PLEASE READ THIS CONTRACT CAREFULLY
THE DEATH BENEFIT AND CONTRACT VALUE, WHEN BASED ON THE INVESTMENT PERFORMANCE
OF THE VARIABLE ACCOUNT, MAY INCREASE OR DECREASE AND ARE NOT GUARANTEED AS TO A
FIXED DOLLAR AMOUNT. PLEASE REFER TO THE VARIABLE ACCOUNT AND DEATH BENEFIT
SECTIONS FOR ADDITIONAL INFORMATION. WE AGREE TO PAY THE BENEFITS OF THIS
CONTRACT IN ACCORDANCE WITH ITS TERMS.
RIGHT TO CANCEL
We want you to be satisfied with the contract you have purchased and we urge you
to examine it closely. If for any reason you are not satisfied, you may return
the contract to us or an authorized representative within 10 days after receipt
of the contract.
If you return the contract, it will be void from the Date of Issue, and you will
receive a refund equal to the total of:
1. the difference between any payments made, including fees or any other
charges, and the amounts allocated to the Variable Account;
2. the value of the amounts in the Variable Account on the date the
returned contract is received at our Principal Office; and
3. any fees or other charges imposed on amounts in the Variable Account.
FIRST ALLMERICA FINANCIAL LIFE INSURANCE COMPANY
Home Office: Dover, Delaware
Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000
This is a legal contract between Allmerica Financial Life Insurance and Annuity
Company and the owner. It is issued in consideration of the payment shown on the
Specifications Page.
President Secretary
MODIFIED SINGLE PAYMENT VARIABLE LIFE INSURANCE CONTRACT
NON-PARTICIPATING
FORM 1036-96
TABLE OF CONTENTS
SPECIFICATIONS 3
DEFINITIONS 7
GENERAL TERMS 9
INFORMATION ABOUT YOU AND THE BENEFICIARY 11
WHAT YOU SHOULD KNOW ABOUT:
THE PAYMENTS 12
YOUR CONTRACT VALUE 14
THE VARIABLE ACCOUNT 16
THE FIXED ACCOUNT 19
TRANSFERS 21
BORROWING FROM YOUR CONTRACT 22
SURRENDERS AND PARTIAL WITHDRAWALS 23
THE DEATH BENEFIT 25
THE BENEFIT OPTIONS 26
FORM 1030-96 2
SPECIFICATIONS
Contract Number: Specimen
----------------------------------------------------------------------------------------------------------------------
[First] Insured: Xxxx Xxx [First] Insured's Sex: Male
[First] Insured's Age: 35 [First] Insured's Underwriting Risk Class: Non-Smoker
----------------------------------------------------------------------------------------------------------------------
[Second Insured:] [Second Insured's Sex:]
[Second Insured's Age:] [Second Insured's Underwriting Risk Class:]
----------------------------------------------------------------------------------------------------------------------
Date of Issue: 08/20/96 Contract Plan: Modified Single
Payment Variable Life
Insurance Contract
Face Amount: $318,554 Monthly Processing Date: 1st of each month
Owner(s): Xxxx Xxx Rider: Living Benefits Rider
Beneficiary at Issue: Xxxx Xxx Rider Date of Issue: 08/20/96
----------------------------------------------------------------------------------------------------------------------
Payment: $50,000
Maximum Payment: The greater of [$50,000] or [$4,123.06] times the current contract year.
