Exhibit 24(b)(4)(a)
Specimen Flexible Payment Variable Accumulation Deferred Annuity Contract
(WL18NY)
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AUSA LIFE INSURANCE COMPANY, INC.
(A STOCK COMPANY) Administrative Office:
Home Office: Purchase, New York ▇.▇. ▇▇▇ ▇▇▇▇
▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇- 9054
(▇▇▇) ▇▇▇-▇▇▇▇
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IN THIS CONTRACT AUSA Life Insurance Company, Inc. will be referred to as WE,
OUR or US. OFFICE refers to our Administrative Office located in Clearwater,
Florida.
WE agree to pay the benefits of this Contract in accordance with its provisions.
CONTRACT VALUES AND BENEFITS DURING THE ACCUMULATION PERIOD WILL INCREASE OR
DECREASE IN ACCORDANCE WITH THE CONTRACT VALUE PROVISIONS AND THE INVESTMENT
EXPERIENCE OF THE APPLICABLE SUBACCOUNTS IN THE SEPARATE ACCOUNT. CONTRACT
VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SUBACCOUNT OF THE SEPARATE
ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT.
THE SMALLEST annual rate of investment return which would have to be earned on
Separate Account assets so that the dollar amount of variable annuity payments
will not decrease is 6.4%.
THE CONSIDERATION for this Contract is the application and the payment of the
Initial Premium.
THE ANNUITANT, OWNER, AND BENEFICIARY are as shown in the application unless
changed in accordance with the provisions of this Contract.
THE PROVISIONS on the following pages are part of this Contract.
IN WITNESS WHEREOF, We have signed this Contract at Our Office in Clearwater,
Florida as of the Contract Date.
/s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇ /s/ ▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇▇▇
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Secretary President
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RIGHT TO EXAMINE CONTRACT
The Owner may cancel this Contract at any time within ten days after receipt
by returning it to Us at ▇.▇. ▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇. If
the Contract is returned within this period: it will be void from the
beginning and a refund will be made to the Owner. The refund will equal the
total of all premiums paid for this Contract.
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FLEXIBLE PAYMENT VARIABLE ACCUMULATION DEFERRED ANNUITY
Death Benefit Prior to Maturity
Monthly Annuity Commencing on Maturity Date
Non-Participating - No Dividends
Page 1
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CONTRACT GUIDE
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Contract Schedule...................................... 3 Separate Account Provisions (continued)
Definitions............................................ 5 Addition, Deletion or Substitution of
Accounts............................................ 5 Investments...................................... 10
Accumulation Period................................. 5 Change of Investment Objective...................... 11
Accumulation Unit Value............................. 5 Accumulation Unit Value............................. 11
Age................................................. 5 Premium Provisions.................................... 11
Annuitant........................................... 5 Premiums............................................ 11
Annuity Proceeds.................................... 5 Contract Value Provisions............................. 12
Annuity Unit Value.................................. 5 Net Premium......................................... 12
Annuity Value....................................... 5 Allocation of Net Premiums.......................... 12
Cash Value.......................................... 5 Subaccount Value.................................... 12
Contingent Beneficiary.............................. 5 Fixed Account....................................... 12
Contract Anniversary................................ 5 Annual Contract Charge.............................. 13
Contract Date....................................... 6 Annuity Value....................................... 13
Death Benefit Proceeds.............................. 6 Partial Surrender................................... 13
Death Report Day.................................... 6 Cash Value.......................................... 15
Fixed Account....................................... 6 Surrender Charge.................................... 15
Maturity Date....................................... 6 Basis of Computation................................ 15
Premium Tax......................................... 6 Death Benefit Provisions.............................. 16
Reallocation Date................................... 6 Death of Annuitant During the 16
SEC................................................. 6 Accumulation Period.............................. 16
Separate Account.................................... 6 Death Benefit Proceeds.............................. 16
Series Fund......................................... 6 Alternative Election................................ 16
Subaccount.......................................... 6 Annuity Provisions.................................... 17
Surrender........................................... 6 Commencement of Annuity Payments.................... 17
Surrender Charge Period............................. 7 Maturity Date....................................... 17
Valuation Date...................................... 7 Annuity Option...................................... 18
Valuation Period.................................... 7 Change of Annuitant................................. 18
Written Notice...................................... 7 Payee............................................... 18
General Provisions..................................... 7 Availability........................................ 18
The Contract........................................ 7 Age................................................. 18
Ownership........................................... 7 Proof of Age and Sex................................ 18
Change of Ownership Upon Request.................... 7 Proof of Survival................................... 18
Change of Ownership Upon Death of Owner............. 8 Death Benefit After Maturity Date................... 18
Beneficiary......................................... 8 Restrictions........................................ 18
Change of Beneficiary............................... 8 Fixed Account Annuity Payments........................ 19
Assignment.......................................... 8 Interest and Mortality.............................. 19
Incontestability.................................... 8 Amount of Monthly Fixed Account Annuity 19
Age and Sex......................................... 9 Payment.......................................... 19
Contract Years...................................... 9 Fixed Account Annuity Options....................... 19
Reports............................................. 9 Variable Account Annuity Payments..................... 21
Contract Payment.................................... 9 Annuity Unit Value.................................. 21
Protection of Proceeds.............................. 9 Determination of the First Variable
Separate Account Provisions............................ 9 Payment.......................................... 22
Subaccounts.......................................... 10 Determination of Subsequent Variable
Transfers Among Subaccounts During the Payments......................................... 22
Accumulation Period.............................. 10 Variable Account Annuity Options.................... 22
Transfers Among Subaccounts After the
Maturity Date..................................... 10
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AUSA LIFE INSURANCE COMPANY, INC.
