BRIGHTHOUSE LIFE INSURANCE COMPANY OF NY
[000 Xxxx Xxxxxx
New York, New York 10166]
BRIGHTHOUSE LIFE INSURANCE COMPANY OF NY (referred to as "we, us and our") will
make Annuity Payments as described in this Contract beginning on the Annuity
Date.
This Contract is issued in return for the payment of the initial Purchase
Payment.
FREE LOOK PROVISION - RIGHT TO CANCEL
This Contract may be returned for any reason within [10] days after you receive
it by mailing or delivering the Contract to either us or the agent who sold it.
Return of this Contract by mail is effective on being postmarked, properly
addressed and postage prepaid. We will promptly refund your Account Value, plus
the sum of all fees, taxes, and charges deducted from the Purchase Payment as
of the effective date of the Free Look on the Business Day we receive your
Contract. Your Account Value may be more or less than your Purchase Payment.
Based on the maximum yearly Asset-Based Insurance Charges, the smallest yearly
rate of investment return required to ensure that the dollar amount of variable
annuity payments does not decrease is [4.35%]. The smallest yearly rate of
investment return is equal to the assumed interest rate (AIR) plus the maximum
yearly Asset-Based Insurance Charge during the payout phase of the Contract.
Signed for the Company.
[/s/ Illegible Secretary] [/s/ Illegible President]
------------- -------------
6010 (3/07)
NOTICE:
-------
DETAILS OF THE SEPARATE ACCOUNT PROVISIONS ON PAGE 6
INDIVIDUAL FLEXIBLE PURCHASE PAYMENT
DEFERRED VARIABLE ANNUITY CONTRACT
NONPARTICIPATING
READ YOUR CONTRACT CAREFULLY
ANNUITY PAYMENTS, DEATH BENEFITS, WITHDRAWAL VALUES AND ANY OTHER CONTRACT
VALUE PROVIDED BY THIS CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE
SEPARATE ACCOUNT, ARE VARIABLE, MAY INCREASE OR DECREASE IN ACCORDANCE WITH
FLUCTUATIONS IN THE NET INVESTMENT FACTOR, AS APPLICABLE, AND ARE NOT
GUARANTEED AS TO DOLLAR AMOUNT, UNLESS OTHERWISE SPECIFIED.
6010 (3/07)
TABLE OF CONTENTS
Page
----
Contract Schedule........................................................... [3
Definitions................................................................. 4
General Provisions.......................................................... 4
Annuitant, Ownership, Assignment Provisions................................. 5
Beneficiary Provisions...................................................... 5
Purchase Payment Provisions................................................. 5
Account Value Provision..................................................... 6
Separate Account Provisions................................................. 6
Transfer Provisions......................................................... 7
Death Benefit Provisions.................................................... 8
Withdrawal Provisions....................................................... 9
Annuity Provisions.......................................................... 9
Suspension or Deferral of Payments or Transfers from the Separate Account... 10
Reserves, Values and Benefits............................................... 11]
6010 (3/07)
DEFINITIONS ISSUE DATE -- The date this Contract
was issued. The Issue Date is shown
ACCOUNT VALUE -- The sum of your on the Contract Schedule.
interests in the Subaccounts of the
Separate Account. JOINT OWNER -- If there is more than
one Owner, each Owner shall be a
ACCUMULATION UNIT -- A unit of Joint Owner of the Contract.
measure used to calculate the Account
Value in a Subaccount of the Separate NOTICE -- Any form of communication
Account during the Accumulation providing information we need, either
Period. in signed writing or another manner
that we approve in advance. All
ACCUMULATION PERIOD -- The period Notices to us must be sent to our
prior to the Annuity Date during Annuity Service Office and received
which you can make Purchase Payments. in good order. To be effective for a
Business Day, a Notice must be
ANNUITANT -- The natural person(s) on received in good order prior to the
whose life Annuity Payments are end of that Business Day.
based. You may change the Annuitant
at any time prior to the Annuity Date OWNER -- The person(s) or entity(ies)
unless an Owner is not a natural entitled to the ownership rights
person. Any reference to Annuitant under this Contract. If Joint Owners
shall also include any Joint are named, all references to Owner
Annuitant under an Annuity Option. shall mean Joint Owners. (Referred to
The Annuitant and Owner do not have as "you or yours.")
to be the same person.
PURCHASE PAYMENT -- Any amount paid
ANNUITY PAYMENTS -- The series of to us under this Contract as
payments made to the Owner or other consideration for the benefits it
named payee after the Annuity Date provides, less any Premium and Other
under the Annuity Option elected. Taxes deducted upon receipt of a
Purchase Payment.
ANNUITY DATE -- The date on which
Annuity Payments begin. The Annuity SEPARATE ACCOUNT -- A segregated
Date is shown on the Contract asset account of the Company
Schedule. designated on the Contract Schedule.
ANNUITY PERIOD -- The period starting SUBACCOUNT -- Separate Account assets
on the Annuity Date during which are divided into Subaccounts. Assets
Annuity Payments are payable. of each Subaccount will be invested
in shares of an Investment Option.
