Founded in 1867...A Mutual Company...P.O. Xxx 00000, Xxxxxxxxxx,
Xxxx 00000
ANNUITANT: Xxxx Xxx
OWNER: Xxxx Xxx
CONTRACT NUMBER: 01234567
CONTRACT DATE: April 05, 2001
WE PROMISE to pay the benefits of this contract in accordance
with its terms.
LOOK AT THE APPLICATION FORMS. This contract is issued based on
payment of the initial premium and the answers in the
application (see copy attached). If all answers are not true
and complete, this contract may be affected.
PLEASE READ THIS CONTRACT CAREFULLY. This is a legal contract
between you and Union Central.
10 DAY RIGHT TO EXAMINE THE CONTRACT. IT IS IMPORTANT TO UNION
CENTRAL THAT YOU ARE SATISFIED WITH THIS CONTRACT. YOU HAVE 10
DAYS AFTER YOU RECEIVE IT TO REVIEW THE CONTRACT. IF YOU ARE
NOT SATISFIED, YOU MAY SEND IT BACK TO US OR GIVE IT TO OUR
AGENT. IN SUCH CASE, THIS CONTRACT WILL BE VOID FROM THE
BEGINNING. WE WILL REFUND, WITHIN 7 DAYS AFTER THIS CONTRACT IS
RETURNED, ANY PREMIUMS PAID.
ALL ACCUMULATION VALUES AND ANNUITY PAYMENTS PROVIDED BY THIS
CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE
ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR
AMOUNTS.
Signed for the Company at Cincinnati, Ohio
/s/ Xxxxx X. Xxxxxxxxxx /s/ Xxxx X. Xxxxxx
Secretary President
Flexible Premium Deferred Variable Annuity
Participating
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Licensed Resident Agent
UC 8134 01/02
INTRODUCTION
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This is a flexible premium deferred variable annuity. This
annuity contract provides that both the accumulation value and
annuity payments may be either fixed or variable, or a
combination of fixed and variable.
You determine the investment allocation for this annuity. You
may allocate your premiums to either the guaranteed account or
the variable account, or a combination of these accounts. If
you select the guaranteed account, then your accumulation value
and annuity payments will be fixed and guaranteed. If you
select the variable account, your accumulation value and annuity
payments will vary with the investment performance of the
separate account's subaccounts. If you select both the
guaranteed and variable accounts, then your values and payments
will be fixed in part, and variable in part.
If you select the variable account, then you must allocate
premiums among one or more subdivisions of the variable account.
These subdivisions are identified in the contract application
and on the schedule page.
CONTRACT INDEX
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Page
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . 4
Ownership . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Premiums. . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Variable Account Provisions . . . . . . . . . . . . . . . . . 8
Guaranteed Account Provisions. . . . . . . . . . . . . . . . 11
Transfers. . . . . . . . . . . . . . . . . . . . . . . . . . 11
Surrender Provisions. . . . . . . . . . . . . . . . . . . . .12
Charges and Deductions. . . . . . . . . . . . . . . . . . . .13
General Provisions. . . . . . . . . . . . . . . . . . . . . .14
Payment of Contract Benefits. . . . . . . . . . . . . . . . .16
Schedule Page
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Initial Allocation of Net Premiums: Money Source
Separate Account: Carillon Account
SUBDIVISIONS OF THE VARIABLE ACCOUNT:
[AIM VI CAP APPRECIATION 0]%
[AIM VI GROWTH 0]
[XXXXX AMERICAN LEVERAGED ALLCAP 0]
[XXXXX AMERICAN MIDCAP GROWTH 0]
[AM CENTURY VP GROWTH & IN 0]
[AM CENTURY VP VALUE 0]
[MFS VIT EMERGING GROWTH 0]
[MFS VIT INVESTORS TRUST 0]
[MFS VIT HIGH INCOME 0]
[MFS VIT NEW DISCOVERY 0]
[MFS VIT TOTAL RETURN 0]
[XXXXXXXXX XXXXXX AMT GUARD 0]
[XXXXXXXXXXX GLOBAL SEC/VA 0]
[XXXXXXXXXXX MAIN ST/VA 0]
[XXXXXXX VSI CAP GROWTH 0]
[XXXXXXX VSI INTL 0]
[XXXXXXX VSI MONEY MARKET 0]
[XXXXXXXX SMALLCAP VALUE CLASS 2 0]
[XXXXXXXX COMM & INFO CLASS 2 0]
[SUMMIT BALANCED INDEX 0]
[SUMMIT BOND 25]
[SUMMIT NASDAQ 100 INDEX 0]
[SUMMIT XXXXXXX 2000 0]
[SUMMIT S&P MID CAP 400 0]
[SUMMIT S&P 500 INDEX 0]
[SUMMIT ZENITH 25]
[FTVIP XXXXXXXXX INTL CLASS 2 0]
GUARANTEED ACCOUNT: [50]
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TOTAL: 100%
Transfer Charge:
Current: [$10]
Maximum: $100
Mortality and Expense Charge:
Current: [1.00%]
Maximum: 2.00%
Administration Fee:
Current: [0.25%]
Maximum: 0.25%
Contract Fee for any full or partial year: $30.00
Guaranteed Account Guaranteed Minimum Interest Rate: 3.00%
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Annuitant: Xxxx Xxx Contract Number: 01234567
Owner: Xxxx Xxx Maturity Date: February 01, 2058
Joint Owner: N/A Contract Date: April 05, 2001
UC 8134 - 3 -
Schedule Page
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Surrender Charge:
We impose a surrender charge on certain early surrenders. The
amount of the surrender charge is a percentage of the amount
withdrawn and is set forth below.
