Cova Financial Services Life Insurance Company
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▇▇. ▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇
COVA FINANCIAL SERVICES LIFE INSURANCE COMPANY (the "Company") will make Annuity
Payments to the Annuitant starting on the Annuity Date subject to the terms of
this Contract. This Contract is issued in return for the Application and payment
of the single Purchase Payment. A copy of the Application is attached to and
made a part of this Contract.
This is a legal contract between the Owner and the Company.
TEN DAY FREE LOOK
Within 10 days of the date of receipt of this Contract by the Owner, it may be
returned by delivering or mailing it to the Company or to the agent through whom
it was purchased. When this Contract is received by the Company, it will be
voided as if it had never been in force. The Company will refund the Contract
Value computed at the end of the Valuation Period during which this Contract is
received by the Company.
Signed for the Company.
/s/ /s/
INDIVIDUAL SINGLE PURCHASE PAYMENT
DEFERRED VARIABLE ANNUITY CONTRACT
NONPARTICIPATING
NO DIVIDENDS
READ YOUR CONTRACT CAREFULLY
ANNUITY PAYMENTS AND VALUES PROVIDED BY THIS CONTRACT, WHEN BASED ON THE
INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT
GUARANTEED AS TO DOLLAR AMOUNT.
THE VARIABLE PROVISIONS OF THIS RIDER CAN BE FOUND ON PAGES 8 - 11.
INDEX
Page
Definitions..............................................................................................................7
General Provisions.......................................................................................................7
The Contract.............................................................................................................7
Incontestability.........................................................................................................7
Non-Participating........................................................................................................7
Misstatement of Age......................................................................................................7
Contract Settlement......................................................................................................7
Reports..................................................................................................................7
Taxes....................................................................................................................7
Evidence of Survival.....................................................................................................7
Modification of Contract.................................................................................................8
▇▇▇▇▇▇▇▇▇, Ownership, Assignment Provisions..............................................................................8
▇▇▇▇▇▇▇▇▇................................................................................................................8
Ownership................................................................................................................8
Assignment...............................................................................................................8
Beneficiary Provisions...................................................................................................8
Beneficiary..............................................................................................................8
Change of Beneficiary....................................................................................................8
Purchase Payment Provisions..............................................................................................8
The Purchase Payment.....................................................................................................8
No Default...............................................................................................................8
Variable Account Provisions..............................................................................................8
The Variable Account.....................................................................................................8
Investments of the Variable Account......................................................................................8
Valuation of Assets......................................................................................................8
Contract Value...........................................................................................................8
Transfers................................................................................................................8
Accumulation Unit........................................................................................................9
Mortality and Expense Risk Premium.......................................................................................9
Administrative Expense Charge............................................................................................9
Mortality and Expense Guarantee..........................................................................................9
Contract Maintenance Charge..............................................................................................9
Deduction for Contract Maintenance Charge................................................................................9
Death Benefit............................................................................................................9
Death of Annuitant.......................................................................................................9
Death of Owner...........................................................................................................9
Payment of Death Benefit................................................................................................10
Annuity Provisions......................................................................................................10
Annuity Date............................................................................................................10
Election of Annuity Option..............................................................................................10
Frequency and ▇▇▇▇▇▇ of Annuity Payments................................................................................10
Annuity Options.........................................................................................................10
Variable Annuity........................................................................................................10
Annuity Unit............................................................................................................10
Net Investment Factor...................................................................................................11
Protection of Proceeds..................................................................................................11
Withdrawal Provisions...................................................................................................11
Withdrawals.............................................................................................................11
Withdrawal Charge.......................................................................................................11
Waiver of Withdrawal Charge.............................................................................................11
Suspension of Payments..................................................................................................11
Suspension of Payments..................................................................................................11
Tables...............................................................................................................12-14
CONTRACT DATA PAGE
ANNUITANT: [▇▇▇▇ ▇▇▇]
CONTRACT NUMBER: [123]
CONTRACT OWNER: [▇▇▇▇ ▇▇▇]
EFFECTIVE DATE: [June 1, 1995]
INCOME DATE: [June 1, 2025]
PURCHASE PAYMENT: [$10,000] THE MINIMUM TOTAL PURCHASE PAYMENT IS
[$5,000] [THE MINIMUM ACCOUNT ONE OR
ACCOUNT TWO PURCHASE PAYMENT IS $5,000]
[INITIAL INTEREST RATE:]
[ACCOUNT ONE INTEREST RATE:] [7% GUARANTEED THROUGH THE END OF
THE CURRENT CALENDAR YEAR.]