ANNUITY SERVICE OFFICE -- The office
indicated on the Contract Schedule to VARIABLE ANNUITY PAYMENTS -- A series
which notices, requests and Purchase of payments made by us during the
Payments must be sent, or as Annuity Period which vary in amount
otherwise directed by Notice from us. with the investment experience of
All sums payable by us under the each applicable Subaccount.
Contract are payable through the
Annuity Service Office. WITHDRAWAL VALUE -- The Account Value
less any applicable withdrawal
ANNUITY UNIT -- A unit of measure charge, less any Premium and Other
used to calculate Variable Annuity Taxes, and less any Account Fee.
Payments after the Annuity Date.
ATTAINED AGE -- The age of any Owner GENERAL PROVISIONS
or Annuitant on his/her last birthday. THE CONTRACT -- The entire contract
consists of this Contract, any riders
BENEFICIARY -- The person(s) or or endorsements attached to this
entity(ies) you name to receive a Contract. This Contract must be
death benefit payable under this returned to us prior to the payment
Contract upon the death of the Owner of any benefit unless otherwise
or a Joint Owner, or in certain, waived by us. Prior to any payment of
circumstances, an Annuitant. a death claim, due proof of death
must be submitted to us.
BUSINESS DAY -- Each day that the New
York Stock Exchange is open for MINIMUM BENEFITS -- The benefits
business. The Separate Account will provided under this Contract are not
be valued each Business Day. A less than those required by the state
Business Day ends as of the close of in which the Contract is delivered.
regular trading on the New York Stock
Exchange. INCONTESTABILITY -- We will not
contest the validity of this Contract
COMPANY -- Brighthouse Life Insurance at any time following the Issue Date.
Company of NY.
NON-PARTICIPATING -- This Contract
CONTRACT ANNIVERSARY -- An will not share in any distribution by
anniversary of the Issue Date of this us of dividends.
Contract.
MISSTATEMENT OF AGE OR SEX -- We may
CONTRACT YEAR -- A one-year period require proof of age or sex of the
starting on the Issue Date and on Annuitant before making any Annuity
each Contract Anniversary thereafter. Payments under this Contract which
are measured by the Annuitant's life.
FIXED ANNUITY PAYMENTS -- A series of If the age or sex of the Annuitant
payments made by us during the has been misstated, the amount
Annuity Period which we guarantee as payable will be the amount that the
to dollar amount. Fixed Annuity Account Value would have provided at
payments are made out of our General the correct age or sex.
Account.
Once Annuity Payments have begun, any
GENERAL ACCOUNT -- All of our assets underpayments by the Company on
other than those in any segregated account of misstatement of age or
asset account. sex, with interest at a rate
specified in the Contract Schedule,
INVESTMENT OPTIONS -- The investment will be made up in one sum with the
choices within the Separate Account next Annuity Payment. Any
available under the Contract.
6010 (3/07) 4
overpayments by the Company on ANNUITANT -- The Annuitant is the
account of misstatement of age or person on whose life Annuity Payments
sex, with interest at a rate are based. The Annuitant is the
specified in the Contract Schedule, person designated by you as of the
will be deducted from future Annuity Issue Date, unless changed prior to
Payments until the total is repaid. the Annuity Date. The Annuitant may
not be changed in a Contract which is
REPORTS -- At least once each owned by a non-natural person. Any
calendar year we will furnish you change of Annuitant is subject to our
with a report showing the Account underwriting rules in effect at the
Value and any other information as time of the request.
may be required by the Investment
Company Act of 1940 and applicable ASSIGNMENT -- You may assign your
state law. We will send you rights under this Contract unless
confirmations of certain restricted by the Internal Revenue
transactions. Reports and Code or other applicable law. For
confirmations will be sent to your example, in certain tax markets
last known address. assignment of this Contract is
prohibited by the Internal Revenue
PREMIUM AND OTHER TAXES -- Any taxes Code. If your contract is assigned
paid by us to any governmental entity absolutely, we will treat it as a
relating to this Contract will be change of ownership and all rights
deducted from the Purchase Payments will be transferred. We are not bound
or Account Value when incurred. We by any assignment unless it is in
will, at our sole discretion, writing and until it is received at
determine when taxes relate to the our Annuity Service Office. We are
Contract, including when they have not responsible for the validity of
resulted from: the investment any assignment. Assignments will be
experience of the Separate Account; effective as of the date the written
receipt by us of the Purchase notice of assignment was signed
Payments; or commencement of Annuity subject to all payments made and
Payments. We may, at our sole actions taken by us before a signed
discretion, pay taxes when due and copy of the assignment form is
deduct that amount from the Account received by us at our Annuity Service
Value at a later date. Payment at an Office.