Administrative Office:Clearwater, Florida
Contract Schedule
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Owner: ▇▇▇▇ ▇▇▇
Annuitant: ▇▇▇▇ ▇▇▇
Issue Age 35
Sex: Male
Annuity Option: D-10 Year Certain Contract Number: 01-12345678
Initial Premium: $50,000.00 Contract Date: September 03, 2000
Maturity Date: August 01, 2055
Reallocation Date: September 18, 2000
Reallocation Account: Money Market
Anticipated Premium Pattern*
Amount Mode Years Payable
$10,000.00 Annual 55 Years
* The anticipated premium pattern is based upon selection made in the
application. The amount may be changed in accordance with the Premium
Provisions on Page 11.
Separate Account Provisions
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Separate Account: AUSA Series Annuity Account
Separate Account Charge
[1.25 -1.40] % Annually
Premium Provisions
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Maximum Additional Annual Premium: $1,000,000 (Without Prior Approval)
Minimum Additional Premium: $50.00
Contract Value Provisions
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Annual Contract Charge: $30
Minimum Balance: $5,000
Fixed Account Minimum Guaranteed
Effective Annual Interest Rate 3%
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Surrender Charge Period: 84 Months from the Date of Each Premium Payment
Surrender Charge Percentage (As a Percentage of Each Respective Premium Payment):
Months Since Date of Payment Percentage
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24 Months or Less 7%
25 Months Through 36 Months 6%
37 Months Through 48 Months 5%
49 Months Through 60 Months 4%
61 Months Through 72 Months 3%
73 Months Through 84 Months 2%
85 Months or More 0%
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DEFINITIONS
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Accounts Allocation options including the Fixed Account
and the Subaccounts of the Separate Account.
Accumulation Period The period between the Contract Date and the
Maturity Date while the Contract is in force.
Accumulation An accounting unit of measure used to calculate
Unit Value Subaccount values for the Contract during the
Accumulation Period.
Age Issue Age refers to the Age of the Annuitant on
his/her birthday immediately proceeding the
Contract Date. Attained Age refers to the Issue
Age plus the number of completed contract
years.
Annuitant The person named on the application, or as
subsequently changed, to receive annuity
payments. The Annuitant may be changed as
provided in the Death Benefit Provisions and
Annuity Provisions.
Annuity Proceeds The amount applied to purchase periodic annuity
payments. Such amount is the Annuity Value on
the Maturity Date, less any applicable Premium
Tax.
Annuity Unit Value An accounting unit of measure used to calculate
annuity payments from a Subaccount after the
Maturity Date.
Annuity Value The value as described in the Annuity Value
section of the Contract Value Provisions.
Cash Value The value as described in the Cash Value
section of the Contract Value Provisions.
Contingent The new Beneficiary upon the current
Beneficiary Beneficiary's death.
Contract Anniversary The same day in each succeeding year as the
Contract Date. If there is no day in a calendar
year which coincides with the Contract Date,
the Contract Anniversary will be the first day
of the next month.
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Contract Date The later of the date on which payments are
first received and the date the properly
completed application is received by Us at Our
Office.
Death Benefit The value as described in the Death Benefit
Proceeds Proceeds section of the Death Benefit
Provisions.
Death Report Day The Valuation Date coincident with or next
following the day on which We have received
both: 1) due proof of death; and 2) a Written
Notice for an election of a) a single sum
payment or b) an alternative election as
described under the Death Benefit Provisions.
Fixed Account An allocation option other than the Separate
Account.
Maturity Date The date of the Annuitant's 90th birthday,
on which the Accumulation Period ends and
annuity payments are to commence. The date may
be changed as provided in the Annuity
Provisions.
Premium Tax Premium Tax levied by a state or other
government entity. The Premium Tax will be paid
when due and charged either against the premium
or the contract value.
Reallocation Date The date on which any premiums are reallocated
from the Reallocation Account to the Accounts
elected by the Owner. The Reallocation Date is
shown on the Contract Schedule page.
SEC The United States Securities and Exchange
Commission.
Separate Account A unit investment trust, consisting of
Subaccounts. Each Subaccount of the Separate
Account buys shares of a corresponding
portfolio of a Series Fund.
Series Fund A designated mutual fund from which a
Subaccount of the Separate Account will buy
shares.
Subaccount A Separate Account allocation option that is
made available under this Contract.
Surrender The termination of the Contract at the option
of the Owner.
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Surrender Charge The period of time during which a Surrender
Charge may be imposed as shown on the Period
Contract Schedule page. For each premium, the
period begins on the date payment is received
by Us.
Valuation Date Each day on which the New York Stock Exchange
is open for business.
Valuation Period The period commencing at the end of one
Valuation Date and continuing to the end of the
next succeeding Valuation Date.
Written Notice Written Notice means a notice by the Owner to
Us requesting or exercising a right of the
Owner as provided in the Contract provisions.
In order for a notice to be considered a
Written Notice, it must: be in writing, signed
by the Owner; be in a form acceptable to Us;
and contain the information and documentation,
as determined in Our sole discretion, necessary
for Us to take the action requested or for the
Owner to exercise the right specified. A
Written Notice will not be considered complete
until all necessary supporting documentation
required or requested by Us has been received
by Us at Our Administrative Office.
GENERAL PROVISIONS
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The Contract This Contract, the attached application, if
any, and any contract Riders constitute the
entire Contract. No Contract provision can be
waived or changed except by endorsement. Such
endorsement must be signed by Our President or
Secretary. We reserve the right to amend the
Contract to meet the requirements of any
applicable Federal or state laws or
regulations.
Ownership This Contract belongs to the Owner. The Owner
as shown on the Contract Schedule page, or as
subsequently changed, may exercise all rights
under this Contract including the right to
transfer ownership. These rights may be subject
to the consent of any assignee or irrevocable
beneficiary.
Change of We will not be bound by any requested change
Ownership Upon in the ownership designation unless it is made
Request by Written Notice. The change will be effective
on the date the Written Notice is signed and
recorded by Us. If We request, this Contract
must be returned to Our Office for endorsement.