[ACCOUNT TWO INTEREST RATE:] [8% GUARANTEED THROUGH THE END OF
THE CURRENT CALENDAR YEAR.]
CONTRACT MAINTENANCE CHARGE: $30.00 EACH CONTRACT YEAR.
AFTER THE INCOME DATE THE CONTRACT MAINTENANCE CHARGE WILL BE
COLLECTED ON A MONTHLY BASIS.
MORTALITY AND EXPENSE RISK PREMIUM:
EQUAL ON AN ANNUAL BASIS TO 1.25% OF THE DAILY NET ASSET VALUE OF
THE VARIABLE ACCOUNT.
ADMINISTRATIVE EXPENSE CHARGE:
EQUAL ON AN ANNUAL BASIS TO .15% OF THE DAILY NET ASSET VALUE OF
THE VARIABLE ACCOUNT.
TRANSFER FEE:
[$25 PER TRANSACTION IF THERE ARE MORE THAN 12 TRANSFERS IN A
CONTRACT YEAR.]
ELIGIBLE INVESTMENTS:
[VAN ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ SERIES TRUST]
- [QUALITY INCOME PORTFOLIO]
- [HIGH YIELD PORTFOLIO]
- [GROWTH AND INCOME PORTFOLIO]
- [MONEY MARKET PORTFOLIO]
VARIABLE ACCOUNT: [COVA VARIABLE ANNUITY ACCOUNT ONE]
ANNUITY SERVICE OFFICE:
Cova Financial Services Life Insurance Company
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▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇ ▇▇▇▇▇
(▇▇▇) ▇▇▇-▇▇▇▇
FOR USE WITH [COVA VARIABLE ANNUITY ACCOUNT ONE]
A SEPARATE INVESTMENT ACCOUNT OF
COVA FINANCIAL SERVICES LIFE INSURANCE COMPANY
DEFINITIONS
ACCUMULATION UNIT -- An accounting unit of measure used to calculate the
Contract Value prior to the Annuity Date.
AGE -- The age on the birthday prior to any date for which age is to be
determined.
ANNUITANT -- The natural person on whose life Annuity Payments are based.
ANNUITY DATE -- The date on which Annuity Payments begin. The Annuity Date is
shown on the Contract Data Page.
ANNUITY PAYMENTS -- The series of payments made to the Annuitant after the
Annuity Date under the Annuity Option elected.
ANNUITY PERIOD -- The period starting on the Annuity Date.
ANNUITY UNIT-- An accounting unit of measure used to calculate Annuity Payments
after the Annuity Date.
BENEFICIARY -- The person(s) who will receive the Death Benefit.
COMPANY -- Cova Financial Services Life Insurance Company at its Annuity Service
Office shown on the Contract Data Page.
CONTRACT ANNIVERSARY -- An anniversary of the Issue Date.
CONTRACT VALUE -- The dollar value as of any Valuation Date of all amounts
accumulated under this Contract.
CONTRACT YEAR -- One year from the Issue Date and from each Contract
Anniversary.
ELIGIBLE INVESTMENT(S) -- An investment entity shown on the Contract Data Page.
ISSUE DATE -- The date this Contract is issued. The Issue Date is shown on the
Contract Data Page.
OWNER -- The person or entity named in the Application who/which has all rights
under this Contract.
PORTFOLIO -- A segment of an Eligible Investment which constitutes a separate
and distinct class of shares.
VALUATION DATE -- The Variable Account will be valued each day that the New York
Stock Exchange is open for trading.
VALUATION PERIOD -- The period beginning at the close of business of the New
York Stock Exchange on each Valuation Date and ending at the close of business
for the next succeeding Valuation Date.
VARIABLE ACCOUNT -- A separate investment account of the Company designated on
the Contract Data Page into which the Purchase Payment will be allocated.
WITHDRAWAL VALUE -- The Withdrawal Value is:
1) the Contract Value for the Valuation Period next following the Valuation
Period during which the written request to the Company for withdrawal is
received; less
2) any applicable taxes not previously deducted; less
3) the Withdrawal Charge, if any; less
4) the Contract Maintenance Charge, if any.
GENERAL PROVISIONS
THE CONTRACT -- The entire contract consists of:
1) this Contract;
2) the Application which is attached to this Contract; and
3) any riders or endorsements attached to this Contract.
This Contract may be changed or altered only by the President or Secretary of
the Company. A change or alteration must be made in writing.