earlier date does not waive any right
we may have to deduct amounts at a
later date. We will deduct any BENEFICIARY PROVISIONS
withholding taxes required by BENEFICIARY -- The Beneficiary
applicable law. designation in effect on the Issue
Date will remain in effect, unless
EVIDENCE OF SURVIVAL -- We may changed. Unless you provide
require satisfactory evidence of the otherwise, the death benefit will be
continued survival of any person(s) paid in equal shares or all to the
on whose life Annuity Payments are Beneficiary(ies) as follows:
based. We reserve the right to
discontinue Annuity Payments until 1. to the primary Beneficiary(ies)
satisfactory proof of continued who survive you (or if the Owner
survival is received. is not a natural person, the
Annuitant's death); or if there
MODIFICATION OF CONTRACT -- This are none, then
Contract may be modified by us in
order to maintain compliance with 2. to the contingent Beneficiary(ies)
applicable state and federal law. who survive you (or if the Owner
This Contract may be changed or is not a natural person, the
altered only in writing signed by our Annuitant's death); or if there
President or our Secretary. are none, then
We will give you 60 days notice to 3. to your estate.
make a Purchase Payment before we
take any action. If Joint Owners have been designated,
unless you inform us otherwise, the
surviving Joint Owner will be treated
ANNUITANT, OWNERSHIP, ASSIGNMENT as the primary Beneficiary. Any other
PROVISIONS Beneficiary designation will be
OWNER -- You, as the Owner, have all treated as a contingent Beneficiary
the interest and rights under this unless otherwise indicated in a
Contract. The Owner is the person Notice to us.
designated as such on the Issue Date,
unless changed. CHANGE OF BENEFICIARY -- Subject to
the rights of any irrevocable
You may change the Owner at any time. Beneficiary, you may change the
A change of Owner will automatically primary Beneficiary or contingent
revoke any prior designation of Beneficiary. A change may be made by
Owner. A request for change must be: filing a Notice with us. The change
will take effect as of the date the
1. by Notice; and Notice is received. We will not be
liable for any payment made or action
2. received by us at the Annuity taken before we receive the change.
Service Office.
The change will become effective as PURCHASE PAYMENT PROVISIONS
of the date the Notice is signed. A PURCHASE PAYMENTS -- The initial
new designation of Owner will not Purchase Payment is due on the Issue
apply to any payment made or action Date. The Minimum Subsequent Purchase
taken by us prior to the time the new Payment and Maximum Total Purchase
designation was received at our Payments permitted under this
Annuity Service Office. Any change of Contract, are shown on the Contract
Owner is subject to our underwriting Schedule.
rules in effect at the time of the
request. CHANGE IN PURCHASE PAYMENTS --
Subject to the Minimum and Maximum
JOINT OWNER -- A Contract may be Purchase Payments shown on the
owned by Joint Owners, limited to two Contract Schedule, you may increase
natural persons. Joint Owners have or decrease or change the frequency
equal ownership rights and must both of subsequent Purchase Payments.
authorize any exercising of those
ownership rights unless otherwise
allowed by us. Upon the death of
either Owner, the surviving Joint
Owner will be deemed to be the
primary Beneficiary.
6010 (3/07) 5
ALLOCATION OF PURCHASE PAYMENTS -- CHANGE IN OPERATION -- We reserve the
The allocation of Purchase Payments right to transfer assets of the
is made in accordance with your Separate Account to another account,
selection made at the Issue Date. and to modify the structure or
Unless you elect otherwise, operation of the Separate Account,
subsequent Purchase Payments will be subject to obtaining any necessary
allocated in accordance with your regulatory approvals. If we do so, we
initial selection. Allocation of the guarantee that such modification will
Purchase Payments is subject to the not affect your Account Value.
Allocation Requirements set forth on
the Contract Schedule. If there are VALUATION OF ASSETS -- Assets of the
Joint Owners, unless we are Separate Account are valued at their
instructed to the contrary, fair market value in accordance with
allocation instructions will be our procedures.
accepted from either one of the Joint
Owners. ACCUMULATION UNIT -- Accumulation
Units shall be used to account for
all amounts allocated to or withdrawn
ACCOUNT VALUE PROVISION from a Subaccount of the Separate
ACCOUNT VALUE -- Your Account Value Account as a result of Purchase
for any Business Day is the sum of Payments, withdrawals, transfers, or
your interests in the Subaccounts of fees and charges. We will determine
the Separate Account as of such the number of Accumulation Units of a
Business Day. Subaccount purchased or canceled.
This is done by dividing the amount
The portion of your Account Value in allocated to (or the amount withdrawn
a Subaccount is determined by from) the Subaccount, by the dollar
multiplying the number of value of one Accumulation Unit of the
Accumulation Units allocated to the Subaccount as of the end of the
Contract for the Subaccount by the Business Day during which the Notice
Accumulation Unit Value. for the transaction is received at
the Annuity Service Office.
ACCOUNT FEE -- We will deduct an
Account Fee from your Account Value ACCUMULATION UNIT VALUE -- The
as set forth on the Contract Schedule. initial Accumulation Unit Value for
each Subaccount was set by us.
