Common use of RIGHT TO EXAMINE CONTRACT Clause in Contracts

RIGHT TO EXAMINE CONTRACT. This Contract may be returned for cancellation within days after the date it is received by the Owner. It may be delivered or mailed to the Company or to any agent of the Company, along with a written request for cancellation. This Contract shall then be canceled and the Company shall refund to the Owner an amount equal to: (a) all contributions allocated to the Interest Accumulation Account, with no deductions; plus (b) the value on the surrender date of all contributions allocated to any Investment Fund. For purposes of this paragraph only, the surrender date shall be the date this Contract is delivered or mailed to the Company, along with the request for cancellation. This Contract is issued in consideration of the application for this Contract and payment of the first contribution (premium). Additional contributions may be made at any time prior to the Annuity Commencement Date or the death of the Owner. Each contribution is subject to the Contributions provision of this Contract. This Contract shall take effect on the Effective Date shown in the Specifications Section of this Contract. This Contract is executed by the Company at its Home Office in New York, New York on the Date of Issue shown in the Specifications Section of this Contract. IRA-2004 IRA-2004 SECTION 1 - SPECIFICATIONS 5 SECTION 2 - DEFINITION 5 Account Value 5 Administrative Charges 5 Annuitant 5 Annuity Commencement Date 6 Beneficiary 6 Business Day 6 Code 6 Commuted Value 6 Contract 6 Current Rate of Interest 6 Date of Issue 6 Effective Date 6 Employer 6 Guaranteed Rate of Interest 6 Home Office 6 Interest Accumulation Account 6 Investment Fund 6 Notice 7 Owner 7 Required Distribution Date 7 Separate Account 7 SIMPLE IRA 7 Surviving Spouse 7 Underlying Investment Company 7 United States Bank 7 Valid Transaction Date 7 Valuation Day 7 Valuation Period 7 SECTION 3 - CONTRIBUTIONS 7 Contributions 7 Allocation of Contributions 8 Change of Allocations 8 SECTION 4 - ACCOUNTS 8 Accounts 8 General Account 8 Separate Account 8 Account Value 9 Accumulation Units 9 Accumulation Unit Value 9 Accumulation Unit Value Change Factor 9 Changes To Separate Account 9 SECTION 5 - WITHDRAWALS AND TRANSFERS 10 Withdrawals and Transfers 10 Amount of Withdrawal or Transfer 10 Requests for Withdrawal or Transfer 10 Postponement of Withdrawals or Transfers 10 SECTION 6 - BENEFITS 11 Annuity Benefit 11 Amount of Annuity Benefit 11 Annuity Options 11 Specified Payments Option 12 Death Benefit 12 Spousal Continuation 12 Death Benefit Settlement Options 12 SECTION 7 - DISTRIBUTIONS 14 SECTION 8 - BENEFICIARY 16 SECTION 9 - GENERAL PROVISIONS 17 Adjustments to Current Rate of Interest and Expense Charges 17 Contract 17 Evidence of Survival 17 Incontestability 17 Misstatements of Age 17 Non-Alienation of Benefits 17 Non-Assignment of Contract 17 Non-Waiver 17 Notices 18 Participating Contract 18 Dividends 18 Payment of Benefits 18 Reports 18 Report to Employer 18 Severability of Provisions 18 Termination of Contract 18 SECTION 10 - TABLE OF RATES 19 SECTION 11 - LIST OF ACCOUNTS AND FUNDS 20 OWNER/ANNUITANT: Xxxxxxx Xxxxxx Simple CONTRACT NUMBER: 00-000000-0 EFFECTIVE DATE: Month Day, YYYY DATE OF ISSUE: Month Day, YYYY STATE OF DELIVERY: Generic SEPARATE ACCOUNT CHARGE Maximum of 2% annually of the net assets in each Investment Fund. CONTRACT CHARGE A monthly contract charge of $2.00 for administrative expenses, except the monthly charge shall not exceed 1/12 of 1% of the Account Value. An explanation of all charges appears under Administrative Charges in the Definitions section of this Contract. The Current Rate of Interest is declared from time to time by the Company, but shall in no event be less than the Guaranteed Rate of Interest. The Guaranteed Rate of Interest on the Effective Date results in an effective annual yield of 0.00% and shall apply from the Effective Date until the first December 31st following the Effective Date. A redetermined Guaranteed Rate of Interest shall be applicable for each calendar year thereafter. The Current Rate of Interest on the Date of Issue results in an effective annual yield of 0.00%. The total expense charge currently being deducted as a Separate Account Charge on the Date of Issue of this Contract is 1.20%.

