FORM OF POLICY

WE AGREE

This contract permits the accumulation of funds on a tax-deferred basis and provides a periodic annuity payment for the life of the Annuitant or for a certain period of time, or a combination of both. Payments start on the Annuity Commencement Date.

The smallest annual rate of investment return that would have to be earned on the assets of the Separate Account so that the dollar amount of variable Annuity Payments will not decrease is 6.50%.

Prior to the Annuity Commencement Date, a daily charge corresponding to an annual charge of no more than 1.85% for the Policy Value death benefit option or 2.05% for the Return of Premium death benefit option, is applied by the Company to the assets of the Separate Account. The corresponding annual charge after the Annuity Commencement Date is no more than 1.50% regardless of death benefit option elected prior to the Annuity Commencement Date. The amounts applicable to this policy are shown on the Policy Data page. In addition, a maximum annual Service Charge of $35 is assessed (prior to the Annuity Commencement Date only) on each Policy Anniversary. However, the Service Charge will not be deducted on a Policy

Anniversary if, (1) the sum of all premium payments less the sum of all Withdrawals taken equals or exceeds $50,000; or (2) the Policy Value equals or exceeds $50,000.

See the “Service Charge” provision in Section 4 and the “Charges and Deductions” provision in Section 6 of this contract for more details. This contract is issued in consideration of the application and payment of the initial premium as provided. This contract may be applied for and issued to qualify as a tax-qualified annuity under the applicable sections of the Internal Revenue Code.

20 DAY RIGHT TO CANCEL

You may cancel this policy by delivering or mailing a written notice to us or Your agent. You must return the policy before midnight of the twentieth day after the day You receive it. Notice given by mail and return of the policy by mail are effective upon being mailed, properly addressed and postage prepaid. We will return the Fixed Account premium and the Policy Value of the Separate Account, including any fees and charges, within 10 days after we receive notice of cancellation and the returned policy.

If this policy is a replacement of another policy, the Right to Cancel period is extended to 60 days and we will return the Fixed Account premium and the Policy Value of the Separate Account, including any fees and charges, for this policy within 10 days after we receive notice of cancellation and the returned policy.

ANNUITANT - The person whose life annuity payments will be based on.

ANNUITY COMMENCEMENT DATE - The Date the Annuitant will begin receiving payments from this policy. You may change the Annuity Commencement Date at any time by giving us 30 days’ written notice. In no event can this date be later than the last day of the month following the month in which the Annuitant attains age 95. The Annuity Commencement Date may not be scheduled at issue to be earlier than the first day of the calendar month coinciding with or next following the first Policy Anniversary.

CASH VALUE - Amount, defined in Section 5 that is available for partial or full Surrenders.

CUMULATIVE EARNINGS - An amount equal to the Policy Value at the time a lump sum payout or systematic payout option payout is made, minus the sum of all premium payments reduced by all prior partial Withdrawals deemed to have been from premium, if any.

DISTRIBUTION - A Withdrawal or disbursement of funds from the Policy Value or Cash Value. Policy Value and Cash Value will be reduced by any Distribution.

EARNINGS - The gains, if any, in the Policy Value.

FIXED ACCOUNT GUARANTEED MINIMUM EFFECTIVE ANNUAL INTEREST RATE - The minimum guaranteed credited rate used to determine the Fixed Account portion of Your Policy Value prior to the Annuity Commencement Date. This rate will apply for the life of the policy and is shown on the Policy Data page.

GAINS - Cumulative Earnings, if any, in the Policy Value.

HOSPITAL - An institution which 1) is operated pursuant to the laws of the jurisdiction in which it is located, 2) operates primarily for the care and treatment of sick and injured persons on an inpatient basis, 3) provides 24-hour nursing service by or under the supervision of registered graduate professional nurses, 4) is supervised by a staff of one or more licensed physicians, and 5) has medical, surgical and diagnostic facilities or access to such facilities.

INCOME OPTIONS - Options through which the distribution of the Policy Value can be directed.

INVESTMENT OPTIONS - The one-year Guaranteed Period Option of the Fixed Account, the Dollar Cost Averaging Fixed Account Option, and any of the Subaccounts of the Separate Account.

NURSING CARE - Care prescribed by a physician and performed or supervised by a registered graduate nurse. Such care includes nursing and rehabilitation services available 24 hours.

NURSING FACILITY - A facility which 1) is operated pursuant to the laws of the jurisdiction in which it is located, 2) provides care prescribed by a physician and performed or supervised by a registered graduate nurse on a 24 hour basis, or provides care designed essentially to help a person with the activities of daily living that require the continuous attention of trained medical or paramedical personnel, and 3) is not, other than incidentally, a hospital, a retirement home, a rest home, a community living center or a place mainly for the treatment of alcoholism, mental illness, or drug abuse.