Final Payment Date: 08/20/60
Initial Payment Allocation:
VARIABLE SUB-ACCOUNTS
---------------------
Select Emerging Markets Allmerica Equity Index
FT VIP Xxxxxxxxx Foreign Securities Fidelity VIP Growth
Xxxxxxxxxxx Global Securities FT VIP Franklin Large Cap Growth
Select International Equity Xxxxxxxxxxx Capital Appreciation
AIM V.I. Aggressive Growth Select Aggresssive Growth
AllianceBernstein Small Cap Value Select Growth
Fidelity VIP Value Strategies AIM V.I. Basic Value
FT VIP Small Cap AllianceBernstein Value
FT VIP Small Cap Value Securities Alliance Growth & Income
MFS New Discovery Fidelity VIP Contrafund
Select Strategic Growth Fidelity Equity Income
Mid Cap Equity MFS Total Return
AIM V.I. Capital Development MFS Utilities
FORM 9030-96 3
VARIABLE SUB-ACCOUNTS
---------------------
Fidelity VIP III Mid Cap Xxxxxxxxxxx Main Street Growth & Income
FT VIP Mutual Shares Securities Xxxxxxxxxxx Multiple Strategies
MFS Mid Cap Growth Select Growth & Income
Select Capital Appreciation Xxxxxxxxxxx High Income
Select Value Opportunity Fixed Income
AIM V.I. Blue Chip Allmerica Government Securities
AIM V.I. Premier Equity Select Investment Grade Income
Alliance Technology Select Strategic Income
Allmerica Core Equity Alliance Premier Growth Allmerica Money Market
FIXED ACCOUNT:
--------------
10% Initial Interest Rate: [4%]
3.1
[First Insured: Xxxx Xxx Contract Number: Specimen
[Second Insured:]
-----------------------------------------------------------------------------------------------------------------------
Minimum Additional Payment: [$10,000]
Minimum Fixed Account Interest Rate: [4% of value not subject to Outstanding Loan]
[4% of value securing Outstanding Loan - not preferred loan]
[5 1/2% of value securing Outstanding Loan - preferred loan]
Outstanding Loan Interest Rate [6%]
Maximum Loan Amount: 90% of Surrender Value
Minimum Loan Amount: [$1.000]
Minimum Balance After Withdrawal: [$25,000]
Free Withdrawal Amount: [10% of Contract Value]
Fees and Deductions: CURRENT GUARANTEED
Administration Charge: [0.25%] Annually (1) [0.25%] Annually (1)
Distribution Fee (Contract Years 1 - 10): [1.15%] Annually (1) [1.15%] Annually (1)
Federal & State Payment Tax Charge (Contract years 1 - 10): [1.75%] Annually (1) [1.75%] Annually (1)
Insurance Protection Charge: [0.50%] Annually (1) See Page 5
Mortality & Expense Risk Charge: [0.90%] Annually (2) [0.90%] Annually (2)
Monthly Maintenance Fee: [$5.00] Monthly (3) [$5.00] Monthly (3)
(1) This charge is deducted monthly from the Contract Value on a Pro Rata
basis. The monthly charge is equal to one-twelfth of this factor times
the Contact Value.
(2) This charge is deducted daily from the Variable Accounts on a pro
rata basis.
(3) This charge is deducted only when the Contract Value is less than
[$25,000.]
If you have any questions, need information about your coverage or require
assistance, please call our Principal Office. The number is [(000)000-0000].
4
[First] Insured: Xxxx Xxx Contract Number: Specimen
[Second Insured:]
GUARANTEED MAXIMUM MONTHLY INSURANCE PROTECTION RATE TABLE
[AGE] [AGE]
[AGE YOUNGER INSURANCE PROTECTION [AGE YOUNGER INSURANCE PROTECTION
INSURED] RATE PER $1,000 INSURED] RATE PER $1,000
------------------------------------------------------------------------------------------------
35 0.14 65 1.87
36 0.15 66 2.07
37 0.16 67 2.29
38 0.17 68 2.53
39 0.18 69 2.79
40 0.19 70 3.09
41 0.21 71 3.44
42 0.22 72 3.83
43 0.24 73 4.29
44 0.26 74 4.79
45 0.28 75 5.33
46 0.31 76 5.90
47 0.33 77 6.51
48 0.36 78 7.15
49 0.39 79 7.84
50 0.42 80 8.62
51 0.46 81 9.49
52 0.51 82 10.50
53 0.56 83 11.62
54 0.62 84 12.86
55 0.68 85 14.17
56 0.75 86 15.56
57 0.83 87 17.00
58 0.91 88 18.48
59 1.01 89 20.04
60 1.11 90 21.69
61 1.23 91 23.48
62 1.36 92 25.50
63 1.51 93 27.96
64 1.69 94 31.38
95 36.79
96 46.58
97 67.04
98 83.33
99 83.33
[Note: Single life, Male, Age 35, Non-smoker]
[Based on 1980 CSO Age Last Birthday Table]
5
[First] Insured: Xxxx Xxx Contract Number: Specimen
[Second Insured:]
GUIDELINE MINIMUM SUM INSURED TABLE