INCONTESTABILITY -- The Company will not contest this Contract from the Issue
Date.
NON-PARTICIPATING -- This Contract will not share in any distribution of
dividends.
MISSTATEMENT OF AGE--The Company may
require proof of age of the Annuitant before making any life Annuity Payments
under this Contract. If the age of the Annuitant has been misstated, the amount
payable will be the amount that the Purchase Payment would have provided at the
correct age.
After the Annuity Date, any underpayments will be made up in one sum with the
next Annuity Payment. Any overpayments will be deducted from future Annuity
Payments until the total is repaid.
CONTRACT SETTLEMENT -- This Contract must be returned to the Company prior to
any settlement. Prior to any payment as a death claim, due proof of death must
be submitted to the Company.
REPORTS -- At least once each calendar year, the Company will furnish the Owner
with a report showing the Contract Value and any other information as may be
required by law. The Company will also furnish an annual report of the Variable
Account. Reports will be sent to the last known address of the Owner.
TAXES--Any taxes paid to any governmental entity relating to this Contract will
be deducted from the Purchase Payment or Contract Value when incurred. The
Company will, in its sole discretion, determine when taxes have resulted from:
the investment experience of the Variable Account; receipt by the Company of the
Purchase Payment; or commencement of Annuity Payments. The Company may, at its
sole discretion, pay taxes when due and deduct that amount from the Contract
Value at a later date. Payment at an earlier date does not waive any right the
Company may have to deduct amounts at a later date. The Company will deduct any
withholding taxes required by applicable law.
EVIDENCE OF SURVIVAL -- The Company may require satisfactory evidence of the
continued survival of any person(s) on whose life Annuity Payments are based.
MODIFICATION OF CONTRACT -- This Contract may not be modified by the Company
without the consent of the Owner except as may be required by applicable law.
ANNUITANT, OWNERSHIP, ASSIGNMENT PROVISIONS
ANNUITANT -- The Annuitant is the person on whose life Annuity Payments are
based. The Annuitant is the person designated in the Application, unless
changed.
OWNERSHIP -- The Owner has all rights and may receive all benefits under this
Contract. Prior to the Annuity Date, the Owner is the person designated in the
Application, unless changed. On and after the Annuity Date, the Annuitant is the
Owner. On and after the death of the Annuitant, the Beneficiary is the Owner.
The Owner may change the Owner at any time. A change of Owner will automatically
revoke any prior designation of Owner. A request for change must be:
1) made in writing; and
2) received at the Company.
The change will become effective as of the date the written request is signed. A
new designation of Owner will not apply to any payment made or action taken by
the Company prior to the time it was received.
ASSIGNMENT -- The Owner may, at any time during his or her lifetime, assign his
or her rights under this Contract. The Company will not be bound by any
assignment until written notice is received by the Company. The Company is not
responsible for the validity of any assignment. The Company will not be liable
as to any payment or other settlement made by the Company before receipt of the
assignment.
BENEFICIARY PROVISIONS
BENEFICIARY -- The Beneficiary is named in the Application, unless changed. The
Beneficiary is entitled to receive the benefits to be paid at the death of the
Owner.
Unless the Owner provides otherwise, the Death Benefit will be paid in equal
shares or all to the survivor as follows:
1) to the primary Beneficiaries who survive the Owner's death; or if there are
none,
2) to the Contingent Beneficiaries who survive the Owner's death; or if there
are none,
3) to the estate of the Owner.
CHANGE OF BENEFICIARY -- Subject to the rights of any irrevocable Beneficiary,
the Owner may change the Beneficiary or Contingent Beneficiary. A change may be
made by filing a written request with the Company. The change will take effect
as of the date the notice is signed. The Company will not be liable for any
payment made or action taken before it records the change.
PURCHASE PAYMENT PROVISIONS
THE PURCHASE PAYMENT -- The Single Purchase Payment is due on the Issue Date.
The Minimum Purchase Payment is shown on the Contract Data Page. The Company
reserves the right to reject any Application or Purchase Payment.
NO DEFAULT -- Unless the Owner makes a total withdrawal, this Contract will
remain in force until the Annuity Date.
VARIABLE ACCOUNT PROVISIONS
THE VARIABLE ACCOUNT -- The Variable Account is a separate investment account of
the Company. It is shown on the Contract Data Page. The Company has allocated a
part of its assets for this and certain other contracts to the Variable Account.
The assets of the Variable Account are the property of the Company. However,
they are not chargeable with the liabilities arising out of any other business
the Company may conduct.