RIGHT TO EXAMINE CONTRACT. This Within 10 days of the date of receipt of this Contract by the Owner, it may be returned for cancellation within days after by delivering or mailing it to the date Company at its Administrative Office or to the Agent through whom it was purchased. When the Contract is received by the OwnerCompany, it will be voided as if it had never been in force. It may be delivered or mailed to The Company will refund the Contract Value computed as of the Business Day the Company or to any agent of receives the Company, along with a written request for cancellation. This Contract shall then be canceled and the Company shall refund to the Owner an amount equal to: (a) all contributions allocated to the Interest Accumulation Account, with no deductions; plus (b) the value on the surrender date of all contributions allocated to any Investment Fund. For purposes of this paragraph only, the surrender date shall be the date this Contract is delivered or mailed to the Company, along with the request for cancellation. This Contract is issued in consideration of the application for this Contract and payment of the first contribution (premium). Additional contributions may be made at any time prior to the Annuity Commencement Date or the death of the Owner. Each contribution is subject to the Contributions provision of this Contract. This Contract shall take effect on the Effective Date shown in the Specifications Section of this Contract. This Contract is executed by the Company returned contract at its Home Office in New YorkAdministrative Office. Secretary President INCOME PAYMENTS, New York on the Date of Issue shown in the Specifications Section of this ContractWITHDRAWAL VALUES AND THE DEATH BENEFITS PROVIDED BY THIS CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE VARIABLE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. IRA-2004 IRA-2004 SECTION 1 - SPECIFICATIONS 5 SECTION 2 - DEFINITION 5 Account Value 5 Administrative Charges 5 Annuitant 5 Annuity Commencement Date CONTRACT SCHEDULE 4 DEFINITIONS 6 Beneficiary 6 Business Day 6 Code 6 Commuted Value 6 Contract 6 Current Rate of Interest 6 Date of Issue 6 Effective Date 6 Employer 6 Guaranteed Rate of Interest 6 Home Office 6 Interest Accumulation Account 6 Investment Fund 6 Notice PURCHASE PAYMENT PROVISIONS 7 Owner PURCHASE PAYMENTS 7 Required Distribution Date ALLOCATION OF PURCHASE PAYMENTS 7 Separate Account SEPARATE ACCOUNT PROVISIONS 7 SIMPLE IRA THE SEPARATE ACCOUNTS 7 Surviving Spouse VARIABLE ACCOUNT 7 Underlying Investment Company 7 United States Bank 7 Valid Transaction Date 7 Valuation Day 7 Valuation Period 7 SECTION 3 - CONTRIBUTIONS 7 Contributions 7 Allocation of Contributions VALUATION OF ASSETS 8 Change of Allocations ACCUMULATION UNITS 8 SECTION 4 - ACCOUNTS ACCUMULATION UNIT VALUE 8 Accounts CONTRACT VALUE 8 General Account SUBSCRIPTION FEE 8 Separate Account DEDUCTION FOR SUBSCRIPTION FEE 8 Account Value DEDUCTION FOR TRANSACTION FEE 9 Accumulation Units TRANSFERS 9 Accumulation Unit Value TRANSFERS DURING THE ACCUMULATION PERIOD 9 Accumulation Unit Value Change Factor WITHDRAWAL PROVISIONS 9 Changes To Separate Account WITHDRAWALS 9 SECTION 5 - WITHDRAWALS PROCEEDS PAYABLE ON DEATH 10 DEATH OF OWNER DURING THE ACCUMULATION PERIOD 10 DEATH BENEFIT AMOUNT DURING THE ACCUMULATION PERIOD 10 DEATH BENEFIT OPTIONS DURING THE ACCUMULATION PERIOD 10 DEATH OF OWNER DURING THE ANNUITY PERIOD 10 DEATH OF ANNUITANT 10 PAYMENT OF DEATH BENEFIT 11 BENEFICIARY 11 CHANGE OF BENEFICIARY 11 SUSPENSION OR DEFERRAL OF PAYMENTS PROVISION 11 OWNER, ANNUITANT, XXXXXXXXX, XXXXXXXXXX XXXXXXXXXX 00 OWNER 11 JOINT OWNER 11 ANNUITANT 11 ASSIGNMENT OF A CONTRACT 12 ANNUITY PROVISIONS 12 GENERAL 12 ANNUITY DATE 12 SELECTION OF AN ANNUITY OPTION 12 FREQUENCY AND TRANSFERS 10 Withdrawals and Transfers 10 Amount of Withdrawal or Transfer 10 Requests for Withdrawal or Transfer 10 Postponement of Withdrawals or Transfers 10 SECTION 6 - BENEFITS 11 Annuity Benefit 11 Amount of Annuity Benefit 11 Annuity Options 11 Specified Payments Option AMOUNT OF ANNUITY PAYMENTS 12 Death Benefit ANNUITY OPTIONS 12 Spousal Continuation OPTION 1. LIFETIME ONLY ANNUITY: 12 Death Benefit Settlement Options OPTION 2. LIFETIME ANNUITY WITH GUARANTEED PERIODS 12 SECTION 7 - DISTRIBUTIONS 14 SECTION 8 - BENEFICIARY 16 SECTION 9 - OPTION 3. PAYMENT FOR A FIXED PERIOD: 12 OPTION 4. JOINT AND SURVIVOR ANNUITY 12 ANNUITY 12 FIXED ANNUITY 13 MORTALITY TABLES 13 GENERAL PROVISIONS 17 Adjustments to Current Rate of Interest and Expense Charges 17 Contract 17 Evidence of Survival 17 Incontestability 17 Misstatements of Age 17 Non13 THE CONTRACT 13 MISSTATEMENT OF AGE 13 INCONTESTABILITY 13 MODIFICATION 13 NON-Alienation of Benefits 17 Non-Assignment of Contract 17 Non-Waiver 17 Notices 18 Participating Contract 18 Dividends 18 Payment of Benefits 18 Reports 18 Report to Employer 18 Severability of Provisions 18 Termination of Contract 18 SECTION 10 - TABLE PARTICIPATING 13 EVIDENCE OF RATES 19 SECTION 11 - LIST SURVIVAL 13 PROOF OF ACCOUNTS AND FUNDS 20 AGE 13 PROTECTION OF PROCEEDS 13 REPORTS 13 TAXES 13 REGULATORY REQUIREMENTS 14 PAYMENTS TO THIRD PARTIES 14 PAYMENTS FROM THIRD PARTIES 14 ANNUITY OPTION TABLES 15 CONTRACT SCHEDULE OWNER/ANNUITANT: Xxxxxxx Xxxxxx Simple «FIRSTNAM» «LASTNAME» CONTRACT ISSUE DATE: «COVISS» JOINT OWNER: «JFIRSTNM» «JLASTNAM» ANNUITY DATE: «EXPDAT» CONTRACT NUMBER: 00-000000-0 EFFECTIVE DATE«POLNUM» INITIAL PURCHASE PAYMENT: Month Day, YYYY DATE OF ISSUE«INITPREM» MAXIMUM TOTAL PURCHASE PAYMENT: Month Day, YYYY STATE OF DELIVERY: Generic SEPARATE ACCOUNT CHARGE Maximum of 2% annually of the net assets in each Investment Fund. CONTRACT CHARGE A