Contract Surrender Charge
Year Percentage
[ 1 7% ]
[ 2 7% ]
[ 3 6% ]
[ 4 5% ]
[ 5 4% ]
[ 6 3% ]
[ 7 2% ]
[ 8 1% ]
[ 9 AND ABOVE 0% ]
Partial surrenders totaling not more than 10% of the
accumulation value may be made each contract year without a
surrender charge being imposed. In no event will the cumulative
total of all surrender charges exceed 9% of premiums.
Annuitant: Xxxx Xxx Contract Number: 01234567
Owner: Xxxx Xxx Maturity Date: February 01, 2058
Joint Owner: N/A Contract Date: April 05, 2001
UC 8134 -3A-
DEFINITIONS
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ACCUMULATION Means the period before the maturity date and
PERIOD during the lifetime of the annuitant.
ACCUMULATION Means a unit of measure that is used to
UNIT calculate the value of your interest in the
separate account (SA) before the maturity
date.
ACCUMULATION Means the sum of the values of the guaranteed
VALUE account and the variable account credited to
this contract.
ANNUITANT Means the person(s) whose life is used to
determine the duration of any annuity payments
involving life contingencies. The annuitant
is named in the application and on the
schedule page.
ANNUITY UNIT Means a unit of measure that is used to
calculate variable annuity payments.
BENEFICIARY Means the person(s) designated by you to
receive the death benefits from this contract
upon your death.
CALCULATION DATE Means a date not more than 10 business days
prior to the maturity date.
CONTRACT YEAR Means a period of 12 consecutive months
beginning on the contract date or any
anniversary thereafter. The contract date is
shown on the schedule page.
DUE PROOF Means one of the following:
OF DEATH 1. A certified copy of a death certificate;
2. A certified copy of a 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; and
4. Any other proof satisfactory to us.
FIXED ANNUITY Means an annuity with payments fixed through-
out the annuity payment period.
GUARANTEED Means this contract's value which is held by
ACCOUNT The Union Central Life Insurance Company other
than those in its separate accounts (SA).
HOME OFFICE Means the home office of The Union Central
Life Insurance Company which is:
0000 Xxxxxxxx Xxxx (X.X. Xxx 00000),
Xxxxxxxxxx, Xxxx 00000.
MATURITY DATE Means the date on which annuity payments
will begin. This date shall be the
annuitant's 95th birthday unless an earlier
date is chosen by you.
NOTICE Means information we have received at
our home office which is written, is
signed by you, and is acceptable to us.
PORTFOLIO OR Means a separate portfolio of one of the
FUND PORTFOLIO mutual funds in which separate account (SA)
invests through its subaccounts, or its
successors and assigns.
SCHEDULE PAGE Means the contract schedule page, or the
supplemental contract schedule page most
recently sent to you by us.
SEPARATE ACCOUNT Means the Carillon Account of The Union
("SA") Central Life Insurance Company. The
separate account is divided into
several subaccounts.
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UC 8134 -4- 01/02
SUBACCOUNT(S) Means one or more of the subaccounts of the
SA. Each subaccount is invested in a different
fund portfolio.
SUBDIVISION Means the portion of your variable account
which is invested in a specific subaccount.
