EX-99.4g
▇▇▇▇▇▇▇ NATIONAL LIFE INSURANCE COMPANY [OBJECT OMITTED]
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A STOCK COMPANY
POLICY NUMBER:
ANNUITANT:
▇▇▇▇▇▇▇ NATIONAL LIFE INSURANCE COMPANY ("the Company" or ▇▇▇▇▇▇▇
National) agrees to provide benefits to the Contract Owner subject to
the provisions set forth in this Contract and in consideration of the
application and Premiums We receive.
THE VALUE OF AMOUNTS ALLOCATED TO THE SEPARATE ACCOUNT DURING THE
ACCUMULATION AND ANNUITY PERIODS IS NOT GUARANTEED AND MAY INCREASE OR
DECREASE BASED UPON THE INVESTMENT EXPERIENCE OF THE FUND UNDERLYING
THE SEPARATE ACCOUNT. INFORMATION ON VARIABLE BENEFITS MAY BE FOUND ON
PAGES 8-13.
THE GUARANTEED ACCOUNT OPTIONS ARE SUBJECT TO AN INTEREST RATE
ADJUSTMENT WHICH MAY INCREASE OR DECREASE AMOUNTS PAYABLE OR
WITHDRAWN, BUT THE GUARANTEED ACCOUNT CONTRACT VALUE WILL NEVER
DECREASE TO LESS THAN THE GUARANTEED ACCOUNT MINIMUM VALUE.
NOTICE OF TWENTY DAY RIGHT TO EXAMINE POLICY
YOU MAY RETURN THIS CONTRACT TO THE SELLING AGENT OR ▇▇▇▇▇▇▇ NATIONAL
WITHIN 20 DAYS AFTER YOU RECEIVE IT. THE COMPANY WILL REFUND THE
CONTRACT VALUE FOR THE VALUATION PERIOD IN WHICH THE CONTRACT IS
RECEIVED. UPON SUCH REFUND, THE CONTRACT SHALL BE VOID.
THIS IS A LEGAL CONTRACT BETWEEN YOU AND THE COMPANY.
READ YOUR CONTRACT CAREFULLY.
EXECUTED FOR THE COMPANY ON THE ISSUE DATE
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INDIVIDUAL DEFERRED VARIABLE AND FIXED THIS CONTRACT IS SIGNED AT THE
ANNUITY CONTRACT (FLEXIBLE PREMIUM). HOME OFFICE OF ▇▇▇▇▇▇▇ NATIONAL
DEATH BENEFIT PRIOR TO LIFE, LANSING, MICHIGAN
MATURITY. MONTHLY INCOME
AT MATURITY. NON-PARTICIPATING
/s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
President
/s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇
Secretary
VA200 4/95 20
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TABLE OF CONTENTS
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PAGE
CONTRACT DATA PAGE.............................................................2
PREMIUM ALLOCATION.............................................................3
DEFINITIONS....................................................................4
GENERAL PROVISIONS.............................................................6
CHARGES AND DEDUCTIONS.........................................................7
ACCUMULATION PROVISIONS........................................................8
TRANSFER PROVISIONS............................................................9
WITHDRAWAL PROVISIONS.........................................................10
DEATH BENEFIT PROVISIONS......................................................11
ANNUITY PROVISIONS............................................................12
ANNUITY OPTIONS...............................................................12
TABLE OF ANNUITY OPTIONS......................................................14
CD002 4/95 Page 1
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CONTRACT DATA PAGE
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Contact Number:
Annuitant:
Owner:
Issue Date: Issue State:
Annuity Date: First Premium:
Annual Contract Maintenance Charge: $35.00 Subsequent Guaranteed Rate: 3%
Separate Account: ▇▇▇▇▇▇▇ National Separate Account - I
Expense Risk Charge: On an annual basis, this charge equals 0.23%
of the daily net assets value of the Portfolios.
Administration Charge: On an annual basis, this charge equals 0.15% of
the daily net asset value of the Portfolios.
Mortality Risk Charge: On an annual basis, this charge equals 0.9% of
the daily net asset value of the Portfolios.
Enhanced Death Benefit Charge: On an annual basis, this charge equals 0.12% of
the daily net asset value of the Portfolios.
Contingent Deferred Sales Charge: CONTRIBUTION YEAR PERCENT
----------------- -------
0 7
1 6
2 5
3 4
4 3
5 2
6 1
7 0
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Home Office:
▇▇▇▇▇▇▇ National Life Insurance Company Annuity Service Center:
▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ [P.O. Box 30389
Lansing, Michigan 48911 Lansing, MI 48909-7889
517/394-3400 800/766-4683]
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All payments and values in the Guaranteed Account are subject to an Interest
Rate Adjustment, the calculation of which may result in an increase or decrease
in amounts payable. In no event will the values be less than the Guaranteed
Account Minimum Value.
CD002 4/95 Page 2
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PREMIUM ALLOCATION
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PORTFOLIO OPTIONS
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AIM/JNL Value II Series
AIM/JNL Large Cap Growth Series
AIM/JNL Small Cap Growth Series
JNL/▇▇▇▇▇ Growth Series
JNL/Alliance Growth Series
JNL/Eagle Core Equity Series
JNL/Eagle SmallCap Equity Series
JNL/Janus Aggressive Growth Series
JNL/Janus Balanced Series
JNL/Janus Capital Growth Series
Lazard/JNL Mid Cap Value Series
Lazard/JNL Small Cap Value Series
JNL/▇▇▇▇▇▇▇▇▇▇▇ Global Growth Series
JNL/▇▇▇▇▇▇▇▇▇▇▇ Growth Series
PIMCO/JNL Total Return Bond Series
JNL/▇▇▇▇▇▇ Growth Series
JNL/▇▇▇▇▇▇ International Equity Series
JNL/▇▇▇▇▇▇ ▇▇▇▇▇▇ Growth Series
JNL/▇▇▇▇▇▇ Value Equity Series
JNL/S&P Conservative Growth Series I
JNL/S&P Moderate Growth Series I
JNL/S&P Aggressive Growth Series I
JNL/S&P Very Aggressive Growth Series I
JNL/S&P Equity Growth Series I
JNL/S&P Equity Aggressive Growth Series I
PPM America/JNL Balanced Series
PPM America/JNL High Yield Bond Series
PPM America/JNL Money Market Series
Salomon Brothers/JNL Global Bond Series
Salomon Brothers/JNL U.S. Government & Quality Bond Series
▇. ▇▇▇▇ Price/JNL Established Growth Series
▇. ▇▇▇▇ Price/JNL Mid-Cap Growth Series
▇. ▇▇▇▇ Price/JNL Value Series
JNL/First Trust The ▇▇▇ ▇▇ Target 10 Series
GUARANTEED ACCOUNT OPTIONS
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1 Year Period
3 Year Period
5 Year Period
7 Year Period
DN004 4/95 Page 3
10-29-01
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DEFINITIONS
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ACCUMULATION UNIT. A unit of measurement used to compute the Contract Value
prior to the Annuity Date.