Subsequent Accumulation Unit values
SEPARATE ACCOUNT PROVISIONS for each Subaccount are determined by
THE SEPARATE ACCOUNT -- The Separate multiplying the Accumulation Unit
Account is designated on the Contract Value for the immediately preceding
Schedule and consists of assets, Business Day by the Net Investment
which are kept separate from our Factor of the Subaccount for the
General Account assets and all of our current Business Day.
other segregated asset accounts. The
assets of the Separate Account, equal The Accumulation Unit Value may
to reserves and other liabilities of increase or decrease from Business
your Contract and those of other Day to Business Day.
owners who have an interest in the
Separate Account, will not be charged NET INVESTMENT FACTOR -- The Net
with liabilities arising out of any Investment Factor for each Subaccount
other business we may do. is determined by dividing A by B and
multiplying by (1-C) where:
Income, gains, and losses, whether or
not realized, from assets allocated A is (i)the net asset value per
to the Separate Account shall be share of the Investment
credited to or charged against the Option held by the
Separate Account without regard to Subaccount at the end of the
other income, gains or losses of the current Business Day; plus
company.
(ii)any dividend or capital
The Separate Account assets are gains per share declared on
divided into Subaccounts. The assets behalf of such Investment
of each Subaccount are allocated to Option that has an ex-
an Investment Option. dividend date as of the
current Business Day.
We own the assets of the Separate
Account. B is the net asset value per share
of the Investment Option held
INVESTMENTS OF THE SEPARATE ACCOUNT by the Subaccount for the
-- Purchase Payments applied to the immediately preceding Business
Separate Account are allocated to the Day.
Subaccounts of the Separate Account.
We may, from time to time, add C is (i)the Separate Account
additional Investment Options. You Product Charges which are
may be permitted to transfer all or a shown on the Contract
portion of your Account Value to the Schedule for each day since
additional Investment Option(s). the last Business Day. The
However, the right to make any daily charge is equal to
transfer will be limited by any terms the annual Separate Account
and conditions in effect at the time Product Charges divided by
of transfer. 365; plus
If the shares of any of the (ii)a charge factor, if any, for
Investment Options become unavailable any taxes or any tax reserve
for investment by the Separate we have established as a
Account, or we deem further result of the operation of
investment in these shares this Subaccount.
inappropriate, we may prohibit or
otherwise limit further purchase of PRODUCT CHARGES -- We deduct Product
such shares or substitute shares of Charges from the Separate Account and
another Investment Option for shares Account Value as shown on the
already purchased under this Contract Schedule.
Contract, subject to obtaining any
necessary regulatory approvals.
6010 (3/07) 6
Portfolio and the reflection of that
TRANSFER PROVISIONS change in the Portfolio's share price
You may make certain transfers of ("arbitrage trading"). Regardless of
your Account Value subject to the the existence of pricing
provisions set forth below. inefficiencies, frequent
transfers/reallocations may also
We will not be liable for any increase brokerage and administrative
transfers made in accordance with costs of the underlying Portfolios
your instructions (or instructions and may disrupt Portfolio management
from your designee if we agree to strategy, requiring a Portfolio to
accept instructions from such maintain a high cash position and
designee). All transfers made on the possibly resulting in lost investment
same Business Day will be treated as opportunities and forced liquidations
one transfer. A transfer will be made ("disruptive trading"). Accordingly,
as of the end of a Business Day when arbitrage trading and disruptive
we receive all the required trading activities (referred to
information necessary to process the collectively as "market timing") may
request in good order at our Annuity adversely affect the long-term
Service Office. All transfers will be performance of the Portfolios, which
subject to the following: may in turn adversely affect contract
owners and other persons who may have
1. we reserve the right to limit the an interest in the Certificates
maximum number of transfers per (e.g., Annuitants and Beneficiaries).
Contract Year as referenced on the
Contract Schedule; We may restrict
transfers/reallocations to deter
2. we reserve the right to charge a market timing.
fee for transfers as referenced on
the Contract Schedule; TRANSFERS DURING THE ACCUMULATION
PERIOD -- During the Accumulation
3. we reserve the right to limit the Period, you may ask us to transfer
amounts of transfers as referenced your Account Value from one
on the Contract Schedule; Subaccount to another, subject to the
following:
4. your right to make transfers is
subject to limitations or 1. the maximum number of transfers
modification by us if we per Contract Year is shown on the
determine, in our sole opinion Contract Schedule;
that the exercise of the right by
one or more owners with interests 2. we reserve the right to assess a
in the Subaccount is, or would be, transfer fee if the number of
to the disadvantage of other transfers exceeds the maximum
owners. Restrictions may be number of permissible free
applied in any manner reasonably transfers shown on the Contract
designed to prevent any use of the Schedule;
transfer right that is considered
by us to be to the disadvantage of 3. the minimum and maximum amounts
other owners. A limitation or which may be transferred are shown
modification could be applied to on the Contract Schedule;
transfers to, or from, one or more
of the Subaccounts and includes: 4. your right to make transfers is
subject to limitations or
a. the requirement of a minimum modification by us if we
of 35 days between each determine, in our sole opinion,
transfer and no more than 12 that the exercise of the right by
transfers per Contract Year; one or more owners with interests
in the Subaccount is, or would be,
b. not accepting a transfer to the disadvantage of other
request from a third party owners. Restrictions may be
acting under authorization on applied in any manner reasonably
behalf of more than one Owner; designed to prevent any use of the
transfer right that is considered
c. limiting the dollar amount by us to be to the disadvantage of
that may be transferred other owners. A limitation or
between the Subaccounts by an modification could be applied to
Owner at any one time to no transfers to, or from, one or more
more than 10% of the Account of the Subaccounts and could
Value; include, but is not limited to:
d. requiring that you deliver an a. the requirement of a minimum
originally executed written time period between each
transfer request to us signed transfer;
by an Owner;
b. not accepting a transfer
e. any restriction imposed by an request from an agent acting
underlying Portfolio; under a power of attorney on
behalf of more than one owner;
f. not accepting transfer or
exchange instructions of c. limiting the dollar amount
individual owners who have that may be transferred
executed pre-authorized between the Subaccounts by an
transfer forms which are owner at any one time;
submitted by market timing
firms or other third parties d. requiring that a written
on behalf of more than one transfer request be provided
owner. to us, signed by an owner;
Frequent requests from certificate 5. to the extent permitted by
owners to make applicable law, during times of
transfers/reallocations may dilute drastic economic or market
the value of a Portfolio's shares if conditions, we may suspend the
the frequent transfers/reallocations transfer privilege temporarily
involve an attempt to take advantage without notice and treat transfer
of pricing inefficiencies created by requests based on their separate
a lag between a change in the value components (a redemption order
of the securities held by the with a simultaneous request for
purchase of another Subaccount).