VARIABLE ACCOUNT Means this contract's value which is invested
in one or more subaccounts of the SA.
VARIABLE ANNUITY Means an annuity with payments which: (1) are
not predetermined or guaranteed as to dollar
amount; and (2) vary in amount in relation
to the investment experience of one or more
specified subaccounts.
WE AND YOU "We," "us," or "our" means The Union Central
Life Insurance Company. "You" or "your" means
the owner of this contract.
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UC 8134 -5- 01/02
OWNERSHIP
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GENERAL The owner of this contract shall be the person
so named in the application or the latest
change filed with us.
CHANGE OF Prior to the maturity date, you may assign the
OWNERSHIP ownership of this contract by providing
notice.
CHANGE OF Prior to the maturity date, you may name a
ANNUITANT new annuitant. Such change must be made by
written notice in a form acceptable to us and
received at our home office.
BENEFITS
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ANNUITY BENEFITS We will pay an annuity benefit to the
annuitant, if living, on the maturity date.
Annuity benefits will begin on the maturity
date and continue while the annuitant is
living, with monthly payments guaranteed for
10 years, unless you elect a different annuity
option at least 30 days before the maturity
date. If you die after the annuity benefits
have begun, the entire remaining interest will
continue to be distributed to the annuitant,
if you are not also the annuitant, at least as
rapidly as under the annuity option being used
as of the date of your death. If you are the
annuitant, we will continue to pay the
beneficiary, if a benefit is payable to a
beneficiary.
We may pay the accumulation value on the
maturity date in one lump sum if it is less
than $5,000. We may change the payment
frequency to quarterly, semiannually or
annually if the first monthly annuity payment
would be less than $50.
At least 30 days before the maturity date you
must select how the accumulation value will be
used to provide the annuity benefit. Any
election must be written in a form
satisfactory to us and received at our home
office. If you do not so select how you wish
settlement to be effected, we will provide a
fixed annuity.
If a variable annuity is used, subsequent
annuity benefit payments will vary based on
the investment experience of the subaccount(s)
used to effect the annuity. The method used
to calculate the amount of subsequent payments
is described in the Variable Annuity Payments
provision.
DEATH BENEFITS Notwithstanding any provision to the contrary,
death benefits shall always be made in
accordance with the distribution requirements
of the Internal Revenue Code for annuity
contracts.
If the death benefit is paid before the
maturity date, the death benefit will be the
greater of : (a) the accumulation value on the
date that due proof of death is received; or
(b) the sum of all premiums paid, less any
amounts deducted in connection with partial
surrenders.
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UC 8134 -6- 01/02
Death of Owner. If you are an owner and if you
die before the maturity date, the following
will apply:
1. If your spouse is not the beneficiary, the
death benefit will be paid to the named
beneficiary:
a. upon written request it may be paid
under any option listed in the Payment
of Contract Benefits section of this
contract over a period not exceeding
the beneficiary's life expectancy. If
the death benefit is paid in
installments, the first installment
payment must be made no later than one
year after the date of your death; or
b. in a single sum. The beneficiary has the
option to elect to receive the single
sum any time within five years after the
date of your death.
2. If your spouse is the beneficiary, your
spouse may elect, by a written request to
us, one of the following options:
a. to continue this contract as the
owner; or
b. to receive the death benefit under
any option listed in the Payment of
Contract Benefits section of this
contract over a period not exceeding
the beneficiary's life expectancy. If
the death benefit is paid in
installments, the first installment
payment must be made no later than one
year after the date of your death; or
c. to receive the death benefit in a single
sum. Your spouse may elect to receive
the single sum any time within five
years after the date of your death.
If none of these options is elected by your
spouse within 45 days after we receive due
proof of death, option a. above shall apply.
3. If no beneficiary is living or if no
beneficiary has been named, at the date of
your death, the death benefit will be paid
in a single sum to the executor or
administrator of your estate within five
years after the date of your death.
Joint Owners. If this contract is owned
jointly, the death of the first joint owner
shall be treated as the death of the owner.
Death of Annuitant before the Maturity Date.
If you, the owner, are a different person from
the annuitant, and the annuitant dies during
your lifetime and before the maturity date,
you will be treated as the annuitant. If you
are not a natural person, and the annuitant
dies before the maturity date, we will pay the
death benefit to you in a single sum. You
have the option to elect to receive the single
sum any time within five years of the death of
the annuitant.
Death of Annuitant on or after the Maturity
Date. If the annuitant dies on or after the
maturity date, the death benefit, if any, will
depend on the annuity option in effect on the
date of the annuitant's death.
