Exhibit 4(c)
Xxxx Xxxxxxx Mutual Life Insurance Company Xxxx Xxxxxxx Xxxxx
XX Xxx 000
Xxxxxx, Xxxxxxxxxxxxx 00000
[1-800-732-5543]
OWNER AT ISSUE [XXXX XXX] ANNUITY CONTRACT NUMBER [000000]
ANNUITANT [XXXX XXX]
Xxxx Xxxxxxx Mutual Life Insurance Company ("the Company") agrees to provide the
benefits, rights and privileges as stated in this contract.
If this contract is in force on the Date of Maturity, we will pay an annuity to
the Annuitant, unless otherwise directed by the Owner. Each annuity payment will
be determined in accordance with Section 14 of this contract. The variable
portion may increase or decrease depending upon the investment experience of the
variable investment options in which the Premiums are invested. Unless another
option offered in Section 15 is elected, annuity payments will be payable for a
guaranteed period of 10 years and as long thereafter as the Annuitant lives.
By written notice, the Owner may elect the Date of Maturity at any time,
provided the Date elected is: (i) not later than the Annuitant's 95th birthday
without our prior approval; (ii) at least 31 days after the written notice; and
(iii) at least six months after the date the first premium is applied to this
contract. If no other election is made, the Date of Maturity will be as shown on
Page 3.
We are issuing this contract in consideration of the payment of premiums.
Signed for the Company at Boston, Massachusetts.
President Secretary
Combination Variable Annuity/Modified Guarantee Annuity
Nonparticipating - not eligible for dividends
Initial Premium shown on page 3
All benefits, payments and values under this contract which are based on the
investment experience of an Account are variable and not guaranteed as to fixed
dollar amount.
Right to Cancel - The Owner may surrender this contract by delivering or mailing
it to the Company's Servicing Office (or to the Company's representative through
which it was delivered) within 10 days after receipt by the Owner of this
contract. Immediately on such delivery or mailing, this contract shall be deemed
void from the beginning and a refund will be made within 10 days. The amount
refunded will be the sum of (i) the Accumulated Value, including any Market
Value Adjustment, at the end of the Valuation Period during which we receive the
contract and (ii) the sum of all charges made with respect to this contract.
Xxxx Xxxxxxx Servicing Office
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[Annuity Servicing Center
P.O. Box 9298
Boston, Massachusetts 02205-9298
Telephone 000-000-0000
Fax 000-000-0000]
CONTRACT PROVISIONS
Numerical Guide
Section
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1. Contract Specifications
2. Definitions
3. Owner, Beneficiary
4. The Contract
5. Premiums
6. Allocation/Transfer Options
7. Accumulations
8. Valuation Procedures
9. Death Benefit
10. Contract Fee and Rider Charges
11. Partial Withdrawals
12. Market Value Adjustment
13. Surrender Provision
14. Conversion
15. Settlement Provisions
16. Proof Required for Payment
17. Misstatements
18. Assignment
19. Claims of Creditors
20. Right to Make Changes
21. Annual Statement
22. Miscellaneous
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1. CONTRACT SPECIFICATIONS
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OWNER(S) [Xxxx Xxx]
ANNUITANT(S) [Xxxx Xxx]
ANNUITY CONTRACT NUMBER [0000000]
AGE OF OWNER(S) AT ISSUE [35]
AGE OF ANNUITANT(S) AT ISSUE [35]
DATE OF ISSUE [January 1, 1999]
INITIAL PREMIUM PAYMENT [$100,000.00]
DATE OF MATURITY [January 1, 2059]
BENEFICIARY [Xxxx Xxx]
CONTRACT ANNIVERSARY [January 1]
MAXIMUM CHARGES [See Section 8]
CONTRACT FEE/1/ [$0.00]
RIDERS ELECTED ANNUAL RIDER CHARGE/2/
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Enhanced Death Benefit Rider [.15%] x Accumulated Value
Guaranteed Retirement Income Benefit [.30%] x Accumulated Value
Accumulation Rate for Allocations to Guarantee Periods and Money Market [4%]
Accumulation Rate for Allocations to All Other Variable Investment Options[5%]
Accumulated Value Enhancement Rider [.40%] x Initial Premium Payment
The Insured Person insured under the Accumulated Value Enhancement Rider is
[Xxxx Xxx].
Deferral Period: 7 Years
Elimination Period: 100 Dates of Service
Accumulated Value Enhancement Monthly Benefit*: [$0.00] per calendar month
Benefit Limit*: [$0.00]
*Subject to increases due to inflation coverage after Deferral Period.
/1/ Not applicable if Accumulated Value exceeds $50,000.
/2/ For an explanation of rider charges, see Section 10 of this contract.
3
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2. DEFINITIONS
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The following terms are commonly used throughout this annuity contract:
The term "Account", unmodified, means a separate investment account established
by us pursuant to applicable law which includes one or more variable investment
options and in which you are eligible to invest under this contract. An Account
may be either a Management Account or a Series Account.
The term "Accumulated Value" means the value of this contract on any date prior
to the commencement of annuity payments. This value equals the sum of (i) the
Accumulated Values for all variable investment options and (ii) the Accumulated
Value of this contract in the MVA Account. The Accumulated Value for each
variable investment option as of any date will equal the number of Accumulation
Units for that variable investment option then credited to this contract
multiplied by the Accumulation Unit Value for that variable investment option on
that date. Accumulated Value for the MVA is defined in Section 7.
The term "Accumulation Unit" means a unit of measurement used in determining the
value of this contract prior to the commencement of annuity payments. The
Accumulation Unit Value for each variable investment option will reflect the
investment experience of that variable investment option. It will vary in dollar
amount.