In such a case, the redemption
order would be processed at the
source Subaccount's next
determined Accumulation Unit
Value. However, the purchase into
the new Subaccount would be
effective at the next determined
Accumulation Unit Value for the
new Subaccount only after we
receive the proceeds from the
6010 (3/07) 7
source Subaccount, or we otherwise DEATH BENEFIT OPTIONS DURING THE
receive cash on behalf of the source ACCUMULATION PERIOD -- A Beneficiary
Subaccount; must elect the death benefit to be
paid under one of the options below
6. transfers do not change the (unless the Owner has previously made
allocation instructions for future such election) in the event of the
Purchase Payments or any death of an Owner during the
pre-scheduled transfers. Accumulation Period. In addition, if
the Beneficiary is the spouse of the
TRANSFERS DURING THE ANNUITY PERIOD Owner, he or she may elect to
-- Transfers made during the Annuity continue the Contract in his or her
Period are subject to the following: own name and exercise all the Owner's
rights under the Contract. The death
1. the maximum number of transfers benefit options available under the
between Subaccounts is shown on Contract are:
the Contract Schedule;
OPTION 1 -- lump sum payment of the
2. you may not make a transfer from death benefit; or
the General Account to the
Separate Account; OPTION 2 -- the payment of the entire
death benefit within five (5) years
3. transfers among Subaccounts will of the date of the death of the Owner
be made by converting the number or the first Joint Owner to die; or
of Annuity Units being transferred
to the number of Annuity Units of OPTION 3 -- payment of the death
the Subaccount to which the benefit under an Annuity Option over
transfer is made, so that the next the lifetime of the Beneficiary or
Annuity Payment if it were made at over a period not extending beyond
that time would be the same amount the life expectancy of the
that it would have been without Beneficiary with distribution
the transfer. Thereafter, Annuity beginning within one year of the date
Payments will reflect changes in of death of the Owner or the first
the value of the new Annuity Joint Owner to die.
Units; and
Any portion of the death benefit not
4. you may make a transfer from the applied under Option 3 within one
Separate Account to the General (1) year of the date of the Owner's
Account. The amount transferred to or Joint Owner's death must be
the General Account from a distributed within five (5) years of
Subaccount of the Separate Account the date of death.
will be equal to the product of
"(a)" multiplied by "(b)" If a lump sum payment is requested,
multiplied by "(c)", where (a) is the amount will be paid within seven
the number of Annuity Units (7) days of receipt of proof of death
representing your interest in the and the election, unless the
Subaccount per Annuity Payment; Suspension or Deferral of Payments
(b) is the Annuity Unit value for Provision is in effect.
the Subaccount; and (c) is the
present value of $1.00 per payment Payment to the Beneficiary, other
period for the remaining annuity than in a lump sum, may only be
benefit period based on the elected during the sixty (60) day
Attained Age of the Annuitant at period beginning with the date of
time of transfer, and calculated receipt of proof of death.
using the same actuarial basis as
the Variable Annuity rates applied DEATH OF OWNER DURING THE ANNUITY
on the Annuity Date for the PERIOD -- If the Owner or a Joint
Annuity Option elected. Amounts Owner, who is not the Annuitant, dies
transferred to the General Account during the Annuity Period, any
will be applied under the Annuity remaining payments under the Annuity
Option elected at the Attained Age Option elected will continue at least
of the Annuitant at the time of as rapidly as under the method of
the transfer using the Fixed distribution in effect at the time of
Annuity Option Table. If at the the Owner's death. Upon the death of
time of transfer, the then current the Owner or a Joint Owner during the
Fixed Annuity Option rates Annuity Period, the Beneficiary
applicable to this class of becomes the Owner.
contracts provide a greater
payment, the greater payment will DEATH OF ANNUITANT -- Upon the death
be made. All amounts and Annuity of an Annuitant, who is not the Owner
Unit values will be determined as or Joint Owner, during the
of the end of the Business Day on Accumulation Period, the Owner
which we receive a Notice. automatically becomes the Annuitant.
