Common use of The Variable Separate Accounts Clause in Contracts

The Variable Separate Accounts. The General Account Valuation Period Accumulation Value Accumulation Value in each Division and Fixed Allocation Fixed Account Measurement of Investment Experience Charges Deducted from Accumulation Value on each Contract Processing Date Copies of any additional Riders and Endorsements are at the back of this Contract. THE SCHEDULE The Schedule gives specific facts about this Contract and its coverage. Please refer to the Schedule while reading this Contract. GA-IA-1090 2 THE SCHEDULE PAYMENT AND INVESTMENT INFORMATION -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- | Annuitant Owner | | [XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Annuitant's Issue Age Annuitant's Sex Owner's Issue Age | | [55] [MALE] [35] | |------------------------------------------------------------------------------| | Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Contract Date Issue Date Residence Status | | [JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE] | |------------------------------------------------------------------------------| | Schedule Date Benefit Option Package | | [JANUARY 1, 1996] [III] | |------------------------------------------------------------------------------| | Separate Account(s) Contract Number | | [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- INITIAL INVESTMENT Initial Premium Payment received: [$10,000] Your initial Accumulation Value has been invested as follows: Percentage of Divisions Accumulation Value --------- ------------------ [Eagle Value Equity 10% MFS Total Return 10% Liquid Asset 10% Alliance VP Premier Growth (Class B) 10% Fidelity VIP Growth (Class S) 10% INVESCO VI Health Sciences 10% Janus Aspen Worldwide Growth (Class S) 5% Pioneer VP Pioneer VP Pioneer Fund (Class II) 5% Xxxxxx XX International Growth & Income (Class B) 5% Xxxxxx XX Voyager II (Class B) 5% PPI MFS Capital Opportunities 5% Pilgrim VP Convertible Bond (Class S) 5% PIMCO Core Bond 5% Fixed Allocation - 1 Year 5%] ----------------------------------------------- ------------------- Total 100% ===== ==== GA-IA-1090 3A1 THE SCHEDULE PAYMENT AND INVESTMENT INFORMATION (continued) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- | Annuitant Owner | | [XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Annuitant's Issue Age Annuitant's Sex Owner's Issue Age | | [55] [MALE] [35] | |------------------------------------------------------------------------------| | Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Contract Date Issue Date Residence Status | | [JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE] | |------------------------------------------------------------------------------| | Schedule Date Benefit Option Package | | [JANUARY 1, 1996] [III] | |------------------------------------------------------------------------------| | Separate Account(s) Contract Number | | [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- ADDITIONAL PREMIUM PAYMENT INFORMATION Except in the case of a Contract issued as an IRA, we will accept additional Premium Payments until either you or the Annuitant reaches the Attained Age of 86. If this Contract is issued as an IRA, no contributions may be made for the taxable year in which you attain age 70 1/2 and thereafter (except for rollover contributions). The minimum additional payment which may be made is $50.00. Any additional payment which would cause the Contract's Accumulation Value to exceed $1,000,000 requires our prior approval. ALLOCATION CHANGES BY TELEPHONE You may request allocation changes by telephone during our telephone request business hours. You may call our Customer Service Center at 1-800-366-0066 to make allocation changes by using the personal identification number you will receive. You may also mail any notice or request for allocation changes to our Customer Service Center at the address shown on the cover page. GA-IA-1090 3A2 THE SCHEDULE THE VARIABLE SEPARATE ACCOUNTS -------------------------------------------------------------------------------- |------------------------------------------------------------------------------| | Annuitant Owner | | [XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Separate Account(s) Contract Number | | [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND Separate Account B (the "Account") is a unit investment trust Separate Account, organized in and governed by the laws of the State of Delaware, our state of domicile. The Account is divided into Divisions. Each Division listed below invests in shares of the mutual fund portfolio (the "Series") designated. Each portfolio is a part of The GCG Trust managed by Directed Services, Inc. SERIES SERIES SERIES ------ ------ ------ [Eagle Value Equity PIMCO Core Bond MFS Research MFS Total Return Liquid Asset Janus Growth and Income The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolios are a part of the Prudential Series Fund, Inc. managed by Xxxxxxxx Associates, LLC. PORTFOLIO PORTFOLIO --------- --------- Prudential Xxxxxxxx (Class S) Prudential XX Xxxxxxxx International Growth (Class S) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolios are a part of the PIMCO Trust managed by Pacific Investment Management Company. PORTFOLIO --------- PIMCO VI High Yield Bond The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Aetna Variable Annuity Funds managed by Aeltus Investment Management, Inc. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- Aetna GET Fund (Class N) Aetna Index Plus Large Cap VP (Class S) Aetna Index Plus Small Cap VP (Class S) Aetna Value Opportunity VP (Class S) Aetna Index Plus Mid Cap VP (Class S) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Alliance Variable Products Series Fund, Inc. managed by Alliance Capital Management, L.P. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- AllianceBernstein Value (Class B) Alliance Growth and Income (Class B) Alliance Premier Growth (Class B) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Xxxxxxx Series Trust managed by Xxxxxxx Advisors, Inc.Alliance Capital Management, L.P. PORTFOLIO --------- Xxxxxxx Tactical Allocation (Class I) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Fidelity Variable Insurance Products Portfolio, managed by Fidelity Management & Research Co. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- Fidelity VIP Growth (Class S2) Fidelity VIP Equity-Income (Class S2) Fidelity VIP II Contrafund (Class S2) GA-IA-1090 3B 3B (CONT'D) THE SCHEDULE THE VARIABLE SEPARATE ACCOUNTS (continued) -------------------------------------------------------------------------------- |------------------------------------------------------------------------------| | Annuitant Owner | | [XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Separate Account(s) Contract Number | | [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Invesco Variable Investment Funds, Inc. managed by INVESCO. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- INVESCO VI Financial Services INVESCO VI Health Sciences INVESCO VI Utilities