Changing the Owner cancels any prior ownership
designation, but it does not change the
Beneficiary or the Annuitant.
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Change of Should the Owner die during the Accumulation
Ownership Upon Period, We will be bound by the following:
Death of Owner
1. If the Owner is the Annuitant, then the
Death Benefit Proceeds are payable as
provided in the Death Benefit Provisions.
2. If the Owner is not the Annuitant and dies
before the Annuitant:
(a) If no Beneficiary is named and alive,
the Owner's estate will become the new
Owner. The Cash Value must be
distributed within five years of the
former Owner's death;
(b) If the Beneficiary is alive and is
the Owner's spouse, this Contract will
continue with the spouse as the new
Owner; or
(c) If the Beneficiary is alive and is
not the Owner's spouse, the
Beneficiary will become the new
Owner. The Cash Value must be
distributed either:
(1) within five years of the former
Owner's death; or
(2) over the lifetime of the new
Owner, if a natural person, with
payments beginning within one
year of the former Owner's death;
or
(3) over a period that does not exceed
the life expectancy (as defined by
the Internal Revenue Code and
Regulations adopted under the
Code) of the new Owner, if a
natural person, with payments
beginning within one year of the
former Owner's death.
Beneficiary The Beneficiary, as named in the application or
subsequently changed, is entitled to receive
the Death Benefit Proceeds, if any, as provided
in the Death Benefit Provisions of this
Contract, or the Cash Value, if any, as
provided in 2.c above. If no Beneficiary is
alive, the benefits payable to the Beneficiary
will be paid to the Owner, if surviving,
otherwise to the Owner's estate.
Change of We will not be bound by any change in the
Beneficiary Beneficiary designation unless it is made by
Written Notice. The change will be effective
on the date the Written Notice was signed;
however, no change will apply to any payment We
made before the Written Notice is received. If
We request, this Contract must be returned to
Our Office for endorsement.
Assignment This Contract may be assigned prior to the
Maturity Date. We will not be bound by any
assignment unless made by Written Notice. The
Assignment will be effective on the date the
Written Notice is received at Our Office and
accepted by Us. We assume no responsibility for
the validity of any assignment.
Incontestability This Contract is incontestable from the
Contract Date.
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Age and Sex If a date of birth or sex has been misstated,
any amount payable will be adjusted to conform
to the correct date of birth and sex. Any
underpayment made by Us will be paid with the
next payment. Any overpayment made by Us will
be deducted from future payments. Any
underpayment or overpayment will include
interest at 5% per year, from the date of
adjustment.
Contract Years Contract years, quarters and anniversaries are
measured from the Contract Date.
Reports During the Accumulation Period, We will send a
report to the Owner at least once each year. It
will show the activity that occurred during the
year and the value of the Contract as of the
date of the report.
The report will also show any other information
required by the laws or regulations of the
state in which the contract is issued.
Contract Payment All payments from the Fixed Account will be
paid in one sum unless otherwise elected under
the Annuity Provisions of this Contract. We
have the right to postpone payments and
transfers from the Fixed Account for up to six
months. All payments and transfers from the
Subaccounts will be processed as provided in
this Contract unless one of the following
situations exist:
1. The New York Stock Exchange is closed, or
2. The SEC requires that trading be restricted
or declares an emergency.
Protection of Unless the Owner directs by filing Written
Proceeds Notice, no Beneficiary may assign any payments
under this Contract before the same are due. To
the extent permitted by law, no payments under
this Contract will be subject to the claims of
creditors of any Beneficiary.
SEPARATE ACCOUNT PROVISIONS
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The variable benefits under this Contract are provided through the Separate
Account referenced on the Contract Schedule page. This Separate Account is
established under the Laws and Regulations of New York. The assets of the
Separate Account are Our property. Assets equal to the liabilities of the
Separate Account will not be charged with liabilities arising out of any other
business We may conduct. If the assets of the Separate Account exceed the
liabilities arising under the contracts supported by the Separate Account, then
the excess may be used to cover the liabilities of Our general account. The
assets of the Separate Account shall be valued as often as any contract benefits
vary, but at least monthly.
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Subaccounts The Separate Account has various Subaccounts.
Each Subaccount invests exclusively in shares
of one of the portfolios of an underlying
Series Fund. Assets invested after the Maturity
Date may be invested in different Subaccounts
than assets invested during the Accumulation
Period. We reserve the right to add or remove
any Subaccount of the Separate Account. Income
and realized and unrealized gains and losses
from assets in each Subaccount are credited to,
or charged against, that Subaccount without
regard to income, gains, or losses in other
Subaccounts. Any amount charged against the
contract value for federal or state income
taxes will be deducted from that Subaccount.
Transfers Among During the Accumulation Period, the Owner may
Subaccounts During transfer all or a portion of this Contract's
the Accumulation value in its Subaccounts to other Subaccounts
Period or the Fixed Account. We reserve the right to
charge a $10 fee for each transfer after the
first twelve transfers during any one contract
year. This charge will be deducted from the
funds transferred. We must be notified in a
manner satisfactory to Us. The transfer
ordinarily will take effect on the first
Valuation Date on or following the date notice
is received at Our Office.
Transfers Among After the Maturity Date, the Owner may transfer
Subaccounts After the value of the variable annuity units from
the Maturity Date one Subaccount to another. 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 reserve the
right to include the value of those variable
annuity units as part of the transfer.
After the Maturity Date, no transfers may be
made to or from the Fixed Account. We reserve
the right to limit transfers to once per
contract year.
Addition, Deletion or We reserve the right to transfer assets of the
Substitution Separate Account, which We determine to be
Investments associated with the class of contracts to which
this Contract belongs, to another of Separate
Account. If this type of transfer is made, the
term "Separate Account", as used in this
Contract, shall then mean the Separate Account
to which the assets were transferred. We also
reserve the right to add, delete, or substitute
investments held by any Subaccount.