The term "Annuitant" means the person(s) upon whose life the contract is issued.
The individual(s) designated as such on Page 3 of this contract and defined in
Section 3.
The term "Annuity Unit" means a unit of measurement used in determining the
amount of the variable portion of each annuity payment. The value of an Annuity
Unit for each variable investment option will depend on the assumed investment
rate and the investment experience of that variable investment option. It will
vary in dollar amount.
The term "Beneficiary" is defined in Section 3.
The term "Contract Year" means the 12 month period beginning on the Date of
Issue and each 12 month period thereafter.
The term "Date of Issue" means the date identified as such in Section 1.
The term "Date of Maturity" is the date annuity payments under this contract
begin, in accordance with Section 14.
The term "Fund" means each division of a Series Fund which has a specific
investment objective.
The term "Guarantee Period" refers to a Guarantee Period elected under the
Market Value Adjusted Account.
The term "In force" means that the Annuitant is living and the Surrender Value
of this contract has not become payable.
The term "Last Valuation Date" means the earliest of the Date of Maturity, the
Surrender Date, and the date of the Annuitant's death.
The term "Management Account" means an Account which directly invests its assets
in accordance with its specific investment objective. A Management Account may
or may not have divisions with separate investment objectives.
The term "Market Value Adjustment" is defined in Section 12.
The term "Market Value Adjustment Factor" is defined in Section 12.
The term "Market Value Adjusted Account" or "MVA Account" means, unmodified, a
separate investment account established by us pursuant to applicable law in
which you are eligible to invest under this contract.
The term "Measuring Person" means the person on whose life annuity payments will
be based.
5 V0599K
The term "partial withdrawal" is defined in Section 11.
The term "payment" means, unless otherwise stated, payment at our Servicing
Office.
The term "Premium" means the premium paid less any applicable taxes based on the
amount of premium payments.
The term "Series Account" means an Account with divisions which invest in Funds
of a Series Fund. Each such division has a specific investment objective and the
assets of each division are invested solely in shares of the corresponding Funds
of a Series Fund.
The term "Series Fund" means a series type mutual fund registered under the
Investment Company Act of 1940 ("the Act") as an open-end diversified management
investment company.
The term "Subaccount" means a variable investment option or a Guarantee Period.
The term "Surrender Date" means the date of receipt of written notice of
surrender under Section 13.
The term "Surrender Value" means the Accumulated Value of your contract,
adjusted by any Market Value Adjustment, less, if applicable, any income taxes
withheld, any rider charges, and any deduction for premium taxes or similar
taxes.
The term "Valuation Date" means any date on which the New York Stock Exchange is
open for trading.
The term "Valuation Period" means that period of time from the beginning of the
day following a Valuation Date to the end of the next following Valuation Date.
The term "variable investment option" means each Management Account without
divisions, each division of a Management Account, and each division of a Series
Account.
The terms "we", "us" , "our" refer only to the Company.
The term "withdrawal" means, unless otherwise specified, the amount withdrawn
prior to any deductions but after any Market Value Adjustment.
The term "written notice" means, unless otherwise stated, a notice in writing
satisfactory to us which is received at our Servicing Office.
The terms "you" and "your" refer to the Owner under this contract.
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3. OWNER, BENEFICIARY
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The Owner and the Beneficiary will be as shown on Page 3 unless you change them
or they are changed by the terms of this provision.
If the Annuitant dies and there is no surviving Beneficiary or surviving
Annuitant, you will be the Beneficiary; but if you were the Annuitant, your
estate will be the Beneficiary. If the Annuitant dies and there is a surviving
Annuitant, the surviving Annuitant becomes the Annuitant.
The Owner shall have the sole and absolute power to exercise all rights and
privileges without the consent of any other person except as provided by this
contract or unless you provide otherwise by written notice.
While the Annuitant is alive, you may change the Owner by written notice. You
may change the Beneficiary by written notice no later than receipt of the
required due proof of the Annuitant's death. A change will take effect when the
notice is received and filed at our Servicing Office. The change will take
effect whether or not you or the Annuitant is then alive. A change shall be
subject to the rights of any assignee of record with us and subject to any
payment made or other action taken by us before we received and filed the
notice.
If more than one Annuitant is listed on page 3, the term "Annuitant" as used in
this contract shall mean the following:
. In relation to the death of the Annuitant or the continuing life of the
Annuitant, "Annuitant" shall mean the last to die of those individuals
listed as Annuitants who have not reached age 95.
. In relation to annuitization under Section 14, "Annuitant" shall mean the
youngest of the individuals listed as Annuitants who is still alive at any
given point in time.
JOINT OWNERS
If joint Owners are named, each joint Owner will be considered the primary
Beneficiary of the other joint Owner. Should another person or entity be
designated as Beneficiary, such Beneficiary will be deemed a contingent
Beneficiary for all Owners with rights subordinate to the rights of each joint
Owner. Signatures of all joint Owners are required for any exercise of Owner
rights requiring written notification.
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4. THE CONTRACT
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The contract is an agreement between the Owner and the Company. The entire
contract consists of this contract, any riders, and any attachments.
Contract years, contract months, and contract anniversaries are measured from
the Date of Issue of this contract.
Only the President, a Vice President, the Secretary, or an Assistant Secretary
of the Company has authority to waive or modify any of the provisions of this
contract.
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5. PREMIUMS
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PAYMENT OF PREMIUMS
All premium payments shall be made to us at our Servicing Office. Premium
payments are subject to the following conditions:
(a) Each premium payment must be at least $200. If payments are made through
the Direct Premium Payment Program, the minimum premium payment allowed is
$100.