The Variable Separate Accounts. The General Account Valuation Period Accumulation Value Accumulation Value in each Division and Fixed Allocation Fixed Account Measurement of Investment Experience Charges Deducted from Accumulation Value on each Contract Processing Date Copies of any additional Riders and Endorsements are at the back of this Contract. THE SCHEDULE The Schedule gives specific facts about this Contract and its coverage. Please refer to the Schedule while reading this Contract. GA-IA-1090 IA-1083 2 THE SCHEDULE PAYMENT AND INVESTMENT INFORMATION -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- | Annuitant ------------------------------------------------------------------------------- |-----------------------------------------------------------------------------| |Annuitant Owner | | [XXXXXX X. XXX|[THOMAS J. DOE] [XXXX X. XXXJOHN Q. DOE] | |------------------------------------------------------------------------------| | Annuitant|-----------------------------------------------------------------------------| |Annuitant's Issue Age Annuitant's Sex Owner's Issue Age | | [55] [MALE] [35] | |------------------------------------------------------------------------------| | Initial |-----------------------------------------------------------------------------| |Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Contract |-----------------------------------------------------------------------------| |Contract Date Issue Date Residence Status | | [JANUARY 1, 1996] [JANUARY 1, 19961996 ] [DELAWARE] | |------------------------------------------------------------------------------| | Schedule Date Benefit Option Package | | [JANUARY 1, 1996] [III] | |------------------------------------------------------------------------------| | Separate |-----------------------------------------------------------------------------| |Separate Account(s) Contract Number | | [SEPARATE ACCOUNT B AND THE FIXED ACCOUNTB] [123456] | -------------------------------------------------------------------------------- |-----------------------------------------------------------------------------| INITIAL INVESTMENT Initial Premium Payment received: [$10,000] Your initial Accumulation Value has been invested as follows: Percentage of Divisions Accumulation Value --------- ------------------ [Eagle Equity Income 10% Fully Managed 10% Capital Appreciation 10% Rising Dividends 10% Growth 10% Real Estate 10% Value Equity 10% MFS Total Return 10Hard Assets 5% Emerging Markets 5% Managed Global 5% Limited Maturity Bond 5% Liquid Asset 10% Alliance VP Premier Growth (Class B) 10% Fidelity VIP Growth (Class S) 10% INVESCO VI Health Sciences 10% Janus Aspen Worldwide Growth (Class S) 5% Pioneer VP Pioneer VP Pioneer Fund (Class II) 5% Xxxxxx XX International Growth & Income (Class B) 5% Xxxxxx XX Voyager II (Class B) 5% PPI MFS Capital Opportunities 5% Pilgrim VP Convertible Bond (Class S) 5% PIMCO Core Bond 5% Fixed Allocation - 1 Year Strategic Equity 5%] ----------------------------------------------- ------------------- ------------------------------ -------------------------- Total 100% ===== ==== GA-IA-1090 3A1 THE SCHEDULE PAYMENT AND INVESTMENT INFORMATION (continued) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- | Annuitant Owner | | [XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Annuitant's Issue Age Annuitant's Sex Owner's Issue Age | | [55] [MALE] [35] | |------------------------------------------------------------------------------| | Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Contract Date Issue Date Residence Status | | [JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE] | |------------------------------------------------------------------------------| | Schedule Date Benefit Option Package | | [JANUARY 1, 1996] [III] | |------------------------------------------------------------------------------| | Separate Account(s) Contract Number | | [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- ADDITIONAL PREMIUM PAYMENT INFORMATION Except in the case of a Contract issued as an IRA, we will accept additional Premium Payments until either you or the Annuitant reaches the Attained Age of 86. If this Contract is issued as an IRA, no contributions may be made for the taxable year in which you attain age 70 1/2 and thereafter (except for rollover contributions). The minimum additional payment which may be made is $50.00. Any additional payment which would cause the Contract's Accumulation Value to exceed $1,000,000 requires our prior approval. ALLOCATION CHANGES BY TELEPHONE You may request allocation changes by telephone during our telephone request business hours. You may call our Customer Service Center at 1-800-366-0066 to make allocation changes by using the personal identification number you will receive. You may also mail any notice or request for allocation changes to our Customer Service Center at the address shown on the cover page. GA-IA-1090 3A2 THE SCHEDULE THE VARIABLE SEPARATE ACCOUNTS -------------------------------------------------------------------------------- |------------------------------------------------------------------------------| | Annuitant Owner | | [XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Separate Account(s) Contract Number | | [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND Separate Account B (the "Account") is a unit investment trust Separate Account, organized in and governed by the laws of the State of Delaware, our state of domicile. The Account is divided into Divisions. Each Division listed below invests in shares of the mutual fund portfolio (the "Series") designated. Each portfolio is a part of The GCG Trust managed by Directed Services, Inc. SERIES SERIES SERIES ------ ------ ------ [Eagle Value Equity PIMCO Core Bond MFS Research MFS Total Return Liquid Asset Janus Growth and Income The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolios are a part of the Prudential Series Fund, Inc. managed by Xxxxxxxx Associates, LLC. PORTFOLIO PORTFOLIO --------- --------- Prudential Xxxxxxxx (Class S) Prudential XX Xxxxxxxx International Growth (Class S) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolios are a part of the PIMCO Trust managed by Pacific Investment Management Company. PORTFOLIO --------- PIMCO VI High Yield Bond The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Aetna Variable Annuity Funds managed by Aeltus Investment Management, Inc. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- Aetna GET Fund (Class N) Aetna Index Plus Large Cap VP (Class S) Aetna Index Plus Small Cap VP (Class S) Aetna Value Opportunity VP (Class S) Aetna Index Plus Mid Cap VP (Class S) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Alliance Variable Products Series Fund, Inc. managed by Alliance Capital Management, L.P. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- AllianceBernstein Value (Class B) Alliance Growth and Income (Class B) Alliance Premier Growth (Class B) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Xxxxxxx Series Trust managed by Xxxxxxx Advisors, Inc.Alliance Capital Management, L.P. PORTFOLIO --------- Xxxxxxx Tactical Allocation (Class I) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Fidelity Variable Insurance Products Portfolio, managed by Fidelity Management & Research Co. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- Fidelity VIP Growth (Class S2) Fidelity VIP Equity-Income (Class S2) Fidelity VIP II Contrafund (Class S2) GA-IA-1090 3B 3B (CONT'D) THE SCHEDULE THE VARIABLE SEPARATE ACCOUNTS (continued) -------------------------------------------------------------------------------- |------------------------------------------------------------------------------| | Annuitant Owner | | [XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Separate Account(s) Contract Number | | [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Invesco Variable Investment Funds, Inc. managed by INVESCO. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- INVESCO VI Financial Services INVESCO VI Health Sciences INVESCO VI Utilities----- ----

The Variable Separate Accounts. The General Account Valuation Period Accumulation Value Accumulation Value in each Division and Fixed Allocation Fixed Account Measurement of Investment Experience Charges Deducted from Accumulation Value on each Contract Processing Date Copies of any additional Riders and Endorsements are at the back of this Contract. THE SCHEDULE The Schedule gives specific facts about this Contract and its coverage. Please refer to the Schedule while reading this Contract. GA-IA-1090 IA-1082 2 THE SCHEDULE PAYMENT AND INVESTMENT INFORMATION -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- | Annuitant ------------------------------------------------------------------------------- |-----------------------------------------------------------------------------| |Annuitant Owner | | [XXXXXX |[XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Annuitant|-----------------------------------------------------------------------------| |Annuitant's Issue Age Annuitant's Sex Owner's Issue Age | | [55] [MALE] [35] | |------------------------------------------------------------------------------| | Initial |-----------------------------------------------------------------------------| |Initial Premium Annuity Option Annuity Commencement Date | | [$10,000|[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Contract |-----------------------------------------------------------------------------| |Contract Date Issue Date Residence Status | | [JANUARY |[JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE] | |------------------------------------------------------------------------------| | Schedule Date Benefit Option Package | | [JANUARY 1, 1996] [III] | |------------------------------------------------------------------------------| | Separate |-----------------------------------------------------------------------------| |Separate Account(s) Contract Number | | [SEPARATE |[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- |-----------------------------------------------------------------------------| INITIAL INVESTMENT Initial Premium Payment received: [$10,000] Your initial Accumulation Value has been invested as follows: Percentage of Divisions Accumulation Value --------- ------------------ [Eagle Equity Income 10% Fully Managed 10% Capital Appreciation 10% Rising Dividends 10% Growth 10% Real Estate 10% Value Equity 105% MFS Total Return 10Hard Assets 5% Emerging Markets 5% Managed Global 5% Limited Maturity Bond 5% Liquid Asset 10% Alliance VP Premier Growth (Class B) 10% Fidelity VIP Growth (Class S) 10% INVESCO VI Health Sciences 10% Janus Aspen Worldwide Growth (Class S) 5% Pioneer VP Pioneer VP Pioneer Fund (Class II) 5% Xxxxxx XX International Growth & Income (Class B) 5% Xxxxxx XX Voyager II (Class B) 5% PPI MFS Capital Opportunities 5% Pilgrim VP Convertible Bond (Class S) 5% PIMCO Core Bond Strategic Equity 5% Fixed Allocation - 1 Year 5%] ----------------------------------------------- ------------------- -------------------------------- ------------------------------------ Total 100% ===== ==== GA-IA-1090 IA-1082 3A1 THE SCHEDULE PAYMENT AND INVESTMENT INFORMATION (continued) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- | Annuitant ------------------------------------------------------------------------------- |-----------------------------------------------------------------------------| |Annuitant Owner | | [XXXXXX |[XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Annuitant|-----------------------------------------------------------------------------| |Annuitant's Issue Age Annuitant's Sex Owner's Issue Age | | [55] [MALE] [35] | |------------------------------------------------------------------------------| | Initial |-----------------------------------------------------------------------------| |Initial Premium Annuity Option Annuity Commencement Date | | [$10,000|[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Contract |-----------------------------------------------------------------------------| |Contract Date Issue Date Residence Status | | [JANUARY |[JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE] | |------------------------------------------------------------------------------| | Schedule Date Benefit Option Package | | [JANUARY 1, 1996] [III] | |------------------------------------------------------------------------------| | Separate |-----------------------------------------------------------------------------| |Separate Account(s) Contract Number | | [SEPARATE |[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- |-----------------------------------------------------------------------------| ADDITIONAL PREMIUM PAYMENT INFORMATION Except in the case of a Contract issued as an IRAXXX, we will accept additional Premium Payments until either you or the Annuitant or Owner reaches the Attained Age of [86]. The minimum additional payment which may be made is $[500.00]. If this Contract is issued as an IRAXXX, no contributions may be made for the taxable year in which you attain age 70 1/2 and thereafter (except for rollover contributions). The minimum additional payment which may be made to a Contract issued as an XXX is $50.00250.00. Any additional payment which would cause ACCUMULATION VALUE ALLOCATION RULES We reserve the Contract's