[AGE] [AGE]
YOUNGER INSURED [YOUNGER INSURED
AGE] PERCENTAGE AGE] PERCENTAGE
---------------------------------------------------------------------------------
[thru 40 250% 60 130%
41 243% 61 128%
42 236% 62 126%
43 229% 63 124%
44 222% 64 122%
45 215% 65 120%
46 209% 66 119%
47 203% 67 118%
48 197% 68 117%
49 191% 69 116%
50 185% 70 115%
51 178% 71 113%
52 171% 72 111%
53 164% 73 109%
54 157% 74 107%
55 150% 75 thru 90 105%
56 146% 91 104%
57 142% 92 103%
58 138% 93 102%
59 134% 94 101%
95 and over 100%]
SURRENDER CHARGE TABLE (PERCENT OF TOTAL PAYMENTS WITHDRAWN)
CONTRACT CONTINGENT DEFERRED UNRECOVERED TOTAL
YEAR* SALES LOAD PAYMENT TAX SURRENDER CHARGE
------------------------------------------------------------------------------------
[1 7.5% 2.25% 9.75%
2 7.5% 2.00% 9.50%
3 6.0% 1.75% 7.75%
4 6.0% 1.25% 7.50%
5 4.5% 1.25% 5.75%
6 4.5% 1.00% 5.50%
7 3.0% 0.75% 3.75%
8 3.0% 0.50% 3.50%
9 1.5% 0.25% 1.75%
10 0% 0% 0%]
*For a contract that lapses and is restored, see Reinstatement provisions.
6
DEFINITIONS
AGE means how old the Insured is on his/her last
birthday measured on the Date of Issue and
each contract anniversary.
APPLICATION is the form you complete to apply for this
contract. It contains your payment, payment
allocation and other information that enable
us to prepare this contract. If a medical
questionnaire or other forms are required,
they become a part of the application. It is
signed by you and the Insured and becomes a
part of this contract.
ASSIGNEE is the person to whom you have transferred
your ownership of this contract.
COMPANY means Allmerica Financial Life Insurance and
Annuity Company, also referred to as we, our,
and us.
CONTRACT CHANGE means any change in the Underwriting Risk
Class or the addition or deletion of a Rider.
CONTRACT VALUE is the sum of your values in the Variable
Account and the Fixed Account.
DATE OF ISSUE is stated on the Specifications
Page. Contract months, years and
anniversaries are measured from this date.
EARNINGS means the amount by which the Contract Value
exceeds the sum of the payments made less any
payments that were previously considered
withdrawn. Earnings are calculated on each
Monthly Processing Date.
EVIDENCE OF INSURABILITY is the information, including
medical information, that we use to decide
the Underwriting Risk Class of the Insured.
FACE AMOUNT is the amount of insurance coverage.
The Face Amount is shown on the
Specifications P e death benefit is based on
the Face Amount; see the Death Benefit
section.
FINAL PAYMENT DATE is the contract anniversary
before the insured's (younger insured's)
100th birthday. This date is shown on the
Specifications Page. The net death benefit
after this date will equal the Contract Value
minus any Outstanding Loan.
FIXED ACCOUNT is the part of the Company's General Account
to which all or a portion of a payment or
transfer may be allocated.
FUND is a separate investment series for
investment by a Sub-Account of the Variable
Account.
GENERAL ACCOUNT is the assets of the Company that are not
allocated to a Separate Account.
INSURANCE PROTECTION is the death benefit minus the Contract
AMOUNT Value.
INSURED is the person or persons covered as indicated
on the Specifications Page. If more than one
person is named, all provisions of the
Contract that are based on the death of the
"Insured" will be based on the date of death
of the last survivor of the persons named.
FORM 1030-96 7
MONTHLY INSURANCE is the amount of money that we deduct from
PROTECTION CHARGE the Contract Value each month to pay for the
insurance.
MONTHLY PROCESSING DATE is the date the monthly
charges are deducted from the Contract Value.
This date is shown on the Specifications
Page. If the Company is not open on this
date, the Monthly Processing Date will be the
next business date.
OUTSTANDING LOAN means all unpaid contract loans plus interest
due or accrued on such loans.
PRINCIPAL OFFICE is the Company's office at 000 Xxxxxxx
Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx, 00000.