We reserve the right, when permitted by law,
to:
1. deregister the Separate Account under the
Investment Company Act of 1940;
2. manage the Separate Account under the
direction of a committee at any time;
3. restrict or eliminate any voting privileges
of contractowners or other persons who
have voting privileges as to the Separate
Account;
4. combine the Separate Account or any
Subaccount(s) with one or more other
Separate Accounts or Subaccounts;
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Change of We reserve the right to change the investment
Investment Objective objective of a Subaccount. If required by law
or regulation, an investment objective of the
Separate Account, or of a Series Fund portfolio
designated for a Subaccount, will not be
materially changed unless a statement of the
change is filed with and approved by the
appropriate insurance official of the state of
Our domicile or deemed approved in accordance
with such law or regulation. If required,
approval of or change of any investment
objective will be filed with the Insurance
Department of the state where this Contract is
delivered.
Accumulation Some of the contract values fluctuate with the
Unit Value investment results of the Subaccounts. In
order to determine how investment results
affect the contract values, an Accumulation
Unit Value is determined for each Subaccount.
The Accumulation Unit Value may increase or
decrease from one Valuation Period to the next.
Accumulation Unit Values also will vary between
Subaccounts.
The Accumulation Unit Value of any Subaccount
at the end of the Valuation Period is the
result of:
1. the total value of the assets held in the
Subaccount, including the value of any
dividends or capital gains distribution
declared and reinvested by the portfolio
during the Valuation Period. This value is
determined by multiplying the number of
shares of the designated Series Fund
portfolio owned by the Subaccount times
the net asset value per share; minus
2. the accrued charge for administration
and mortality and expense. The daily
amount of this charge is equal to the
daily net assets of the Subaccounts
multiplied by the daily Separate Account
Charge. The maximum annual factor for the
Separate Account Charge is shown on the
Contract Schedule page; minus
3. the accrued amount of reserve for any
taxes that are determined by Us, subject
to prior approval by the Superintendent of
Insurance of New York State, to have
resulted from the investment operations of
the Subaccount; and the result divided by
4. the number of outstanding units in the
Subaccount prior to the purchase or
redemption of any units on that date.
The use of the Accumulation Unit Value in
determining contract values is described in the
Contract Value Provisions.
PREMIUM PROVISIONS
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Premiums Premiums after the first are payable at Our
Office. The amount of premium which may be paid
during any contract year may not exceed the
Maximum Additional Annual Premium shown on the
Contract Schedule page without Our consent.
Premiums will not be accepted in an amount less
than the Minimum Additional Premium shown on
the Contract Schedule page without Our consent.
Our acceptance of any premium shall not
constitute a waiver of these limits with
respect to subsequent premiums.
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CONTRACT VALUE PROVISIONS
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Net Premium The net premium will be the premium received
less Premium Tax, if any.
Allocation of Net Net Premiums will be allocated to the
Premiums Accounts on the first Valuation Date on or
following the date the premium is received at
Our Office. With respect to the Initial
Premium, the allocation will take place on the
Contract Date. Any premium received prior to
the Reallocation Date will be allocated to the
Reallocation Account. On the first Valuation
Date on or following the Reallocation Date, the
values in the Reallocation Account will be
transferred in accordance with the Owner's
current premium allocation instructions.
All allocation percentages must be in whole
numbers. The allocation of future net premiums
may be changed by the Owner. We reserve the
right to limit such change to once each year.
The request for change of allocations must be
in a manner satisfactory to Us. The allocation
change will be effective the date the request
for change is recorded by Us.
Subaccount Value At the end of any Valuation Period, the
Subaccount value is equal to the number of
units that the Contract has in the Subaccount,
multiplied by the Accumulation Unit Value of
that Subaccount.
The number of units that the Contract has in
each Subaccount is equal to:
1. the initial units purchased on the
Contract Date; plus
2. units purchased at the time additional net
premiums are allocated to the Subaccount;
plus
3. units purchased through transfers from
another Account; minus
4. any units that are redeemed to pay for
partial Surrenders; minus
5. any units that are redeemed as part of a
transfer to another Account; minus
6. any units that are redeemed to pay the
Annual Contract Charge, Premium Tax and
transfer fees, if any.
Fixed Account At the end of any Valuation Period, the Fixed
Account value is equal to:
1. the sum of all net premiums allocated to
the Fixed Account; plus
2. any amounts transferred from a Subaccount
to the Fixed Account; plus
3. total interest credited to the Fixed
Account; minus
4. any amounts withdrawn from the Fixed
Account to pay for partial Surrenders;
minus
5. any amounts transferred to a Subaccount
from the Fixed Account; minus
6. any amounts charged to pay the Annual
Contract Charge, Premium Tax and transfer
fees, if any.
Interest on the Fixed Account will be
compounded daily at a minimum guaranteed
effective annual interest rate of 3% per year.
We may declare from time to time higher current
interest rates. The interest rates We set will
be credited for increments of at least one year
measured from each purchase payment or transfer
date.
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On transfers from the Fixed Account to a
Subaccount, unless We otherwise consent:
1. Written Notice must be within 30 days
after a contract anniversary.
2. The transfer will ordinarily take place
on the first Valuation Date on or
following the date We receive such Written
Notice.
3. The amount that may be transferred is the
greater of (a) 25% of the amount in the
Fixed Account; or (b) the amount
transferred in the prior contract year
from the Fixed Account.
Unless We otherwise consent, transfers to the
Fixed Account or allocation of Net Premiums to
the Fixed Account may be restricted if the
Fixed Account value following the transfer or
allocation would exceed $500,000.
We reserve the right to defer payment of any
amounts from the Fixed Account for no longer
than six months after We receive such Written
Notice.
Annual Contract During the Accumulation Period, the Annual
Charge Contract Charge shown on the Contract Schedule
page will be made once a year from the Annuity
Value on each contract anniversary. This charge
will be deducted from each Subaccount and the
Fixed Account in proportion to the value each
bears to the Annuity Value. If the Contract is
surrendered on other than a contract
anniversary, the charge will also be made on
the date of Surrender.