INVESTMENTS OF THE VARIABLE ACCOUNT -- The Purchase Payment applied to the
Variable Account will be allocated to the Eligible Investment(s) and the
Portfolio(s), if any, within an Eligible Investment shown on the Contract Data
Page. The allocation is elected by the Owner on the Application. Allocation of
the Purchase Payment is subject to the terms and conditions imposed by the
Company. The assets of the Variable Account are segregated by Eligible
Investments and Portfolios within the Eligible Investment. Therefore, a series
of sub-accounts is established within the Variable Account. The Company may,
from time to time, add additional Eligible Investments or Portfolios to those
shown on the Contract Data Page. The Owner may be permitted to transfer Contract
Values to the additional Eligible Investments or Portfolios. However, the right
to make any transfer will be limited by the terms and conditions imposed by the
Company.
If the shares of any of the Eligible Investment(s) or any Portfolio(s) within
the Investments become unavailable for investment by the Variable Account, or
the Company's Board of Directors deems further investment in these shares
inappropriate, the Company may substitute shares of another Eligible Investment
for shares already purchased under this Contract.
VALUATION OF ASSETS -- Assets of the Variable Account are valued at their fair
market value in accordance with procedures of the Company.
CONTRACT VALUE -- The Purchase Payment is allocated to the Variable Account and
is converted into Accumulation Units. The number of Accumulation Units credited
to this Contract is determined by dividing the Purchase Payment allocated to the
Variable Account by the Accumulation Unit Value for the Variable Account.
Withdrawals will result in the cancellation of Accumulation Units. The value of
the Variable Account is determined by multiplying the number of Accumulation
Units attributable to the Variable Account by the Accumulation Unit Value for
the Variable Account.
TRANSFERS -- Prior to the Annuity Date, the Owner may transfer all or a part of
the Owner's interest in a sub-account to another sub-account without the
imposition of any fee or charge if there have been no more than 12 transfers
made in the Contract Year. If more than 12 transfers have been made in the
Contract Year, the Company will deduct a Transfer Fee. After the Annuity Date,
the Owner may make a transfer once each Contract Year. All transfers are subject
to the following:
1) The deduction of any Transfer Fee that may be imposed as shown on the
Contract Data Page. The Transfer Fee will be deducted from the sub-account
from which the transfer is made. However, if the entire interest in the
sub-account is being transferred, the Transfer Fee will be deducted from
the amount which is transferred.
2) The minimum amount which may be transferred is the lesser of:
A) $1,000; or
B) the Owner's entire interest in the sub-account.
3) Transfers will be effected during the Valuation Period next following
receipt by the Company of a written transfer request (or by telephone, if
authorized) containing all required information. However, no transfer may
be made effective within seven calendar days of the Annuity Date.
4) Any transfer direction must clearly specify:
A) the amount which is to be transferred; and
B) the sub-accounts which are to be affected.
5) The Company reserves the right at any time and without prior notice to any
party to terminate, suspend or modify the transfer privileges described
above.
If the Owner elects to use the telephone transfer privilege, neither the Company
nor its Annuity Service Office will be liable for transfers made in accordance
with the Owner's instructions.
ACCUMULATION UNIT -- The Purchase Payment is converted into Accumulation Units
by dividing the Purchase Payment by the Accumulation Unit Value for the
Valuation Period during which the Purchase Payment is allocated to the Variable
Account. The Accumulation Unit Value for each sub-account was arbitrarily set
initially at $10. The Accumulation Unit Value for any later Valuation Period is
determined by subtracting (b) from (a) and dividing the result by (c) where:
(a) is the net result of
1) the assets of the sub-account; i.e., the aggregate value of the underlying
Eligible Investment shares held at the end of such Valuation Period; plus or
minus
2) the cumulative charge or credit for taxes reserved which is determined by the
Company to have resulted from the operation of the sub-account;
(b) is the cumulative unpaid charge for the Mortality and Expense Risk Premium
and for the Administrative Expense Charge which are shown on the Contract Data
Page; and
(c) is the number of Accumulation Units outstanding at the end of the Valuation
Period.
The Accumulation Unit Value may increase or decrease from Valuation Period to
Valuation Period.
MORTALITY AND EXPENSE RISK PREMIUM -- The Company deducts a Mortality and
Expense Risk Premium which is equal, on an annual basis, to the amount shown on
the Contract Data Page. The Mortality and Expense Risk Premium compensates the
Company for assuming the mortality and expense risks under this Contract.
