30
|
35
|
3.35
|
3.35
|
75
|
80
|
9.76
|
7.87
|
|
31
|
36
|
3.39
|
3.39
|
76
|
81
|
10.19
|
8.03
|
|
32
|
37
|
3.42
|
3.42
|
77
|
82
|
10.65
|
8.19
|
|
33
|
38
|
3.46
|
3.45
|
78
|
83
|
11.14
|
8.34
|
|
34
|
39
|
3.50
|
3.49
|
79
|
84
|
11.66
|
8.49
|
|
35
|
40
|
3.54
|
3.53
|
80
|
85*
|
12.22
|
8.62
|
|
36
|
41
|
3.58
|
3.57
|
81
|
12.83
|
8.75
|
|
|
37
|
42
|
3.63
|
3.62
|
82
|
13.47
|
8.87
|
|
|
38
|
43
|
3.68
|
3.66
|
83
|
14.16
|
8.98
|
|
|
39
|
44
|
3.73
|
3.71
|
84
|
14.90
|
9.08
|
|
|
40
|
45
|
3.78
|
3.76
|
85**
|
15.69
|
9.17
|
|
|
41
|
46
|
3.83
|
3.82
|
||||
|
42
|
47
|
3.89
|
3.87
|
||||
|
43
|
48
|
3.95
|
3.93
|
||||
|
44
|
49
|
4.01
|
3.99
|
||||
|
*
Payment show applies to all younger ages
|
|||||||
|
**Payment
shown applies to all older ages.
|
|||||||
FLEXIBLE
PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT
Flexible
premiums as stated in the Premiums Provision.
Policy
values are variable, except for amounts in the Guaranteed Account.
After the
Maturity Date, payment Options are on a guaranteed basis.
Death
benefit payable upon death of Annuitant before maturity date.
Non-participating
– Policy does not pay dividends.
Providentmutual
Life and Annuity Company of America
A Stock
Life insurance company
▇▇▇▇
▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