Accumulation Value right to exceed $1,000,000 requires our prior approvalimpose a charge for any allocation change in excess of twelve per Contract Year. The Excess Allocation Charge is shown in the Schedule.Allocations into and out of the Guaranteed Interest Divisions are subject to restrictions (see General Account). ALLOCATION CHANGES BY TELEPHONE You may request allocation changes by telephone during our telephone request business hours. You may call our Customer Service Center at 1-800-366-0066 to make allocation changes by using the personal identification number you will receive. You may also mail any notice or request for allocation changes to our Customer Service Center at the address shown on the cover page. GA-IA-1090 IA-1082 3A2 THE SCHEDULE THE VARIABLE SEPARATE ACCOUNTS -------------------------------------------------------------------------------- |------------------------------------------------------------------------------| | Annuitant ------------------------------------------------------------------------------ |-----------------------------------------------------------------------------| |Annuitant Owner | | [XXXXXX |[XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Initial | |-----------------------------------------------------------------------------| |Initial Premium Annuity Option Annuity Commencement Date | | [$10,000Date| |[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Separate |-----------------------------------------------------------------------------| |Separate Account(s) Contract Number | | [SEPARATE |[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- |-----------------------------------------------------------------------------| DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND Separate Account B (the "Account") is a unit investment trust Separate Account, organized in and governed by the laws of the State of Delaware, our state of domicile. The Account is divided into Divisions. Each Division listed below invests in shares of the mutual fund portfolio (the "Series") designated. Each portfolio is a part of The GCG Trust managed by Directed Services, Inc. SERIES SERIES SERIES ------ ------ ------ [Eagle Value Equity PIMCO Core Bond MFS Research MFS Total Return Liquid Asset Janus Growth and Income The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolios are a part of the Prudential Series Fund, Inc. managed by Xxxxxxxx Associates, LLC. PORTFOLIO PORTFOLIO --------- --------- Prudential Xxxxxxxx (Class S) Prudential XX Xxxxxxxx International Growth (Class S) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolios are a part of the PIMCO Trust managed by Pacific Investment Management Company. PORTFOLIO --------- PIMCO VI High Yield Bond The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Aetna Variable Annuity Funds managed by Aeltus Investment Management, Inc. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- Aetna GET Fund (Class N) Aetna Index Plus Large Cap VP (Class S) Aetna Index Plus Small Cap VP (Class S) Aetna Value Opportunity VP (Class S) Aetna Index Plus Mid Cap VP (Class S) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Alliance Variable Products Series Fund, Inc. managed by Alliance Capital Management, L.P. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- AllianceBernstein Value (Class B) Alliance Growth and Income (Class B) Alliance Premier Growth (Class B) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Xxxxxxx Series Trust managed by Xxxxxxx Advisors, Inc.Alliance Capital Management, L.P. PORTFOLIO --------- Xxxxxxx Tactical Allocation (Class I) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Fidelity Variable Insurance Products Portfolio, managed by Fidelity Management & Research Co. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- Fidelity VIP Growth (Class S2) Fidelity VIP Equity-Income (Class S2) Fidelity VIP II Contrafund (Class S2) GA-IA-1090 3B 3B (CONT'D) THE SCHEDULE THE VARIABLE SEPARATE ACCOUNTS (continued) -------------------------------------------------------------------------------- |------------------------------------------------------------------------------| | Annuitant Owner | | [XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Separate Account(s) Contract Number | | [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Invesco Variable Investment Funds, Inc. managed by INVESCO. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- INVESCO VI Financial Services INVESCO VI Health Sciences INVESCO VI Utilities).

The Variable Separate Accounts. The General Account Valuation Period Accumulation Value Accumulation Value in each Division and Fixed Allocation Fixed Account Measurement of Investment Experience Charges Deducted from Accumulation Value on each Contract Processing Date Copies of any additional Riders and Endorsements are at the back of this Contract. THE SCHEDULE The Schedule The Schedule gives specific facts about this Contract and its coverage. Please refer to the Schedule while reading this Contract. GA-IA-1090 2 THE SCHEDULE PAYMENT AND INVESTMENT INFORMATION The Schedule Payment and Investment Information -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- | Annuitant Owner | | [XXXXXX Xxxxxx X. XXXXxx] [XXXX Xxxx X. XXXXxx] | |------------------------------------------------------------------------------| | -------------------------------------------------------------------------------- Annuitant's Issue Age Annuitant's Sex Owner's Issue Age | | [55] [MALEMale] [35] | |------------------------------------------------------------------------------| | -------------------------------------------------------------------------------- Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE Life 10-YEAR CERTAINYear Certain] [JANUARY January 1, 2026] | |------------------------------------------------------------------------------| | ------------------------------------------------------------------------------- Contract Date Issue Date Residence Status | | [JANUARY January 1, 1996] [JANUARY January 1, 1996] [DELAWARENew York] | |------------------------------------------------------------------------------| | -------------------------------------------------------------------------------- Schedule Date Benefit Option Package | | [JANUARY January 1, 1996] [III] | |------------------------------------------------------------------------------| | -------------------------------------------------------------------------------- Separate Account(s) Contract Number | | [SEPARATE ACCOUNT Separate Account NY-B AND THE FIXED ACCOUNT] and the Fixed Account [123456] | -------------------------------------------------------------------------------- INITIAL INVESTMENT Initial Premium Payment received: [$10,000] Your initial Accumulation Value has been invested as follows: Percentage of Divisions