Death of Beneficiary. Unless otherwise
provided, if any beneficiary dies before, at
the same time as, or within 30 days after your
death, that beneficiary will be treated as if
their death occurred before yours.
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UC 8134 -7- 01/02
PREMIUMS
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GENERAL All premiums under this contract are payable
at our home office or such other place as we
may designate.
No premium may be paid under this contract
unless it is at least $50. Premiums may be
paid at any time. The amount of the premium
may be increased or decreased any time subject
to the $50 minimum and a maximum of $10,000
per contract year. We may waive the $10,000
per year maximum, but waiver in one instance
does not constitute waiver for additional
premiums.
NET PREMIUM The net premium is the premium less any
premium tax.
ALLOCATION OF You determine the allocation of the net
NET PREMIUM premiums between the guaranteed account and
the variable account. You may allocate the
net premiums totally to the guaranteed
account, totally to the variable account or
partially to both accounts. The minimum
amount of any net premium that you can
allocate to the guaranteed account or any
subdivision of the variable account is $10.
If you allocate a part or all of your premiums
to the variable account, then you will further
allocate that portion of your premiums among
one or more subdivisions of the variable
account. To the extent that you allocate
premiums to the variable account, your
accumulation value will be subject to the
investment experience of the SA.
Premiums that you allocate to the guaranteed
account will be guaranteed a minimum value.
We will credit interest to amounts allocated
to the guaranteed account at a rate of at
least the guaranteed interest rate as shown
on the schedule page, compounded annually.
We may credit a higher rate of interest to
such amounts, but we are not required to do
so.
When we receive the premiums, the net premiums
will be allocated in accordance with the net
premium allocation percentages shown in the
application or as of the most recent change of
allocation received from you. No allocation
will be made prior to the contract date. You
may change the allocation of subsequent
premiums at any time, without charge, by
giving us written notice.
VARIABLE ACCOUNT PROVISIONS
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SEPARATE ACCOUNT The separate account is shown on the schedule
page. It is a unit investment trust
registered with the Securities and Exchange
Commission under the Investment Company Act
of 1940. It is established under the laws of
Ohio. The assets in the separate account are
kept separate from our general assets and
assets of other separate accounts.
SUBACCOUNTS The separate account is divided into
subaccounts, each of which invests in a
different portfolio.
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UC 8134 -8- 01/02
CREDITING OF We will credit net premiums allocated to the
ACCUMULATION variable account in the form of variable
UNITS accumulation units. The number of variable
accumulation units to be credited to this
contract for each subdivision of the variable
account will be determined by dividing the net
premium allocated to each subdivision of the
variable account by the accumulation unit
value for the corresponding subaccount as of
the end of the valuation period during which
the premium is received. In the case of the
initial premium, accumulation units will be
credited on the later of these dates:
1. the contract date; or
2. the date we receive the premium.
Accumulation units are credited when amounts
are transferred into a subaccount.
Accumulation units are deducted when the
charges and deductions are assessed or when
amounts are partially surrendered or
transferred, including transfer charges, out
of a subaccount.
VARIABLE ACCOUNT At any time prior to the maturity date, the
variable account of this contract equals the
sum for all subdivisions of the variable
account of (1) times (2) where:
1. equals the number of accumulation units
credited to a subdivision of the variable
account; and
2. equals the value of the appropriate
accumulation unit.
VALUATION DATE A valuation date is any date on which the New
AND VALUATION York Stock Exchange is open for trading and we
PERIOD are open for business. The assets of each
subaccount will be valued on each valuation
date. A valuation period is a period
beginning with the close of the New York Stock
Exchange on a valuation date and ending at the
close of the New York Stock Exchange for the
next valuation date.
ACCUMULATION The value of a variable accumulation unit for
UNIT each subaccount was arbitrarily set at $10
when funds were first credited to the
respective subaccount. The variable
accumulation unit value for any subsequent
valuation period is determined by multiplying
the variable accumulation unit value for the
immediately preceding valuation period by the
"net investment factor" for the valuation
period for which the value is being
determined. The value of a variable
accumulation unit may increase or decrease
from one valuation period to the next.