ADMINISTRATIVE EXPENSE CHARGE -- The Company deducts an Administrative Expense
Charge which is equal, on an annual basis, to the amount shown on the Contract
Data Page. The Administrative Expense Charge compensates the Company for the
costs associated with the administration of this Contract and the Variable
Account.
MORTALITY AND EXPENSE GUARANTEE -- The Company guarantees that the dollar amount
of each Annuity Payment after the first Annuity Payment will not be affected by
variations in mortality or expense experience.
CONTRACT MAINTENANCE CHARGE
DEDUCTION FOR CONTRACT MAINTENANCE CHARGE -- The Company deducts an annual
Contract Maintenance Charge shown on the Contract Data Page from the Contract
Value by cancelling Accumulation Units to reimburse it for expenses relating to
maintenance of this Contract. The Contract Maintenance Charge will be deducted
from the Contract Value on each Contract Anniversary while this Contract is in
force.
If a total withdrawal is made on other than a Contract Anniversary, the Contract
Maintenance Charge will be deducted at the time of withdrawal. If the Annuity
Date is not a Contract Anniversary, a prorata portion of the annual Contract
Maintenance Charge will be deducted on the Annuity Date. After the Annuity Date,
the Contract Maintenance Charge will be collected on a monthly basis and will
result in a reduction of each Annuity Payment.
DEATH BENEFIT
DEATH OF ANNUITANT -- Upon death of the Annuitant prior to the Annuity Date, the
Owner must designate a new Annuitant. If no designation is made within 30 days
of the death of the Annuitant, the Owner will become the Annuitant.
Upon death of the Annuitant after the Annuity Date, the Death Benefit, if any,
will be as specified in the Annuity Option elected.
DEATH OF OWNER -- Upon death of the Owner prior to the Annuity Date, the Death
Benefit will be paid to the Beneficiary designated by the Owner. The Death
Benefit will be the greater of:
1) the Purchase Payment less any Withdrawals and any applicable Withdrawal
Charge; or
2) the Contract Value; or
3) the Contract Value on the fifth Contract Anniversary or, if later, every
fifth Contract Anniversary thereafter less any Withdrawals and any
applicable Withdrawal Charge made since the last fifth Contract
Anniversary.
The Death Benefit will be determined and paid as of the Valuation Period next
following the date of receipt by the Company of both due proof of death and an
election for a single sum payment or election under an Annuity Option as of the
date of death.
If a single sum payment is requested, the proceeds will be paid within seven (7)
days of receipt of proof of death and the election.
Payment under an Annuity Option may be elected during the sixty-day period
beginning with the date of receipt of proof of death or a single sum payment
will be made to the Beneficiary at the end of the sixty-day period.
The entire Death Benefit must be paid within five (5) years of the date of death
unless:
1) the Beneficiary is the spouse of the Owner, the Beneficiary will become the
Owner and this Contract will remain in effect; or
2) the Beneficiary is not the spouse of the Owner, the Death Benefit is
payable under an Annuity Option over the lifetime of the Beneficiary
beginning within 1 year of the date of death.
PAYMENT OF DEATH BENEFIT -- The Company will require due proof of death before
any Death Benefit is paid. Due proof of death will be:
1) a certified death certificate;
2) a certified decree of a court of competent jurisdiction as to the finding
of death;
3) a written statement by a medical doctor who attended the deceased; or
4) any other proof satisfactory to the Company.
Any Death Benefit will be paid in accordance with applicable law or regulations
governing death benefit payments.
ANNUITY PROVISIONS
ANNUITY DATE -- The Annuity Date is elected by the Owner on the Application. The
Annuity Date is shown on the Contract Data Page. The Annuity Date must be the
first day of a calendar month and must be at least one month after the Issue
Date. The Annuity Date may not be later than the first day of the calendar month
following the Annuitant's 85th birthday.
Prior to the Annuity Date, the Owner may, subject to the above, change the
Annuity Date upon 30 days prior written notice to the Company.
ELECTION OF ANNUITY OPTION -- The Annuity Option is elected by the Owner on the
Application. If no Annuity Option is elected, Option 2 with 10 years guaranteed
will automatically be applied. Prior to the Annuity Date, the Owner may, upon 30
days prior written notice to the Company, change the Annuity Option.