Accumulation Value --------- ------------------ [Eagle Value Equity 10% MFS Total Return 10% Liquid Asset 10% Alliance VP Premier Growth (Class B) 10% Fidelity VIP Growth (Class S) 10% INVESCO VI Health Sciences 10% Janus Aspen Worldwide Growth (Class S) 5% Pioneer VP Pioneer VP Pioneer Fund (Class II) 5% Xxxxxx XX International Growth & Income (Class B) 5% Xxxxxx XX Voyager II (Class B) 5% PPI MFS Capital Opportunities 5% Pilgrim VP Convertible Bond (Class S) 5% PIMCO Core Bond 595% Fixed Allocation - 1 Year Year] 5%] ----------------------------------------------- ------------------- --------------------------------------- -------------------------------- Total 100% ===== ==== GARLNY-IA-1090 IA-1080 3A1 THE SCHEDULE PAYMENT AND INVESTMENT INFORMATION The Schedule Payment and Investment Information (continued) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- | Annuitant Owner | | [XXXXXX Xxxxxx X. XXXXxx] [XXXX Xxxx X. XXXXxx] | |------------------------------------------------------------------------------| | Annuitant's Issue Age Annuitant's Sex Owner's Issue Age | | [55] [MALE] [35] | |------------------------------------------------------------------------------| | -------------------------------------------------------------------------------- Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE Life 10-YEAR CERTAINYear Certain] [JANUARY January 1, 2026] | |------------------------------------------------------------------------------| | Contract Date Issue Date Residence Status | | [JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE] | |------------------------------------------------------------------------------| | Schedule Date Benefit Option Package | | [JANUARY 1, 1996] [III] | |------------------------------------------------------------------------------| | -------------------------------------------------------------------------------- Separate Account(s) Contract Number | | [SEPARATE ACCOUNT Separate Account NY-B AND THE FIXED ACCOUNT] and the Fixed Account [123456] | -------------------------------------------------------------------------------- ADDITIONAL PREMIUM PAYMENT INFORMATION Except in the case of a Contract issued as an IRA, we will accept additional Premium Payments until either you or the Annuitant reaches the Attained Age of 86. The minimum additional payment which may be made is $500.00. If this Contract is issued as an IRA, no contributions may be made for the taxable year in which you attain age 70 1/2 and thereafter (except for rollover contributions). The minimum additional payment which may be made to a Contract issued as an IRA is $50.00. 50.00 Any additional payment which would cause the Contract's Accumulation Value to exceed $1,000,000 requires our prior approval. ALLOCATION CHANGES BY TELEPHONE You may request allocation changes by telephone during our telephone request business hours. You may call our Customer Service Center at 1RLNY-800-366-0066 to make allocation changes by using the personal identification number you will receive. You may also mail any notice or request for allocation changes to our Customer Service Center at the address shown on the cover page. GA-IA-1090 IA-1080 3A2 THE SCHEDULE THE VARIABLE SEPARATE ACCOUNTS The Schedule The General Account -------------------------------------------------------------------------------- |------------------------------------------------------------------------------| | -------------------------------------------------------------------------------- Annuitant Owner | | [XXXXXX Xxxxxx X. XXXXxx] [XXXX Xxxx X. XXXXxx] | |------------------------------------------------------------------------------| | -------------------------------------------------------------------------------- Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE Life 10-YEAR CERTAINYear Certain] [JANUARY January 1, 2026] | |------------------------------------------------------------------------------| | -------------------------------------------------------------------------------- Separate Account(s) Contract Number | | [SEPARATE ACCOUNT Separate Account NY-B AND THE FIXED ACCOUNT] and the Fixed Account [123456] | -------------------------------------------------------------------------------- DIVISIONS INVESTING IN SHARES OF General Account Guaranteed Interest Division A MUTUAL FUND Guaranteed Interest Division provides an annual minimum interest rate of 3%. At our sole discretion, we may periodically declare higher interest rates for specific Guarantee Periods. Such rates will apply to periods following the date of declaration. Any declaration will be by class and will be based on our future expectations. Limitations of Allocations We reserve the right to restrict allocations into and out of the General Account. Such limits may be dollar restrictions on allocations into the General Account or we may restrict reallocations into the General Account. Transfers from a Guaranteed Interest Division We currently require that an amount allocated to a Guarantee Period not be transferred until the Maturity Date, except pursuant to our published rules. We reserve the right not to allow amounts previously transferred from a Guaranteed Interest Division to the Variable Separate Account B (Divisions or to a Fixed Allocation to be transferred back to a Guaranteed Interest Division for a period of at least six months from the "Account") is a unit investment trust Separate Account, organized in and governed by the laws date of the State of Delaware, our state of domiciletransfer. RLNY-IA-1080 3B The Account is divided into Divisions. Each Division listed below invests in shares of the mutual fund portfolio (the "Series") designated. Each portfolio is a part of The GCG Trust managed by Directed Services, Inc. SERIES SERIES SERIES ------ ------ ------ [Eagle Value Equity PIMCO Core Bond MFS Research MFS Total Return Liquid Asset Janus Growth and Income The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolios are a part of the Prudential Series Fund, Inc. managed by Xxxxxxxx Associates, LLC. PORTFOLIO PORTFOLIO --------- --------- Prudential Xxxxxxxx (Class S) Prudential XX Xxxxxxxx International Growth (Class S) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolios are a part of the PIMCO Trust managed by Pacific Investment Management Company. PORTFOLIO --------- PIMCO VI High Yield Bond The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Aetna Variable Annuity Funds managed by Aeltus Investment Management, Inc. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- Aetna GET Fund (Class N) Aetna Index Plus Large Cap VP (Class S) Aetna Index Plus Small Cap VP (Class S) Aetna Value Opportunity VP (Class S) Aetna Index Plus Mid Cap VP (Class S) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Alliance Variable Products Series Fund, Inc. managed by Alliance Capital Management, L.P. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- AllianceBernstein Value (Class B) Alliance Growth and Income (Class B) Alliance Premier Growth (Class B) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Xxxxxxx Series Trust managed by Xxxxxxx Advisors, Inc.Alliance Capital Management, L.P. PORTFOLIO --------- Xxxxxxx Tactical Allocation (Class I) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Fidelity Variable Insurance Products Portfolio, managed by Fidelity Management & Research Co. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- Fidelity VIP Growth (Class S2) Fidelity VIP Equity-Income (Class S2) Fidelity VIP II Contrafund (Class S2) GA-IA-1090 3B 3B (CONT'D) THE SCHEDULE THE VARIABLE SEPARATE ACCOUNTS (continued) Schedule Contract Facts -------------------------------------------------------------------------------- |------------------------------------------------------------------------------| | Annuitant Owner | | [XXXXXX Xxxxxx X. XXXXxx] [XXXX Xxxx X. XXXXxx] | |------------------------------------------------------------------------------| | -------------------------------------------------------------------------------- Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE Life 10-YEAR CERTAINYear Certain] [JANUARY January 1, 2026] | |------------------------------------------------------------------------------| | -------------------------------------------------------------------------------- Separate Account(s) Contract Number | | [SEPARATE ACCOUNT Separate Account NY-B AND THE FIXED ACCOUNT] and the Fixed Account [123456] | -------------------------------------------------------------------------------- The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Invesco Variable Investment Funds, Inc. managed by INVESCO. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- INVESCO VI Financial Services INVESCO VI Health Sciences INVESCO VI Utilities]

The Variable Separate Accounts. The General Account Valuation Period Accumulation Value Accumulation Value in each Division and Fixed Allocation Fixed Account Measurement of Investment Experience Charges Deducted from Accumulation Value on each Contract Processing Date Copies of any additional Riders and Endorsements are at the back of this Contract. THE SCHEDULE The Schedule gives specific facts about this Contract and its coverage. Please refer to the Schedule while reading this Contract. GA-IA-1090 IA-1083 2 THE SCHEDULE PAYMENT AND INVESTMENT INFORMATION -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- | Annuitant ------------------------------------------------------------------------------- |-----------------------------------------------------------------------------| |Annuitant Owner | | [XXXXXX |[XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Annuitant|-----------------------------------------------------------------------------| |Annuitant's Issue Age Annuitant's Sex Owner's Issue Age | | [55] [MALE] [35] | |------------------------------------------------------------------------------| | Initial |-----------------------------------------------------------------------------| |Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Contract |-----------------------------------------------------------------------------| |Contract Date Issue Date Residence Status | | [JANUARY 1, 1996] [JANUARY 1, 19961996 ] [DELAWARE] | |------------------------------------------------------------------------------| | Schedule Date Benefit Option Package | | [JANUARY 1, 1996] [III] | |------------------------------------------------------------------------------| | Separate |-----------------------------------------------------------------------------| |Separate Account(s) Contract Number | | [SEPARATE ACCOUNT B AND THE FIXED ACCOUNTB] [123456] | -------------------------------------------------------------------------------- |-----------------------------------------------------------------------------| INITIAL INVESTMENT Initial Premium Payment received: [$10,000] Your initial Accumulation Value has been invested as follows: Percentage of Divisions Accumulation Value --------- ------------------ [Eagle Equity Income 10% Fully Managed 10% Capital Appreciation 10% Rising Dividends 10% Growth 10% Real Estate 10% Value Equity 10% MFS Total Return 10Hard Assets 5% Emerging Markets 5% Managed Global 5% Limited Maturity Bond 5% Liquid Asset 10% Alliance VP Premier Growth (Class B) 10% Fidelity VIP Growth (Class S) 10% INVESCO VI Health Sciences 10% Janus Aspen Worldwide Growth (Class S) 5% Pioneer VP Pioneer VP Pioneer Fund (Class II) 5% Xxxxxx XX International Growth & Income (Class B) 5% Xxxxxx XX Voyager II (Class B) 5% PPI MFS Capital Opportunities 5% Pilgrim VP Convertible Bond (Class S) 5% PIMCO Core Bond 5% Fixed Allocation - 1 Year Strategic Equity 5%] ----------------------------------------------- ------------------- ------------------------------ -------------------------- Total 100% ===== ==== GA-IA-1090 3A1 THE SCHEDULE PAYMENT AND INVESTMENT INFORMATION (continued) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- | Annuitant Owner | | [XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Annuitant's Issue Age Annuitant's Sex Owner's Issue Age | | [55] [MALE] [35] | |------------------------------------------------------------------------------| | Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Contract Date Issue Date Residence Status | | [JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE] | |------------------------------------------------------------------------------| | Schedule Date Benefit Option Package | | [JANUARY 1, 1996] [III] | |------------------------------------------------------------------------------| | Separate Account(s) Contract Number | | [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- ADDITIONAL PREMIUM PAYMENT INFORMATION Except in the case of a Contract issued as an IRA, we will accept additional Premium Payments until either you or the Annuitant reaches the Attained Age of 86. If this Contract is issued as an IRA, no contributions may be made for the taxable year in which you attain age 70 1/2 and thereafter (except for rollover contributions). The minimum additional payment which may be made is $50.00. Any additional payment which would cause the Contract's Accumulation Value to exceed $1,000,000 requires our prior approval. ALLOCATION CHANGES BY TELEPHONE You may request allocation changes by telephone during our telephone request business hours. You may call our Customer Service Center at 1-800-366-0066 to make allocation changes by using the personal identification number you will receive. You may also mail any notice or request for allocation changes to our Customer Service Center at the address shown on the cover page. GA-IA-1090 3A2 THE SCHEDULE THE