PAYEE - The person to whom annuity payments will be made.

POLICY ANNIVERSARY - The anniversary of the Policy Date for each year the policy remains in force.

POLICY DATE - The date shown on the Policy Data page of this policy and the date on which this policy becomes effective.

POLICY VALUE - Amount defined in Section 4, that can be used to fund one of the Income Options.

POLICY YEAR - The 12-month period following the Policy Date shown on the Policy Data page. The first Policy Year starts on the Policy Date. Each subsequent year starts on the anniversary of the Policy Date.

SEPARATE ACCOUNT - The separate investment account(s) established by us, as described in Section 6. The investment performance of the Separate Account is independent of the performance of the general assets of the Company.

SUBACCOUNT - A division of the Separate Account which invests in shares of one Portfolio. The investment performance of each Subaccount is directly linked to the investment performance of the corresponding Portfolio, as described in Section 6.

SURRENDER - A partial or full Withdrawal of funds from the Policy Value or Cash Value.

WITHDRAWAL - A distribution of funds from the Policy Value or Cash Value.

YOU, YOUR - The Owner of this policy. Unless otherwise specified on the Policy Data page, the Annuitant and the Owner shall be one and the same person. If the Owner is a trust and the trust allows any person(s) other than the trustee to exercise ownership rights under the policy, then such person(s) must be named as the Annuitant, as applicable. The Owner, while living, controls all rights and benefits under the policy.

PAYMENT OF PREMIUMS

Premium payments may be made any time while this policy is in force before the Annuity Commencement Date. You may start or stop, increase or decrease, or skip any premium payments. We reserve the right to prohibit premium payments to the Fixed Account options described in Section 7 after the Policy Date. We will provide 30 days advance written notice of this decision. We will also provide timely written notification to You once any such prohibition of premiums to the Fixed Account is no longer in effect.

MAXIMUM AND MINIMUM PREMIUM PAYMENT

The premium payments may not be more than the amount permitted by law if this is a tax-qualified annuity. The minimum initial premium payment is $5,000. If this policy is being used as a tax-qualified annuity, the minimum initial premium is $1,000, except that no minimum initial premium payment will be required for 403(b) annuities. The minimum subsequent premium payment we will accept is $50. The maximum total premium payments which we will accept without prior Company approval is $1,000,000 for issue ages 0-80, $500,000 for issue ages 81 and older.

If premium payments are discontinued, the Policy Value at the cessation of premium payments will be held by us and the Fixed Account portion of the policy will continue to be credited with at least the Fixed Account Guaranteed Minimum Effective Annual Interest Rate provided in this policy. We may declare a higher rate in advance. Any portion of the Policy Value that is allocated to the Subaccounts of the Separate Account at the time premium payments are discontinued, will remain in those Subaccounts unless You transfer the value to another Subaccount or to the Fixed Account.

The values in the Subaccounts will change from business day to business day reflecting the investment experience of the Subaccount. On the Annuity Commencement Date we will distribute the Policy Value under one of the Income Options.

PREMIUM PAYMENT DATE

The premium payment date is the date on which the premium payment is credited to the policy. The initial premium payment less any applicable premium taxes will be credited to the policy within two business days of receipt of the premium payment and the information needed. Subsequent additional premium payments will be credited to the policy as of the business day the premium payment and required information are received. A business day is any day that the New York Stock Exchange is open for trading.

ALLOCATION OF PREMIUM PAYMENTS

Premium payments may be applied to various Investment Options, which we make available. For each premium payment, You must indicate what percentage to allocate to various Investment Options. Each percent may be either zero or any whole number; however, the allocation among all accounts must total 100%.

CHANGE OF ALLOCATION

You may change the allocation of premium payments to various Investment Options by providing us notice containing the facts that we need. Premium payments received after the date on which we receive Your notice will be applied on the basis of the new allocation.

PREMIUM TAXES

The insurance laws of the State of New York as of 2011 do not allow the imposition of premium taxes on annuity considerations. Therefore, wherever reference is made in this annuity policy to the deduction of premium taxes, such deductions will not be made while the Owner is a resident of the State of New York, unless subsequent changes in New York’s insurance laws provide otherwise. The amount of any applicable premium tax imposed on amounts relating to this annuity policy may be deducted from this annuity policy. For purposes of this annuity policy, premium taxes include retaliatory taxes or similar taxes.

POLICY VALUE

On or before the Annuity Commencement Date, the Policy Value is equal to Your:

You may use the Policy Value on the Annuity Commencement Date to provide income under the General Payment Provisions in Section 10.

SERVICE CHARGE

On each Policy Anniversary during any Policy Year before the Annuity Commencement Date, we reserve the right to assess a Service Charge up to $35 for policy administration expenses.