NET INVESTMENT The net investment factor is an index that
FACTOR measures the investment performance of a
subaccount from one valuation period to the
next. The net investment factor for each
subaccount for any valuation period is
determined by dividing (1) by (2) and
subtracting (3) from the result, where:
1. is the net result of:
a. the net asset value per share of a
portfolio share held in the subaccount
determined as of the end of the current
valuation period, plus
b. the per share amount of any dividend or
capital gain distributions made by the
portfolio on shares held in the
subaccount if the "exdividend" date
occurs during the current valuation
period, plus or minus
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UC 8134 -9- 01/02
c. a per share charge or credit for any
taxes incurred by or reserved for in the
subaccount, which is determined by us to
have resulted from the maintenance of
the subaccount; and
2. is the net result of:
a. the net asset value per share of a
portfolio share held in the subaccount
determined as of the end of the
immediately preceding valuation period
(adjusted for an "exdividend"), plus or
minus
b. the per share charge or credit for any
taxes reserved for the immediately
preceding valuation period; and
3. is a factor representing the charges
deducted from the subaccounts on a daily
basis for administrative expenses and
mortality and expense risks. Such factor
is equal on an annual basis to the amount
shown on the schedule page.
VARIABLE ANNUITY The amount of the first variable annuity
PAYMENT payment is determined by applying the variable
account accumulation value of your contract,
measured as of the calculation date (minus any
applicable premium taxes), to the appropriate
Option Table contained in this contract. This
is done separately for each subdivision of the
variable account. We will determine subsequent
payments by dividing the first payment derived
from each subdivision of the variable account
by the annuity unit value determined as of the
calculation date. This number of annuity units
is then multiplied by the annuity unit value
for each subsequent determination date which
is a uniformly applied date not more than 10
business days before payment is due.
ANNUITY UNIT The value of an annuity unit for each
VALUE subaccount was arbitrarily set at $10 when
funds were first credited to the respective
subaccount. Subsequently, the value of an
annuity unit in each subaccount for any
valuation period is determined as follows:
(a) the net investment factor for each
subaccount for the valuation period for
which the annuity unit value is being
calculated is multiplied by the value of
the annuity unit on the preceding
valuation date; and
(b) the result is adjusted to compensate for
the interest rate assumed in the Option
Tables used to determine the first
variable annuity payment.
The dollar value of annuity units may change
from one valuation period to the next.
ADDITION, We reserve the right, subject to compliance
DELETION, OR with applicable law, to make additions to,
SUBSTITUTION OF deletions from, or substitution for the
INVESTMENTS portfolio shares that are held by the separate
account or that the separate account may
purchase. We reserve the right to eliminate
the shares of any of the eligible portfolios
and to substitute shares of another portfolio,
or of another open-end, registered investment
company, if the shares of an eligible
portfolio are no longer available for
investment, or if in our judgment further
investment in any eligible portfolio should
become inappropriate in view of the purposes
of the separate account. We will not
substitute any shares attributable to your
interest in a subaccount without notice to you
and prior approval of the Securities and
Exchange Commission, to the extent required by
the Investment Company Act of 1940. Nothing
contained herein shall prevent the separate
account from purchasing other securities for
other series or classes of policies, or from
effecting a conversion between series or
classes of policies on the basis of requests
made by owners.
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UC 8134 -10- 01/02
We reserve the right to establish additional
subaccounts, each of which would invest in a
new portfolio, or in shares of another open-
end investment company. We also reserve the
right to eliminate existing subaccounts.
In the event of any such substitution or
change, we may, by appropriate endorsement,
make such changes in this and other policies
as may be necessary or appropriate to reflect
such substitution or change. If deemed by us
to be in the best interest of persons having
voting rights under the policies, the separate
account may be operated as a management
company under the Investment Company Act of
1940 or it may be deregistered under such Act
in the event such registration is no longer
required.
The investment contract of the separate
account will not be changed without the
approval of the Insurance Commissioner of the
State of Ohio. If required, the approval
process is on file with the Commissioner of
the state in which this contract is issued.
GUARANTEED ACCOUNT PROVISIONS
----------------------------------------------------------------
GUARANTEED The guaranteed account of your contract at
ACCOUNT any time equals:
1. the total of all net premiums allocated to
the guaranteed account; plus
2. the total of all amounts transferred to the
guaranteed account from the variable
account; minus
3. the total of all amounts transferred from
the guaranteed account to the variable
account (including the transfer fee); minus
4. the total of all partial surrenders from
the guaranteed account (including any
surrender charges); plus
5. interest.
GUARANTEED The guaranteed interest rate used in the
ACCOUNT INTEREST calculation of the guaranteed account is found
RATE on the schedule page. Interest in excess of
the guaranteed rate may be used in the
calculation of the guaranteed account at such
increased rates and in such a manner as we
may determine.