VARIABLE SEPARATE ACCOUNTS -------------------------------------------------------------------------------- |------------------------------------------------------------------------------| | Annuitant Owner | | [XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Separate Account(s) Contract Number | | [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND Separate Account B (the "Account") is a unit investment trust Separate Account, organized in and governed by the laws of the State of Delaware, our state of domicile. The Account is divided into Divisions. Each Division listed below invests in shares of the mutual fund portfolio (the "Series") designated. Each portfolio is a part of The GCG Trust managed by Directed Services, Inc. SERIES SERIES SERIES ------ ------ ------ [Eagle Value Equity PIMCO Core Bond MFS Research MFS Total Return Liquid Asset Janus Growth and Income The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolios are a part of the Prudential Series Fund, Inc. managed by Xxxxxxxx Associates, LLC. PORTFOLIO PORTFOLIO --------- --------- Prudential Xxxxxxxx (Class S) Prudential XX Xxxxxxxx International Growth (Class S) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolios are a part of the PIMCO Trust managed by Pacific Investment Management Company. PORTFOLIO --------- PIMCO VI High Yield Bond The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Aetna Variable Annuity Funds managed by Aeltus Investment Management, Inc. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- Aetna GET Fund (Class N) Aetna Index Plus Large Cap VP (Class S) Aetna Index Plus Small Cap VP (Class S) Aetna Value Opportunity VP (Class S) Aetna Index Plus Mid Cap VP (Class S) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Alliance Variable Products Series Fund, Inc. managed by Alliance Capital Management, L.P. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- AllianceBernstein Value (Class B) Alliance Growth and Income (Class B) Alliance Premier Growth (Class B) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Xxxxxxx Series Trust managed by Xxxxxxx Advisors, Inc.Alliance Capital Management, L.P. PORTFOLIO --------- Xxxxxxx Tactical Allocation (Class I) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Fidelity Variable Insurance Products Portfolio, managed by Fidelity Management & Research Co. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- Fidelity VIP Growth (Class S2) Fidelity VIP Equity-Income (Class S2) Fidelity VIP II Contrafund (Class S2) GA-IA-1090 3B 3B (CONT'D) THE SCHEDULE THE VARIABLE SEPARATE ACCOUNTS (continued) -------------------------------------------------------------------------------- |------------------------------------------------------------------------------| | Annuitant Owner | | [XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Separate Account(s) Contract Number | | [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Invesco Variable Investment Funds, Inc. managed by INVESCO. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- INVESCO VI Financial Services INVESCO VI Health Sciences INVESCO VI Utilities----- ----

The Variable Separate Accounts. The General Account Valuation Period Accumulation Value Accumulation Value in each Division and Fixed Allocation Fixed Account Measurement of Investment Experience Charges Deducted from Accumulation Value on each Contract Processing Date Copies of any additional Riders and Endorsements are at the back of this Contract. THE SCHEDULE The Schedule gives specific facts about this Contract and its coverage. Please refer to the Schedule while reading this Contract. GA-IA-1090 IA-1082 2 THE SCHEDULE PAYMENT AND INVESTMENT INFORMATION -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- | Annuitant ------------------------------------------------------------------------------- |-----------------------------------------------------------------------------| |Annuitant Owner | | [XXXXXX X. XXX|[THOMAS J. DOE] [XXXX X. XXXJOHN Q. DOE] | |------------------------------------------------------------------------------| | Annuitant|-----------------------------------------------------------------------------| |Annuitant's Issue Age Annuitant's Sex Owner's Issue Age | | [55] [MALE] [35] | |------------------------------------------------------------------------------| | Initial |-----------------------------------------------------------------------------| |Initial Premium Annuity Option Annuity Commencement Date | | [$10,000|[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Contract |-----------------------------------------------------------------------------| |Contract Date Issue Date Residence Status | | [JANUARY |[JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE] | |------------------------------------------------------------------------------| | Schedule Date Benefit Option Package | | [JANUARY 1, 1996] [III] | |------------------------------------------------------------------------------| | Separate |-----------------------------------------------------------------------------| |Separate Account(s) Contract Number | | [SEPARATE |[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- |-----------------------------------------------------------------------------| INITIAL INVESTMENT Initial Premium Payment received: [$10,000] Your initial Accumulation Value has been invested as follows: Percentage of Divisions Accumulation Value --------- ------------------ [Eagle Equity Income 10% Fully Managed 10% Capital Appreciation 10% Rising Dividends 10% Growth 10% Real Estate 10% Value Equity 105% MFS Total Return 10Hard Assets 5% Emerging Markets 5% Managed Global 5% Limited Maturity Bond 5% Liquid Asset 10% Alliance VP Premier Growth (Class B) 10% Fidelity VIP Growth (Class S) 10% INVESCO VI Health Sciences 10% Janus Aspen Worldwide Growth (Class S) 5% Pioneer VP Pioneer VP Pioneer Fund (Class II) 5% Xxxxxx XX International Growth & Income (Class B) 5% Xxxxxx XX Voyager II (Class B) 5% PPI MFS Capital Opportunities 5% Pilgrim VP Convertible Bond (Class S) 5% PIMCO Core Bond Strategic Equity 5% Fixed Allocation - 1 Year 5%] ----------------------------------------------- ------------------- -------------------------------- ------------------------------------ Total 100% ===== ==== GA-IA-1090 IA-1082 3A1 THE SCHEDULE PAYMENT AND INVESTMENT INFORMATION (continued) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- | Annuitant ------------------------------------------------------------------------------- |-----------------------------------------------------------------------------| |Annuitant Owner | | [XXXXXX X. XXX|[THOMAS J. DOE] [XXXX X. XXXJOHN Q. DOE] | |------------------------------------------------------------------------------| | Annuitant|-----------------------------------------------------------------------------| |Annuitant's