The Service Charge will be deducted from each Subaccount in proportion to the portion of Policy Value (prior to such charge) in each Subaccount. In no event will the Service Charge exceed 2% of the Policy Value on the Policy Anniversary.

The Service Charge will not be deducted on a Policy Anniversary if, (1) the sum of all premium payments less the sum of all Withdrawals taken equals or exceeds $50,000; or (2) the Policy Value equals or exceeds $50,000.

CASH VALUE

On or before the Annuity Commencement Date, the Cash Value is equal to the Policy Value. Information on the current amount of Your policy’s Cash Value is available upon request. The Cash Value may be partially withdrawn or will be paid in the event of a full Surrender of the policy. We must receive Your written partial Withdrawal or Surrender request before the Annuity Commencement Date.

There is no Cash Value once Annuity payments have begun.

MINIMUM VALUES

Benefits available under this policy, including any paid up annuity Cash Value or death benefits that may be available, are not less than those required by the insurance laws of the State of New York. Such benefits will be increased as interest is credited to the policy as described in the Fixed Account, or increased/decreased by Separate Account gains/losses.

PARTIAL WITHDRAWALS

We may delay payment of the Cash Value from the Fixed Account for up to 6 months after we receive the request. If payment of the Partial Withdrawal or full Surrender is not made within 10 business days of our receipt of the request, we will pay interest on that amount from the date of receipt of the request to the date of payment as described in the Deferment provision in Section 11. If the Owner dies after we receive the request, but before the request is processed, the request will be processed before the death proceeds are determined.

The Gross Partial Withdrawal is the total amount which will be deducted from Your Policy Value as a result of each Partial Withdrawal. The Gross Partial Withdrawal equals the requested Partial Withdrawal.

If no premium payments have been made for three Policy Years and any Partial Withdrawal reduces the Policy Value below $2,000, we reserve the right to pay the full Policy Value and terminate the policy.

For interest crediting purposes only, the oldest premium payment is considered to be withdrawn first, then the interest associated with that premium payment. If the amount withdrawn exceeds this amount, the next oldest premium payment, and its associated interest is considered to be withdrawn, and so on until the most recent premium payment and its associated interest is considered to be withdrawn (i.e. Partial Withdrawals are made on a First-ln, First-Out or FIFO basis).

Amounts also may be withdrawn under one of the options as described below.

LUMP SUM

Beginning in the first Policy Year, partial withdrawals are available as lump sum distributions in one or more withdrawals during a policy year.

The minimum withdrawal is $500.

SYSTEMATIC PAYOUT OPTION

Beginning in the first Policy Year, a Systematic Payout Option (SPO) is available on a monthly, quarterly, semi-annual or annual basis. At the time a SPO payout is made, such payout must be at least $50 and may not exceed the greater of A or B, divided by the number of payouts made per year (e.g. 12 for monthly).

Monthly and quarterly payouts must be sent through electronic funds transfer directly to a checking or savings account. You may start or stop SPO payouts at any time; however, 30 days’ written notice is required to stop SPO payouts.

Once You have elected a SPO, You must wait a minimum time before the first SPO payment. 1 month for monthly, 3 months for quarterly, 6 months for semi-annual, or 12 months for annual. If a Lump Sum or Partial Withdrawal distribution is taken in the same Policy Year when SPO payments are being taken, and the total Withdrawal would exceed the greater of A or B above in that Policy Year, the SPO will be stopped.

MINIMUM REQUIRED DISTRIBUTION

For tax-qualified plans, Partial Withdrawals taken to satisfy minimum distribution requirements under Section 401(a)(9) of the Internal Revenue Code (IRC) are available. The amount available from this annuity with respect to the minimum distribution requirements is based solely on this policy.

Systematic minimum distributions must be at least $50 or a lump sum Distribution is available if minimum required distributions are less than $50.

NURSING CARE AND TERMINAL CONDITION WITHDRAWAL OPTION

Beginning in the first Policy Year, if the Owner or Owner’s spouse (Annuitant or Annuitant’s spouse if the Owner is not a natural person) has been 1) confined in a hospital or nursing facility for 30 consecutive days or 2) diagnosed as having a terminal condition and the confinement begins or diagnosis is made on or after the Policy Date, You may elect to withdraw all or a portion of the Policy Value. The minimum Withdrawal under this option is $1000. This option is available even during the Policy Years other partial Withdrawal options were exercised prior to nursing care.

For nursing care, we must receive each Withdrawal request and proof of eligibility with each request no later than 90 days following the date that confinement has ceased, unless it can be shown that it was not reasonably possible to provide the notice and proof within the above time period and that the notice and proof were given as soon as reasonably possible. However, in no event, except the absence of legal capacity, shall the notice and proof be provided later than one year following the date that confinement has ceased. Proof of confinement may be a physician’s statement or a statement from a hospital or nursing facility administrator.