FREQUENCY AND AMOUNT OF ANNUITY PAYMENTS -- Annuity Payments will be paid as
monthly installments. The Contract Value on the Annuity Date is applied to the
Annuity Table for the Annuity Option elected. If the amount of the Contract
Value to be applied under an Annuity Option is less than $5,000, the Company
reserves the right to make one lump sum payment in lieu of Annuity Payments. If
the amount of any Annuity Payment would be or become less than $100, the Company
will reduce the frequency of payments to an interval which will result in each
payment being at least $100.
The Annuity Tables are based on the 1983 Individual Annuity Mortality Tables
with interest at the rate of 3% per year.
ANNUITY OPTIONS -- The following Annuity Options or any other Annuity Option
acceptable to the Company may be elected.
Option 1 -- Life Annuity -- The Company will make equal monthly payments during
the life of the Annuitant.
Option 2 -- Life Annuity with 5, 10 or 20 Years Guaranteed -- The Company will
make equal Annuity Payments during the life of the Annuitant, with the guarantee
that, if payments have been made for less than the guaranteed period at the
death of the Annuitant, payments will continue to the Beneficiary for the
remainder of the guaranteed period.
Option 3 -- Joint and Last Survivor Annuity -- The Company will make equal
Annuity Payments for the joint lifetime of the Annuitant and another person. At
the death of either ▇▇▇▇▇, Annuity Payments will continue to be made to the
survivor Payee. The survivor's Annuity Payments will be equal to 100%, 662/3% or
50% of the amount payable during the joint lifetime, as chosen.
VARIABLE ANNUITY -- A variable annuity is an annuity with Annuity Payments
which:
1) are not predetermined as to dollar amount; and
2) will vary in amount with the net investment results of the applicable
sub-account(s) of the Variable Account at the Annuity Date.
The Contract Value will be applied to the applicable Annuity Tables. The Annuity
Table used will depend upon the Annuity Option elected. The amount of the first
payment for each $1,000 of Contract Value is shown in the Annuity Tables. If, as
of the Annuity Date, the then current Annuity Option rates applicable to this
class of contracts provide a first Annuity Payment greater than guaranteed under
the same Annuity Option under this Contract, the greater payment will be made.
The dollar amount of Annuity Payments after the first is determined as follows:
1) the dollar amount of the first Annuity Payment is divided by the value of
an Annuity Unit as of the Annuity Date. This establishes the number of
Annuity Units for each monthly payment. The number of Annuity Units remains
fixed during the Annuity Period;
2) the fixed number of Annuity Units is multiplied by the Annuity Unit Value
for the last Valuation Period of the month preceding the month for which
the payment is due. This result is the dollar amount of the payment.
The total dollar amount of each Variable Annuity Payment is the sum of all
sub-account Variable Annuity Payments reduced by the Contract Maintenance
Charge.
ANNUITY UNIT -- The value of an Annuity Unit for each sub-account was
arbitrarily set initially at $10. This was done when the first Eligible
Investment shares were purchased.
The sub-account Annuity Unit Value at the end of any subsequent Valuation Period
is determined by multiplying the sub-account Annuity Unit Value for the
immediately preceding Valuation Period by the net investment factor for the day
for which the Annuity Unit Value is being calculated; and multiplying the result
by 0.999919.
NET INVESTMENT FACTOR -- The Net Investment Factor for any sub-account for any
Valuation Period is determined by dividing:
1) the Accumulation Unit Value as of the close of the current Valuation
Period; by
2) the Accumulation Unit Value as of the close of the immediately preceding
Valuation Period.
The Net Investment Factor may be greater or less than one, as the Annuity Unit
Value may increase or decrease.
PROTECTION OF PROCEEDS -- No Payee may commute, encumber, alienate or assign any
payments under this Contract. To the extent permitted by law, no payments will
be subject to the debts, contracts or engagements of any Payee or to any
judicial process to levy upon or attach the same for payment thereof.
WITHDRAWAL PROVISIONS
WITHDRAWALS -- Prior to the Annuity Date, the Owner may, upon written request
received by the Company, make a total or partial withdrawal of the Withdrawal
Value. A withdrawal will result in the cancellation of Accumulation Units from
each applicable sub-account in the ratio that the value of the sub-account bears
to the total Contract Value. The Owner must specify in writing in advance which
units are to be cancelled if other than the above method is desired. The Company
will pay the amount of any withdrawal within seven (7) days of receipt of a
request unless the Suspension of Payments provision is in effect.
Each partial withdrawal must be for an amount which is not less than $1,000 or,
if smaller, the remaining Withdrawal Value. The remaining Withdrawal Value must
be at least $1,000 after a partial withdrawal is completed.
WITHDRAWAL CHARGE -- The Withdrawal Charge is 5% of the Purchase Payment
withdrawn.