The Annual Contract Charge prior to Surrender
will be waived if either (1) the Annuity Value
or (2) the sum of all net premiums received,
minus all partial Surrenders, equals or exceeds
$50,000 as of the contract anniversary for
which the charge is payable.
Annuity Value At the end of any Valuation Period, the Annuity
Value is equal to the sum of the Account
values.
Partial Surrender Prior to the Maturity Date, a partial Surrender
may be made by the Owner without full Surrender
of this Contract. Unless We otherwise consent:
1. The request must be made by Written Notice.
2. The partial Surrender may not reduce the
Cash Value to less than the Minimum
Balance shown on the Contract Schedule
page.
3. No amount from the Fixed Account may be
partially surrendered.
Except as provided below, the amount payable
will be the amount of the partial Surrender
less any applicable Surrender Charge and
Premium Tax. The Subaccount(s) for the partial
Surrender may be specified. If not specified,
partial Surrenders will be deducted from each
Subaccount and, if We consent, the Fixed
Account in proportion to the value each bears
to the Annuity Value.
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Partial Surrenders may be made, without a
Surrender Charge being deducted at the time the
partial Surrender is made, in one of the
following ways:
1. Lump Sum
-------------------
During any Contract Year, the Owner may request
a lump sum partial Surrender. The maximum
amount available without a Surrender Charge for
a lump sum partial Surrender is equal to A + B,
where:
A is equal to:
(i) the Annuity Value on the date of the
partial Surrender; plus
(ii) any amounts previously surrendered
from this Contract under provision B
below; plus
(iii) any amounts previously surrendered
from this Contract that were subject
to Surrender Charges; minus
(iv) the total of all premiums paid for
this Contract.
And
B is equal to:
(i) 10% of the remaining Annuity Value
following the determination of A
above on the date of the partial
Surrender; minus
(ii) any amounts partially surrendered
under B(i) above during the contract
year in which the partial Surrender
is requested.
Unless We otherwise consent, the minimum lump
sum payment amount is $500.
2. Systematic Payout Option
-------------------------------------
During any contract year, a Systematic Payout
Option is available on a monthly, quarterly,
semi-annual or annual basis without a Surrender
Charge. Systematic payouts must be at least $50
and may not exceed 10% of the Annuity Value at
the time the payout is made, divided by the
number of payouts made per calendar year. We
reserve the right to discontinue systematic
payouts if any payout would reduce the Annuity
Value below the Minimum Balance shown on the
Contract Schedule page.
The Owner may elect to begin or discontinue
systematic payouts at any time. However, We
must receive Written Notice at least 30 days
prior to the date systematic payouts are to be
discontinued.
The Systematic Payout Option cannot be used to
continue the contract In Force beyond the
Maturity Date. On the Maturity Date the
contract must annuitize.
Page 14
The adjusted partial Surrender used in the
calculation of the Death Benefit Proceeds item
3, is equal to (a) multiplied by (b) where:
(a) is the ratio of the value of any proceeds
that would have been payable had death
occurred, to the Annuity Value, as these
amounts existed on the date the partial
Surrender is processed, but prior to the
processing; and
(b) is the amount of the partial Surrender.
Cash Value This Contract may be surrendered by the Owner
for its Cash Value upon Written Notice at any
time prior to the then current Maturity Date.
The Cash Value at any time equals the Annuity
Value on the Valuation Date coincident with or
next following the date We receive Written
Notice of Surrender, less:
1. any applicable Surrender Charge; less
2. any applicable Premium Tax; less
3. the Annual Contract Charge.
Surrender Charge On the Surrender or partial Surrender of
premiums paid beyond the Surrender Charge
Period shown on the Contract Schedule page, no
Surrender Charge will be imposed.
Except as provided in the Partial Surrender
provision, on the partial Surrender of premiums
within the Surrender Charge Period, the
Surrender Charge will equal the premium paid
within the Surrender Charge Period, times the
applicable Surrender Charge Percentage shown on
the Contract Schedule page.
On the full Surrender of premium payments
within the Surrender Charge Period, the
Surrender Charge will equal the premium paid
within the Surrender Charge Period (including
any premiums previously withdrawn to pay for
partial Surrenders for which a Surrender Charge
was not deducted), times the applicable
Surrender Charge Percentage shown on the
Contract Schedule page.
Basis of Computation A detailed statement of the method of
computation of values has been filed with the
insurance supervisory official of the
jurisdiction in which this Contract is
delivered. All values for this Contract are
equal to or greater than the values required by
statutes in such jurisdiction.
Page 15
DEATH BENEFIT PROVISIONS
================================================================================
Death of Annuitant If the Annuitant dies during the Accumulation
During the Period and the Owner is a natural person other
Accumulation Period than the Annuitant, the Owner will
automatically become the Annuitant and this
Contract will continue.
If the Annuitant dies during the Accumulation
Period and the Owner is either (1) the same
individual as the Annuitant; or (2) other than
a natural person, then the Death Benefit
Proceeds as calculated below are payable to the
Beneficiary.
Death Benefit If the Annuitant dies during the Accumulation
Proceeds Period, the Death Benefit Proceeds, if payable,
will be the greater of:
1. the Annuity Value as of the Death Report
Day; or
2. the excess of (a) the amount of premium
paid as of the Death Report Day, less (b)
any amount withdrawn from this Contract to
pay for partial Surrenders; or
3. the highest Annuity Value as of any
Contract Anniversary prior to the
Annuitant's 81st birthday. The highest
Annuity Value will be increased for
premiums made and decreased for adjusted
partial Surrenders taken following the
date of the Contract Anniversary on which
the highest Annuity Value occurs.