FIXED ANNUITY We guarantee the amount of fixed annuity
PAYMENTS payments. The payment amount depends only
on the annuity option elected, the age (and
possibly sex) of the annuitant, and the
amount applied to purchase the fixed
annuity, in accordance with the Option
Tables contained in the contract.
TRANSFERS
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TRANSFERS BEFORE Before the maturity date you may transfer
MATURITY DATE amounts between the guaranteed account and
subdivisions of the variable account or among
subdivisions. Transfers from subdivisions of
the variable account will be made based on
the accumulation unit values at the end of
the valuation period during which we receive
the request for transfer. You must transfer
at least $300 or, if less, the entire amount
in the guaranteed account or a subdivision
each time you make a transfer. If after the
transfer the amount remaining in the
guaranteed account or any subdivision of the
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variable account from which the transfer
is made is less than $25, then we will
transfer the entire amount instead of the
requested amount. A transfer charge as
shown on the schedule page will be imposed
for each transfer. The charge will be
deducted from the account from which the
transfer is made.
TRANSFERS AFTER After annuity payments have been made for
MATURITY DATE at least 12 months, you may, no more than
once each 12 months, change all or part of
the investment upon which your annuity
payments are based from one subaccount to
another. After your death, the annuitant
assumes this right. To do this, we will
convert the number of annuity units being
changed to the number of annuity units of the
subaccount to which you are changing so as to
result in the next annuity payment being of
the same amount that it would have been
without the change. After that, annuity
payments will reflect changes in the values
of your new annuity units. You must give us
notice at least 30 days before the due date
of the first annuity payment to which the
change will apply.
No transfers may be made with respect to
fixed annuity payments.
SURRENDER PROVISIONS
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PAYMENT OF You may totally or partially surrender the
SURRENDERS contract and receive all of the accumulation
value at any time before the earlier of the
death of the annuitant or the maturity date,
by sending us a written request. We will pay
all surrenders from the variable account
within seven days of receipt of the written
request, subject to postponement for any
period during which the New York Stock
Exchange is closed for trading (except for
normal holiday closing) or when the Securities
and Exchange Commission has determined that a
state of emergency exists. We reserve the
right to postpone surrenders from the
guaranteed account for up to six months after
we receive the request.
TOTAL SURRENDERS If you are totally surrendering the contract,
we will deduct the surrender charge, if
applicable, and the administration fee from
the amount paid.
PARTIAL SURRENDER If you are partially surrendering the
contract, you should specify the amounts that
should be withdrawn from the guaranteed
account or each subdivision of the variable
account. If you do not so specify, the
requested amount will be withdrawn from the
guaranteed account and each subdivision of
the variable account in which you have an
interest, in the same proportion that your
interest therein bears to the accumulation
value. You may pre-authorize periodic
surrenders by entering into a separate
agreement with us. Under this agreement,
you may withdraw part of your accumulation
value at a regular interval chosen by you.
You may choose to withdraw a level dollar
amount or a percentage of your accumulation
value. If you choose the latter, the
accumulation value for the first year you
choose to make these withdrawals is set on
the date we approve your request. In later
years, the accumulation value is set on the
first day of the contract year. These
surrenders may be subject to the 10%
federal tax on early withdrawals. We will
deduct the surrender charge, if applicable,
from the accumulation value remaining
after the payment of the requested amount.
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FREQUENCY AND You may make as many partial surrenders as you
AMOUNT OF wish. Any surrender from the guaranteed
SURRENDERS account or a subdivision of the variable
account must be at least $100 or the entire
balance of the guaranteed account or
subdivision of the variable account. If,
after the surrender (and deduction of any
surrender charge), the amount remaining in
the guaranteed account or a subdivision is
less than $25, then we may consider the
surrender request to be a request for
surrender of the entire amount held in the
guaranteed account or subdivision. If a
partial surrender would reduce the
accumulation value to less than $100, then
we may treat the partial surrender request
as a total surrender of the contract.
CHARGES AND DEDUCTIONS
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MORTALITY AND To compensate us for assuming the mortality
EXPENSE RISK and expense risks, we deduct from the variable
CHARGE account a charge each valuation period. The
current charge is shown on the schedule page
as is the maximum effective annual rate that
can be charged. We will deduct the charge
from each subdivision of the variable account
in the same proportion that the value of each
subdivision bears to the variable account.