ANNUITY SERVICE CENTER. The address and telephone number are as specified on the
Contract Data Page. The Company will notify Contract Owners of any change in
address or telephone number.
ANNUITANT. The natural person on whose life the annuity benefit for this
Contract is based.
ANNUITY DATE. The date on which annuity payments are to start. The latest
possible Annuity Date will be set by us.
ANNUITY UNIT. A unit of measurement used to compute the amount of Variable
Annuity payments.
BENEFICIARY(IES). The person(s) designated to receive any benefits under a
contract upon the death of the Annuitant.
CODE. The Internal Revenue Code of 1986, as amended, or as the same may be
amended or superseded.
CONTRACT VALUE. The sum of the Separate Account Contract Value and the
Guaranteed Account Contract Value.
CONTRACT YEAR. A year starting from the Issue Date in one calendar year and
ending on the Issue Date in the succeeding calendar year.
CONTRIBUTION YEAR. A year beginning from the date of the payment of a Premium in
one calendar year and ending on the anniversary of such date in the succeeding
calendar year. The Contribution Year in which a Premium is made is "Contribution
Year 0." Subsequent Contribution Years are successively numbered beginning with
Contribution Year 1.
CURRENT INTEREST RATE. The rate of interest established by the Company for a
specified Guaranteed Period. In no event will the Current Interest Rate be less
than the Subsequent Guaranteed Rate shown on the Contract Data Page.
DEFERRED ANNUITY. An annuity contract under which the start of annuity payments
is deferred to a future date.
FIXED ANNUITY. A series of periodic payments made during the annuity period to a
payee under the Contract that are fixed in amount.
FUND. A collective term used to represent an investment entity which may be
selected to be an underlying investment of the Contract.
GUARANTEED ACCOUNT. Contract Values allocated to one or more of the Guaranteed
Account Options under the Contract.
GUARANTEED ACCOUNT CONTRACT VALUE. The sum of all amounts credited to the
Guaranteed Account Options under the Contract, less any amounts canceled or
withdrawn for charges, deductions, surrenders or transfers.
GUARANTEED ACCOUNT MINIMUM VALUE. Premiums, less premium tax, and transfers
allocated to the Guaranteed Account, less Withdrawal Amounts and associated
Withdrawal Charges from the Guaranteed Account, accumulated at 3%, less any
Withdrawal Charge or Premium Tax due.
GUARANTEED ACCOUNT OPTION. A Premium or transfer allocated to a subaccount of
the Guaranteed Account for a specific Guaranteed Period and associated
expiration date.
GUARANTEED PERIOD. A period for which the Current Interest Rate is credited. The
available Guaranteed Periods are listed on the Contract application.
HOME OFFICE. The address and telephone number are as specified on the Contract
Data Page.
INTEREST RATE ADJUSTMENT. An adjustment applied, with certain exceptions, to
amounts withdrawn, transferred or annuitized from the Guaranteed Account prior
to the end of the applicable Guaranteed Account Option.
ISSUE DATE. The date Your Contract is issued, shown on the Contract Data Page.
LATEST ANNUITY DATE. The date on which the Owner attains age 90 under a
Non-Qualified Plan Contract, or age 70 and one-half under a Qualified Plan
Contract, unless otherwise approved by the Company.
DN004 4/95 Page 4
NONQUALIFIED PLAN. A retirement plan which does not receive favorable tax
treatment under Section 401, 403, 408 or 457 of the Internal Revenue Code.
OWNER ("YOU," "YOUR"). The person or entity named in the application who is
entitled to exercise all rights and privileges under this Contract. Usually, but
not always, the Owner is also the Annuitant. The Owner is responsible for taxes,
regardless of who receives annuity benefits. If Joint Owners are named, the
Joint Owner must be a spouse. Joint Owners share ownership in all respects.
PAYEE. Any person receiving payment of annuity benefits under this Contract
during the Annuity Period.
PORTFOLIO. A subdivision of the Separate Account invested wholly in shares of
one of the investment series of the Underlying Funds.
PREMIUMS. Payments made by or on behalf of the Owner to the Company for the
Contract.
QUALIFIED PLAN. A retirement plan which receives favorable tax treatment under
Sections 401, 403, 408 or 457 of the Internal Revenue Code.
SEPARATE ACCOUNT. A segregated asset account named on the Contract Data Page,
established by the Company in accordance with Michigan law. The Separate Account
consists of several Portfolios, each investing in a separate series of the
Underlying Funds. The Prospectus should be read for complete details regarding
the Separate Account and Contracts.
SEPARATE ACCOUNT CONTRACT VALUE. The sum of the value of all Portfolio
Accumulation Units under the Contract.
SUBSEQUENT GUARANTEED RATE. The rate of interest established by the Company for
the applicable subsequent Guaranteed Period, but in no event less than the rate
set forth on the Contract Data Page.