(b) The maximum premium that may be deposited to this contract in any Contract
Year is $1,000,000.
(c) No premium payments may be made to this contract afterthe Annuitant's 85th
birthday.
Upon request we will consider waiving any of the above conditions.
PREMIUM TAXES
A deduction for a premium tax, if any, or a similar tax, if any, will be made
either from premiums or from the Accumulated Value if and when such a tax is
incurred by us. However, if premium taxes or similar taxes are incurred by us at
the time premiums are paid and we defer the deduction for such taxes, then a
deduction will be made upon any withdrawal under Section 11 and either on the
Surrender Date, the Date of Maturity, or the date of payment of the Death
Benefit. Such deduction will be equal to the tax percentage multiplied by (i) in
the case of withdrawals, the withdrawal amount requested, (ii) in the case of
surrender or annuitization, the Accumulated Value as of the Surrender Date or
the Date of Maturity as the case may be, or (iii) in the case of death, the
Death Benefit as of the date of receipt of due proof of the Annuitant's death.
The "tax percentage" is equal to the percentage of premium which the premium tax
or similar tax in question constitutes.
7 V0799K
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6. ALLOCATION / TRANSFER OPTIONS
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INVESTMENT ALLOCATION
The Premium will be allocated to the Subaccounts according to the investment
allocation then in effect. The initial investment allocation is that elected by
you. You may elect to change the investment allocation. The change will be
effective as to the application of any Premium made on or after the date of
receipt at our Servicing Office of notice satisfactory to us. The minimum
percentage that may be allocated to any Subaccount and the maximum number of
Subaccounts in which amounts may be held will be subject to our administrative
rules in effect at the time of the election. All percentages you elect must be
whole numbers.
If allocation is made to the MVA Account, the Owner may select from the
Guarantee Periods then available. We reserve the right to change the duration of
Guarantee Periods offered. The period selected will determine the guaranteed
interest rate applicable, which will be payable for a Guarantee Period. A
Guarantee Period begins on the date Premium or Accumulated Value is credited to
it.
If a new Guarantee Period becomes effective that causes this contract to
continue beyond the Date of Maturity, then the Date of Maturity will become the
Annuitant's 95th birthday, or a later age with our prior approval.
SUBACCOUNT TRANSFER OPTION
You may elect to reallocate amounts among the Subaccounts up to twelve times in
a Contract Year. If additional transfers are elected, the Company reserves the
right to prohibit such transfers or impose a transfer charge, not to exceed $25,
for each transfer in excess of twelve. Transfers between the Subaccounts will be
effective on the date of receipt at our Servicing Office of notice satisfactory
to us. We reserve the right to prohibit a transfer less than 30 days prior to
the Date of Maturity.
The number of Accumulation Units or Annuity Units and the amount of Accumulated
Value of the MVA Account transferred to or from each Subaccount will reflect the
respective values in each Subaccount. The maximum number of Subaccounts in which
Accumulated Value may be held will be subject to our rules in effect at the time
of election.
The maximum amount which may be transferred or paid into a Subaccount in any
Contract Year is $1,000,000 without our prior approval. Any transfer made out of
a Guarantee Period of the MVA Account may be subject to a Market Value
Adjustment.
TRANSFER OPTION AT EXPIRATION OF GUARANTEE PERIOD
At least 30 days prior to the end of any Guarantee Period, we will provide you
with written notice of the expiry of any such Guarantee Period. We must receive
within 30 days preceding the expiry of such Guarantee Period, a written request
to transfer the amount in such Guarantee Period to any Subaccount from among
those that are then available. The transfer elected will be effective on the
last day of the expiring Guarantee Period without incurring a Market Value
Adjustment.
If we do not receive written notice within 30 days prior to the expiry of any
Guarantee Period to elect a new Guarantee Period, then amounts available under
such Guarantee Period will be transferred to the Money Market Account. The
effective date of the transfer will be the first day following the expiry of
such Guarantee Period.
ALLOCATION AT ANNUITY COMMENCEMENT AND BEFORE CONVERSION
If the Accumulated Value is invested in more than [four] Subaccounts on the Date
of Maturity or other date elected for commencement of annuity payments and
before conversion in accordance with Section 14, we will allocate the
Accumulated Value to the [four] Subaccounts then having the largest portions of
the Accumulated Value. To determine the number of Subaccounts in which the
Accumulated Value is invested, each variable investment option is counted
separately as one Subaccount while all Guarantee Periods are counted together as
one Subaccount. The Accumulated Value in Subaccounts other than such [four]
Subaccounts will be allocated to the [four] Subaccounts in proportion to the
amounts in the [four] Subaccounts. Such allocation will be made notwithstanding
any transfer restrictions specified in this subsection. Upon commencement of
annuity payments, transfers are only permitted between variable investment
options. The rules that will be applied as of any date will be those in effect
on that date.
8 V0899K
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7. ACCUMULATIONS
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PURCHASE OF ACCUMULATION UNITS
The portion of the Premium not allocated to the MVA Account will be allocated to
each elected variable investment option for investment with other funds in each
such variable investment option and applied to the purchase of Accumulation
Units. The number of Accumulation Units in each variable investment option
purchased by each premium payment will be determined by dividing the applicable
portion of the Premium by the applicable Accumulation Unit Value on the first
Valuation Date which is the same as or next follows the receipt of the premium
payment at our Servicing Office.
ACCUMULATED VALUE IN THE MVA ACCOUNT
We will accumulate (i) the portion of any Premium allocated to the MVA Account
and (ii) any amount transferred to the MVA Account from a variable investment
option, from the date the premium is received or the transfer is made. The
Accumulated Value of this contract's share of the MVA Account on any date prior
to the date annuity payments commence is equal to A minus B.