SURRENDER CHARGE A surrender charge is imposed on total and
partial surrenders other than those made
pursuant to the death of the annuitant or
upon annuitization under the contract. The
amount of the charge and the period for
which it will be assessed are shown on the
schedule page.
ADMINISTRATION During the accumulation period we deduct an
FEE annual administration fee of $30 as partial
compensation for the cost of providing and/or
purchasing certain administrative services.
The fee is not imposed during the annuity
period.
The administrative fee is deducted on the
anniversary date. It is withdrawn from the
guaranteed account or any subdivision of the
variable account in which you have an
interest, in proportion to their value. If
the contract is totally surrendered on any
date other than the last day of any contract
year, we will deduct the full amount of the
administrative fee from the amount paid.
We also deduct from the variable account a
charge each valuation period at an effective
annual rate of .25% to partially defray the
expenses of maintaining the contract.
TAXES We will charge certain taxes against your
premiums, accumulation value, or annuity
payments, when incurred. These taxes include
any premium taxes or other taxes levied by
any government entity which we, in our sole
discretion, determine have resulted from:
1. the establishment or maintenance of the
variable account; or
2. from the investment experience of the
variable account; or
3. from the receipt by us of the premium; or
4. from the issuance of this contract, or
5. from the commencement or continuance of
annuity payments under this contract.
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GENERAL PROVISIONS
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ENTIRE CONTRACT This contract is a legal contract that you
have entered into with us. The entire
contract consists of this contract, any
endorsements, schedule pages, amendments,
and the attached copy of the application
and supplemental applications. Any change
in the contract must be written and signed
by our President, one of our Vice Presidents,
our Secretary or Assistant Secretary. No
agent or person other than the above-named
has the authority to change or modify this
contract or waive any of its provisions. Words
that can be interpreted as singular or plural
shall mean both singular and plural.
BENEFICIARY The primary and any contingent beneficiaries
of this contract are named in the application.
If changed, the beneficiary is as shown in the
latest change. Unless the beneficiary
designation provides otherwise, any death
benefits will be divided equally among
beneficiaries of the same class. The
contingent beneficiary will receive the death
benefits if no primary beneficiary is living
at the time of the event giving rise to the
benefit payment. Prior to the maturity date,
if no beneficiary survives you, your estate
will be the beneficiary. The interest of any
beneficiary is subject to that of any
assignee.
CHANGE OF You may change the beneficiary, unless an
BENEFICIARY irrevocable designation has been made. Any
such change must be made by written notice
in a form acceptable to us and received at
our home office. If you die after the
maturity date, the annuitant may change
the beneficiary unless an irrevocable
designation has been made.
CHANGE IN Prior to the maturity date, you may change
MATURITY DATE the maturity date by written request at least
30 days before the previously specified
maturity date. After the election, the new
maturity date will become the maturity date.
ASSIGNMENT You may assign this contract. No assignment
will be binding on us unless it is written in
a form acceptable to us and received at our
home office. We will not be responsible for
the validity of any assignment. We will not
be liable for any payments we make or actions
we take before we receive notice of an
assignment.
CLAIMS OF Any accumulation value, before paid, under
CREDITORS this contract, will not be subject to the
claims of a beneficiary's creditors, except as
required by law.
MISSTATEMENT AND We may require proof of age, sex, or
PROOF OF AGE, survival of any person upon whose age, sex,
SEX OR SURVIVAL or survival any payments depend.
If the age or sex of the annuitant has been
misstated, the benefits will be those which
the premiums would have provided for the
correct age and sex. If we have made
incorrect annuity payments, we will adjust
future payments. The adjustments will reflect
any overpayment or underpayment.
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DIVIDEND As long as this contract is in force, you will
receive any dividends declared by us. It is
anticipated that no dividends will be
declared.
You have these options:
1. take the dividends in cash; or
2. use the dividends to be credited as
additional accumulation units with
respect to the variable account or
added to the guaranteed account.
You may choose either option or change options
by notice to us. If none is chosen, the
second option will be used.
REPORTS At least once a year we will send you a report
showing:
1. the accumulation unit value as of the
beginning date of the report;
2. the accumulation unit value as of the
ending date of the report;
3. the total number of accumulation units as
of the ending date of the report;
4. the value of the guaranteed account
and/or each subdivision of the variable
account on the beginning date of the
report;
5. the value of the guaranteed account
and/or each subdivision of the variable
account on the ending date of the report;
and
6. the gain or loss for each subdivision of
the variable account and/or the
guaranteed account.