The Owner may select a new Annuitant
if the Owner does not want to be the
DEATH BENEFIT PROVISIONS Annuitant. Any new Annuitant
DEATH OF OWNER DURING THE designation will be subject to the
ACCUMULATION PERIOD -- During the Company's underwriting rules then in
Accumulation Period, the death effect. However, if the Owner is a
benefit will be paid to your non-natural person, the death of the
Beneficiary(ies) upon your death, or primary Annuitant will be treated as
upon the first death of a Joint Owner. the death of the Owner.
DEATH BENEFIT AMOUNT DURING THE Upon the death of the Annuitant
ACCUMULATION PERIOD -- The death during the Annuity Period, the death
benefit is the Account Value benefit, if any, will be as specified
determined as of the end of the in the Annuity Option elected. Death
Business Day on which we have benefits will be paid at least as
received both due proof of death and rapidly as under the method of
an election for the payment method. distribution in effect at the
The death benefit amount in the Annuitant's death.
Separate Account remains in the
Separate Account until distribution PAYMENT OF DEATH BENEFIT -- We will
begins. From the time the death require due proof of death before any
benefit is determined until complete death benefit is paid. Due proof of
distribution is made, any amount in death will be:
the Separate Account will continue to
be subject to investment risk. This 1. a certified death certificate;
risk is borne by the Beneficiary.
6010 (3/07) 8
2. a certified decree of a court of ANNUITY OPTIONS -- You may elect to
competent jurisdiction as to the receive Annuity Payments monthly,
finding of death; quarterly, semi-annually or annually.
The following Annuity Options, or any
3. a written statement by a licensed other Annuity Option acceptable to
medical doctor who attended the you and us, may be elected:
deceased; or
OPTION 1 -- LIFE ANNUITY -- We will
4. any other proof satisfactory to us. make Annuity Payments, payable at the
frequency elected, during the
Any death benefit will be paid in lifetime of the Annuitant and
accordance with applicable law or terminating with the last payment due
regulations governing death benefit prior to the Annuitant's death.
payments.
OPTION 2 -- LIFE ANNUITY WITH 10
In all events, this Contract will be YEARS OF ANNUITY PAYMENTS GUARANTEED
continued and administered in -- We will make Annuity Payments,
accordance with Section 72 (s) of the payable at the frequency elected,
Internal Revenue Code, as amended. during the lifetime of the Annuitant
with a guarantee that if at the
Annuitant's death there have been
WITHDRAWAL PROVISIONS less than 10 years of Annuity
WITHDRAWALS -- Prior to the Annuity Payments made as selected, Annuity
Date, you may, upon Notice to us, Payments will continue for the
make a total or partial withdrawal of remainder of the Guaranteed Period.
the Withdrawal Value. A withdrawal You may elect to have the present
will result in the cancellation of value of the guaranteed Variable
Accumulation Units from each Annuity Payments remaining, as of the
applicable Subaccount of the Separate date due proof of the Annuitant's
Account in the ratio that the Account death is received at our Annuity
Value in the Subaccount bears to the Service Office, commuted at the
total Account Value. You must specify Assumed Investment Return selected.
in a Notice to us from which We will require the return of this
Subaccount(s) values are to be Contract and proof of death prior to
withdrawn if other than the above the payment of any commuted values.
method is desired. We will pay the
amount of any withdrawal within seven OPTION 3 -- JOINT AND LAST SURVIVOR
(7) days of receipt of the Notice in ANNUITY -- We will make Annuity
good order unless the Suspension or Payments, payable at the frequency
Deferral of Payments or Transfers elected, during the joint lifetime of
from the Separate Account provision the Annuitant and the Joint
is in effect. Annuitant. Upon the death of either
the Annuitant or Joint Annuitant,
Each partial withdrawal must be for Annuity Payments will continue to be
an amount which is not less than the paid during the remaining lifetime of
minimum shown on the Contract the survivor. Annuity Payments cease
schedule or, if smaller, the with the final Annuity Payment due
remaining Withdrawal Value. If the prior to the last survivor's death.
withdrawal would result in the
Account Value being less than the OPTION 4 -- JOINT AND LAST SURVIVOR
Minimum Withdrawal Value which must ANNUITY WITH 10 YEARS OF ANNUITY
remain in the Contract after a PAYMENTS GUARANTEED -- We will make
Partial Withdrawal as shown on the Annuity Payments, payable at the
Contract schedule we will treat the frequency elected, during the joint
withdrawal request as a request for a lifetime of the Annuitant and the
full withdrawal. Joint Annuitant. Upon the death of
either the Annuitant or Joint
Partial withdrawals can impact the Annuitant, Annuity Payments will
amount of the death benefit. continue to be paid during the
remaining lifetime of the survivor.