For a terminal condition, we must receive each Withdrawal request and the applicable proof of eligibility no later than one year following diagnosis of the terminal condition. Proof of a terminal condition is required only with the initial Withdrawal request and must be furnished by the Owner’s, Owner’s spouse’s, Annuitant’s, or Annuitant’s spouse’s physician, as applicable.

SEPARATE ACCOUNT

We have established and will maintain one or more Separate Account(s), under the laws of the state of New York. Any realized or unrealized income, net gains and losses from the assets of the Separate Account are credited to or charged against it without regard to our other income, gains or losses. Assets are put in the Separate Account for this policy, as well as for other variable annuity policies. Any Separate Account may invest assets in shares of one or more mutual fund portfolios, or in the case of a managed Separate Account, direct investments in stocks or other securities as permitted by law. Fund shares refer to shares of underlying mutual funds or prorata ownership of the assets held in a Subaccount of a managed Separate Account. Fund shares are purchased, redeemed and valued on behalf of the Separate Account.

The Separate Account is divided into Subaccounts. Each Subaccount invests exclusively in shares of one of the portfolios of an underlying fund. We reserve the right to add or remove any Subaccount of the Separate Account.

The Separate Account meets the definition of a “Separate Account” under rule 0-1(e)(1) of the Investment Company Act of 1940 (the “1940 Act”). The assets of the Separate Account are our property. These assets will equal or exceed the reserves and other contract liabilities of the Separate Account. These assets will not be chargeable with liabilities arising out of any other business we conduct. We reserve the right, subject to regulations governing the Separate Account, to transfer assets of a Subaccount, in excess of the reserves and other contract liabilities with respect to that Subaccount, to another Subaccount or to our General Account

We will determine the fair market value of the assets of the Separate Account in accordance with a method of valuation, which we establish in good faith. Valuation Period means the period of time from one determination of the value of each Subaccount to the next. Such determinations are made when the value of the assets and liabilities of each Subaccount is calculated. This is generally the close of business on each day on which the New York Stock Exchange is open. In order to determine the value of an asset on a day that is not a Business Day, the Company will use the value of that asset as of the end of the next Business Day on which trading takes place.

The Company will determine the value of the reserves for assets in the Separate Account at the end of each Business Day. In order to determine the value of reserves for assets on a day that is not a Business Day, the Company will use the value of that asset as of the end of the prior Business Day on which trading took place.

We also reserve the right (with prior authorization from the Superintendent) to transfer assets of the Separate Account, which we determine to be associated with the class of policies to which this policy belongs, to another Separate Account. If this type of transfer is made, the term “Separate Account”, as used in the policy, shall then mean the Separate Account to which the assets were transferred.

We also reserve the right, when permitted by law to:

The Net Asset Value of a fund share is the per-share value calculated by the mutual fund or, in the case of a managed Separate Account, by the Company. The Net Asset Value is computed by adding the value of the Subaccount’s investments, cash and other assets, subtracting its liabilities, and then dividing by the number of shares outstanding. Net Asset Values of fund shares reflect investment advisory fees and other expenses incurred in managing a mutual fund or a managed Separate Account.

CHANGE IN INVESTMENT OBJECTIVE OR POLICY OF A MUTUAL FUND

If required by law or regulation, an investment policy of the Separate Account will only be changed if approved by the appropriate insurance official of the state of New York or deemed approved in accordance with such law or regulation. If so required, the process for obtaining such approval is filed with the insurance official of the state or district in which this policy is delivered.

CHARGES AND DEDUCTIONS

The Mortality and Expense Risk Fee and Administrative Charge is deducted both before and after the Annuity Commencement Date to compensate for changes in mortality and expenses not anticipated by the mortality and administration charges guaranteed in the policy. Neither expenses actually incurred, other than taxes on the investment return, nor mortality actually experienced, shall adversely affect the dollar amount of variable benefits under the policy.

The Service Charge is deducted prior to the Annuity Commencement Date only.

If the Mortality and Expense Risk Fee and Administrative Charge is more than sufficient, the Company will retain the balance as profit or may reduce this fee in the future.

ACCUMULATION UNITS

The Policy Value in the Separate Account before the Annuity Commencement Date is represented by accumulation units. The dollar value of accumulation units for each Subaccount will change from business day to business day reflecting the investment experience of the Subaccount.

Premium Payments allocated to and any amounts transferred to the Subaccounts will be applied to provide accumulation units in those Subaccounts. The number of accumulation units purchased in a Subaccount will be determined by dividing the amount allocated to or transferred to that Subaccount, by the value of an accumulation unit for that Subaccount on the premium payment or transfer date.

The number of accumulation units withdrawn or transferred from the Subaccounts will be determined by dividing the amount withdrawn or transferred by the value of an accumulation unit for that Subaccount on the Withdrawal or transfer date.