For the column headings within the report, the
accumulation unit is referred to as "unit."
INSULATION The assets of SA are not chargeable with
liabilities arising out of any other business
we may conduct.
OWNERSHIP OF We shall have exclusive and absolute ownership
ASSETS and control of our assets, including the
assets of SA.
MODIFICATION We may not modify this contract without
OF CONTRACT your consent except:
1. to make the contract meet the requirements
of the Investment Company Act of 1940;
2. to make the contract comply with any
changes in the Internal Revenue Code; or
3. as required by any other applicable law in
order to continue treatment of the contract
as an annuity.
INCONTESTABILITY We cannot contest this contract after it has
been in force during the lifetime of the
annuitant for a period of two years from the
date of issue.
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WAIVER OF Notwithstanding the surrender charge described
SURRENDER on the contract schedule page, the surrender
CHARGES charge will be waived in the event (a) or (b)
below:
(1) You become confined in a qualified
institution for a period of at least 30
consecutive days after the contract date,
subject to the following:
(a) You must be a natural person (not a
Trust, Corporation, or other legal
entity).
(b) You must have been an owner of this
contract continuously since the
contract date.
(c) You were not confined in a qualified
institution at any time during the 60
day period just prior to the contract
date.
(d) We receive a written request for a full
or partial surrender along with due
proof of confinement within 12 months
following such confinement.
(e) A "qualified institution" means any
licensed hospital or licensed skilled
or intermediate care nursing facility
at which:
(i) medical treatment is available on
a daily basis; and
(ii) daily medical records are kept for
each patient.
(2) You acquire a terminal illness after the
contract date, subject to the following:
(f) You must be a natural person (not a
Trust, Corporation, or other legal
entity).
(g) You must have been an owner of this
contract continuously since the
contract date.
(h) You Must have less than 12 months to
live.
(i) We must receive a written statement
for full or partial surrender
together with a certificate from your
attending physician stating your life
expectancy and any other proof we may
require.
(j) "Physician" means a medical doctor
licensed in the United States who:
(i) is operating within the scope
of that license; and
(ii) is not the owner and is not
related to the owner.
PAYMENT OF CONTRACT BENEFITS
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GENERAL Annuity benefits under this contract are
payable in accordance with the Option Tables
given below or under such other annuity
options as we may agree to.
ALTERNATE Instead of an annuity in accordance with the
ANNUITY OPTIONS Option Tables given below, you may choose an
alternate type of fixed annuity payment. Such
alternate annuity option shall be based on
rates at least as favorable as those for fixed
dollar single premium immediate annuities
being issued by us on the maturity date. They
may only be elected within 30 days before that
date.
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DESCRIPTION OF Option 1: Life Annuity
ANNUITY OPTIONS
(a) Nonrefund. We will make payments during
the lifetime of the annuitant. No
payments are due after the death of the
annuitant.
(b) 5-Years Certain. We will make payments
for 5 years and after that during the
lifetime of the annuitant. No payments
are due after the death of the annuitant
or, if later, the end of the 5-year period
certain.
(c) 10-Years Certain. We will make payments
for 10 years and after that during the
lifetime of the annuitant. No payments
are due after the death of the annuitant
or, if later, the end of the 10-year
period certain.
(d) Installment Refund. We will make payments
for a period certain and after that during
the lifetime of the annuitant. No
payments are due after the death of the
annuitant or, if later, the end of the
period certain. The number of period
certain payments is equal to the amount
applied under this Installment Refund
Option divided by the amount of the first
annuity payment; provided, however, that
the amount of the final period certain
payment shall be multiplied by that part
of the preceding quotient which is not an
integer.
Option 2: Joint and Survivor Life Annuity
(a) Joint and Survivor Nonrefund. We will
make payments during the joint lifetime of
the annuitant and contingent annuitant.
Payments will then continue during the
remaining lifetime of the survivor of
them. No payments are due after the death
of the last survivor of the annuitant and
contingent annuitant.
(b) Joint and Survivor with 10-Years Certain.
We will make payments for 10 years and
after that during the joint lifetime of
the annuitant and contingent annuitant.
Payments will then continue during the
remaining lifetime of the survivor of
them. No payments are due after the
death of the survivor of the annuitant
and contingent annuitant or, if later,
the end of the 10-year period certain.
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Flexible Premium Deferred Variable Annuity
Participating
UC 8134