WITHDRAWAL CHARGE -- Upon withdrawal If at the last death of the Annuitant
of all or a portion of the Account and the Joint Annuitant, there have
Value, a Withdrawal Charge as set been less than 10 years of Annuity
forth on the Contract schedule may be Payments made as selected, Xxxxxxx
assessed. Under certain Payments will continue to be made for
circumstances, described on the the remainder of the Guaranteed
Contract schedule, a withdrawal may Period. You may elect to have the
be made without the imposition of a present value of the guaranteed
Withdrawal Charge. Variable Annuity Payments remaining,
as of the date due proof of the
For a partial withdrawal, the Annuitant's death is received at our
Withdrawal Charge will be deducted Annuity Service Office, commuted at
from the remaining Account Value, if the Assumed Investment Return
sufficient, or from the amount selected. We will require the return
withdrawn. of this Contract and proof of death
prior to the payment of any commuted
values.
ANNUITY PROVISIONS
ANNUITY DATE -- The Annuity Date is ANNUITY -- You can elect to have the
shown on the Contract Schedule. Prior Annuity Option payable as Fixed
to the Annuity Date, you may, subject Annuity Payments or Variable Annuity
to the Annuity Requirements set forth Payments or a combination. Fixed
on the Contract Schedule, change the Annuity Payments are guaranteed as to
Annuity Date upon thirty (30) days dollar amount. Variable Annuity
prior Notice to us. Payments will reflect the investment
experience of the Separate Account in
ELECTION OF ANNUITY OPTION -- The accordance with the allocation of the
Annuity Option is elected by you. If Account Value to the Subaccounts.
no Annuity Option is elected, Option Unless another payee is designated,
2--Life Annuity with Ten (10) Years you will be the payee of the Annuity
of Annuity Payments Guaranteed will Payments.
automatically be applied. Upon thirty
(30) days Notice prior to the Annuity The Adjusted Account Value will be
Date you may change the Annuity applied to the applicable Fixed
Option. and/or Variable Annuity Tables to
determine your first Annuity Payment.
The Adjusted Account Value is
determined on the Annuity Calculation
Date which is a Business Day no more
than five Business Days prior to the
Annuity Date. The Adjusted Account
Value is the Account Value, less any
6010 (3/07) 9
Premium and Other Taxes or other Assumed Investment Return (which must
applicable taxes and less the Account be acceptable to us) to be used at
Fee. The amount of the first payment the time this Contract is issued.
for each $1,000 of Adjusted Account Upon thirty (30) days Notice, prior
Value is shown in the Annuity Tables. to the Annuity Date, you may change
the selected Assumed Investment
If, as of the Annuity Calculation Return. If you do not select an
Date, the then current Annuity rates Assumed Investment Return, the
applicable to this class of contracts Assumed Investment Return will be the
provide an Income Payment greater one shown in the Annuity Requirements
than the one guaranteed under this on the Contract Schedule.
Contract for the same Annuity Option,
then the greater payment will be made. FREQUENCY AND AMOUNT OF ANNUITY
PAYMENTS -- Annuity Payments will be
FIXED ANNUITY -- Fixed Annuity paid as monthly installments or at
Payments are based upon the Annuity any frequency acceptable to you and
Option elected, the Annuitant's us. The Adjusted Account Value on the
Attained Age and sex, and the Annuity Calculation Date is applied
appropriate Fixed Annuity Option to the Annuity Table for the Annuity
Table. If, as of the Annuity Option elected. If the amount of the
Calculation Date, the then-current Adjusted Account Value to be applied
Fixed Annuity Option rates applicable under an Annuity Option is less than
to this class of contracts provide an $5,000, we reserve the right to make
Annuity Payment greater than that one lump sum payment in lieu of
which is guaranteed under the same Annuity Payments. If the amount of
Annuity Option under this Contract, any Annuity Payment would be or
then the greater payment will be made. becomes less than $100, we may reduce
the frequency of payments to an
VARIABLE ANNUITY -- Variable Annuity interval which will result in each
Payments are not predetermined as to payment being at least $100.
dollar amount; and will increase or
decrease in proportion to the amount ANNUITY PAYMENT GUARANTEE -- We
that the Net Investment Factor guarantee that the dollar amount of
exceeds the Assumed Investment Return each Variable Annuity Payment after
selected. the first Annuity Payment will not be
affected by variations in actual
The dollar amount of the first mortality experience or expenses, but
Variable Annuity Payment is only by investment experience. The
determined as follows. The first amount of each Fixed Annuity Payment
Variable Annuity Payment will be will not change.
based upon the Annuity Option
elected, the Annuitant's Attained Age BASIS OF PAYMENTS -- The Annuity
and sex, and the appropriate Variable Tables are based on the tables
Annuity Option Table. If, as of the defined under the Annuity
Annuity Calculation Date, the then Requirements set forth on the
current Variable Annuity Option rates Contract Schedule.