A is the sum of (i), (ii) and (iii) below, accumulated with interest to that
date, where:
(i) is any premiums allocated to the MVA Account;
(ii) is any amounts transferred to the MVA Account; and
(iii) is the amount of any positive Market Value Adjustments.
B is the sum of (i), (ii), (iii), and (iv) below, accumulated with interest to
that date, where:
(i) is any partial withdrawals from the MVA Account;
(ii) is any amounts transferred from the MVA Account;
(iii) is any contract fees, rider charges, premium taxes or similar
taxes; and
(iv) is the amount of any negative Market Value Adjustments.
INTEREST ON PREMIUM ALLOCATED TO MVA ACCOUNT
Premium earns interest for as long as it remains in this contract beginning on
the date it is credited. Interest will be credited daily and will then earn
interest from such date. During a Guarantee Period, the interest rate credited
will be based upon our declared interest rate then in effect and will apply
throughout such Guarantee Period. Such declared interest rate will be expressed
on an annual effective basis and will never be less than the guaranteed minimum
rate of 3% on an annual effective basis. The interest credited on any given day
will be at a rate which, if compounded daily for one year, would equal the
applicable declared interest rate.
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8. VALUATION PROCEDURES
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ACCUMULATION UNIT VALUE
The Accumulation Unit Value is calculated separately for each variable
investment option. The value of one Accumulation Unit was set at $10 on the date
assets were first allocated to each variable investment option. The value of one
Accumulation Unit on any Valuation Date thereafter will be determined for each
variable investment option by multiplying the immediately preceding Accumulation
Unit Value by the applicable Net Investment Factor for the Valuation Period
ending on that Valuation Date. On any date other than a Valuation Date, the
Accumulation Unit Value will be the same as that on the next following Valuation
Date.
ANNUITY UNIT VALUE
The Annuity Unit Value is calculated separately for each variable investment
option. The value of one Annuity Unit was set at $1 on the date assets were
first allocated to each variable investment option. The value of one Annuity
Unit on any Valuation Date thereafter will be determined for each variable
investment option by multiplying (1) the immediately preceding Annuity Unit
Value by (2) the applicable Net Investment Factor for the Valuation Period
ending on the Valuation Date reduced by no less than .000094246 times the
applicable Net Investment Factor for each calendar day in the Valuation Period.
On any date other than a Valuation Date, the Annuity Unit Value will be the same
as that on the next following Valuation Date.
9 V0999K
NET INVESTMENT FACTOR
The Net Investment Factor for each variable investment option for any Valuation
Period is equal to one plus the applicable net investment rate for such period.
A Net Investment Factor may be more or less than one. The net investment rate
for each variable investment option for any Valuation Period will be determined
by: (1) taking the sum of the accrued investment income and capital gains and
losses, realized or unrealized, of the variable investment option for the
Valuation Period; (2) subtracting the sum of (i) an amount for any applicable
income taxes and (ii) an amount for mortality and expense risks and
administrative expenses computed by multiplying an amount not to exceed
[.00003425] times the number of calendar days in the Valuation Period and
multiplying the result by the value of the variable investment option at the
beginning of the Valuation Period; and (3) dividing the result by the value of
the variable investment option at the beginning of the Valuation Period.
VALUATION OF ASSETS
The values of the assets in the variable investment options shall be determined
at a fair value in accordance with applicable law. Liabilities attributable to
the variable investment option will be deducted to determine the value of the
variable investment option.
ADJUSTMENT OF UNITS AND VALUES
We reserve the right to change the number and value of the Accumulation Units or
Annuity Units or both without your consent or the consent of any other person,
provided strict equity is preserved and the change does not otherwise affect the
benefits, provisions or investment return of this contract.
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9. DEATH BENEFIT
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If the Annuitant dies before the Date of Maturity, and there is no surviving
Annuitant, we will pay the Death Benefit to the Beneficiary. If there is a
surviving Annuitant, the surviving Annuitant becomes the Annuitant. The Death
Benefit will equal the greater of: (i) the Accumulated Value of this contract,
adjusted by any Market Value Adjustment, as of the date of receipt of due proof
of the Annuitant's death; and (ii) the amount of the premiums paid less the
amount of all partial withdrawals made.
Notwithstanding any of the above, the following will apply upon the death of the
Owner, or in the case of joint Owners, upon the death of the first to die, if
the contract value has not already been converted into an annuity:
(i) If the Beneficiary is the spouse of the Owner, the Beneficiary may continue
this contract in force as the Owner.
(ii) If the Beneficiary is not the spouse of the Owner, or if the Beneficiary is
the spouse of the Owner but does not choose to continue this contract, we will
pay the Death Benefit (or the Surrender Value if the Owner is not the Annuitant)
in full to the Beneficiary within five years of the Owner's death or apply the
Accumulated Value in full towards the purchase of a life annuity on the
Beneficiary with payments beginning within one year of the Owner's death.
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10. CONTRACT FEE/RIDER CHARGES
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We will deduct a contract fee of $30 on each of the following: (i) any contract
anniversary prior to the Date of Maturity on which the Accumulated Value is then
less than $50,000; and (ii) the Surrender Date if the Accumulated Value on such
date is less than $50,000. The fee will be deducted from the Accumulated Value
of all Subaccounts according to the proportion the Accumulated Value of each
Subaccount bears to the total Accumulated Value of this contract. We reserve the
right to increase the contract fee up to $50, subject to applicable state
regulations.