monthly contract charge of $2.00 for administrative expenses, except the monthly charge shall not exceed 1/12 of 1% of the Account Value. An explanation of all charges appears under Administrative Charges in the Definitions section of this Contract. The Current Rate of Interest is declared from time to time by the Company, but shall in no event be less than the Guaranteed Rate of Interest. The Guaranteed Rate of Interest on the Effective Date results in an effective annual yield of 0.00% and shall apply from the Effective Date until the first December 31st following the Effective Date. A redetermined Guaranteed Rate of Interest shall be applicable for each calendar year thereafter. The Current Rate of Interest on the Date of Issue results in an effective annual yield of 0.00%. The total expense charge currently being deducted as a Separate Account Charge on the Date of Issue of this Contract is 1.20%.[10,000,000.00] without prior Company approval ALLOCATION GUIDELINES:

RIGHT TO EXAMINE CONTRACT. This Contract may be returned for cancellation within [10] days after the date it is received by the Owner. It may be delivered or mailed to the Company or to any agent of the Company, along with a written request for cancellation. This Contract shall then be canceled cancelled and the Company shall refund to the Owner an amount equal to: (a) all contributions allocated to the Interest Accumulation Account, with no deductions; , plus (b) the value on the surrender date of all contributions allocated to any Investment Fund. For purposes of this paragraph only, the surrender date shall be the date this Contract is delivered or mailed to the Company, along with the request for cancellation. This Contract is issued in consideration of the application for this Contract and payment of the first contribution (premium). Additional contributions may be made at any time prior to the Annuity Commencement Date or the death of the Owner. Each contribution is made, subject to the Contributions provision of this Contract. This Contract shall take effect on the Effective Date shown in the Specifications Section of this Contract. This Contract is executed by the Company at its Home Office in New York, New York on the Date of Issue shown in the Specifications Section of this Contract. IRA-2004 IRA-2004 INHER XXX-2010 INHER XXX-2010 SECTION 1 - SPECIFICATIONS 5 SECTION 2 - DEFINITION DEFINITIONS 5 Account Value 5 Administrative Charges 5 Annuitant 5 Annuity Commencement Date 6 Beneficiary 6 Business Day 6 5 Code 6 Commuted Value 5 Contract 6 Contract Charge 6 Current Rate of Interest 6 Date of Issue 6 Designated Beneficiary 6 Effective Date 6 Employer Eligible Rollover Distribution 6 Guaranteed Rate of Interest 6 Home Office XXX 6 Interest Accumulation Account 6 Investment Fund 6 Notice 7 Owner 7 Required Distribution Beginning Date 7 Retirement Plan 7 Separate Account 7 SIMPLE IRA 7 Surviving Spouse 7 Underlying Investment Company 7 United States 0 Xxxxxxxxxx Xxxxxxxxxx Xxxxxxx 0 Xxxxxx Xxxxxx Bank 7 Valid Transaction Date 7 Valuation Day 7 Valuation Period 7 SECTION 3 - CONTRIBUTIONS 7 Contributions 7 Allocation of Contributions 8 Change of Allocations 8 SECTION 4 - ACCOUNTS 8 Accounts 8 General Account 8 Separate Account 8 Account Value 9 8 Accumulation Units 9 Accumulation Unit Value 9 Accumulation Unit Value Change Factor 9 Changes To Separate Account 9 SECTION 5 - WITHDRAWALS AND TRANSFERS 10 Withdrawals and Transfers 10 Amount of Withdrawal or Transfer 10 Requests for Withdrawal or Transfer 10 Postponement of Withdrawals or Transfers 10 SECTION 6 - BENEFITS DISTRIBUTIONS 10 Rules for Distribution 10 Distribution Methods 11 Annuity Benefit 11 Amount of Annuity Benefit 11 Annuity Options 11 Specified Payments Option 12 Death Benefit 12 Spousal Continuation 12 Death Benefit Settlement Options 12 SECTION 7 - DISTRIBUTIONS 14 DESIGNATED BENEFICIARY 12 SECTION 8 - BENEFICIARY 16 SECTION 9 - GENERAL PROVISIONS 17 12 Adjustments to Current Rate of Interest and Expense Charges 17 12 Contract 17 12 Evidence of Survival 17 12 Overpayments 13 Incontestability 17 Misstatements of Age 17 13 Non-Alienation of Benefits 17 13 Non-Assignment of Contract 17 13 Non-Waiver 17 13 Notices 18 13 Participating Contract 18 13 Dividends 18 13 Payment of Benefits 18 13 Reports 18 Report to Employer 18 14 Severability of Provisions 18 14 Termination of Contract 18 14 SECTION 10 - TABLE OF RATES 19 SECTION 11 9 - LIST OF ACCOUNTS AND FUNDS 20 14 OWNER/ANNUITANT: Xxxxxxx Xxxxxx Simple CONTRACT NUMBER: 00-000000-0 EFFECTIVE DATE: Month Day[Xxxx Xxx], YYYY DATE OF ISSUE: Month Day, YYYY STATE OF DELIVERY: Generic beneficiary of [Xxxx Xxxxx] SEPARATE ACCOUNT CHARGE Maximum of [2% %] annually of the net assets in each Investment Fund. CONTRACT CHARGE A monthly contract charge of [$2.00 2.50] for administrative expenses[, except the monthly charge shall not exceed 1/12 of 1% of the Account Value]. An explanation of all charges appears under Administrative Charges in the Definitions section of this Contract. The Current Rate of Interest is declared from time to time by the Company, but shall in no event be less than the Guaranteed Rate of Interest. The Guaranteed Rate of Interest on the Effective Date results in an effective annual yield of 0.00% [2%] and shall apply from the Effective Date until the first December 31st following the Effective Date. A redetermined Guaranteed Rate of Interest shall be applicable for each calendar year thereafter. The Current Rate of Interest on the Date of Issue results in an effective annual yield of 0.00[3%]. The total expense charge currently being deducted as a Separate Account Charge on the Date of Issue of this Contract is 1.20%[1.20]%.