PRO RATA refers to an allocation among the
Sub-Accounts of the Variable Account and the
Fixed Account. A Pro Rata allocation will be
in the same proportion that the Contract
Value in each Sub-Account of the Variable
Account and the Contract Value in the Fixed
Account (other than value that is subject to
Outstanding Loan) have to the total Contract
Value.
RIDER is an optional benefit that may be added to
your contract.
SEPARATE ACCOUNT is a segregated account established
by the Company. The assets are not commingled
with the Company's general assets.
SPECIFICATIONS PAGES contain information specific to your contract
and are located after the Table of Contents.
SUB-ACCOUNTS are subdivisions of the Variable Account
investing exclusively in the shares of one or
more Funds.
UNDERWRITING RISK CLASS means the insurance risk classification that
we assign to the Insured based on the
information in the Application
and any other Evidence of Insurability we
obtain. The Underwriting Risk Class affects
the Monthly Insurance Protection Charge.
VARIABLE ACCOUNT is the Company's Separate Account,
consisting of Sub-Accounts that invest in the
underlying Funds.
WRITTEN REQUEST is a request you make in written form that is
satisfactory to us and filed at our
Principal Office.
YOU OR YOUR means the owner of this contract as shown in
the Application or in the latest change
filed with us.
8
GENERAL TERMS
ENTIRE CONTRACT This contract, with a copy of the
Application, and any attached endorsements,
is the entire contract between you and us.
The entire contract also includes: a copy of
any Application to change to a better
Underwriting Risk Class, any new
Specifications Pages, and any supplemental
pages issued.
We assume that the information you and the
Insured provide in any Application is
accurate and complete to the best of your
knowledge. If we contest this contract or
deny a claim, we may use only the information
you and the Insured provided in an
Application. Our representatives are not
permitted to change this contract or extend
the time for making payments. Only our
President, a Vice President or Secretary may
change the provisions of this contract, and
then only in writing.
RIGHT TO CONTEST THE A contest is any action taken by us to cancel
CONTRACT IS LIMITED your insurance or deny a claim based on
untrue or incomplete answers in your
Application. We cannot contest the Face
Amount of the contract if it has been in
force for two
years from the Date of Issue and the Insured
is alive at the end of this two-year period.
If the Underwriting Risk Class is changed at
your request, we cannot contest the change
after it has been in force for two years from
its effective date and the Insured is alive.
NON-PARTICIPATING No insurance dividends will be paid on this
contract.
ADJUSTMENT OF INTEREST We determine the Fixed Account interest rates
RATES used to calculate the Contract Value,
subject to the guarantees on the
Specifications Page. Any changes in these
rates will be based on changes in our future
expectations for our investment earnings.
SUICIDE EXCLUSION If an Insured, while sane or insane, commits
suicide within two years of the Date of Issue
of this contract, we will not pay a death
benefit. The beneficiary will receive only
the total amount of payments made to us less
any Outstanding Loan and amounts withdrawn.
NOTICE OF FIRST TO DIE In the case of second-to-die insurance, upon
the death of the Insured who dies first, the
owner agrees to mail to the Principal Office,
within 90 days of the date of death, or as
soon thereafter as is reasonably possible,
proof of death.
MISSTATEMENT OF AGE OR On the date of death of the insured, the
SEX death benefit will be reduced or increased if
the Age or sex is misstated. The adjustment
will be based upon the ratio of the Maximum
Payment for this contract to the Maximum
Payment for the contract issued at the
correct Age or sex.
PROTECTION OF BENEFITS To the extent allowed by law, the benefits
provided by this contract cannot be
reached by the beneficiary's creditors. No
beneficiary may assign, transfer, anticipate,
or encumber the Contract Value or benefit
unless you give them this right.
PERIODIC REPORT We will mail a report to you at your
last know address at least once a year. This
report will provide the following
information:
- Contract Values in each Sub-Account and
in the Fixed Account;
- the value of the contract if
surrendered;
9
- payments made by you and charges
deducted by us since the last report;
- the Outstanding Loan and any other
information required by law; and
- the death benefit.
10
INFORMATION ABOUT YOU AND THE BENEFICIARY
OWNER The owner of the contract is shown on the
Specifications Page. The owner may change the
ownership of this contract without the
consent of any beneficiary. However, an
irrevocable beneficiary must agree to the
change in writing.