Optional riders may only be elected at issue. We will deduct separate monthly
charges for each optional rider elected. The charges, made at the beginning of
each month, are equal to 1/12th of the Annual Rider Charge, as specified on Page
3 of this contract, for each rider elected. The charge for each rider elected
will be deducted from the Accumulated Value of all Subaccounts according to the
proportion the Accumulated Value of each Subaccount bears to the total
Accumulated Value of this contract.
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11. PARTIAL WITHDRAWALS
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Subject to the limits described in this Section, you may request a withdrawal of
less than the Surrender Value. The total of the requested amount is called a
partial withdrawal. We will pay the requested amount on receipt of written
notice before the Annuitant's death and before the commencement of annuity
payments. The amount of the partial withdrawal will then be deducted from the
Accumulated Value. Without our prior approval, we will not permit a partial
withdrawal of less than $100 nor will we permit a partial withdrawal if the
Accumulated Value after such requested partial withdrawal would be less than
$1000.
Unless specified in writing otherwise, withdrawals will be removed
proportionately from the values in all Subccounts. Withdrawal amounts removed
from the MVA Account will be subject to a Market Value Adjustment as described
in Section 12. Prior to payment, the amount of any withdrawal will be reduced by
any applicable income taxes, premium taxes, and similar taxes.
Any withdrawal, other than one on the last day of a Guarantee Period, will be
effective on the date we receive your written notice. To make a withdrawal that
is to be effective on the last day of any Guarantee Period, we must receive
written notice from you at least 30 days prior to the expiry of such Guarantee
Period.
We may defer payment of a withdrawal in the same manner as we may defer payment
of the Surrender Value, described in Section 13.
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12. MARKET VALUE ADJUSTMENT
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Prior to the last day of any Guarantee Period, amounts withdrawn or transferred
from the MVA Account will be adjusted up or down by the application of a Market
Value Adjustment. No Market Value Adjustment will apply to withdrawals or
transfers made on the last day of any Guarantee Period.
FORMULA
The Market Value Adjustment is equal to A times (B minus 1) where:
A is the amount subject to a market value adjustment, and
B is the market value adjustment factor below:
n
--
[ 1+g ]12
--------
[1+c+.005]
Where:
g = The guaranteed rate in effect for the current Guarantee Period (in
decimal form).
c = The current rate (in decimal form) in effect for durations equal to the
number of years remaining in the current Guarantee Period (years rounded up
to the nearest whole number). If not available, we will declare a rate
solely for this purpose that is consistent with rates for durations that
are currently available.
n = The number of complete months from the date of withdrawal to the end of
the current Guarantee Period. (Where less than one complete month remains,
n will equal one.)
The Market Value Adjustment may be positive or negative. In addition, the Market
Value Adjustment will not exceed, in a positive or negative direction, the
amount of any excess interest earned on the amount withdrawn or transferred
during a Guarantee Period up to the point of withdrawal or surrender. Excess
interest is defined as the dollar amount of interest earned since the beginning
of the Guarantee Period in excess of the amount of interest that would have been
earned had the effective annual interest rate been 3% and the Accumulated Value
determined in accordance with Section 7, Accumulations.
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13. SURRENDER PROVISION
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Upon receipt of written notice from you before the Annuitant's death and the
Date of Maturity, we will pay the Surrender Value. To make a surrender that is
to be effective on the last day of any Guarantee Period, we must receive written
notice from you at least 30 days prior to the expiry of such Guarantee Period.
The Surrender Value will be determined by us as of the date of receipt of
written notice. We may defer payment of a Surrender Value for the period
provided by law. With respect to the MVA Account, we will not defer payment more
than six months beyond the date we receive written notice. If we defer payment
for more than 30 days, we will pay interest on the Surrender Value at a rate
equal to the greater of (i) the rate required by law; and (ii) the rate declared
by us.
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14. CONVERSION
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Unless changed by you or in accordance with Section 6, the Date of Maturity will
be as shown on page 3. You may change the Date of Maturity at any time by
written notice provided that we receive the written notice prior to the Date of
Maturity then in effect and provided that the new Date of Maturity is (i) no
later than the Annuitant's 95th birthday, without our prior approval; (ii) at
least 31 days after our receipt of the written notice; and (iii) at least six
months after the date the first Premium was applied to this contract.
CONVERSION OF ACCUMULATION UNITS TO ANNUITY UNITS
On the Date of Maturity or other date elected under Section 15 for commencement
of annuity payments, the Accumulation Units credited to this contract will be
converted into Annuity Units. Annuity payments will then commence subject to the
limitations specified in Section 15 and all other applicable provisions. The
number of Annuity Units credited to each variable investment option will be
determined by: (1) multiplying the number of Accumulation Units credited to the
variable investment option on the date of conversion by the Accumulation Unit
Value for the variable investment option as of ten days prior to the date the
first annuity payment is due; (2) deducting any applicable premium tax; (3)
dividing the resulting value by 1000; (4) multiplying the value from (3) by the
applicable factor from the Table of First Variable Annuity Payment Factors for
the option elected, or if no option is elected the applicable factor for the
Option A (Variable) with a guaranteed period of ten years, to determine that
variable investment option's portion of the variable portion of the first
monthly annuity payment, and (5) dividing the value from (4) by the Annuity Unit
Value for the variable investment option as of ten days prior to the date the
first annuity payment is due.
VARIABLE ANNUITY PAYMENTS
The amount of the variable portion of the monthly annuity payment due on the
first payment date is equal to the sum of the portions for each variable
investment option determined as described in the preceding paragraph. The amount
of the variable portion of any monthly annuity payment subsequent to the first
will be determined by adding together for each variable investment option the
product of the number of Annuity Units credited to the variable investment
option and the Annuity Unit Value for the variable investment option 10 days
prior to the date the payment is due. We guarantee that the Annuity Unit Values
used in determining annuity payments will not be affected by variations in our
actual mortality experience or our actual expenses from those assumed.