UNDERLYING FUND(S). The underlying entities in which the Portfolios invest.
VALUATION DATE. Each day the New York Stock Exchange is open for business.
VALUATION PERIOD. The period beginning at the close of business of the New York
Stock Exchange (NYSE) on each Valuation Date and ending at the close of the NYSE
on the next succeeding Valuation Date.
VARIABLE ANNUITY. A series of periodic payments which vary in amount according
to the investment experience of the Portfolios to which Contract Values have
been allocated.
WE, OUR, US, THE COMPANY. ▇▇▇▇▇▇▇ National Life Insurance Company.
WITHDRAWAL AMOUNT. The amount transferred to a Guaranteed Account Option or
Portfolio in the event of a transfer or the amount paid to a Contract Owner in
the event of a withdrawal, annuitization or death.
WITHDRAWAL CHARGE. The Contingent Deferred Sales Charge assessed against certain
withdrawals.
WITHDRAWAL VALUE. The Contract Value, less any premium tax payable, minus any
applicable Contract charges, including the Interest Rate Adjustment.
DN004 4/95 Page 5
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GENERAL PROVISIONS
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ASSIGNMENT. The Owner may assign this Contract before the Annuity Date, but we
will not be bound by an assignment unless it is in writing and has been recorded
at our Annuity Service Center. We are not responsible for any payments made
before an assignment is recorded. The Owner may exercise these rights subject to
the interest of any assignee or irrevocable beneficiary. We assume no
responsibility for the validity or tax consequences of any assignment. If the
Contract is issued pursuant to a Qualified Plan (or a Nonqualified Plan that is
subject to ERISA), it may not be assigned except under such conditions as may be
allowed under applicable law.
CONFORMITY WITH STATE LAWS. This Contract will be interpreted under the law of
the state in which it is issued. Any provision which, on the Issue Date, is in
conflict with the law of such state, is amended to conform to the minimum
requirements of such law.
CREDITING OF INTEREST. Interest will be credited to the Guaranteed Account
Contract Value during the Guaranteed Period from the date premium is received by
the Company. The rate of interest for the Guaranteed Period selected will be as
declared in advance by the Company's Board of Directors. The rate of interest
will never be less than the rate shown on the Contract Data Page.
DEFERMENT OF PAYMENTS. We may defer making payments from the Guaranteed Account
for up to 6 months. Interest, subject to state requirements, will be credited
during the deferral period.
ENTIRE CONTRACT. The policy is a Contract. The Contract, Contract Data Page,
application, if any, and any applicable endorsements together make up the entire
Contract.
MISSTATEMENT OF AGE OR SEX. If the age or sex of the Annuitant has been
misstated, the benefits will be those which the Premiums paid would have
purchased at the correct age and sex.
Any underpayments will be made up immediately by the Company. Overpayments will
be deducted from future payments.
MODIFICATION OF CONTRACT. Any change or waiver of the provisions of this
Contract must be in writing and signed by the President, a Vice President, the
Secretary or Assistant Secretary of the Company. No agent has authority to
change or waive any provision of this Contract.
NONPARTICIPATING. This Contract does not share in our surplus or earnings.
PREMIUMS. Premiums are flexible. This means that you, subject to Company
declared minimums and maximums, may change the amounts, frequency or timing of
Premiums. The initial Premium must be at least $5,000 for Nonqualified Plan
Contracts and $2,000 for Qualified Plan Contracts. Subsequent Premiums must be
at least $500 ($50 if made in connection with an automatic payment plan). Total
Premiums under a contract may not exceed $1,000,000. The Company may waive the
minimums or maximums at any time.
Premiums may be allocated among one or more of the Guaranteed Account Options
and one or more of the Portfolios of the Separate Account in accordance with
instructions from you. Such election may be made in any percent from 0% to 100%
in whole percentages. The minimum that may be allocated to a Guaranteed Account
Option or a Portfolio under the Contract is $100.
PREMIUM TAXES. The Company may deduct from the Contract Value any premium taxes
or other taxes payable to a state or other government entity. Should we advance
any amount so due, we are not waiving any right to collect such amounts at a
later date. The Company will deduct any withholding taxes required by applicable
law.
PROOF OF AGE, SEX OR SURVIVAL. The Company may require satisfactory proof of
correct age or sex upon annuitization. If any payment under this Contract
depends on the Annuitant being alive, the Company may require satisfactory proof
of survival.
QUARTERLY REPORTS. The Company will furnish each Owner with a statement of the
Contract Value and Portfolio balances at least quarterly.
SEPARATE ACCOUNT. The Separate Account is a separate investment account of the
Company. It is shown on the Contract Data Page. The assets of the Separate
Account are the property of the Company. However, they are not credited with
earnings or chargeable with liabilities arising out of any other business the
Company may conduct. Each Portfolio is not chargeable with liabilities arising
out of any other Portfolio.
GE004 2/98 Page 6
SUSPENSION OF PAYMENTS. We may suspend or postpone any payments from the
Portfolios if any of the following occur:
a) The New York Stock Exchange is closed.
b) Trading on the New York Stock Exchange is restricted.
c) An emergency exists such that it is not reasonably practical to dispose of
securities in the Separate Account or to determine the value of its assets,
or
d) The Securities and Exchange Commission, by order, so permits for the
protection of security holders.
SUBSTITUTION OF FUND. If the shares of any of the Funds or any series of the
Fund should no longer be available for investment by the Separate Account or if,
in the judgment of the Company's Board of Directors, further investment in the
shares of a Fund is no longer appropriate in view of the purpose of the
Contract, the Company may substitute shares of another mutual fund or a series
within a mutual fund for Fund shares already purchased or to be purchased in the
future by Premiums under the Contract. No substitution of securities may take
place without prior approval of the Securities and Exchange Commission and under
such requirements as it may impose.
WRITTEN NOTICE. Any notice we send to the Owner will be sent to the Owner's
address shown in the application unless the Owner requests otherwise. Any
written request or notice to us must be sent to our Annuity Service Center.