RIGHT TO EXAMINE CONTRACT. This Contract may be returned for cancellation within Within 10 days after the date it is received by the Owner. It may be delivered or mailed to the Company or to any agent of the Company, along with a written request for cancellation. This Contract shall then be canceled and the Company shall refund to the Owner an amount equal to: (a) all contributions allocated to the Interest Accumulation Account, with no deductions; plus (b) the value on the surrender date of all contributions allocated to any Investment Fund. For purposes of this paragraph only, the surrender date shall be the date this Contract is delivered first received, it may be cancelled for any reason without penalty (e.g., no withdrawal charges will be deducted) by delivering or mailed mailing it to the Companyrepresentative through whom it was purchased, along with or to our Servicing Office. When the request for cancellationContract is received at the Servicing Office, the Company will return the value of the Variable Account and/or the value of the Fixed Account of the Contract as of the date of cancellation where permitted by law. This If this Contract is issued in as an IRA, then the entire amount of Premium Payments made shall be returned. The contract is governed by the laws of the State of New York; it is issued and accepted subject to the terms set forth on this page and on the following pages which are made a part of this contract. In consideration of the application for it, and the Premium Payment(s) as provided this Contract and payment of the first contribution (premium). Additional contributions may be made at any time prior to the Annuity Commencement Date or the death of the Owner. Each contribution is subject to the Contributions provision of this Contract. This Contract shall take effect on the Effective Date shown in the Specifications Section of this Contract. This Contract contract is executed by the Company at as of its Home Office in New York, New York on the Date of Issue shown in the Specifications Section of this ContractIssue. IRA-2004 IRA-2004 SECTION 1 - SPECIFICATIONS 5 SECTION 2 - DEFINITION 5 Account Value 5 Administrative Charges 5 Annuitant 5 Annuity Commencement Date 6 Beneficiary 6 Business Day 6 Code 6 Commuted Value 6 Contract 6 Current Rate of Interest 6 Date of Issue 6 Effective Date 6 Employer 6 Guaranteed Rate of Interest 6 Home Office 6 Interest Accumulation Account 6 Investment Fund 6 Notice 7 Owner 7 Required Distribution Date 7 Separate Account 7 SIMPLE IRA 7 Surviving Spouse 7 Underlying Investment Company 7 United States Bank 7 Valid Transaction Date 7 Valuation Day 7 Valuation Period 7 SECTION 3 - CONTRIBUTIONS 7 Contributions 7 Allocation of Contributions 8 Change of Allocations 8 SECTION 4 - ACCOUNTS 8 Accounts 8 General Account 8 Separate Account 8 Account Value 9 Accumulation Units 9 Accumulation Unit Value 9 Accumulation Unit Value Change Factor 9 Changes To Separate Account 9 SECTION 5 - /s/ Xxxxxx X. Xxxxxxx PRESIDENT PAYMENTS AND VALUES BASED ON THE FIXED ACCOUNT ARE SUBJECT TO A MARKET VALUE ADJUSTMENT FORMULA, THE OPERATION OF WHICH MAY RESULT IN UPWARD OR DOWNWARD ADJUSTMENTS IN AMOUNTS PAYABLE TO THE OWNER, INCLUDING WITHDRAWALS AND TRANSFERS 10 Withdrawals and Transfers 10 Amount of Withdrawal or Transfer 10 Requests for Withdrawal or Transfer 10 Postponement of Withdrawals or Transfers 10 SECTION 6 - BENEFITS 11 Annuity Benefit 11 Amount of Annuity Benefit 11 Annuity Options 11 Specified Payments Option 12 Death Benefit 12 Spousal Continuation 12 Death Benefit Settlement Options 12 SECTION 7 - DISTRIBUTIONS 14 SECTION 8 - BENEFICIARY 16 SECTION 9 - GENERAL TRANSFERS. PAYMENTS MADE FROM THE FIXED ACCOUNT PURSUANT TO AN ELECTION WHICH BECOMES EFFECTIVE AT THE END OF A GUARANTEED PERIOD AND PAYMENTS MADE UNDER THE "ANNUITY BENEFIT" PROVISIONS 17 Adjustments to Current Rate of Interest and Expense Charges 17 Contract 17 Evidence of Survival 17 Incontestability 17 Misstatements of Age 17 NonAND UNDER THE "PENALTY-Alienation of Benefits 17 Non-Assignment of Contract 17 Non-Waiver 17 Notices 18 Participating Contract 18 Dividends 18 Payment of Benefits 18 Reports 18 Report to Employer 18 Severability of Provisions 18 Termination of Contract 18 SECTION 10 - TABLE FREE ANNUITIZATION" PROVISION ARE NOT SUBJECT TO THE MARKET VALUE ADJUSTMENT. PAYMENTS MADE UNDER THE "DEATH BENEFIT" PROVISIONS ARE NOT SUBJECT TO ANY MARKET VALUE ADJUSTMENT. ALL PAYMENTS AND VALUES PROVIDED BY THIS CONTRACT WHEN BASED ON INVESTMENT EXPERIENCE OF RATES 19 SECTION 11 - LIST THE VARIABLE ACCOUNT ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. WITH THE CONTRACT ASSET CHARGES OF ACCOUNTS AND FUNDS 20 OWNER/ANNUITANT: Xxxxxxx Xxxxxx Simple CONTRACT NUMBER: 00-000000-0 EFFECTIVE DATE: Month Day1.40%, YYYY DATE THE SMALLEST ANNUAL RATE OF ISSUE: Month Day, YYYY STATE INVESTMENT RETURN WHICH WOULD HAVE TO BE EARNED ON THE ASSETS OF DELIVERY: Generic THE SEPARATE ACCOUNT CHARGE Maximum of 2% annually of the net assets in each Investment Fund. CONTRACT CHARGE A monthly contract charge of $2.00 for administrative expenses, except the monthly charge shall not exceed 1/12 of 1% of the Account Value. An explanation of all charges appears under Administrative Charges in the Definitions section of this Contract. The Current Rate of Interest is declared from time to time by the Company, but shall in no event be less than the Guaranteed Rate of Interest. The Guaranteed Rate of Interest on the Effective Date results in an effective annual yield of 0.00% and shall apply from the Effective Date until the first December 31st following the Effective Date. A redetermined Guaranteed Rate of Interest shall be applicable for each calendar year thereafter. The Current Rate of Interest on the Date of Issue results in an effective annual yield of 0.00%. The total expense charge currently being deducted as a Separate Account Charge on the Date of Issue of this Contract is 1.20SO THAT THE DOLLAR AMOUNT OF VARIABLE ANNUITY PAYMENTS WILL NOT DECREASE IS 5.40%.