CONVERSION OF ACCUMULATED VALUE IN MVA ACCOUNT
On the Date of Maturity or other date elected to begin annuity payments, we will
convert the Accumulated Value of the MVA Account adjusted by a Market Value
Adjustment, if applicable, into annuity payments.
We will determine the fixed portion of the annuity payments by: (i) dividing the
adjusted Accumulated Value by 1000; and (ii) multiplying the result by the
annuity payment rate then in effect for the option elected in Section 15.
The fixed portion of the annuity payment will never be less than that available
by applying the adjusted Accumulated Value to buy an immediate fixed annuity
offered by us. If the annuity payments are made monthly, the annuity payment
rate is guaranteed to be at least that provided in the Table of Fixed Annuity
Payment Factors in Section 15.
12
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15. SETTLEMENT PROVISIONS
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ANNUITY ON DATE OF MATURITY
We shall make the annuity payments provided on the first page of this contract
automatically as a Life Annuity with Payments for a Guaranteed Period of 10
Years in accordance with the provisions of Option A unless another option is
elected. We shall determine the amounts of the annuity payments in accordance
with the provisions of this Section and of Section 14. Amounts in the variable
investment option will be used to provide variable benefits. Amounts in the MVA
Account will be used to provide fixed benefits.
If the amount of the first monthly annuity payment would be less than $20, we
will make a single payment equal to the Surrender Value on the Date of Maturity.
This single payment shall be in place of all other benefits provided by this
contract. If the amount of the first monthly annuity payment would be at least
$20 but less than $50, we may make payments at quarterly, semi-annual or annual
intervals.
OPTIONAL METHODS OF SETTLEMENT
In place of (i) the Annuity provided on the first page of this contract or (ii)
a single payment in case of death prior to the date annuity payments commence or
(iii) a single payment in case of surrender which occurs at least 6 months after
the date the first premium is applied to this contract, proceeds payable under
this contract may be left with us in accordance with one of the optional methods
of payment then available for contracts of this type and the terms of a
supplementary agreement to be issued when the option becomes effective, but only
if (i) such proceeds are in an amount of $5000 or more and (ii) the amount of
the first monthly annuity payment would be $50 or more.
Option A
--------
Option A(Variable) - Life Annuity on a Variable Basis with Payments for a
Guaranteed Period of 5, 10, or 20 years.
If the Measuring Person's death occurs within the Guaranteed Period, payments
will be made for the remainder of the Guaranteed Period in accordance with the
terms of the supplementary agreement.
Option A(Fixed) - Life Annuity with Payments for a Guaranteed Period of 5, 10,
or 20 years.
If the Measuring Person's death occurs within the Guaranteed Period, payments
will be made for the remainder of the Guaranteed Period in accordance with the
terms of the supplementary agreement.
Option A with a five year Guaranteed Period cannot be elected without our prior
approval if the Measuring Person is over age 85 at the time of annuitization.
Option B
--------
Option B(Variable) - Life Annuity on a Variable Basis Without Further Payment on
Death of the Measuring Person.
Option B(Fixed) - Life Annuity Without Further Payment on Death of the Measuring
Person.
Option B cannot be elected without our prior approval if the Measuring Person is
over age 85 at the time of annuitization.
Other options may be available.
You may elect an option by written notice before the death of the Annuitant and
before the commencement of annuity payments. If you have made no election before
the death of the Annuitant, the Beneficiary may make an election by written
notice before the proceeds become payable.
13
ANNUITY PAYMENT AND OPTION LIMITATIONS
While the Annuitant is living (i) the Measuring Person will be the Annuitant;
(ii) the Payee will be the Annuitant unless otherwise directed by you; and (iii)
the Contingent Payee will be the Beneficiary unless otherwise provided by
written notice.
If the Annuitant dies and Death Benefit proceeds are left with us in accordance
with a settlement option election (i) the Measuring Person will be the
Beneficiary, (ii) the Payee will be the Beneficiary unless otherwise designated
in the election, and (iii) the Contingent Payee will be the person or persons so
designated in the election and in accordance with the terms of the supplementary
agreement.
Other options may be available and may require our consent if the proceeds are
payable to an executor, administrator, trustee, corporation, partnership or
association.
If the Owner of this contract dies on or after annuity payments have begun, any
remaining benefit under such annuity on the date of the Owner's death must be
paid out at least as rapidly as under the method of making annuity payments then
in effect.
FIRST VARIABLE ANNUITY PAYMENT FACTORS
The Table of First Variable Annuity Payment Factors shows the amount of the
variable portion of the first monthly annuity payment provided on the first page
of this contract and under Option A(Variable) and Option B(Variable) for each
$1,000 applied. The factors in this table are based on the 1983a Individual
Annuity Mortality Table with mortality and age adjustments and interest at the
rate of 3 1/2% a year. If permitted by state law, the Owner may choose 5% or 6%
in place of the 3 1/2% rate. The amount of the variable portion of the first
payment will depend on the sex and adjusted age of the Measuring Person on the
date the first annuity payment is due. The adjusted age is determined from the
actual age on the Measuring Person's birthday nearest the date the first annuity
payment is due, by subtracting one year for each complete 10 year period elapsed
since the Date of Issue.
FIXED ANNUITY PAYMENTS
The Table of Fixed Annuity Payment Factors shows the guaranteed amount of the
fixed portion of the monthly annuity payments for each $1,000 applied. The
factors in this table are based on the 1983a Individual Annuity Mortality Table
with interest at the rate of 2 1/2% a year. The guaranteed amount of the fixed
portion of the annuity payments will depend on the adjusted age of the Measuring
Person on the date the first annuity payment is due. The adjusted age is
determined from the actual age on the Measuring Person's birthday nearest the
date the first annuity payment is due, by subtracting one year for each complete
10 year period elapsed since the Date of Issue.