Issue Age Annuitant's Sex Owner's Issue Age | | [55] [MALE] [35] | |------------------------------------------------------------------------------| | Initial |-----------------------------------------------------------------------------| |Initial Premium Annuity Option Annuity Commencement Date | | [$10,000|[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Contract |-----------------------------------------------------------------------------| |Contract Date Issue Date Residence Status | | [JANUARY |[JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE] | |------------------------------------------------------------------------------| | Schedule Date Benefit Option Package | | [JANUARY 1, 1996] [III] | |------------------------------------------------------------------------------| | Separate |-----------------------------------------------------------------------------| |Separate Account(s) Contract Number | | [SEPARATE |[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- |-----------------------------------------------------------------------------| ADDITIONAL PREMIUM PAYMENT INFORMATION Except in the case of a Contract issued as an IRA, we will accept additional Premium Payments Payxxxts until either you or the Annuitant or Owner reaches the Attained Age of [86]. The minimum additional payment which may be made is $[500.00]. If this Contract is issued as an IRA, no contributions may be made for the taxable xxxable year in which you attain age 70 1/2 and thereafter (except for rollover contributions). The minimum additional payment which may be made to a Contract issued as an IRA is $50.00250.00. Any additional payment which would cause ACCUMULATION VALUE ALLOCAXXXN RULES We reserve the Contract's Accumulation Value right to exceed $1,000,000 requires our prior approvalimpose a charge for any allocation change in excess of twelve per Contract Year. The Excess Allocation Charge is shown in the Schedule.Allocations into and out of the Guaranteed Interest Divisions are subject to restrictions (see General Account). ALLOCATION CHANGES BY TELEPHONE You may request allocation changes by telephone during our telephone request business hours. You may call our Customer Service Center at 1-800-366-0066 to make allocation changes by using the personal identification number you will receive. You may also mail any notice or request for allocation changes to our Customer Service Center at the address shown on the cover page. GA-IA-1090 IA-1082 3A2 THE SCHEDULE THE VARIABLE SEPARATE ACCOUNTS -------------------------------------------------------------------------------- |------------------------------------------------------------------------------| | Annuitant ------------------------------------------------------------------------------ |-----------------------------------------------------------------------------| |Annuitant Owner | | [XXXXXX X. XXX|[THOMAS J. DOE] [XXXX X. XXXJOHN Q. DOE] | |------------------------------------------------------------------------------| | Initial | |-----------------------------------------------------------------------------| |Initial Premium Annuity Option Annuity Commencement Date | | [$10,000Date| |[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Separate |-----------------------------------------------------------------------------| |Separate Account(s) Contract Number | | [SEPARATE |[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- |-----------------------------------------------------------------------------| DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND Separate Account B (the "Account") is a unit investment trust Separate Account, organized in and governed by the laws of the State of Delaware, our state of domicile. The Account is divided into Divisions. Each Division listed below invests in shares of the mutual fund portfolio (the "Series") designated. Each portfolio is a part of The GCG Trust managed by Directed Services, Inc. SERIES SERIES SERIES ------ ------ ------ [Eagle Value Equity PIMCO Core Bond MFS Research MFS Total Return Liquid Asset Janus Growth and Income The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolios are a part of the Prudential Series Fund, Inc. managed by Xxxxxxxx Associates, LLC. PORTFOLIO PORTFOLIO --------- --------- Prudential Xxxxxxxx (Class S) Prudential XX Xxxxxxxx International Growth (Class S) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolios are a part of the PIMCO Trust managed by Pacific Investment Management Company. PORTFOLIO --------- PIMCO VI High Yield Bond The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Aetna Variable Annuity Funds managed by Aeltus Investment Management, Inc. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- Aetna GET Fund (Class N) Aetna Index Plus Large Cap VP (Class S) Aetna Index Plus Small Cap VP (Class S) Aetna Value Opportunity VP (Class S) Aetna Index Plus Mid Cap VP (Class S) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Alliance Variable Products Series Fund, Inc. managed by Alliance Capital Management, L.P. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- AllianceBernstein Value (Class B) Alliance Growth and Income (Class B) Alliance Premier Growth (Class B) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Xxxxxxx Series Trust managed by Xxxxxxx Advisors, Inc.Alliance Capital Management, L.P. PORTFOLIO --------- Xxxxxxx Tactical Allocation (Class I) The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Fidelity Variable Insurance Products Portfolio, managed by Fidelity Management & Research Co. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- Fidelity VIP Growth (Class S2) Fidelity VIP Equity-Income (Class S2) Fidelity VIP II Contrafund (Class S2) GA-IA-1090 3B 3B (CONT'D) THE SCHEDULE THE VARIABLE SEPARATE ACCOUNTS (continued) -------------------------------------------------------------------------------- |------------------------------------------------------------------------------| | Annuitant Owner | | [XXXXXX X. XXX] [XXXX X. XXX] | |------------------------------------------------------------------------------| | Initial Premium Annuity Option Annuity Commencement Date | | [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] | |------------------------------------------------------------------------------| | Separate Account(s) Contract Number | | [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] | -------------------------------------------------------------------------------- The Division listed below invests in shares of the mutual fund portfolio (the "Portfolio") designated. The portfolio is a part of the Invesco Variable Investment Funds, Inc. managed by INVESCO. PORTFOLIO PORTFOLIO PORTFOLIO --------- --------- --------- INVESCO VI Financial Services INVESCO VI Health Sciences INVESCO VI Utilities).