ASSIGNMENT You may change the ownership of this contract
by sending us a Written Request. An absolute
assignment will transfer ownership of the
contract from you to another person called
the Assignee.
You may also assign this contract as
collateral to a collateral Assignee. The
limitations on your ownership rights while a
collateral assignment is in effect are
specified in the assignment.
An assignment will take place only when the
Written Request is recorded at our Principal
Office. When recorded, it will take effect on
the date it was signed by you. Any rights
created by the assignment will be subject to
any payments made or actions taken by us
before the change is recorded. We are not
responsible for assuring that any assignment
or any Assignee's interest is valid.
BENEFICIARY You name the beneficiary to receive the net
death benefit. The beneficiary's interest
will be affected by any assignment you make.
If you assign this contract as collateral,
all or a portion of the net death benefit
will first be paid to the collateral
Assignee; any money left over from the amount
due the Assignee will go to those otherwise
entitled.
Your choice of beneficiary may be revocable
or irrevocable. You may change a revocable
beneficiary at any time by Written Request;
but an irrevocable beneficiary must agree to
any change in writing. You will also need an
irrevocable beneficiary's permission to
exercise other rights and options granted by
this contract. Unless you have asked
otherwise, the beneficiary will be revocable.
Any change of the beneficiary must be made
while the Insured is living. This change will
take place on the date the request is signed,
even if the Insured is not living on the day
we receive it at the Principal Office. Any
rights created by the change will be subject
to any payments made, or actions taken,
before we receive the Written Request.
If a beneficiary dies before the Insured, his
or her interest in this contract will pass to
any surviving beneficiaries in proportion to
their share in the net death benefit, unless
you have requested otherwise. If all
beneficiaries die before the Insured, the net
death benefit will pass to you or your
estate.
COMMON DISASTER The common disaster option may be elected by
OPTION Written Request. If the common disaster
option is in effect on the date of the
Insured's death, the beneficiary must be
alive a certain number of days following the
Insured's date of death in order to be
entitled to receive a benefit. Otherwise, we
will pay the net death benefit as though the
beneficiary died before the Insured. The
number of days that the beneficiary must
live after the Insured's death is selected
by you when you elect the common disaster
option.
11
WHAT YOU SHOULD KNOW ABOUT THE PAYMENTS
PAYMENTS This contract will not be in force until the
payment is made to us. The payment must be
sent to either our Principal Office or an
authorized representative. If you request it
in writing, we will send you a signed receipt
after the payment is received.
Additional payments under the contract will
be permitted prior to the Final Payment Date
only under the following circumstances:
1. An additional payment is required to
keep the contract in force subject to
the Grace Period provisions.
2. An additional payment is required for
reinstatement.
3. Additional payments may be made at any
time provided total payments do not
exceed the Maximum Payment shown on the
Specifications Page. The minimum amount
of the additional payment is indicated
on the Specifications Page. We may
require Evidence of Insurability if the
additional payment would increase the
net death benefit. A payment received
while there is an Outstanding Loan on
the contract will be considered a loan
repayment rather than an additional
payment.
This contract will terminate 62 days after a
Monthly Processing Date on which the
surrender value is less than zero. The 62 day
period is a grace period. At least 61 days
before the end of the grace period, we will
mail the owner and any Assignee written
notice of the amount of payment that will be
required to continue this contract in force.
The required payment will be no greater than
the amount required to pay the monthly
deductions for three months as of the day the
grace period began. If that payment is not
paid by the end of the grace period, the
contract will terminate without value.
The death benefit during the grace period
will be reduced by any overdue charges. The
contract will lapse if the amount shown in
the notice remains unpaid at the end of the
grace period. The contract terminates on the
date of lapse.
REINSTATEMENT If this contract has lapsed or foreclosed for
failure to pay loan interest and has not been
surrendered, it may be restored (called
"reinstate" in this contract) within three
years after the date of default or
foreclosure. We will reinstate the contract
on the Monthly Processing Date following the
day we receive all of the following items:
- a written Application for reinstatement;
- Evidence of Insurability showing the
Insured is insurable according to our
underwriting rules at that time;
- a payment sufficient to cover the cost
of all contract charges that were due
and unpaid during the grace period;
- a payment large enough to keep the
contract in force for three months; and
- a payment or reinstatement of any loans
against the contract that existed at the
end of the grace period.