14 V1499K
TABLE OF FIRST VARIABLE ANNUITY PAYMENT FACTORS
Monthly life annuity with payments on a variable basis for each $1,000 applied.
--------------------------------------------------------------------------------
Option A(Variable) Option B (Variable)
Life Annuity Without
Life Annuity with Payments Further Payment on Death
Adjusted for a Guaranteed Period of Measuring Person
Age of Measuring ----------------------------------------------------------------- ----------------------------
Person on Birthday 5 Years 10 Years 20 Years
Nearest Date ------- -------- --------
of First Payment Male Female Male Female Male Female Male Female
---------------- ---- ------ ---- ------ ---- ------ ---- ------
55 4.50 4.13 4.46 4.11 4.32 4.05 4.51 4.13
56 4.58 4.19 4.54 4.18 4.38 4.10 4.59 4.20
57 4.67 4.26 4.62 4.24 4.44 4.16 4.68 4.27
58 4.76 4.33 4.71 4.31 4.50 4.22 4.78 4.34
59 4.86 4.41 4.80 4.39 4.57 4.28 4.88 4.42
60 4.96 4.49 4.90 4.46 4.63 4.35 4.98 4.50
61 5.08 4.58 5.00 4.55 4.70 4.41 5.10 4.59
62 5.20 4.67 5.11 4.64 4.77 4.48 5.22 4.69
63 5.32 4.77 5.23 4.73 4.84 4.55 5.36 4.79
64 5.46 4.88 5.35 4.83 4.91 4.62 5.50 4.89
65 5.61 4.99 5.47 4.94 4.97 4.69 5.65 5.01
66 5.76 5.11 5.61 5.05 5.04 4.77 5.81 5.13
67 5.93 5.24 5.74 5.17 5.11 4.84 5.99 5.27
68 6.10 5.38 5.89 5.29 5.17 4.92 6.17 5.41
69 6.29 5.53 6.04 5.43 5.24 5.00 6.37 5.56
70 6.49 5.69 6.20 5.57 5.30 5.07 6.59 5.73
71 6.69 5.86 6.36 5.72 5.35 5.15 6.81 5.91
72 6.91 6.05 6.52 5.88 5.41 5.22 7.05 6.10
73 7.14 6.25 6.69 6.04 5.46 5.29 7.31 6.32
74 7.39 6.46 6.87 6.22 5.50 5.35 7.58 6.55
75 7.65 6.70 7.05 6.40 5.54 5.41 7.88 6.79
76 7.92 6.94 7.23 6.59 5.58 5.47 8.19 7.06
77 8.21 7.20 7.41 6.78 5.61 5.52 8.53 7.35
78 8.52 7.48 7.59 6.98 5.64 5.56 8.90 7.66
79 8.84 7.78 7.78 7.19 5.67 5.61 9.29 8.00
80 9.17 8.10 7.96 7.40 5.69 5.64 9.71 8.36
81 9.52 8.44 8.14 7.61 5.71 5.67 10.16 8.76
82 9.88 8.81 8.31 7.82 5.73 5.70 10.64 9.20
83 10.26 9.19 8.48 8.03 5.74 5.72 11.16 9.67
84 10.65 9.59 8.64 8.23 5.74 5.73 11.71 10.18
85 and over 11.05 10.02 8.79 8.42 5.75 5.74 12.30 10.74
15 V1599K
TABLE OF FIXED ANNUITY PAYMENT FACTORS
Monthly life annuity with payments on a fixed basis for each $1,000 applied.
--------------------------------------------------------------------------------
Option A (Fixed) Option B (Fixed)
Life Annuity Without
Life Annuity with Payments Further Payment on Death
Adjusted for a Guaranteed Period of Measuring Person
Age of Measuring ---------------------------------------------------------------------- -------------------------
Person on Birthday 5 Years 10 Years 20 Years
Nearest Date ------- -------- --------
of First Payment Male Female Male Female Male Female Male Female
---------------- ---- ------ ---- ------ ---- ------ ---- ------
55 3.92 3.55 3.89 3.54 3.76 3.48 3.93 3.55
56 4.00 3.62 3.97 3.60 3.82 3.54 4.01 3.62
57 4.09 3.69 4.05 3.67 3.89 3.60 4.10 3.69
58 4.18 3.76 4.14 3.74 3.96 3.66 4.19 3.77
59 4.28 3.84 4.23 3.82 4.02 3.73 4.30 3.85
60 4.39 3.92 4.33 3.90 4.09 3.79 4.40 3.93
61 4.50 4.01 4.44 3.99 4.16 3.86 4.52 4.02
62 4.62 4.11 4.55 4.08 4.24 3.94 4.64 4.12
63 4.75 4.21 4.67 4.17 4.31 4.01 4.78 4.22
64 4.89 4.32 4.79 4.28 4.38 4.08 4.92 4.33
65 5.04 4.43 4.92 4.38 4.45 4.16 5.07 4.45
66 5.19 4.55 5.05 4.50 4.52 4.24 5.23 4.57
67 5.36 4.68 5.20 4.62 4.59 4.32 5.41 4.70
68 5.53 4.82 5.34 4.75 4.66 4.40 5.59 4.85
69 5.72 4.97 5.50 4.88 4.73 4.48 5.79 5.00
70 5.92 5.14 5.66 5.03 4.79 4.56 6.00 5.17
71 6.12 5.31 5.82 5.18 4.85 4.64 6.23 5.35
72 6.34 5.50 5.99 5.34 4.91 4.71 6.46 5.54
73 6.57 5.70 6.16 5.51 4.96 4.78 6.72 5.75
74 6.82 5.91 6.34 5.69 5.01 4.85 6.99 5.98
75 7.08 6.14 6.53 5.87 5.05 4.92 7.29 6.23
76 7.36 6.39 6.71 6.07 5.09 4.97 7.60 6.49
77 7.65 6.65 6.90 6.27 5.13 5.03 7.94 6.78
78 7.96 6.93 7.09 6.47 5.16 5.08 8.30 7.09
79 8.28 7.23 7.28 6.68 5.19 5.12 8.69 7.42
80 8.61 7.55 7.46 6.90 5.21 5.16 9.11 7.79
81 8.97 7.90 7.65 7.11 5.23 5.19 9.55 8.18
82 9.33 8.26 7.83 7.33 5.24 5.22 10.03 8.62
83 9.71 8.65 8.00 7.54 5.25 5.23 10.55 9.08
84 10.11 9.05 8.16 7.74 5.26 5.25 11.10 9.59
85 and over 10.51 9.48 8.32 7.94 5.27 5.26 11.68 10.15
16 V1699K
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16. PROOF REQUIRED FOR PAYMENT
--------------------------------------------------------------------------------
Before making the first annuity payment, we shall have the right to require
proof of the correct age of the Measuring Person. We shall also have the right
to require proof that the Measuring Person is living on the date each annuity
payment is due.