applicable to this class of Contracts
provide a first Annuity Payment
greater than that which is guaranteed SUSPENSION OR DEFERRAL OF PAYMENTS OR
under the same Annuity Option under TRANSFERS FROM THE SEPARATE ACCOUNT
this Contract, the greater payment We reserve the right to suspend or
will be made. postpone payments for a withdrawal or
transfer for any period when:
The dollar amount of Variable Annuity
Payments for each applicable 1. the New York Stock Exchange is
Subaccount after the first payment is closed (other than customary
determined as follows: weekend and holiday closings);
1. the dollar amount of the first 2. trading on the New York Stock
Variable Annuity Payment is Exchange is restricted;
divided by the value of an Annuity
Unit for each applicable 3. an emergency exists as a result of
Subaccount as of the Annuity which disposal of securities held
Calculation Date. This establishes in the Separate Account is not
the number of Annuity Units for reasonably practicable or it is
each monthly payment. The number not reasonably practicable to
of Annuity Units for each determine the value of the
applicable Subaccount remains Separate Account's net assets; or
fixed during the Annuity Period,
unless you transfer values from 4. during any other period when the
the Subaccount to another Securities and Exchange
Subaccount; Commission, by order, so permits
for the protection of the Owner.
2. the fixed number of Annuity Units
per payment in each Subaccount is The applicable rules and regulations
multiplied by the Annuity Unit of the Securities and Exchange
value for that Subaccount for the Commission will govern as to whether
Business Day for which the Annuity the conditions described in (2) and
Payment is being calculated. This (3) exist.
result is the dollar amount of the
payment for each applicable
Subaccount, less any Account Fee. RESERVES, VALUES AND BENEFITS
All reserves are greater than, or
The total dollar amount of each equal to, those required by statute.
Variable Annuity Payment is the sum Any values and death benefits that
of all Subaccount Variable Annuity may be available under this Contract
Payments. are not less than the minimum
benefits required by any law of the
ANNUITY UNIT -- The initial Annuity state in which this Contract is
Unit Value for each Subaccount of the delivered.
Separate Account was set by us.
The subsequent Annuity Unit value for
each Subaccount is determined by
multiplying the Annuity Unit value
for the immediately preceding
Business Day by the Net Investment
Factor for the Subaccount for the
current Business Day and multiplying
the result by a factor for each day
since the last Business Day which
offsets the Assumed Investment Return
used to develop the Variable Annuity
Tables. You select the
6010 (3/07) 10
FIXED ANNUITY TABLES AND VARIABLE ANNUITY TABLES
AMOUNT OF FIRST MONTHLY PAYMENT
PER $1000 OF CONTRACT VALUE
Annuitant Only
Option 1: Life Annuity Option 2: Life Annuity with 10 Years of Annuity
Payments Guarantee
------------------------------------------------- ---------------------------------------------------
Attained age of Attained Age of
Annuitant Male Female Annuitant Male Female
------------------------------------------------- ---------------------------------------------------
55 3.95 3.72 55 3.93 3.71
60 4.30 4.01 60 4.26 3.99
65 4.75 4.40 65 4.68 4.36
70 5.37 4.92 70 5.23 4.84
75 6.24 5.64 75 5.92 5.47
80 7.43 6.68 80 6.73 6.29
85 9.08 8.22 85 7.61 7.26
Annuitant and Joint Annuitant
Option 3: Joint and Last Survivor Life Annuity
Age of Female Joint Annuitant
------------------------------------------------------------------------------------------------------
Attained Age of 10 Years 5 Years Same 5 Years 10 Years
Male Xxxxxxxxx Xxxxxxx Younger Age Older Older
------------------------------------------------------------------------------------------------------
55 3.21 3.33 3.44 3.56 3.66
60 3.37 3.52 3.67 3.81 3.94
65 3.58 3.77 3.96 4.15 4.33
70 3.84 4.09 4.35 4.61 4.85
75 4.19 4.53 4.89 5.25 5.58
80 4.66 5.13 5.64 6.15 6.59
85 5.31 5.98 6.71 7.42 8.02
Option 4: Joint and Last Survivor Annuity with 10 Years of Annuity Payments
Guaranteed
Age of Female Joint Annuitant
------------------------------------------------------------------------------------------------------
Attained Age of 10 Years 5 Years Same 5 Years 10 Years
Male Xxxxxxxxx Xxxxxxx Younger Age Older Older
------------------------------------------------------------------------------------------------------
55 3.21 3.33 3.44 3.55 3.66
60 3.37 3.52 3.67 3.81 3.94
65 3.58 3.76 3.96 4.15 4.32
70 3.84 4.09 4.35 4.60 4.83
75 4.19 4.52 4.87 5.22 5.51
80 4.65 5.10 5.58 6.03 6.38
85 5.27 5.88 6.50 7.02 7.35
Monthly installments for ages not shown will be furnished on request.
THIS PAGE INTENTIONALLY LEFT BLANK
INDIVIDUAL FLEXIBLE PURCHASE PAYMENT
DEFERRED VARIABLE ANNUITY CONTRACT
NONPARTICIPATING
NO DIVIDENDS
BRIGHTHOUSE LIFE INSURANCE COMPANY OF NY
[000 Xxxx Xxxxxx
Xxx Xxxx, Xxx Xxxx 00000]