12
Your reinstatement payment will be allocated
to the Fixed Account until we approve your
Application. At that time, we will transfer
the reinstatement payment, plus accrued
interest, as you directed in your last
payment allocation request.
The Contract Value on the reinstatement date
is:
- the payment to reinstate the contract,
including the interest earned from the
date we receive your payment; plus
- an amount equal to the Contract Value
less any Outstanding Loan on the default
date; less
- the monthly deductions due on the
reinstatement date.
For the purpose of measuring the surrender
charge period, the contract will be
reinstated as of the date of default. The
surrender charge on the reinstatement date is
the charge that was in effect on the date of
default.
13
WHAT YOU SHOULD KNOW ABOUT YOUR CONTRACT
VALUE
Your Contract Value is the sum of the
Variable Account value and the Fixed Account
value.
ALLOCATION OF INITIAL If you make a payment with your Application
PAYMENTS or at any time before your right to examine
the contract expires, we may put that
payment into the Money Market
Fund Sub-Account on the date it is received
at our Principal Office or the Date of Issue,
if later. We will transfer the Contract Value
as you directed in your Application, or by
later request, no later than the expiration
of the period during which you may exercise
your right to cancel the contract.
MONTHLY DEDUCTION Beginning on the date this contract
is issued and on every Monthly Processing
Date until the Final Payment Date, we will
deduct the following monthly charges Pro Rata
from the Contract Value:
- the Administration Charge;
- the Distribution Fee;
- the Federal & State Payment Tax Charge;
- the Insurance Protection Charge; and
- the Monthly Maintenance Fee.
These amounts are shown on the Specifications
Page.
Charges allocated to the Fixed Account will
be deducted on a last-in, first-out basis.
This means that we use the most recent
payments to pay the fees.
ADMINISTRATION CHARGE The Administration Charge compensates
us for the cost of providing administrative
services attributable to this Contract.
DISTRIBUTION FEE The Distribution Fee compensates us for
distribution expenses.
FEDERAL & STATE PAYMENT This charge compensates us for federal, state
TAX CHARGE and local taxes we must pay.
INSURANCE PROTECTION The Insurance Protection Charge
compensates us for the cost of providing a
death benefit in excess of the Contract
Value. This charge will not exceed the
guaranteed maximum Insurance Protection
Charge. The guaranteed maximum Insurance
Protection Charge for any contract month is
equal to (a) times (b), where:
(a) is the rate shown in the Guaranteed
Maximum Monthly Insurance Protection
Table shown on the Specifications Page,
and
(b) is the Insurance Protection Amount.
The insurance protection rates actually
charged will usually be lower than, and never
will be higher than, the guaranteed rates. We
may change the monthly insurance protection
rate from time to time based on our
expectations as to future experience for
mortality, expenses, taxes, or persistency.
Any change in insurance protection rates will
apply to all individuals in the same
Underwriting Risk Class as the Insured. We
will review the actual insurance protection
rates for
14
this contract whenever we change these rates
for new contracts. In any event, rates will
be reviewed no more often than once each
year, but not less than once in a five-year
period.
MONTHLY MAINTENANCE The Monthly Maintenance Fee shown on the
FEE Specifications page will be deducted on each
Monthly Processing Date.
15
WHAT YOU SHOULD KNOW ABOUT THE VARIABLE
ACCOUNT
VARIABLE ACCOUNT The value of your contract will vary if it is
funded through investments in the
Sub-Accounts of the Variable Account. This
account is separate from our Fixed Account.
We have exclusive and absolute ownership and
control of all assets, including those in the
Variable Account. However, the portion of
assets in the Variable Account equal to the
reserves and liabilities of the contracts
that are supported by this account will not
be charged with liabilities that arise out of
any other business we conduct.
This account, established to support variable
life insurance contracts, is registered with
the Securities and Exchange Commission (SEC)
as a unit investment trust under the
Investment Company Act of 1940. It is also
governed by the laws of the State of
Delaware.