The adjusted partial Surrender is equal to (a)
multiplied by (b) where:
(a) is the ratio of the value of any proceeds
that would have been payable had death
occurred, to the Annuity Value, as these
amounts existed on the date the partial
Surrender is processed, but prior to the
processing; and
(b) is the amount of the partial Surrender.
Alternative Election If the Beneficiary is entitled to receive the
Death Benefit Proceeds, the Beneficiary may
elect, in lieu of a lump sum payment, one of
the following options that provides for
complete distribution and termination of this
Contract at the end of the distribution period:
1. within five years of the date of death of
the Annuitant; or
2. over the lifetime of the Beneficiary; or
3. over a period that does not exceed the
life expectancy (as defined by the
Internal Revenue Code and Regulations
adopted under the Code) of such
Beneficiary.
Multiple beneficiaries may choose individually
among any of the three options.
Page 16
For subparagraphs (1) and (3), the Annuity
Value as of the Death Report Day will be
adjusted to equal the Death Benefit Proceeds
and this Contract will remain in force as a
deferred annuity until the end of the elected
distribution period. For subparagraph (2), the
Maturity Date will be changed to the Death
Report Day and the Death Benefit Proceeds will
be used to purchase annuity payments under the
Annuity Provisions of this Contract.
For elections made under subparagraph (1), We
will:
a. at the time of election, allow one partial
Surrender and one transfer of all or a
portion of the Contract's value among
Subaccounts or the Fixed Account without a
transfer charge. Additional partial
Surrender and transfers are not permitted;
b. not deduct the Annual Contract Charge upon
complete distribution;
c. not permit payment of the Death Benefit
Proceeds under the Annuity Provisions of
this Contract upon complete distribution.
The Beneficiary may not name a Beneficiary for
payment of the Death Benefit Proceeds. In the
event the Beneficiary dies prior to
distribution of all Death Benefit Proceeds, We
will pay the remaining value of the Death
Benefit Proceeds to the Contingent Beneficiary,
if named by the Owner. If no Contingent
Beneficiary is named, such payment will be made
to the Beneficiary's estate.
Subparagraphs (2) and (3) may be elected only
if the Beneficiary is a natural person and
payments start within one year of the date of
death of the Annuitant.
During the Accumulation Period provision, if
the Beneficiary is entitled to receive the
Death Benefit Proceeds and is the spouse of the
deceased Annuitant, then the Beneficiary may
elect to become the new Annuitant and Owner and
keep the Contract in force in lieu of receiving
the Death Benefit Proceeds.
ANNUITY PROVISIONS
================================================================================
Commencement of Monthly annuity payments will begin as of the
Annuity Payments Maturity Date shown on the Contract Schedule
page, unless another Maturity Date has been
elected as provided in these provisions.
Maturity Date The Maturity Date shown on the Contract
Schedule page may be changed to a different
Maturity Date, subject to all of the following:
Page 17
1. Written Notice prior to the Maturity Date.
2. The new Maturity Date is at least 5 years
after the Contract Date.
3. The new Maturity Date is not beyond the
Annuitant's 90th birthday.
Annuity Option The Annuity Option shown on the Contract
Schedule page may be changed to any other
option available upon Written Notice prior to
the Maturity Date. If a variable account
annuity payment option is chosen, the Owner
must include in the Written Notice the
Subaccount allocation of the Annuity Proceeds
as of the Maturity Date.
Change of As of the Maturity Date and upon agreement with
Annuitant Us, the Owner may elect a different Annuitant
or add a joint Annuitant who will be a joint
payee under either Option C or Option E.
Payee The Annuitant(s) on the Maturity Date will
become the payee(s) and receive the annuity
payments.
Availability If the payee is not a natural person, an
Annuity Option is only available with Our
permission. No Annuity Option is available if:
1. the payee is an assignee; or
2. the periodic payment is less than $20.
Age Age, when required, means age nearest birthday
on the effective date of the option. We will
furnish rates for ages or combination of ages
not shown upon request.
Proof of Age Prior to making the first monthly annuity
and Sex payment under this Contract, We reserve the
right to require satisfactory evidence of the
birthdate and the sex of any payee. If required
by law to ignore differences in sex of any
payee, annuity payments will be determined
using unisex rates.
Proof of Survival Prior to making any payment under this
Contract, We reserve the right to require
satisfactory evidence that the payee is:
1. alive on the due date of such payment; and
2. legally qualified to receive such payment.
Death Benefit After The death benefit after the Maturity Date and
the Maturity Date after the commencement of annuity payments
depends upon the annuity option selected. If a
payee dies on or after the commencement of
annuity payments, the remaining portion of any
interest In the Contract will be distributed at
least as rapidly as under the method of
distribution being used as of the date of the
payee's death.
Restrictions After the Maturity Date, no additional
premiums, partial Surrenders, full Surrenders,
change of Annuitants or Annuity Options may be
made under this Contract.
Page 18
FIXED ACCOUNT ANNUITY PAYMENTS
================================================================================
Interest and All Fixed Account annuity option payments are
Mortality based on a guaranteed interest rate of 3%.
Mortality is based on the "Annuity 2000"(male,
female, and unisex if required by law)
mortality table projected for improvement using
projection scale G.
Amount of Monthly The amount of each monthly annuity payment will
Fixed Account be determined by multiplying:
Annuity Payment
1. the appropriate rate based on the
guaranteed interest rate and, for Options
B and C, the mortality table for Fixed
Account annuity payments; multiplied by
2. the Annuity Proceeds as of the Maturity
Date.
Fixed Account The following options are available for payment
Annuity Options of Fixed Account monthly annuity payments. The
rates shown are the guaranteed rates for each
$1,000 of Annuity Proceeds at adjusted ages.
Any guaranteed rates not shown for the options
below will be available upon request. Higher
current rates may be available at the Maturity
Date.