The value of an accumulation unit on any business day is determined by multiplying the value of that unit at the end of the immediately preceding valuation period by the net investment factor for the valuation period.

The net investment factor used to calculate the value of an accumulation unit in each Subaccount for the Valuation Period is determined by dividing (a) by (b) and subtracting (c) from the result, where:

Since the net investment factor may be greater or less than one, the accumulation unit value may increase or decrease.

FIXED ACCOUNT

The Fixed Account is comprised of a one-year Guaranteed Period Option and the Dollar Cost Averaging Fixed Option that we may choose to offer. Premium payments applied to and any amounts transferred to the Fixed Account will reflect a fixed interest rate. The interest rates we set will be credited for increments of at least one year measured from each premium payment or transfer date. These rates will never be less than the Fixed Account Guaranteed Minimum Effective Annual Interest Rate shown on the Policy Data page.

After the policy date, we reserve the right, to prohibit premium payments and/or transfers allocated to the Fixed Account described in this section. We will provide 30 days advance written notice of this decision. We will also provide timely written notification to You once any such prohibition of premium payments and/or transfers is no longer in effect.

Even if we are prohibiting premium payments or transfers to the Fixed Account, funds will still roll into a new one-year Guaranteed Period Option at the end of the expiring option’s guaranteed period.

GUARANTEED PERIOD OPTION

We will offer the one-year Guaranteed Period Option. The current interest rate we set for funds entering a Guaranteed Period Option (GPO) is guaranteed until the end of that option’s Guaranteed Period. At that time, the premium payment made or amount transferred into the GPO, less any Withdrawals or transfers from that GPO, plus accrued interest, will be rolled into a new one-year GPO or may be transferred to any Subaccount(s) within the Separate Account(s).

You may choose the Investment Option(s) You want the funds transferred into by giving us a written notice within 30 days before the end of the expiring option’s Guaranteed Period. However, any Guaranteed Period elected may not extend beyond the maximum Annuity Commencement Date defined in Section 11.

In the absence of such election, the funds will be rolled into a new one-year GPO. You will be mailed a notice of completion of any rollover with the new interest rate applicable. The new GPO will be deemed as accepted if we do not receive a written rejection within 30 days from the postmark date of the completion notice.

When funds are withdrawn or transferred from the one-year GPO, the Policy Value associated with the oldest premium payment or rollover is considered to be withdrawn/transferred first. If the amount withdrawn/transferred exceeds the Policy Value associated with the oldest premium, the Policy Value associated with the next oldest premium payment or rollover is considered to be withdrawn/transferred next, and so on until the Policy Value associated with the most recent premium payment or rollover is considered to be withdrawn/transferred (this is a “First-ln, First-Out” or FIFO basis).

DOLLAR COST AVERAGING FIXED ACCOUNT OPTION

We may offer a Dollar Cost Averaging one-year (DCA) Fixed Account Option separate from the Guaranteed Period Option. This option will have a one-year interest rate guarantee. The current interest rate we set for the DCA Fixed Account may differ from the rates credited on the one-year GPO in the Fixed Account In addition, the current interest rate we credit may vary on different portions of the DCA Fixed Account. The credited interest rate will never be less than the Fixed Account Guaranteed Minimum Effective Annual Interest Rate shown on Page 3. The DCA Fixed Account Option will only be available under a Dollar Cost Averaging program as described in Section 8.

Prior to the Annuity Commencement Date, You may transfer the value of the accumulation units from one Investment Option to another by providing us notice containing the facts that we need.

Transfers of interest credited in the one-year GPO to other Investment Options are allowed on a “First-ln, First-Out” basis. Such transfers may be made monthly, quarterly, semi-annually, or annually. Each such transfer must be at least $50.

Transfers of Policy Value from the Separate Account are subject to a minimum of $500 or the entire Subaccount Policy Value, if less. However, if the remaining Subaccount Policy Value is less than $500, we reserve the right to include that amount as part of the transfer.

We reserve the right to limit transfers to no more than 12 in any one Policy Year. Any transfers in excess of 12 per Policy Year may be charged a $10 per transfer fee. Transfers among multiple Investment Options will be treated as one transfer in determining the number of transfers that have occurred. We also reserve the right to prohibit transfers to the Fixed Account. We may prohibit premium payments and/or transfers if the yield on investments at such time is not sufficient to support the statutory minimum interest rate guarantee and other company expenses. If we are prohibiting transfers to the Fixed Account, we will provide 30 days advance written notice of this decision. You must indicate which Investment Option(s) to transfer the funds to while such prohibition is in effect. We will also provide timely written notification to You once any such prohibition of transfers is no longer in effect.