For a partial withdrawal, the Withdrawal Charge will be deducted from the
remaining Withdrawal Value, if sufficient, or from the amount withdrawn. The
Withdrawal Charge will be deducted by cancelling Accumulation Units from each
applicable sub-account in the ratio that the value of each sub-account bears to
the total Contract Value. The Owner must specify in writing in advance which
units are to be cancelled if other than the above method of cancellation is
desired.
WAIVER OF WITHDRAWAL CHARGE -- A withdrawal of 10% of the Purchase Payment may
be made free from the Withdrawal Charge once each Contract Year after the first
Contract Year on a non-cumulative basis if the Contract Value prior to the
withdrawal exceeds $5,000.
Additionally, the Owner may, within 30 days following the fifth Contract
Anniversary and every fifth Contract Anniversary thereafter, make a withdrawal
of all or a portion of the Contract Value free from the Withdrawal Charge.
SUSPENSION OF PAYMENTS
The Company reserves the right to suspend or postpone payments for any period
when:
1) the New York Stock Exchange is closed (other than customary weekend and
holiday closings);
2) trading on the New York Stock Exchange is restricted;
3) an emergency exists as a result of which disposal of securities held in the
Variable Account is not reasonably practicable or it is not reasonably
practicable to determine the value of the Variable Account's net assets; or
4) during any other period when the Securities and Exchange Commission, by
order, so permits for the protection of Owners; provided that applicable
rules and regulations of the Securities and Exchange Commission will govern
as to whether the conditions described in (2) and (3) exist.
TABLE 1: MONTHLY ANNUITY PAYMENT UNDER OPTION 1 FOR EACH
$1,000 OF CONTRACT VALUE APPLIED
Annuitant's Monthly Annuitant's Monthly Annuitant's Monthly
Age Payment Age Payment Age Payment
------------- --------- ------------- -------- ------------ ---------
5 2.79 32 3.27 59 4.94
6 2.80 33 3.31 60 5.07
7 2.81 34 3.34 61 5.20
8 2.82 35 3.37 62 5.33
9 2.83 36 3.41 63 5.48
10 2.84 37 3.44 64 5.64
11 2.86 38 3.48 65 5.81
12 2.87 39 3.52 66 5.99
13 2.88 40 3.57 67 6.19
14 2.90 41 3.61 68 6.39
15 2.91 42 3.66 69 6.62
16 2.93 43 3.71 70 6.86
17 2.94 44 3.76 71 7.11
18 2.96 45 3.81 72 7.39
19 2.98 46 3.87 73 7.69
20 2.99 47 3.93 74 8.01
21 3.01 48 3.99 75 8.36
22 3.03 49 4.05 76 8.73
23 3.05 50 4.12 77 9.13
24 3.07 51 4.20 78 9.56
25 3.09 52 4.27 79 10.03
26 3.12 53 4.35 80 10.53
27 3.14 54 4.44 81 11.07
28 3.17 55 4.53 82 11.65
29 3.19 56 4.62 83 12.27
30 3.22 57 4.72 84 12.94
31 3.25 58 4.83 85+ 13.64
TABLE 2: MONTHLY ANNUITY PAYMENT UNDER OPTION 2 FOR EACH
$1,000 OF CONTRACT VALUE APPLIED
Annuitant's 5 Years 10 Years 20 Years Annuitant's 5 Years 10 Years 20 Years
Age Guaranteed Guaranteed Guaranteed Age Guaranteed Guaranteed Guaranteed
-------------------------- ------------ ------------- ------------- ------------ ------------ -----------