The amount of the first payment depends upon
the adjusted Age of the Annuitant. The adjusted
Age is the Annuitant's Age nearest the Maturity
Date, adjusted as follows:
Maturity Date Adjusted Age
---------------------------------------
Before 2010 Actual Age
2010 - 2019 Actual Age minus 1
2020 - 2026 Actual Age minus 2
2027 - 2033 Actual Age minus 3
2034 - 2040 Actual Age minus 4
After the year 2040 as determined by Us.
Option A - The Annuity Proceeds will be paid in equal
Fixed Period installments. The installments will be paid
over a fixed period determined from the
following table:
Fixed Period
(in Months) Rate
---------------------- ------------------
60 17.91
120 9.61
180 6.87
240 5.51
Page 19
Option B - The Annuity Proceeds will be paid in equal
Life Income installments determined from the following
table. Such installments are payable:
1. during the payee's lifetime only (Life
Annuity); or
2. during a 10 year fixed period certain and
for the payee's remaining lifetime (Certain
Period); or
3. until the sum of installments paid equals
the Annuity Proceeds applied and for the
payee's remaining lifetime (Installment
Refund).
-------------------------------------------------------------------------------------------------------------------------
Option B: Life Income
Monthly Income Payments
=========================================================================================================================
Guaranteed for Life Guaranteed for 10 Years Guaranteed Return of
Policy Proceeds
------------------------------------------------- ----------------------------------- -----------------------------------
Age* Male Female Unisex Male Female Unisex Male Female Unisex
50 $ 3.82 3.70 3.74 3.80 3.69 3.72 3.70 3.62 3.65
55 4.18 4.01 4.06 4.13 3.99 4.03 3.99 3.89 3.92
60 4.64 4.42 4.49 4.57 4.38 4.44 4.36 4.23 4.27
65 5.30 4.98 5.08 5.14 4.89 4.97 4.83 4.67 4.72
70 6.21 5.78 5.90 5.86 5.58 5.66 5.43 5.26 5.31
------------- ----------- ----------- ----------- ----------- ----------- ----------- ----------- ----------- -----------
*Adjusted Age as defined in Fixed Account Annuity Options Provision
Option C - The Annuity Proceeds will be paid in equal
Joint and Survivor installments during the joint lifetime of two
Life Income payees and continuing upon the death of the
first payee for the remaining lifetime of the
survivor.
----------------------------------------------------------------------------------------------------------------------------
Option C: Joint and Survivor Life Income
============================================================================================================================
Monthly Payments for Each $1,000 of Amount Retained
----------------------------------------------------------------------------------------------------------------------------
Age of Other Payee (Female)
--------------------------------------------------------------------------------------------------------
Age of One 15 Years Less 12 Years Less 9 Years Less 6 Years Less 3 Years Less Same as
Payee* (Male) Than Male Than Male Than Male Than Male Than Male Male
Payee's Payee's Payee's Payee's Payee's Payee's
-------------------- ---------------- ------------------ ---------------- ----------------- ----------------- --------------
50 $3.06 $ 3.12 $ 3.19 $ 3.25 $3.31 $3.38
55 3.20 3.27 3.35 3.44 3.52 3.61
60 3.37 3.47 3.57 3.68 3.79 3.91
65 3.59 3.72 3.86 4.01 4.16 4.32
70 3.88 4.06 4.25 4.45 4.67 4.89
-------------------- ---------------- ------------------ ---------------- ----------------- ----------------- --------------
*Adjusted Age as defined in Fixed Account Annuity Options Provision
Page 20
--------------------------------------------------------------------------------------------------------------------------
Unisex Monthly Payments for Each $1,000 of Amount Retained
--------------------------------------------------------------------------------------------------------------------------
Age of Other Payee*
--------------------------------------------------------------------------------------------------------------------------
Age of First 15 Years Less 12 Years Less 9 Years Less 6 Years Less 3 Years Less Same as
Payee* Than First Than First Than First Than First Than First First Payee's
Payee's Payee's Payee's Payee's Payee's
----------------- ----------------- ----------------- ------------------ ----------------- --------------- ---------------
50 $3.07 $ 3.13 $ 3.19 $3.25 3.31 3.37
55 3.20 3.28 3.36 3.44 3.52 3.60
60 3.38 3.48 3.58 3.68 3.79 3.89
65 3.61 3.73 3.87 4.01 4.16 4.30
70 3.90 4.07 4.26 4.46 4.66 4.86
----------------- ----------------- ----------------- ------------------ ----------------- --------------- ---------------
*Adjusted Age as defined in Fixed Account Annuity Options Provision
VARIABLE ACCOUNT ANNUITY PAYMENTS
================================================================================
Annuity Unit Value The Annuity Proceeds will be used to purchase
variable annuity units in the chosen
Subaccount(s). The Annuity Unit Value in any
Subaccount will increase or decrease reflecting
the investment experience of that Subaccount.
The Annuity Unit Value of any Subaccount at the
end of a Valuation Period is equal to (a)
multiplied by (b) multiplied by (c), where:
(a) is the Annuity Unit Value for that
Subaccount at the end of the immediately
preceding Valuation Period;
(b) is the net investment factor for the
Subaccount for the Valuation Period; and
(c) is the Assumed Investment Return
adjustment factor for the Valuation
Period.
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 the Annuity Unit Value in each
Subaccount for the Valuation Period is
determined by dividing (d) by (e) and
subtracting (f) from the result, where:
(d) is the net result of:
(1) the net asset value of a Series Fund
share held in that Subaccount
determined as of the end of the
current Valuation Period; plus
(2) the per share amount of any dividend
or capital gain distributions made by
the Series Fund for shares held in
that Subaccount if the ex-dividend
date occurs during the Valuation
Period; plus or minus
(3) a per share charge or credit for any
taxes reserved for, which We
determine to have resulted from the
investment operations of the
Subaccount.
Page 21
(e) is the net asset value of a Series Fund
share held in the Subaccount determined as
of the end of the immediately preceding
Valuation Period.