The policy was not designed for professional market timing organizations or other persons that use programmed, large, or frequent transfers. The use of such transfers may be disruptive to an underlying portfolio. We reserve the right to reject any transfer request from any person in the interest of overall fund management or, if, in our judgment, an underlying fund would be unable to invest effectively in accordance with its investment objectives and policies or would otherwise be potentially adversely affected or if an underlying fund would reject our purchase order. We also reserve the right to revoke Your fax and electronic transfer privileges at any time without revoking all owners’ fax and electronic transfer privileges.

DOLLAR COST AVERAGING OPTION

Prior to the Annuity Commencement Date, You may instruct us to automatically transfer a specified amount from the Money Market Subaccount, U.S. Government Securities

Subaccount, or out of the Dollar Cost Averaging (DCA) Fixed Account Option to any other Subaccount(s) of the Separate Account. The automatic transfers can occur monthly or quarterly.

Transfers will continue until the elected Subaccount or DCA Fixed Account value is depleted. The amount transferred each time must be at least $500. All transfers from the DCA account will be the same amount as the initial transfer. Changes to the Subaccounts to which these transfers are allocated are not restricted. Transfers must be scheduled for at least 6, but not more than 24 months or for at least 4, but not more than 8 quarters each time the Dollar Cost Averaging program is started or restarted following termination of the program for any reason.

Dollar Cost Averaging results in the purchase of more accumulation units when the value of the accumulation unit is low, and fewer accumulation units when the value of the accumulation unit is high. However, there is no guarantee that the Dollar Cost Averaging program will result in higher Policy Values.

Dollar Cost Averaging may be discontinued before its scheduled completion by sending written notice to us. While Dollar Cost Averaging is in effect, Asset Rebalancing is not available. If Dollar Cost Averaging is discontinued prior to the end of the scheduled period, all remaining funds in the Dollar Cost Averaging Fixed Account will be transferred at that time. Unless we are notified otherwise, the funds remaining in the Dollar Cost Averaging Fixed Account will be transferred to the Subaccounts in the percentages currently indicated.

ASSET REBALANCING

Prior to the Annuity Commencement Date, You may instruct us to automatically transfer amounts among the Subaccounts of the Separate Account on a regular basis to maintain a desired allocation of the Policy Value among the various Subaccounts offered. Rebalancing will occur on a monthly, quarterly, semi-annual or annual basis, beginning on a date selected by You. You must select the percentage of the Policy Value desired in each of the various Subaccounts offered (totaling 100%). Any amounts in the Fixed Account are ignored for the purposes of Asset Rebalancing. Rebalancing can be started, stopped or changed at any time. Asset Rebalancing is not available while Dollar Cost Averaging is in effect. Rebalancing will cease as soon as we receive a request for any other transfer.

After the Annuity Commencement Date, You may transfer the value of the variable annuity units from one Subaccount to another within the Separate Account or to the Fixed Account. If You want to transfer the value of the variable annuity units, You must provide a signed notice, containing the facts that we need. We reserve the right to limit transfers between the Subaccounts or to the Fixed Accounts to once per Policy Year.

The minimum amount which may be transferred is the lesser of $10 monthly income or the entire monthly income of the variable annuity units in the Subaccount from which the transfer is being made. If the monthly income of the remaining units in a Subaccount is less than $10, we have the right to include the value of those variable annuity units as part of the transfer.

After the Annuity Commencement Date, no transfers may be made from the Fixed Account to any other Investment Options.

The amount of death proceeds will be the greater of (a) or (b) where:

For purposes of this policy, due proof of death means:

If You have not selected a payment option by the date of death, the beneficiary may make such election within one year of the date we receive due proof of the Owner’s or Annuitant’s death as described in C below. The beneficiary may elect to receive the death proceeds as a lump sum payment or may use the death proceeds to provide any of the annuity Income Options described in Section 10.

We will pay interest on death proceeds from the date of death to the date of payment at an annual interest rate of 1.5%, or the guaranteed annual rate used for calculating settlement options, whichever is greater.

The amount of the Guaranteed Minimum Death Benefit (GMDB) is based on the death benefit option shown on the Policy Data Page. You may not change the GMDB option after the policy is issued.

Return of Premium Death Benefit

This GMDB is equal to the total premiums paid for this policy, less any Adjusted Partial Withdrawals (as described below), as of the date of death.

Adjusted Partial Withdrawal

A partial Withdrawal taken as provided in Section 5 will reduce the Guaranteed Minimum Death Benefit by an amount referred to as the “Adjusted Partial Withdrawal”. The Adjusted Partial Withdrawal may be a different amount than the Gross Partial Withdrawal described in Section 5. If at the time of the partial Withdrawal, the Policy Value is greater than the GMDB, the Adjusted Partial Withdrawal will equal the Gross Partial Withdrawal.

The Adjusted Partial Withdrawal formula is APW = GPW times (DP/PV) where:

Payment of death proceeds depends upon the relationships between the Owner, Annuitant, and beneficiary as outlined below.