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CHARGES AND DEDUCTIONS
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We will deduct the following charges from the Contract:
ADMINISTRATION CHARGE.The charge specified on the Contract Data Page. This
charge is to compensate Us for all administrative expenses associated with the
Contract.
ANNUAL CONTRACT MAINTENANCE CHARGE. The charge specified on the Contract Data
Page will be deducted on each Contract anniversary that occurs on or prior to
the Annuity Date. It will also be deducted when the Contract Value is withdrawn
in full if withdrawal is not on a Contract anniversary. We reserve the right to
assess a charge on a class basis which is less than the charge specified on the
Contract Data Page.
CONTINGENT DEFERRED SALES CHARGE. This charge may be deducted upon withdrawal of
the Contract Value, in whole or in part. See WITHDRAWAL PROVISIONS.
ENHANCED DEATH BENEFIT CHARGE. The charge specified on the Contract Data Page.
This charge is to compensate Us for the risk assumed as a result of contractual
obligations to provide an Enhanced Death Benefit prior to the Annuity Date.
EXPENSE RISK CHARGE. The charge specified on the Contract Data Page. This charge
is to compensate Us for assuming the expense risks under the Contract.
INTEREST RATE ADJUSTMENT. See INTEREST RATE ADJUSTMENT section.
MORTALITY RISK CHARGE. The charge specified on the Contract Data Page. This
charge is to compensate Us for assuming the mortality risks under the Contract.
TRANSFER FEE. A transfer fee of $25.00 will apply to transfers in excess of 15
in a Contract Year. The Company may waive the transfer fee in connection with
preauthorized automatic transfer programs.
GE004 2/98 Page 7
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ACCUMULATION PROVISIONS
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ACCUMULATION UNIT VALUE (AUV). Accumulation Unit Value is determined Monday
through Friday on each day that the New York Stock Exchange is open for
business.
A separate Accumulation Unit Value is determined for each Portfolio. If the
Company elects or is required to assess a charge for taxes, a separate
Accumulation Unit Value may be calculated for Contracts issued in connection
with Nonqualified and Qualified Plans, respectively, within each Portfolio.
The Accumulation Unit Value for each Portfolio will vary with the price of a
share in the Underlying Fund and in accordance with the Mortality (including the
Enhanced Death Benefit Charge) and Expense Risk Charge, Administration Charge,
and any provision for taxes.
Assessments of Withdrawal Charges, Transfer Fees and Contract Maintenance
Charges are effected by redemption of Accumulation Units and do not affect
Accumulation Unit Value.
The Accumulation Unit Value of a Portfolio for any Valuation Period is
calculated by subtracting (2) from (1) and dividing the result by (3) where:
1) is the total value at the end of the given Valuation Period of the assets
attributable to the Accumulation Units of the Portfolio minus the total
liabilities;
2) is the cumulative unpaid charge for assumptions of Mortality and Expense
Risk Charge, and for Administration Charge; and
3) is the number of Accumulation Units outstanding at the end of the given
Valuation Period.
GUARANTEED ACCOUNT CONTRACT VALUE. The Guaranteed Account Value under the
contract shall be the sum of all monies allocated or transferred to the
Guaranteed Account, reduced by any applicable premium taxes, plus all interest
credited to the Guaranteed Account during the period that the Contract has been
in effect. This amount shall be adjusted for withdrawals, annuitizations,
transfers, and charges.
GUARANTEED ACCOUNT OPTIONS. For any amounts allocated to the Guaranteed Account,
the Owner will select the duration of the Guaranteed Account Option from those
made available by the Company. Such amounts will earn interest at the Current
Interest Rate for the chosen duration, compounded annually during the entire
Guaranteed Period. In no event will the Current Interest Rate be less than the
Subsequent Guaranteed Rate specified on the Contract Data Page.
You may allocate Premiums, or make transfers from the Portfolios, to the
Guaranteed Account at any time prior to the latest Annuity Date. However, no
Guaranteed Period other than one year may be chosen which extends beyond the
latest Annuity Date. Withdrawals from a Guaranteed Account Option may take place
thirty (30) days following the end of the corresponding Guaranteed Period
without being subject to an Interest Rate Adjustment.
If the Owner does not specify a Guaranteed Period at the time of renewal, We
will select the same Guaranteed Period as has just expired, so long as such
Guaranteed Period does not extend beyond the Annuity Date. If such Guaranteed
Period does extend beyond the Annuity Date, We will choose the longest period
that will not extend beyond such date. If a renewal occurs within one year of
the Annuity Date, We will credit interest up to the Annuity Date at the then
Current Interest Rate for the one-year Guaranteed Period.
INTEREST RATE ADJUSTMENT. Except in the 30-day period following the end of a
Guaranteed Period, any amount withdrawn or transferred from a Guaranteed Account
Option will be subject to an Interest Rate Adjustment. The Interest Rate
Adjustment will be calculated by multiplying the amount withdrawn, transferred
or annuitized by the formula described below:
[1 + 1] (m/12)
------- -1
[1 + J] (m/12)
where:
I = The base rate credited to the current Guaranteed Period.
AC004 12/95 Page 8
J = The base rate that would be credited to the Guaranteed Account Option of
the same duration at the time of withdrawal or transfer, increased by 0.5%.
When no Guaranteed Account Option of the same duration is available, the
rate will be established by linear interpolation.
M = The number of complete months remaining to the end of the Guaranteed
Account Option.
There will be no Interest Rate Adjustment when J is greater than I but by less
than 0.5%.
In addition, the Interest Rate Adjustment will not be applied to amounts
withdrawn for:
a) the payment of death benefit proceeds,
b) the payment of charges or fees; or
c) transfers relating to Dollar Cost Averaging from the one-year Guaranteed
Account Option.
In no event will the total Withdrawal Amount available be less than the
Guaranteed Account Minimum Value.