RIGHT TO EXAMINE CONTRACT. This Contract may be returned for cancellation within days after the date it is received by the Owner. It may be delivered or mailed to the Company or to any agent of the Company, along with a written request for cancellation. This Contract shall then be canceled and the Company shall refund to the Owner an amount equal to: (a) all contributions allocated to the Interest Accumulation Account, with no deductions; plus (b) the value on the surrender date of all contributions allocated to any Investment Fund. For purposes of this paragraph only, the surrender date shall be the date this Contract is delivered or mailed to the Company, along with the request for cancellation. This Contract is issued in consideration of the application for this Contract and payment of the first contribution (premium). Additional contributions may be made at any time prior to the Annuity Commencement Date or the death of the Owner. Each contribution is subject to the Contributions provision of this Contract. This Contract shall take effect on the Effective Date shown in the Specifications Section of this Contract. This Contract is executed by the Company at its Home Office in New York, New York on the Date of Issue shown in the Specifications Section of this Contract. IRA-2004 IRA-2004 SECTION 1 - SPECIFICATIONS 5 SECTION 2 - DEFINITION 5 Account Value 5 Administrative Charges 5 Annuitant 5 Annuity Commencement Date 6 Beneficiary 6 Business Day 6 Code 6 Commuted Value 6 Contract 6 Current Rate of Interest 6 Date of Issue 6 Effective Date 6 Employer 6 Guaranteed Rate of Interest 6 Home Office 6 Interest Accumulation Account 6 Investment Fund 6 Notice 7 Owner 7 Required Distribution Date 7 Separate Account 7 SIMPLE IRA 7 Surviving Spouse 7 Underlying Investment Company 7 United States Bank 7 Valid Transaction Date 7 Valuation Day 7 Valuation Period 7 SECTION 3 - CONTRIBUTIONS 7 Contributions 7 Allocation of Contributions 8 Change of Allocations 8 SECTION 4 - ACCOUNTS 8 9 Accounts 8 9 General Account 8 9 Separate Account 8 9 Account Value 9 Accumulation Units 9 Accumulation Unit Value 9 Accumulation Unit Value Change Factor 9 Changes To Separate Account 9 10 SECTION 5 - WITHDRAWALS AND TRANSFERS 10 Withdrawals and Transfers 10 Amount of Withdrawal or Transfer 10 Requests for Withdrawal or Transfer 10 Postponement of Withdrawals or Transfers 10 11 SECTION 6 - BENEFITS 11 Annuity Benefit 11 Amount of Annuity Benefit 11 Annuity Options 11 Specified Payments Option 12 Death Benefit 12 Spousal Continuation 12 Death Benefit Settlement Options 12 13 SECTION 7 - DISTRIBUTIONS 14 SECTION 8 - BENEFICIARY 16 IRA-2004 Page 3 SECTION 9 - GENERAL PROVISIONS 17 Adjustments to Current Rate of Interest and Expense Charges 17 Contract 17 Evidence of Survival 17 Incontestability 17 Misstatements of Age 17 Non-Alienation of Benefits 17 Non-Assignment of Contract 17 18 Non-Waiver 17 18 Notices 18 Participating Contract 18 Dividends 18 Payment of Benefits 18 Reports 18 Report to Employer 18 Severability of Provisions 18 Termination of Contract 18 SECTION 10 - TABLE OF RATES 19 SECTION 11 - LIST OF ACCOUNTS AND FUNDS 20 OWNER/ANNUITANT: Xxxxxxx Xxxxxx Simple CONTRACT NUMBER: Traditional 00-000000-0 EFFECTIVE DATE: Month Day, YYYY DATE OF ISSUE: Month Day, YYYY STATE OF DELIVERY: Generic SEPARATE ACCOUNT CHARGE Maximum of 2% annually of the net assets in each Investment Fund. CONTRACT CHARGE A monthly contract charge of $2.00 for administrative expenses, except the monthly charge shall not exceed 1/12 of 1% of the Account Value. An explanation of all charges appears under Administrative Charges in the Definitions section of this Contract. The Current Rate of Interest is declared from time to time by the Company, but shall in no event be less than the Guaranteed Rate of Interest. The Guaranteed Rate of Interest on the Effective Date results in an effective annual yield of 0.00% and shall apply from the Effective Date until the first December 31st following the Effective Date. A redetermined Guaranteed Rate of Interest shall be applicable for each calendar year thereafter. The Current Rate of Interest on the Date of Issue results in an effective annual yield of 0.00%. The total expense charge currently being deducted as a Separate Account Charge on the Date of Issue of this Contract is 1.20%.