This account has several Sub-Accounts. Each
Sub-Account invests its assets in a separate
series of a registered investment company
(called a "Fund"). We reserve the right, when
the law allows, to change the name of the
Variable Account or any of its Sub-Accounts.
A list of the available Sub-Accounts in which
you may choose to invest is on the
Application.
VARIABLE ACCOUNT The portion of the payment you make to us
CONTRACT VALUE which is not allocated to the Fixed Account
will be allocated to the Money market Fund
Sub-Account on the date we receive the
payment or
the Date of Issue, if it occurs after the
date we receive the payment. This value will
be transferred to the Sub-Accounts in
accordance with your payment allocation no
later than the expiration of the period
during which you may exercise your right to
cancel the contract. Payments made thereafter
that are allocated to the Sub-Accounts will
purchase additional units of the
Sub-Accounts.
The number of units purchased in each
Sub-Account is equal to the portion of the
payment allocated to the Sub-Account, divided
by the value of the applicable unit as of the
valuation date the payment is received at our
Principal Office, or on the valuation date
that value is transferred to the Sub-Account
from another Sub-Account or the Fixed
Account.
The number of units will remain fixed unless
(1) changed by a subsequent split of unit
value, or (2) reduced because of a transfer,
contract loan, partial withdrawal, partial
withdrawal transaction charge, monthly
deductions, surrender or surrender charge
allocated to the Sub-Account. Any transaction
described in (2) will result in the
cancellation of an appropriate number of
units. On each valuation date, we will value
the assets of each Sub-Account where activity
has occurred. The Contract Value in a
Sub-account at any time is equal to the
number of units this contract then has in
that Sub-Account multiplied by the
Sub-Account's unit value. The value of a unit
for any Sub-Account for any valuation period
is determined by multiplying that
Sub-Account's unit value for the immediately
preceding valuation period by the net
investment factor for the valuation period
for which the unit value is being calculated.
The unit value will reflect the investment
advisory fee and other expenses incurred by
the registered investment companies.
NET INVESTMENT FACTOR This measures the
investment performance of a Sub-Account
during the valuation period that has just
ended. The net investment factor is the
result of (a) plus (b), divided by (c), minus
(d) where:
(a) is the net asset value per share of a
Fund share held in the Sub-Account
determined at the end of the current
valuation period, plus
16
(b) is the per share amount of any dividend
or capital gain distributions made by
the Fund on shares held in the
Sub-Account if the "ex-dividend" date
occurs during the current valuation
period.
(c) is the net asset value per share of a
Fund share held in the Sub-Account
determined as of the end of the
immediately preceding valuation period.
(d) is a charge for mortality and expense
risks in the valuation period. The
current mortality and expense risk
charge is shown on the Specifications
Page. This charge may be increased or
decreased, but will never exceed the
maximum mortality and expense risk
charge shown on the Specifications
Page. Expense and mortality results
may not adversely affect this maximum
charge.
Since the net investment factor may be more
or less than one, the unit value may increase
or decrease. You bear the investment risk. We
reserve the right, subject to any required
regulatory approvals, to change the method we
use to determine the net investment factor.
VALUATION DATES AND A valuation date is each day that the New
PERIODS York Stock Exchange (NYSE) is open for
business and any other day that there is
enough trading in the Variable Account's
underlying portfolio securities to materially
affect the value of the Variable Account. A
valuation period is the period between
valuation dates.
ADDITION, DELETION OR We may not change the investment policy of
SUBSTITUTION OF the Variable Account without the approval of
INVESTMENTS the Insurance Commissioner of Delaware. This
approval process is on file with the
Commissioner of your state.
We reserve the right, subject to compliance
with applicable law, to add, delete, or
substitute the shares of a Fund that are held
by the Variable Account or that the Variable
Account may purchase. We also reserve the
right to eliminate the shares of any Fund if
they are no longer available for investment,
or if we believe investing more in any Fund
is no longer appropriate for the purposes of
the Variable Account.
We will notify you before we substitute any
of your shares in the Variable Account. This
will not, however, prevent the Variable
Account from buying other shares of
underlying securities for other series or
classes of policies, or from permitting a
conversion between series or classes of
policies or contracts when requested by the
contract owner.