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TRANSFER PROVISIONS
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TRANSFERS. Transfers between Portfolios and Guaranteed Account Options may be
made as described below. Such transfers are not subject to Withdrawal Charges.
Transfers from the Guaranteed Account will be subject to applicable Interest
Rate Adjustments.
The minimum transfer amount is $100. The remaining Contract Value of a Portfolio
or Guaranteed Account Option after a transfer must be at least $100. If a
transfer would cause a remaining value to be less than $100, all of the value
must be transferred, or no transfer can take place. The Company reserves the
right to waive the minimum transfer amount in connection with preauthorized
automatic transfer programs.
FROM PORTFOLIO TO PORTFOLIO. Both prior to and after the Annuity Date, You may
transfer all or a portion of Your investment in one Portfolio to another
Portfolio. A transfer will result in the purchase of Accumulation Units in a
Portfolio and redemption of Accumulation Units in the other Portfolio. Transfers
will be effected at the end of the Valuation Period in which We receive Your
request for the transfer.
FROM PORTFOLIO TO THE GUARANTEED ACCOUNT. Prior to the Annuity Date, You may
transfer all or a portion of the value of Your Portfolio(s) to a Guaranteed
Account Option. This will result in the redemption of Accumulation Units and
will be effected at the end of the Valuation Period in which We receive Your
request for transfer.
FROM GUARANTEED ACCOUNT TO GUARANTEED ACCOUNT OR PORTFOLIO. Other than on
renewal of a Guaranteed Account Option (see GUARANTEED ACCOUNT OPTIONS),
transfers made between Guaranteed Account Options or from a Guaranteed Account
Option to a Portfolio are subject to an Interest Rate Adjustment.
AC004 12/95 Page 9
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WITHDRAWAL PROVISIONS
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Prior to the Annuity Date, you may withdraw all or part of the Contract Value
amounts under this Contract by informing us at our Annuity Service Center. For
full withdrawal, this Contract, or a Lost Contract Affidavit, must be returned
to Our Annuity Service Center.
Except in connection with a systematic withdrawal program, the minimum partial
withdrawal amount is $500, or if less, the Owner's entire interest in the
Portfolio or Guaranteed Account Option from which a withdrawal is requested. The
Owner's interest in the Portfolio or Guaranteed Account Option from which the
withdrawal is requested must be at least $100 after the withdrawal is completed
if anything is left in that Portfolio or Guaranteed Account Option.
Absent written notification to the contrary, withdrawals and any applicable
charge will be deducted from the Contract Value in proportion to their
allocation among the Portfolios and Guaranteed Account Options. Withdrawals will
be based on values at the end of the Valuation Period in which the request for
withdrawal and the Contract, or a Lost Contract Affidavit, (in the case of a
full withdrawal), are received at the Annuity Service Center. Withdrawals are
subject to applicable Interest Rate Adjustments.
CONTINGENT DEFERRED SALES CHARGE. A Contingent Deferred Sales Charge, which is
referred to as the Withdrawal Charge, may be imposed upon certain withdrawals.
Withdrawal Charges will vary in amount depending upon the Contribution Year of
the Premium at the time of withdrawal in accordance with the Withdrawal Charge
table shown below.
The Withdrawal Charge schedule is:
Contribution Year Percent
0 7
1 6
2 5
3 4
4 3
5 2
6 1
7 0
The Withdrawal Charge is deducted from the remaining Contract Value so that the
actual reduction in Contract Value as a result of the withdrawal will be greater
than the withdrawal amount requested and paid. For purposes of determining the
Withdrawal Charge, withdrawals will be allocated first to earnings, if any
(which may be withdrawn free of Withdrawal Charge), and then to Premium on a
first-in, first-out basis so that all withdrawals are allocated to Premium to
which the lowest (if any) Withdrawal Charge applies.
Premiums that are no longer subject to the Withdrawal Charge (and not previously
withdrawn), plus earnings in the Owner's account may be withdrawn free of
Withdrawal Charges at any time.
In addition, there may be a free withdrawal amount for the first withdrawal
during a Contract Year ("Additional Free Withdrawal"). The Additional Free
Withdrawal amount is equal to 10% of Premium that remains subject to the
Withdrawal Charge and that has not previously been withdrawn, less earnings in
the Owner's account. Although Additional Free Withdrawal amounts reduce
principal in an Owner's account, they do not reduce Premium for purposes of
calculating the Withdrawal Charge. As a result, an Owner will not receive the
benefit of an Additional Free Withdrawal in a full surrender.
If the withdrawal request does not specify from which Portfolio(s) or Guaranteed
Account Option(s) the withdrawal is to be made, the request will be processed by
making withdrawals from each Portfolio and each Guaranteed Account Option in
proportion to their allocations. In no event shall the amount withdrawn exceed
the Withdrawal Value.
The Company will waive the Withdrawal Charge on any withdrawal necessary to
satisfy the minimum distribution requirements of the Code.
In addition to a Withdrawal Charge, a withdrawal from the Guaranteed Account may
also incur an Interest Rate Adjustment. See INTEREST RATE ADJUSTMENT for further
details.
DE004 12/95 Page 10
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DEATH BENEFIT PROVISIONS
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DEATH OF CONTRACT OWNER BEFORE THE ANNUITY DATE: Upon Your death, or the death
of any Joint Contract Owner, before the Annuity Date, the Death Benefit will be
paid to the Beneficiary(ies) designated by You. Upon the death of a Joint
Contract Owner, the surviving Joint Contract Owner, if any, will be treated as
the primary Beneficiary. Any other Beneficiary designation on record at the
Company's Home Office at the time of death will be treated as a contingent
Beneficiary.
DEATH BENEFIT AMOUNT BEFORE THE ANNUITY DATE: The standard Death Benefit is
equal to the greater of:
1) the Contract Value at the end of the Valuation Period during which due
proof of death and an election of the type of payment to the Beneficiary is
received by the Company, at Home Office; or
2) the total Premiums paid prior to the death of the Owner, minus the sum of:
a) the total withdrawals and any Withdrawal Charges assessed; and
b) premium taxes incurred.