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17. MISSTATEMENTS
--------------------------------------------------------------------------------
If the age or sex of the Measuring Person has been misstated, we will adjust the
amount of each annuity payment to reflect the correct age and sex. Any
overpayment will be repaid to us. If it is not repaid, we will deduct the
overpayment from future payments we make under this contract. Any underpayment
will be added to future payments we make under this contract. Interest will be
paid on any overpayment or underpayment at a rate equal to the greater of (i)
the rate required by law; and (ii) the rate declared by us.
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18. ASSIGNMENT
--------------------------------------------------------------------------------
You may assign your interest in this contract, except as otherwise provided,
without the consent of any revocable Beneficiary. Your interest, any interest of
the Annuitant, and of any revocable Beneficiary shall be subject to the terms of
the assignment.
We will not be on notice of any assignment unless it is in writing; nor will we
be on notice until a duplicate of the original assignment has been filed at our
Servicing Office. We assume no responsibility for the validity or sufficiency of
any assignment.
If this contract is issued in a tax qualified plan, this contract is subject to
assignment restrictions for Federal Income Tax purposes. In such event, this
contract shall not be sold, assigned, discounted, or pledged as collateral for a
loan or as security for the performance of an obligation or for any other
purpose, to any person other than us.
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19. CLAIMS OF CREDITORS
--------------------------------------------------------------------------------
The proceeds and all other payments under this contract will be exempt from the
claims of creditors to the extent permitted by law. The proceeds and payments
may not be assigned or withdrawn before becoming payable without our agreement.
--------------------------------------------------------------------------------
20. RIGHT TO MAKE CHANGES
--------------------------------------------------------------------------------
We reserve the right to make certain changes if, in our judgment, they would
best serve the interest of the owners of contracts such as this or would be
appropriate in carrying out the purposes of such contracts. Any changes will be
made only to the extent and in the manner permitted by applicable laws. We will
inform our domiciliary state of the changes and will make any additional filings
which may be required in your jurisdiction.
If any changes result in a material change in the underlying investment of
Subaccounts to which the reserves for this contract are allocated, we will
notify you of such change. You may then make a new election under the
Allocation/Transfer Options provision.
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21. ANNUAL STATEMENT
--------------------------------------------------------------------------------
We will furnish you with reports annually, or more frequently, as required by
applicable law. They will include: (i) a statement of the investments held in
each Fund and each Management Account; and (ii) a statement of the condition and
value of this contract which will show the number of Accumulation Units, if any,
credited to each variable investment option, the value of each Accumulation
Unit, and the Accumulated Value of this contract.
17 V1799K
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22. MISCELLANEOUS
--------------------------------------------------------------------------------
If the Accumulated Value of this contract becomes zero, we reserve the right to
terminate this contract.
Under applicable law, all income, gains and losses, realized or unrealized, of
an Account shall be credited to or charged against the amounts placed in the
Account without regard to our other income, gains and losses. The assets of the
Account are owned solely by us. We are not a trustee with respect to any part or
the whole of those assets. The portion of the assets in the Account equal to the
reserves and other liabilities under this contract with respect to the Account
shall not be chargeable with liabilities arising out of any other business we
may conduct.
In place of operating an Account as a Series Account trust, we reserve the right
to make investments directly, operating the Account as a Management Account, or
in any other form permitted by law, the investment adviser of which would be us
or an affiliate. Account assets would be invested as provided with respect to
the investment objectives of the Account.
18 V1899K
The OWNER, by virtue of this CONTRACT, is a member of the Xxxx Xxxxxxx Mutual
Life Insurance Company, and is entitled to vote either in person or by proxy at
any and all meetings of the Company. The annual meetings are held at the
Company's Home Office on the second Monday of April in each year, at twelve
o'clock noon.
Communications about this contract should be sent to the Company at its
Servicing Office.
Combination Variable Annuity/Modified Guarantee Annuity
Nonparticipating - not eligible for dividends
Initial Premium shown on page 3
All benefits, payments and values under this contract which are based on the
investment experience of an Account are variable and not guaranteed as to fixed
dollar amount.
99REVNSC VBP99K Printed in U.S.A.