5 2.79 2.79 2.78 46 3.85 3.85 3.78
6 2.80 2.80 2.79 47 3.92 3.90 3.83
7 2.81 2.81 2.81 48 3.98 3.96 3.88
8 2.82 2.82 2.82 49 4.05 4.03 3.93
9 2.83 2.83 2.83 50 4.12 4.09 3.99
10 2.84 2.84 2.84 51 4.19 4.16 4.04
11 2.86 2.86 2.85 52 4.26 4.23 4.10
12 2.87 2.87 2.87 53 4.34 4.31 4.16
13 2.88 2.88 2.88 54 4.42 4.39 4.22
14 2.90 2.90 2.89 55 4.51 4.47 4.28
15 2.91 2.91 2.91 56 4.61 4.56 4.35
16 2.93 2.93 2.92 57 4.70 4.65 4.41
17 2.94 2.94 2.94 58 4.81 4.75 4.48
18 2.95 2.95 2.95 59 4.92 4.85 4.55
19 2.95 2.95 2.97 60 5.04 4.96 4.62
20 2.96 2.96 2.99 61 5.17 5.07 4.68
21 3.01 3.01 3.01 62 5.30 5.19 4.75
22 3.03 3.03 3.02 63 5.44 5.32 4.82
23 3.05 3.05 3.04 64 5.60 5.45 4.88
24 3.07 3.07 3.06 65 5.76 5.59 4.95
25 3.09 3.09 3.08 66 5.93 5.74 5.01
26 3.12 3.11 3.11 67 6.11 5.89 5.07
27 3.14 3.14 3.13 68 6.31 6.05 5.13
28 3.16 3.16 3.15 69 6.52 6.21 5.18
29 3.19 3.19 3.18 70 6.74 6.38 5.23
30 3.22 3.21 3.20 71 6.97 6.56 5.27
31 3.24 3.24 3.23 72 7.22 6.74 5.31
32 3.27 3.27 3.26 73 7.49 6.92 5.35
33 3.30 3.30 3.29 74 7.77 7.11 5.38
34 3.33 3.33 3.32 75 8.07 7.30 5.40
35 3.37 3.37 3.35 76 8.39 7.48 5.43
36 3.41 3.40 3.38 77 8.72 7.67 5.44
37 3.44 3.44 3.41 78 9.07 7.85 5.46
38 3.48 3.48 3.45 79 9.43 8.03 5.47
39 3.52 3.51 3.48 80 9.81 8.20 5.48
40 3.56 3.56 3.52 81 10.20 8.37 5.49
41 3.61 3.60 3.56 82 10.61 8.52 5.50
42 3.65 3.65 3.60 83 11.02 8.66 5.50
43 3.70 3.69 3.64 84 11.44 8.79 5.51
44 3.75 3.74 3.69 85+ 11.86 8.91 5.51
45 3.81 3.79 3.73
TABLE 3: MONTHLY ANNUITY PAYMENT UNDER OPTION 3
FOR EACH $1,000 OF CONTRACT VALUE APPLIED
JOINT AND 50% SURVIVOR ANNUITY
Age/Age 50 55 60 65 70 75 79
------- -- -- -- -- -- -- --
50 3.87 3.94 3.99 4.03 4.06 4.09 4.10
55 3.94 4.21 4.29 4.37 4.42 4.46 4.48
60 3.99 4.29 4.65 4.77 4.87 4.94 4.98
65 4.03 4.37 4.77 5.27 5.43 5.57 5.65
70 4.06 4.42 4.87 5.43 6.12 6.36 6.51
75 4.09 4.46 4.94 5.57 6.36 7.34 7.62
79 4.10 4.48 4.98 5.65 6.51 7.62 8.69
JOINT AND 66 2/3% SURVIVOR ANNUITY
Age/Age 50 55 60 65 70 75 79
------- -- -- -- -- -- -- --
50 3.94 4.10 4.27 4.47 4.68 4.90 5.08
55 4.10 4.29 4.50 4.73 4.98 5.24 5.46
60 4.27 4.50 4.75 5.04 5.35 5.67 5.94
65 4.47 4.73 5.04 5.39 5.78 6.20 6.54
70 4.68 4.98 5.35 5.78 6.28 6.83 7.29
75 4.90 5.24 5.67 6.20 6.83 7.55 8.18
79 5.08 5.46 5.94 6.54 7.29 8.18 8.97
JOINT AND 100% SURVIVOR ANNUITY
Age/Age 50 55 60 65 70 75 79
------- -- -- -- -- -- -- --
50 3.63 3.75 3.85 3.93 3.99 4.03 4.06
55 3.75 3.91 4.06 4.19 4.30 4.37 4.42
60 6.85 4.06 4.28 4.48 4.66 4.79 4.87
65 3.93 4.19 4.48 4.78 5.06 5.30 5.44
70 3.99 4.30 4.66 5.06 5.48 5.87 6.13
75 4.03 4.37 4.79 5.30 5.87 6.46 6.92
79 4.06 4.42 4.87 5.44 6.13 6.92 7.56
Information about different age combinations will be furnished upon request.
INDIVIDUAL SINGLE PURCHASE PAYMENT
DEFERRED VARIABLE ANNUITY CONTRACT
NONPARTICIPATING
NO DIVIDENDS
Cova Financial Services Life Insurance Company
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XL-100 (7/89) 07-AFPE-MO-U