In addition, where permitted by state law, the Company will provide an Enhanced
Death Benefit. The Enhanced Death Benefit is determined by (A) recomputing the
standard Death Benefit by accumulating all amounts under (2) above annually at
5% (4% if the Owner was age 70 or older on the Issue Date) to the date of death,
and (B) paying the greater of the amount so determined and the following amount,
which is deemed to be $0 if the Owner dies prior to the seventh Contract Year:
The Contract Value at the seventh Contract Year, plus any Premiums paid
since that time and prior to death, minus the sum of:
a) total withdrawals and any Withdrawal Charges assessed since such
seventh Contract Year; and
b) premium taxes incurred since the seventh Contract Year,
all accumulated annually at 5% (4% is the Owner was age 70 or older on the Issue
Date) to the date of death.
The Enhanced Death Benefit shall never exceed 250% of all Premiums paid to the
Contract, reduced by the amount of any withdrawals.
DEATH BENEFIT OPTIONS BEFORE ANNUITY DATE: In the event of Your death or any
Joint Contract Owner's death before the Annuity Date, a Beneficiary must request
that the Death Benefit be paid under one of the Death Benefit Options below. In
addition, if the Beneficiary is the spouse of the Contract Owner, he or she may
elect to continue the Contract, at the then Contract Value, in his or her own
name and exercise all the Contract Owner's rights under the Contract. The
following are the Death Benefit Options:
o Option 1 - lump-sum payment of the Death Benefit; or
o Option 2 - the payment of the entire Death Benefit within 5 years of the
date of the death of the Contract Owner or any Joint Contract Owner; or
o Option 3 - payment of the Death Benefit under an Annuity Option over the
lifetime of the Beneficiary or over a period not extending beyond the life
expectancy of the Beneficiary, with distribution beginning within one year
of the date of Your death or the death of any Joint Contract Owner.
Any portion of the death benefit not applied under Option 3 within one year of
the date of a Contract Owner's death, must be distributed within five years of
the date of death.
If a lump-sum payment is requested, the amount will be paid within seven (7)
days of receipt of proof of death and the election unless the Suspension or
Deferral of Payments Provision is in effect.
Payment to the Beneficiary, other than in a single sum, may only be elected
during the sixty-day period beginning with the date of receipt of proof of
death.
DEATH OF CONTRACT OWNER AFTER THE ANNUITY DATE: If You, or any Joint Contract
Owner, die after the Annuity Date, and You are not an Annuitant, any remaining
payments under the Annuity Option elected will continue at least as rapidly as
under the method of distribution in effect at the Contract Owner's death. Upon
Your death after the Annuity Date, the Beneficiary becomes the Contract Owner.
DE004 12/95 Page 11
DEATH OF ANNUITANT: Upon the death of an Annuitant, who is not a Contract Owner,
before the Annuity Date, You may designate a new Annuitant, subject to the
Company's underwriting rules then in effect. If no designation is made within 30
days of the death of the Annuitant, You will become the Annuitant. If the
Contract Owner is a non-natural person,
the death of the Annuitant will be treated as the death of the Contract Owner
and a new Annuitant may not be designated.
Upon the death of the Annuitant after the Annuity Date, the death benefit, if
any, will be as specified in the Annuity Option elected. Death benefits will be
paid at least as rapidly as under the method of distribution in effect at the
Annuitant's death.
DE004 12/95 Page 11a
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ANNUITY PROVISIONS
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ANNUITY DATE. The date on which annuity payments are to begin. In selecting an
Annuity Date, the Owner may wish to consider the applicability of a Withdrawal
Charge, which is imposed upon annuitizations which occur within one year of the
Issue Date. Annuity payments will begin no later than the Latest Annuity Date.
If no Annuity Date is selected, the Annuity Date will be the Latest Annuity
Date. The Owner may change the Annuity Date at any time, at least seven days
prior to the Annuity Date then indicated on the Company's records, by written
notice to the Company at its Annuity Service Center.
ANNUITY OPTIONS. The Owner, or any Beneficiary who is so entitled, may elect to
receive a lump sum at the end of the accumulation period. However, a lump-sum
distribution may be deemed to be a withdrawal, and at least a portion of it may
be subject to income tax. Alternatively, an Annuity Option may be elected. The
Owner may, upon prior written notice to the Company at its Annuity Service
Center, elect an Annuity Option at any time prior to the Annuity Date.
A change of Annuity Options is permitted if made at least 7 days before the
Annuity Date. If no other Annuity Option is elected, monthly annuity payments
will be made in accordance with Option 3 below, a Life annuity with 120-month
period certain. Annuity payments will be made in monthly, quarterly, semi-annual
or annual installments as selected by the Owner. However, if the amount
available to apply under an Annuity Option is less than $5,000, and state law
permits, the Company has the right to pay the annuity in one lump sum. In
addition, if the first payment provided would be less than $50, and state law
permits, the Company shall have the right to require the frequency of payments
be at quarterly, semiannual or annual intervals so as to result in an initial
payment of at least $50.
NO WITHDRAWALS OF CONTRACT VALUE ARE PERMITTED DURING THE ANNUITY PERIOD FOR ANY
ANNUITY OPTION UNDER WHICH PAYMENTS ARE BEING MADE PURSUANT TO LIFE
CONTINGENCIES.
Upon written election filed with The Company at its Annuity Service Center, all
of the Contract Value will be applied to provide one of the following Annuity
Options. The portion of the Contract Value which is in the Guaranteed Account
immediately prior to the Annuity Date, applied to an Annuity Option, will be
subject to applicable Interest Rate Adjustments.
OPTION 1 - LIFE INCOME An annuity payable monthly during the lifetime of the
Annuitant. Under this option, no further payments are payable after the death of
the Annuitant, and there is no provision for a death benefit payable to the
Beneficiary. Therefore, it is possible under Option 1 for the payee to receive
only one monthly annuity payment under this Contract.