RIGHT TO EXAMINE CONTRACT. This Within 10 days of the date of receipt of this contract, or 60 days if a replacement contract, of the date of receipt of this Contract by the Owner, it may be returned for cancellation within days after by delivering or mailing it to the date Company at its Administrative Office or to the Registered Representative through whom it was purchased. When the Contract is received by the OwnerCompany, it will be voided as if it had never been in force. It may be delivered or mailed to The Company will refund the Contract Value computed as of the Business Day the Company receives the returned contract at its Administrative Office. This refund amount will be the Contract Value plus the amount of fees and other charges deducted from gross consideration or to any agent imposed under the contract, if applicable. The refund will be issued within 10 days of the Company, along with a written request receipt of policy or contract for cancellation. This Contract shall then be canceled and the Company shall refund to the Owner an amount equal to: (a) all contributions allocated to the Interest Accumulation Account, with no deductions; plus (b) the value on the surrender date of all contributions allocated to any Investment Fund. For purposes of this paragraph only, the surrender date shall be the date this Contract is delivered or mailed to the Company, along with the request for cancellation. This Contract is issued in consideration of the application for this Contract and payment of the first contribution (premium). Additional contributions may be made at any time prior to the Annuity Commencement Date or the death of the Owner. Each contribution is subject to the Contributions provision of this Contract. This Contract shall take effect on the Effective Date shown in the Specifications Section of this Contract. This Contract is executed by the Company at its Home Office in New York, New York on the Date of Issue shown in the Specifications Section of this Contract. IRA-2004 IRA-2004 SECTION 1 - SPECIFICATIONS 5 SECTION 2 - DEFINITION 5 Account Value 5 Administrative Charges 5 Annuitant 5 Annuity Commencement Date 6 Beneficiary 6 Business Day 6 Code 6 Commuted Value 6 Contract 6 Current Rate of Interest 6 Date of Issue 6 Effective Date 6 Employer 6 Guaranteed Rate of Interest 6 Home Office 6 Interest Accumulation Account 6 Investment Fund 6 Notice JNL-2300-1-NY CONTRACT SCHEDULE 4 DEFINITIONS 7 Owner 7 Required Distribution Date 7 Separate Account 7 SIMPLE IRA 7 Surviving Spouse 7 Underlying Investment Company 7 United States Bank 7 Valid Transaction Date 7 Valuation Day 7 Valuation Period 7 SECTION 3 - CONTRIBUTIONS 7 Contributions 7 Allocation of Contributions PURCHASE PAYMENT PROVISIONS 8 Change of Allocations PURCHASE PAYMENTS 8 SECTION 4 - ALLOCATION OF PURCHASE PAYMENTS 8 SEPARATE ACCOUNT PROVISIONS 8 THE SEPARATE ACCOUNTS 8 Accounts VARIABLE ACCOUNT 8 General Account VALUATION OF ASSETS 8 Separate Account ACCUMULATION UNITS 8 Account Value ACCUMULATION UNIT VALUE 9 Accumulation Units CONTRACT VALUE 9 Accumulation Unit Value SUBSCRIPTION FEE 9 Accumulation Unit Value Change Factor DEDUCTION FOR SUBSCRIPTION FEE 9 Changes To Separate Account 9 SECTION 5 - DEDUCTION FOR LOW COST PLATFORM FEE 10 DEDUCTION FOR OPTIONAL ASSET ALLOCATION MODEL FEE TRANSFERS 11 TRANSFERS DURING THE ACCUMULATION PERIOD 11 WITHDRAWAL PROVISIONS 11 WITHDRAWALS 11 PROCEEDS PAYABLE ON DEATH 11 DEATH OF OWNER DURING THE ACCUMULATION PERIOD 11 DEATH BENEFIT AMOUNT DURING THE ACCUMULATION PERIOD 11 DEATH BENEFIT OPTIONS DURING THE ACCUMULATION PERIOD 12 DEATH OF OWNER DURING THE ANNUITY PERIOD 12 DEATH OF ANNUITANT 12 PAYMENT OF DEATH BENEFIT 12 BENEFICIARY 12 CHANGE OF BENEFICIARY 13 SUSPENSION OR DEFERRAL OF PAYMENTS PROVISION 13 OWNER, ANNUITANT, XXXXXXXXX, XXXXXXXXXX XXXXXXXXXX 00 OWNER 13 JOINT OWNER 13 ANNUITANT 13 ASSIGNMENT OF A CONTRACT 13 ANNUITY PROVISIONS 14 GENERAL 14 ANNUITY DATE 14 SELECTION OF AN ANNUITY OPTION 14 FREQUENCY AND TRANSFERS 10 Withdrawals and Transfers 10 Amount of Withdrawal or Transfer 10 Requests for Withdrawal or Transfer 10 Postponement of Withdrawals or Transfers 10 SECTION 6 - BENEFITS 11 Annuity Benefit 11 Amount of Annuity Benefit 11 Annuity Options 11 Specified Payments Option 12 Death Benefit 12 Spousal Continuation 12 Death Benefit Settlement Options 12 SECTION 7 - DISTRIBUTIONS AMOUNT OF ANNUITY PAYMENTS 14 SECTION 8 - BENEFICIARY 16 SECTION 9 - ANNUITY OPTIONS 14 OPTION 1. LIFETIME ONLY ANNUITY: 14 OPTION 2. LIFETIME ANNUITY WITH GUARANTEED PERIODS 14 OPTION 3. PAYMENT FOR A FIXED PERIOD: 14 OPTION 4. JOINT AND SURVIVOR ANNUITY 14 ANNUITY 14 FIXED ANNUITY 14 MORTALITY TABLES 15 GENERAL PROVISIONS 17 Adjustments to Current Rate of Interest and Expense Charges 17 Contract 17 Evidence of Survival 17 Incontestability 17 Misstatements of Age 17 Non15 THE CONTRACT 15 MISSTATEMENT OF AGE 15 INCONTESTABILITY 15 MODIFICATION 15 NON-Alienation of Benefits 17 NonPARTICIPATING 15 EVIDENCE OF SURVIVAL 15 PROOF OF AGE 15 PROTECTION OF PROCEEDS 15 REPORTS 15 TAXES 15 REGULATORY REQUIREMENTS 15 ANNUITY OPTION TABLES 16-Assignment of Contract 17 Non-Waiver 17 Notices 18 Participating Contract 18 Dividends 18 Payment of Benefits 18 Reports 18 Report to Employer 18 Severability of Provisions 18 Termination of Contract 18 SECTION 10 - TABLE OF RATES 19 SECTION 11 - LIST OF ACCOUNTS AND FUNDS 20 PRIMARY OWNER/: [Xxxx Xxx] CONTRACT ISSUE DATE: [1/1/2015] JOINT OWNER: [Xxxx Xxx] ANNUITANT: Xxxxxxx Xxxxxx Simple [Xxxx Xxx] ANNUITANT AGE: [35 ] ANNUITANT GENDER: [Male/Female] ANNUITY DATE: [1/1/2055] CONTRACT NUMBER: 00-000000-0 EFFECTIVE DATE[12345678] INITIAL PURCHASE PAYMENT: Month Day, YYYY DATE OF ISSUE[$25,000.00] MINIMUM TOTAL PURCHASE PAYMENT: Month Day, YYYY STATE OF DELIVERY[$25,000.00] MAXIMUM TOTAL PURCHASE PAYMENT: Generic SEPARATE ACCOUNT CHARGE Maximum of 2% annually of the net assets in each Investment Fund. CONTRACT CHARGE A monthly contract charge of [$2.00 for administrative expenses, except the monthly charge shall not exceed 1/12 of 1% of the Account Value. An explanation of all charges appears under Administrative Charges in the Definitions section of this Contract. The Current Rate of Interest is declared from time to time by the Company, but shall in no event be less than the Guaranteed Rate of Interest. The Guaranteed Rate of Interest on the Effective Date results in an effective annual yield of 0.00% and shall apply from the Effective Date until the first December 31st following the Effective Date. A redetermined Guaranteed Rate of Interest shall be applicable for each calendar year thereafter. The Current Rate of Interest on the Date of Issue results in an effective annual yield of 0.00%. The total expense charge currently being deducted as a Separate Account Charge on the Date of Issue of this Contract is 1.20%.10,000,000.00] without prior Company approval

RIGHT TO EXAMINE CONTRACT. This Contract may be returned for cancellation within [10] days after the date it is received by the Owner. It may be delivered or mailed to the Company or to any agent of the Company, along with a written request for cancellation. This Contract shall then be canceled cancelled and the Company shall refund to the Owner an amount equal to: (a) all contributions allocated to the Interest Accumulation Account, with no deductions; plus (b) the value on the surrender date of all contributions allocated to any Investment Fund. For purposes of this paragraph only, the surrender date shall be the date this Contract is delivered or mailed to the Company, along with the request for cancellation. This Contract is issued in consideration of the application for this Contract and payment of the first contribution (premium)) of at least [$10] . Additional contributions may be made at any time prior to the Annuity Commencement Date Date, the death of the Annuitant or the death of the Owner. Each contribution is subject to the Contributions provision of this Contract. This Contract shall take effect on the Effective Date shown in the Specifications Section of this Contract. This Contract is executed by the Company at its Home Office in New York, New York on the Date of Issue shown in the Specifications Section of this Contract. IRA-2004 IRA-2004 SECTION 1 - SPECIFICATIONS 5 SECTION 2 - DEFINITION 5 Account Value 5 Administrative Charges 5 Annuitant 5 Annuity Commencement Date 6 Beneficiary 6 Business Day 6 Code 6 Commuted Value 6 Contract 6 Current Rate of Interest 6 Date of Issue 6 Effective Date 6 Employer 6 Guaranteed Rate of Interest 6 Home Office 6 Interest Accumulation Account 6 Investment Fund 6 Notice 7 Owner 7 Required Distribution Date 7 Separate Account 7 SIMPLE IRA 7 Surviving Spouse 7 Underlying Investment Company 7 United States Bank 7 Valid Transaction Date 7 Valuation Day 7 Valuation Period 7 SECTION 3 - CONTRIBUTIONS 7 Contributions 7 Allocation of Contributions 8 Change of Allocations 8 SECTION 4 - ACCOUNTS 8 Accounts 8 General Account 8 Separate Account 8 Account Value 9 Accumulation Units 9 Accumulation Unit Value 9 Accumulation Unit Value Change Factor 9 Changes To Separate Account 9 SECTION 5 - WITHDRAWALS AND TRANSFERS 10 Withdrawals /s/ Xxxxx Xxxxx /s/ Xxxxxx X. Xxxxx ------------------------------- ------------------------------------- Vice President President and Transfers 10 Amount of Withdrawal or Transfer 10 Requests for Withdrawal or Transfer 10 Postponement of Withdrawals or Transfers 10 SECTION 6 - BENEFITS 11 Annuity Benefit 11 Amount of Annuity Benefit 11 Annuity Options 11 Specified Payments Option 12 Death Benefit 12 Spousal Continuation 12 Death Benefit Settlement Options 12 SECTION 7 - DISTRIBUTIONS 14 SECTION 8 - BENEFICIARY 16 SECTION 9 - Chief Executive Officer AMOUNTS HELD IN CONNECTION WITH THIS CONTRACT MAY BE HELD IN THE COMPANY'S GENERAL PROVISIONS 17 Adjustments to Current Rate of Interest and Expense Charges 17 Contract 17 Evidence of Survival 17 Incontestability 17 Misstatements of Age 17 Non-Alienation of Benefits 17 Non-Assignment of Contract 17 Non-Waiver 17 Notices 18 Participating Contract 18 Dividends 18 Payment of Benefits 18 Reports 18 Report to Employer 18 Severability of Provisions 18 Termination of Contract 18 SECTION 10 - TABLE OF RATES 19 SECTION 11 - LIST OF ACCOUNTS AND FUNDS 20 OWNERACCOUNT AND/ANNUITANT: Xxxxxxx Xxxxxx Simple CONTRACT NUMBER: 00-000000-0 EFFECTIVE DATE: Month Day, YYYY DATE OF ISSUE: Month Day, YYYY STATE OF DELIVERY: Generic OR THE COMPANY'S SEPARATE ACCOUNT CHARGE Maximum of 2% annually of the net assets in each Investment FundTHAT THE COMPANY MAINTAINS IN CONNECTION WITH THIS CONTRACT AND CERTAIN OTHER CONTRACTS. CONTRACT CHARGE A monthly contract charge of $2.00 for administrative expenses, except the monthly charge shall not exceed 1/12 of 1% of the Account Value. An explanation of all charges appears under Administrative Charges in the Definitions section of this Contract. The Current Rate of Interest is declared from time to time by the Company, but