If there are surviving Owners, the surviving Owners automatically take the place of any beneficiary designation.

When we have due proof that the Annuitant died before the Annuity Commencement Date, we will provide the death proceeds to the beneficiary. Interest upon the death proceeds will be computed daily at the rate set forth in Section 9, A, above from the date of death to the date of payment and will be considered part of the total sum paid. If no beneficiary is designated, the Owner or Owner’s estate will become the beneficiary.

If the beneficiary elects to have the death proceeds paid rather than continue the policy, the death proceeds must be distributed pursuant to subsections b)(1) and (2) below.

In 1035 exchanges where there are joint Annuitants, the death proceeds will only be payable upon the death of the surviving Annuitant, subject to the distribution rules described in section II.

If the deceased Owner is also the Annuitant, Subsection C.I. “Annuitant Death” above applies.

If an Owner or joint Owner who is not an Annuitant dies prior to the Annuity Commencement Date and before the entire interest in the policy is distributed, the successor Owner as defined below will become the new Owner, and no death proceeds are payable. The person or entity first listed below who is alive or in existence on the date of that death will become the successor Owner:

The successor Owner will need to take distributions according to a), b), or c) below:

The death proceeds on or after the Annuity Commencement Date depend on the payment option selected. If any Owner dies on or after the Annuity Commencement Date, but before the entire interest in the policy is distributed, the remaining portion of such interest in the policy will be distributed to the Owner’s beneficiary at least as rapidly as under the method of distribution being used as of the date of that Owner’s death.

In the case of a non tax-qualified annuity, if any Owner or beneficial Owner is not an individual, then for purposes of Section 72(s) of the Internal Revenue Code’s mandatory distribution provisions in subsection C or D above, (1) the primary Annuitant will be treated as the Owner of the policy, and (2) if there is any change in the primary Annuitant, such a change will be treated as the death of the Owner.

If this policy is in force on the Annuity Commencement Date, we will use the Fixed Account portion and/or the Separate Account portion of the Policy Value to make annuity payments to the Annuitant under Option 2 and/or 3-V, respectively, with 10 years certain, or if elected, under one or more of the other options described in this section. However, the option(s) elected must provide for lifetime income or income for a period of at least 60 months. You will become the Annuitant at the Annuity Commencement Date. Payments will be made at 1, 3, 6 or 12-month intervals. We reserve the right to change the frequency of payments to avoid making payments of less than $20.00.

Before the Annuity Commencement Date, if the death proceeds become payable or if You Surrender this policy, we will pay any proceeds in one sum, or if elected, all or part of these proceeds may be placed under one or more of the options described in this section. If we agree, the proceeds may be placed under some other method of payment instead.

Betterment of Rates

The amounts shown in the tables on page 16-17 are the guaranteed amounts. Current amounts offered to individuals of the same class may be obtained from us. Fixed annuity payments at the time of their commencement will not be less than those which would be provided by the application of the Policy Value to purchase any single consideration immediate annuity contract (as described in Section 4223 (a)(1)(E) of the New York Insurance Law) offered by the Company at the time to the same class of Annuitant.

Adjusted Age

Payments under Options 2 and 4 and the first payment under Options 3-V and 5-V are determined based on the adjusted age of the Annuitant. The adjusted age is the Annuitant’s actual age on the Annuitant’s nearest birthday, at the Annuity Commencement Date, adjusted as follows:

Election of Optional Method of Payment Before the Annuity Commencement Date You can elect or change an Income Option. You may elect, in a notice You sign which gives us the facts that we need, annuity payments that may be either variable, fixed, or a combination of both. If You elect a combination, You must also tell us what part of the policy proceeds on the Annuity Commencement Date are to be applied to provide each type of payment (You must also specify which Subaccounts.) The amount of a combined payment will be the sum of the variable and fixed payments. Payments under a variable Income Option will reflect the investment performance of the selected Subaccount of the Separate Account.

Payee

Unless You specify otherwise, the Payee shall be the Annuitant, or the beneficiary as defined in the Beneficiary provision in Section 11.

Proof of Age

We may require proof of the age of any person who has an annuity purchased under Options 2, 3-V, 4 and 5 -V of this section before we make the first payment.

Minimum Proceeds

If the Policy Value on the Annuity Commencement Date is less than $2,000, we reserve the right to pay the Policy Value as a lump sum instead of applying it to an income option.

Premium Tax

The Insurance laws of the State of New York as of 2011 do not allow the imposition of premium taxes on the amount applied to a settlement option. Therefore, such deductions will not be made while the Owner is a resident of the State of New York, unless subsequent changes in New York’s insurance laws provide otherwise. However, if the Owner becomes a non-resident of New York or if New York changes its insurance laws to allow the imposition of premium taxes on the amount applied to a settlement option, we will deduct the applicable premium tax before applying the proceeds.