OPTION 2 - JOINT AND SURVIVOR An annuity payable monthly while both the
Annuitant and a designated second person are living. Upon the death of either
person, the monthly income payable will continue during the lifetime of the
survivor. If a reduced payment to the survivor is desired, variable annuity
payments will be determined using either one-half or two-thirds of the number of
each type of Annuity Unit credited. Fixed payments will be equal to either
one-half or two-thirds of the fixed payment payable during the joint life of the
Annuitant and the designated second person.
Annuity payments terminate automatically and immediately upon the death of the
surviving person without regard to the number or total amount of payments
received.
There is no minimum number of guaranteed payments, and it is possible to have
only one annuity payment if both the Annuitant and the designated second person
die before the due date of the second payment.
OPTION 3 - LIFE ANNUITY WITH 120 OR 240 MONTHLY PAYMENTS GUARANTEED An annuity
payable monthly during the lifetime of the Annuitant with the guarantee that if,
at the death of the Annuitant, payments have been made for fewer than the
guaranteed 120 or 240 monthly periods, as elected by the Owner, the balance of
the guaranteed number of payments will be made to the Beneficiary.
OPTION 4 - INCOME FOR A SPECIFIED PERIOD Under this option, a payee can elect an
annuity payable monthly for any period of years from 5 to 30. This election must
be made for full 12-month periods. In the event the payee dies before the
specified number of payments has been made, the Beneficiary may elect to
continue receiving the scheduled payments or may alternatively elect to receive
the discounted present value of any remaining guaranteed payments in a lump sum.
ADDITIONAL OPTIONS. Other Annuity Options may be made available by the Company.
AN002 4/95 Page 12
FIXED ANNUITY PAYMENTS. To the extent a fixed Annuity Option has been elected,
the proceeds payable under this Contract, less any applicable premium taxes,
shall be applied to the payment of the Annuity Option elected at whichever of
the following is more favorable to the Payee; (a) the annuity rates based upon
the applicable tables in the contract; (b) the then current rates provided by
The Company on contracts of this type on the Annuity Date. In no event will the
Fixed Annuity payments be changed once they begin.
AMOUNT OF FIXED ANNUITY PAYMENTS. The amount of each Fixed Annuity payment will
be determined by applying the portion of the Contract Value allocated to Fixed
Annuity payments less any applicable premium taxes, charges and any Interest
Rate Adjustment that may apply in the case of premature annuitizations, to the
annuity table applicable to the Annuity Option chosen.
AMOUNT OF VARIABLE ANNUITY PAYMENTS. FIRST VARIABLE PAYMENT. THE DOLLAR AMOUNT
OF THE FIRST MONTHLY ANNUITY PAYMENT WILL BE DETERMINED BY APPLYING THE PORTION
OF THE CONTRACT VALUE ALLOCATED TO VARIABLE ANNUITY PAYMENTS, LESS ANY
APPLICABLE PREMIUM TAXES, TO THE ANNUITY TABLE APPLICABLE TO THE ANNUITY OPTION
CHOSEN. THOSE TABLES ARE BASED ON A SET AMOUNT PER $1,000 OF PROCEEDS APPLIED.
The dollars applied are then divided by 1,000 and the result multiplied by the
appropriate annuity factor appearing in the table to compute the amount of the
first monthly annuity payment. That amount is divided by the value of an Annuity
Unit as of the Annuity Date to establish the number of Annuity Units
representing each Variable Annuity payment. The number of Annuity Units
determined for the first Variable Annuity payment remains constant for the
second and subsequent monthly Variable Annuity payments, assuming that no
reallocation of Contract Values is made. The total Variable Annuity payment is
equal to the sum of the annuity payments as determined above for each Portfolio
to which the Contract Value is allocated on the Annuity Date.
NUMBER OF VARIABLE ANNUITY UNITS. The number of Annuity Units for each
applicable Portfolio is the amount of the first annuity payment attributable to
that Portfolio divided by the value of the applicable Annuity Unit for that
Portfolio as of the Annuity Date. The number will not change as a result of
investment experience.
ANNUITY UNIT VALUE. The initial value of an Annuity Unit of each Portfolio was
set when the Portfolios were established. The value may increase or decrease
from one Valuation Period to the next. For any Valuation Period, the value of an
Annuity Unit of a particular Portfolio is the value of that Annuity Unit during
the last Valuation Period, multiplied by the net investment factor for that
Portfolio for the current Valuation Period.
THE NET INVESTMENT FACTOR for any Portfolio for any Valuation Period is
determined by dividing (a) by (b) and then subtracting (c) from the result
where:
a) is the net result of:
1) the net asset value of the Fund share held in the Portfolio determined
as of the end of the Valuation Period, plus
2) the per share amount of any dividend or other distribution declared by
the Fund on the shares held in the Portfolio if the "ex-dividend" date
occurs during the Valuation Period, plus or minus
3) a per share credit or charge with respect to any taxes paid or
reserved for by the Company during the Valuation Period which are
determined by the Company to be attributable to the operation of the
Portfolio. (No federal income taxes are applicable under present law.)
b) is the net asset value of the Fund share held in the Portfolio determined
as of the end of the preceding Valuation Period; and
c) is the asset charge factor determined by the Company for the Valuation
Period to reflect the Expense Risk Charge, Administration Charge, Mortality
Risk Charge and Enhanced Death Benefit Charge.
The result is then multiplied by a factor that neutralizes the assumed
investment rate.
SUBSEQUENT VARIABLE ANNUITY PAYMENTS. After the first Variable Annuity payment,
payments will vary in amount according to the investment performance of the
applicable Portfolios. The amount may change from month to month. The amount of
each subsequent payment is the sum of:
The number of Annuity Units for each Portfolio as determined for the first
annuity payment, multiplied by the value of an Annuity Unit for that Portfolio
at the end of the Valuation Period immediately preceding in which payment is
due.