(f) is a factor representing the mortality and
expense risk fee, and administrative
charge. This factor is equal, on an annual
basis, to 1.40% of the daily net asset
value of a Series Fund share held in the
Separate Account for that Subaccount.
Determination of The amount of the first variable payment is
the First Variable determined by multiplying the Annuity Proceeds
Payment times the appropriate rate from the variable
option selected. The tables are based on the
"Annuity 2000" (male, female, and unisex if
required by law) mortality table projected for
improvement using projection scale G.
The amount of the first payment depends upon
the adjusted Age of the Annuitant. The adjusted
Age is the Annuitant's Age nearest the Maturity
Date, adjusted as follows:
Maturity Date Adjusted Age
Before 2010 Actual Age
2010 - 2019 Actual Age minus 1
2020 - 2026 Actual Age minus 2
2027 - 2033 Actual Age minus 3
2034 - 2040 Actual Age minus 4
After the year 2040 as determined by Us.
Determination of The amount of variable annuity payments after
Subsequent the first will increase or decrease according
Variable Payments to the Annuity Unit Value which reflects the
investment experience of the selected
Subaccount(s). Each variable annuity payment
after the first will be equal to the number of
variable annuity units in each selected
Subaccount multiplied by the Annuity Unit Value
of that Subaccount on the date the payment is
processed. The number of variable annuity units
in any selected Subaccount is determined by
dividing the first variable annuity payment
allocated to that Subaccount by the variable
Annuity Unit Value of that Subaccount on the
date the first annuity payment is processed.
The number of variable annuity units in any
selected Subaccount will be increased or
reduced by the number of units transferred to
or from another Subaccount.
Variable Account The following options are available for payment
Annuity Options of Variable Account monthly annuity payments.
The rates shown are the guaranteed rates for
each $1,000 of Annuity Proceeds at selected
ages. These rates are used to determine the
first variable payment under each option. Any
guaranteed rates not shown for the options
below will be available upon request.
Page 22
Option D - The Annuity Proceeds will be paid in
Variable Life Income installments determined from the following
table. Such installments are payable:
1. during the payee's lifetime only (Variable
Life Annuity); or
2. during a 10 year fixed period certain and
for the payee's remaining lifetime
(Variable Certain Period).
=================== =================================================== =================================================
Variable Life Annuity Variable Certain Period
--------------------------------------------------- -------------------------------------------------
Payee's Age* Male Female Unisex Male Female Unisex
------------------- ---------------- --------------- ------------------ ----------------- ----------------- -------------
50 5.07 4.93 4.98 5.04 4.92 4.95
55 5.40 5.22 5.27 5.34 5.18 5.23
60 5.85 5.61 5.68 5.75 5.55 5.61
65 6.50 6.16 6.26 6.29 6.03 6.11
70 7.41 6.94 7.08 6.98 6.69 6.77
=================== ================ =============== ================== ================= ================= =============
*Adjusted Age as defined in Variable Account Annuity Options Provision
Option E - The Annuity Proceeds will be paid in
Variable Joint and Survivor installments during the joint lifetime of two
Life Income payees and continuing upon the death of the
first payee for the remaining lifetime of the
survivor.
--------------------------------------------------------------------------------------------------------------------------
Option E: Monthly Installment For Joint and Full Survivor
==========================================================================================================================
Monthly Payments for Each $1,000 of Amount Retained
--------------------------------------------------------------------------------------------------------------------------
Age of Other Payee (Female)*
--------------------------------------------------------------------------------------------------------
Age of First 15 Years Less 12 Years Less 9 Years Less 6 Years Less 3 Years Less Same as
Payee* (Male) Than Male Than Male Than Male Than Male Than Male Male Payee's
Payee's Payee's Payee's Payee's Payee's
----------------- ----------------- ---------------- ----------------- ---------------- ----------------- ----------------
50 $4.37 $4.42 $4.46 $4.51 $4.56 $4.62
55 4.48 4.54 4.60 4.67 4.74 4.81
60 4.62 4.70 4.79 4.88 4.98 5.08
65 4.81 4.92 5.04 5.17 5.31 5.46
70 5.07 5.23 5.40 5.59 5.79 6.00
----------------- ----------------- ---------------- ----------------- ---------------- ----------------- ----------------
*Adjusted Age as defined in Variable Account Annuity Options Provision
--------------------------------------------------------------------------------------------------------------------------
Unisex Monthly Payments for Each $1,000 of Amount Retained
----------------- --------------------------------------------------------------------------------------------------------
Age of Other Payee*
--------------------------------------------------------------------------------------------------------
Age of First 15 Years Less 12 Years Less 9 Years Less 6 Years Less 3 Years Less Same as
Payee* Than First Than First Than First Than First Than First First Payee's
Payee's Payee's Payee's Payee's Payee's
----------------- ----------------- ----------------- ------------------ ----------------- --------------- ---------------
50 $4.38 $ 4.42 $ 4.47 $4.51 $4.56 $4.61
55 4.48 4.54 4.60 4.67 4.73 4.80
60 4.63 4.70 4.79 4.88 4.97 5.07
65 4.82 4.93 5.05 5.17 5.30 5.44
70 5.09 5.24 5.41 5.59 5.78 5.97
----------------- ----------------- ----------------- ------------------ ----------------- --------------- ---------------
*Adjusted Age as defined in Variable Account Annuity Options Provision
Page 23
AUSA LIFE INSURANCE COMPANY, INC.
Home Office: ▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇
▇▇▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇ ▇▇▇▇▇
Administrative Office:
▇.▇. ▇▇▇ ▇▇▇▇
▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇
------------------------------------------------------------------------------
FLEXIBLE PAYMENT VARIABLE ACCUMULATION DEFERRED ANNUITY
Death Benefit Prior to Maturity
Monthly Annuity Commencing on Maturity Date
Non-Participating
No Dividends
Page 24