Supplementary Contract

Once proceeds become payable and an income option has been selected, we will issue a supplementary contract to reflect the terms of the selected option. The contract will name the Payee(s) and will describe the payment schedule.

Guaranteed Income Options

The fixed income option is determined by multiplying each $1,000 of policy proceeds allocated to a fixed income option by the amounts shown on pages 16 and 17 for the option You select Options 1 and 3 are based on a guaranteed interest rate of 1.5%. Options 2 and 4 are based on a guaranteed interest rate of 1.5% and the “Annuity 2000” male, female mortality table projected for improvement using projection scale G (50% of the female scale G factors were used, while 100% of the male scale G factors were used). The rates were projected dynamically using an assumed Annuity Commencement date of 2005. The “Annuity 2000” mortality rates are adjusted based on improvements in mortality since 2000 to more appropriately reflect increased longevity. This is accomplished using a set of improvement factors referred to as projection scale G.

Option 1 - Income for a Specified Period

We will make level payments only for the fixed period. You choose. The duration of the payments may not exceed the Annuitant’s life expectancy, (as defined by the Internal Revenue Code and regulations adopted under that code) nor be for a period of time that is less than 60 months. In the event of the death of the person receiving payments prior to the end of the fixed period elected, payments will be continued to that person’s beneficiary.

Option 2 – Life Income – You may choose between:

Option 2(1) is not available for Adjusted Age(s) greater than 85.

If any life income settlement option with a period certain provides for installment payments of the same amount at some ages for different periods certain, the Company will deem the election to have been made for the longest period certain which could have been elected for such age and amount.

Option 3 – Income of a Specified Amount Payments are made for any specified amount until the amount applied to this option, with interest is exhausted. This will be a series of level payments followed by a smaller final payment. In the event of the death of the person receiving payments prior to the time proceeds with interest are exhausted, payments will be continued to that person’s beneficiary.

Option 4 – Joint and Survivor Annuity

Payments are made during the joint lifetime of the Payee and a joint Payee of Your selection. Payments will be made as long as either person is living.

Option 4 is not available for Adjusted Age(s) greater than 85.

Current Income Options

The amounts shown in the tables on pages 16 and 17 are the guaranteed amounts. Current amounts offered to individuals of the same class may be obtained from us. Any rates not shown in the Tables contained in this annuity policy and which are available will be provided by the Company upon request.

Variable Annuity Units

The policy proceeds You tell us to apply to a variable income option will be used to purchase variable annuity units in Your chosen Subaccounts. The dollar value of variable annuity units in Your chosen Subaccounts will increase or decrease reflecting the investment experience of Your chosen Subaccounts. The value of a variable annuity unit in a particular Subaccount on any business day is equal to (a) multiplied by (b) multiplied by (c), where:

The Assumed Investment Return adjustment factor for the valuation period is the product of discount factors of .99986634 per day to recognize the 5.0% effective annual Assumed Investment Return.

The net investment factor used to calculate the value of a variable annuity unit in each Subaccount for the Valuation Period is determined by dividing (a) by (b) and subtracting (c) from the result, where:

Determination of the First Variable Payment The amount of the first variable payment is determined by multiplying each $1,000 of policy proceeds allocated to a variable income option by the amounts shown on pages 18 and 19 for the variable option You select. The tables are based on a 5% effective annual Assumed Investment Return and the “Annuity 2000” male, and female mortality table projected for improvement using projection scale G (50% of the female scale G factors were used, while 100% of the male scale G factors were used). The rates were projected dynamically using an assumed Annuity Commencement date of 2005. The “Annuity 2000” mortality rates are adjusted based on improvements in mortality since 2000 to more appropriately reflect increased longevity. This is accomplished using a set of improvement factors referred to as projection scale G.

Option 3-V – Life Income – You may choose between:

Option 3-V(1) is not available for Adjusted Age(s) greater than 85.

Option 5-V – Joint and Survivor Annuity:

Payments are made as long as either the Annuitant or the joint Annuitant is living.

Option 5-V is not available for Adjusted Age(s) greater than 85.

Determination of Subsequent Variable Payments

The amount of each variable annuity payment after the first will increase or decrease according to the value of the variable annuity units which reflect the investment experience of the selected Subaccounts. Each variable annuity payment after the first will be equal to the number of variable annuity units in the selected Subaccounts multiplied by the variable annuity unit value on the date the payment is made. The number of variable annuity units in each selected Subaccount is determined by dividing the first variable annuity payment allocated to the Subaccount by the variable annuity unit value of that Subaccount on the Annuity Commencement Date.

Once Annuity Payments begin, neither expenses actually incurred other than taxes on the investment return, nor mortality actually experienced by the Company, shall adversely affect the dollar amount of Variable Annuity Payments to any Annuitant for whom such payments have commenced.