The Company guarantees that the amount of each Variable Annuity payment will not
be affected by variations in expenses or mortality experience.
BASIS OF COMPUTATION. The actuarial basis for the Table of Guaranteed Annuity
Rates is the 1983a Annuity Mortality Table, without projection with interest at
3.0%. The Table of Guaranteed Annuity Rates does not include any applicable
premium tax.
AN002 4/95 Page 13
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TABLE OF ANNUITY OPTIONS
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The following table is for a contract whose net proceeds are $1,000, and will
apply pro rata to the amount payable under this contract.
------------------------------------------------------------------------------
UNDER OPTION 4 MONTHLY INSTALLMENT UNDER OPTIONS 1 OR 3
------------------------------------------------------------------------------
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No. of Monthly Age of No. of Mos. Age of No. of Mos. Age of No. of Mos. Age of No. of Mos.
Monthly Install- Payee Payee Payee Payee
Install -ments Certain Certain Certain Certain
-ments
------- ----- ------ ----- ------- ------ ------ ----- -------- ----- ------ ----- -------- ------ ------ ---
Male Life 120 240 Male Life 120 240 Female Life 120 240 Female Life 120 240
---------- --------- ------- ----- ------ ----- ------- ------ ------ ----- -------- ----- ------ ----- -------- ------ ------ ---
60 17.95 40 3.67 3.66 3.61 70 7.28 6.64 5.28 40 3.44 3.43 3.42 70 6.29 5.99 5.14
72 15.17 41 3.72 3.71 3.68 71 7.56 6.82 5.33 41 3.48 3.47 3.45 71 6.52 6.17 5.20
84 13.19 42 3.77 3.76 3.70 72 7.86 7.00 5.36 42 3.52 3.51 3.48 72 6.78 6.35 5.24
96 11.71 43 3.82 3.81 3.74 73 8.19 7.17 5.39 43 3.56 3.55 3.52 73 7.02 6.54 5.30
108 10.56 44 3.89 3.86 3.79 74 8.52 7.35 5.41 44 3.60 3.59 3.56 74 7.31 6.73 5.34
120 9.64 45 3.95 3.92 3.83 75 8.90 7.53 5.43 45 3.64 3.63 3.60 75 7.82 6.92 5.37
132 8.89 46 4.00 3.98 3.89 76 9.30 7.71 5.45 46 3.70 3.69 3.64 76 7.96 7.12 5.40
144 8.26 47 4.07 4.04 3.94 77 9.71 7.89 5.47 47 3.75 3.74 3.69 77 8.32 7.33 5.43
156 7.73 48 4.14 4.10 3.99 78 10.17 8.05 5.48 48 3.80 3.79 3.74 78 8.72 7.53 5.45
168 7.28 49 4.21 4.17 4.04 79 10.66 8.21 5.49 49 3.86 3.84 3.79 79 9.16 7.73 5.46
180 6.88 50 4.28 4.24 4.10 80 11.19 8.37 5.50 50 3.92 3.91 3.83 80 9.62 7.93 5.48
192 6.55 51 4.37 4.31 4.16 81 11.75 8.51 5.50 51 3.98 3.96 3.89 81 10.13 8.11 5.49
204 6.25 52 4.45 4.39 4.22 82 12.34 8.65 5.51 52 4.05 4.02 3.95 82 10.68 8.30 5.50
216 5.97 53 4.53 4.47 4.27 83 12.97 8.77 5.51 53 4.11 4.09 4.00 83 11.28 8.47 5.50
228 5.74 54 4.63 4.55 4.33 84 13.65 8.90 5.52 54 4.20 4.17 4.06 84 11.93 8.83 5.51
240 5.52 55 4.72 4.65 4.40 85 14.36 9.00 5.52 55 4.27 4.24 4.13 85 12.64 8.77 5.51
252 5.34 56 4.83 4.74 4.47 86 15.11 9.10 5.52 56 4.36 4.31 4.19 86 13.39 8.91 5.52
264 5.16 57 4.94 4.84 4.53 87 15.91 9.19 5.52 57 4.44 4.40 4.25 87 14.20 9.02 5.52
276 5.00 58 5.05 4.94 4.60 88 16.74 9.26 5.52 58 4.53 4.49 4.31 88 15.07 9.13 5.52
288 4.86 59 5.18 5.05 4.68 89 17.84 9.34 5.52 59 4.64 4.57 4.39 89 15.99 9.21 5.52
300 4.72 60 5.31 5.17 4.73 90 18.59 9.39 5.52 60 4.74 4.68 4.45 90 16.96 9.30 5.52
61 5.45 5.28 4.79 91 19.61 9.44 5.52 61 4.86 4.78 4.52 91 17.97 9.36 5.52
62 5.61 5.42 4.86 92 20.71 9.49 5.52 62 4.97 4.89 4.60 92 19.04 9.41 5.52
63 5.77 5.56 4.92 93 21.89 9.52 5.52 63 5.10 5.00 4.67 93 20.15 9.46 5.52
64 5.94 5.69 4.98 94 23.16 9.56 5.52 64 5.23 5.12 4.74 94 21.31 9.50 5.52
65 6.13 5.84 5.04 95 24.55 9.58 5.52 65 5.38 5.25 4.81 95 22.51 9.54 5.52
66 6.33 5.98 5.10 96 26.07 9.60 5.52 66 5.54 5.38 4.88 96 23.78 9.57 5.52
67 6.55 6.14 5.15 97 27.73 9.62 5.52 67 5.70 5.52 4.95 97 25.14 9.59 5.52
68 6.78 6.31 5.20 98 29.58 9.62 5.52 68 5.88 5.67 5.01 98 26.62 9.61 5.52
69 7.02 6.48 5.24 99 31.63 9.63 5.52 69 6.08 5.83 5.08 99 28.27 9.62 5.52
AT002 4/95 Page 14