shall in no event be less than the Guaranteed Rate of Interest. The Guaranteed Rate of Interest on the Effective Date results in an effective annual yield of 0.00% and shall apply from the Effective Date until the first December 31st following the Effective DateTHE AMOUNTS HELD IN THE SEPARATE ACCOUNT ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNTS AND SHALL INCREASE OR DECREASE IN VALUE BASED UPON THE INVESTMENT RESULTS OF THE SEPARATE ACCOUNT. A redetermined Guaranteed Rate of Interest shall be applicable for each calendar year thereafterDESCRIPTION OF THE SEPARATE ACCOUNT APPEARS IN THE ACCOUNTS SECTION OF THIS CONTRACT. The Current Rate of Interest on the Date of Issue results in an effective annual yield of 0.00%A DESCRIPTION OF THE CHARGES DEDUCTED FROM THE AMOUNTS HELD IN THE SEPARATE ACCOUNT APPEARS IN THE DEFINITION OF ADMINISTRATIVE CHARGES IN THE DEFINITIONS SECTION OF THIS CONTRACT. The total expense charge currently being deducted as a Separate Account Charge on the Date of Issue of this Contract is 1.20%.THIS IS A PARTICIPATING CONTRACT. THIS PAGE LEFT BLANK INTENTIONALLY

RIGHT TO EXAMINE CONTRACT. This Contract may be returned for cancellation within days after the date it is received by the Owner. It may be delivered or mailed to the Company or to any agent of the Company, along with a written request for cancellation. This Contract shall then be canceled and the Company shall refund to the Owner an amount equal to: (a) all contributions allocated to the Interest Accumulation Account, with no deductions; plus (b) the value on the surrender date of all contributions allocated to any Investment Fund. For purposes of this paragraph only, the surrender date shall be the date this Contract is delivered or mailed to the Company, along with the request for cancellation. This Contract is issued in consideration of the application for this Contract and payment of the first contribution (premium). Additional contributions may be made at any time prior to the Annuity Commencement Date or the death of the Owner. Each contribution is subject to the Contributions provision of this Contract. This Contract shall take effect on the Effective Date shown in the Specifications Section of this Contract. This Contract is executed by the Company at its Home Office in New York, New York on the Date of Issue shown in the Specifications Section of this Contract. IRA-2004 IRA-2004 SECTION 1 - SPECIFICATIONS 5 SECTION 2 - DEFINITION 5 Account Value 5 Administrative Charges 5 Annuitant 5 Annuity Commencement Date 6 Beneficiary 6 Business Day 6 Code 6 Commuted Value 6 Contract 6 Current Rate of Interest 6 Date of Issue 6 Effective Date 6 Employer 6 Guaranteed Rate of Interest 6 Home Office 6 Interest Accumulation Account 6 Investment Fund 6 Notice 7 Owner 7 Required Distribution Date XXXX XXX 7 Separate Account 7 SIMPLE IRA 7 Surviving Spouse 7 Underlying Investment Company 7 United States Bank 7 Valid Transaction Date 7 Valuation Day 7 Valuation Period 7 SECTION 3 - CONTRIBUTIONS 7 Contributions 7 Allocation of Contributions 8 9 Change of Allocations 8 9 SECTION 4 - ACCOUNTS 8 9 Accounts 8 9 General Account 8 9 Separate Account 8 9 Account Value 9 10 Accumulation Units 9 10 Accumulation Unit Value 9 10 Accumulation Unit Value Change Factor 9 10 Changes To Separate Account 9 10 SECTION 5 - WITHDRAWALS AND TRANSFERS 10 11 Withdrawals and Transfers 10 11 Amount of Withdrawal or Transfer 10 11 Requests for Withdrawal or Transfer 10 11 Postponement of Withdrawals or Transfers 10 11 SECTION 6 - BENEFITS 11 Annuity Benefit 11 Amount of Annuity Benefit 11 12 Annuity Options 11 12 Specified Payments Option 12 13 Death Benefit 12 13 Spousal Continuation 12 13 Death Benefit Settlement Options 12 13 SECTION 7 - DISTRIBUTIONS 14 SECTION 8 - BENEFICIARY 16 IRA-2004 Page 3 SECTION 9 - GENERAL PROVISIONS 17 16 Adjustments to Current Rate of Interest and Expense Charges 17 16 Contract 17 16 Evidence of Survival 17 16 Incontestability 17 Misstatements of Age 17 Non-Alienation of Benefits 17 Non-Assignment of Contract 17 Non-Waiver 17 Notices 18 17 Participating Contract 18 17 Dividends 18 17 Payment of Benefits 18 17 Reports 18 Report to Employer 18 Severability of Provisions 18 Termination of Contract 18 SECTION 10 - TABLE OF RATES 19 18 SECTION 11 - LIST OF ACCOUNTS AND FUNDS 20 OWNER/ANNUITANT: Xxxxxxx Xxxxxx Simple Xxxx CONTRACT NUMBER: 00-000000-0 EFFECTIVE DATE: Month Day, YYYY DATE OF ISSUE: Month Day, YYYY STATE OF DELIVERY: Generic SEPARATE ACCOUNT CHARGE Maximum of 2% annually of the net assets in each Investment Fund. CONTRACT CHARGE A monthly contract charge of $2.00 for administrative expenses, except the monthly charge shall not exceed 1/12 of 1% of the Account Value. An explanation of all charges appears under Administrative Charges in the Definitions section of this Contract. The Current Rate of Interest is declared from time to time by the Company, but shall in no event be less than the Guaranteed Rate of Interest. The Guaranteed Rate of Interest on the Effective Date results in an effective annual yield of 0.00% and shall apply from the Effective Date until the first December 31st following the Effective Date. A redetermined Guaranteed Rate of Interest shall be applicable for each calendar year thereafter. The Current Rate of Interest on the Date of Issue results in an effective annual yield of 0.00%. The total expense charge currently being deducted as a Separate Account Charge on the Date of Issue of this Contract is 1.20%.