We reserve the right to establish other
Sub-Accounts, and to make them available to
any class or series of policies as we think
appropriate. Each new Sub-Account would
invest in a new investment company or in
shares of another open-end investment
company. We also reserve the right to
eliminate or combine existing Sub-Accounts of
the Variable Account and to transfer the
assets between Sub-Accounts, when allowed by
law.
If we make any substitutions or changes that
we believe are necessary or appropriate, we
may make changes in this contract by written
notice to reflect the substitution or change.
If we think it is in the best interests of
our contract owners, we may operate the
Variable Account as a management company
under the Investment Company Act of 1940, or
we may de-register it under that Act if
registration is no longer required. We may
also combine it with other Separate Accounts.
17
FEDERAL TAXES If we must pay taxes on the Variable
Account, we will charge you for that tax.
Although the Variable Account is currently
not taxable, we reserve the right to charge
for taxes if it becomes taxable.
SPLITTING OF UNITS We reserve the right to split the
value of a unit, to either increase or
decrease the number of units. Any splitting
of units will have no material effect on
contract benefits.
18
WHAT YOU SHOULD KNOW ABOUT THE FIXED ACCOUNT
FIXED ACCOUNT The Fixed Account is part of our
General Account. The General Account consists
of all assets owned by us, other than those
in the Variable Account and other Separate
Accounts. Except as limited by law, we have
sole control over the investment of these
General Account assets. You do not share
directly in the investment experience of the
General Account, but are allowed to allocate
and transfer funds into the Fixed Account.
FIXED ACCOUNT INTEREST The interest rate credited to Contract Value
RATES in the Fixed Account is set by us. We will
review this interest rate from time to time,
at least once a year. The following
guarantees apply to money in the Fixed
Account.
- The interest rate in effect on the Date
of Issue is guaranteed until the next
contract anniversary, unless you borrow
money from that Contract Value.
- The interest rate in effect on the day
funds are transferred from a Sub-Account
of the Variable Account to the Fixed
Account is guaranteed until the next
contract anniversary, unless you borrow
from that Contract Value.
- The interest rate in effect on a
contract anniversary is guaranteed for
one year for those Contract Values in
the Fixed Account on the contract
anniversary as long as those values
remain in the Fixed Account and are not
borrowed.
- The interest rate(s) we use for that
portion of the Contract Value that
equals the Outstanding Loan will be at
least the minimum rates shown on the
Specifications Page. One of the rates
shown is the Preferred Loan Rate which
applies only to the portion of the
Outstanding Loan that is secured by
Earnings.
FIXED ACCOUNT CONTRACT On each Monthly Processing Date, the Contract
VALUE Value of the Fixed Account is equal to:
- the Contract Value in this account on
the preceding Monthly Processing Date
increased by one month's interest, plus
- payments received since the last Monthly
Processing Date that are allocated to
the Fixed Account plus the interest
accrued from the date the payments are
received by us, plus
- Variable Account Contract Value
transferred to the Fixed Account from
any Sub-Accounts since the preceding
Monthly Processing Date, increased by
interest from the date the Contract
Value is transferred, minus
- Contract Value transferred from the
Fixed Account to a Sub-Account since the
preceding Monthly Processing Date and
interest accrued on these transfers from
the transfer date to the Monthly
Processing Date, minus
- partial withdrawals from the Fixed
Account, partial withdrawal transaction
charges and surrender charges since the
last Monthly Processing Date, interest
accrued on these withdrawals, and
charges from the withdrawal date to the
Monthly Processing Date, minus
- the portion of the Monthly Deductions
allocated to the Contract Value in the
Fixed Account.
19
During any contract month the Fixed Account
Contract Value will be calculated on a
consistent basis.
BASIS OF VALUE OF THE We base the minimum surrender value in the
FIXED ACCOUNT Fixed Account on the minimum Fixed Account
interest rates and mortality table shown on
the Specifications Page. Actual Contract
Values are based on interest and insurance
protection rates that we set. We have filed a
detailed description of the way we determine
this value with the State Insurance
Department. All values equal or exceed the
minimums required by law in the state in
which this contract is delivered.
20
WHAT YOU SHOULD KNOW ABOUT TRANSFERS
While the contract is in force, you may
transfer amounts between the Fixed Account
and the Sub-Accounts or among Sub-Accounts on
request.
You may transfer, without charge, all of the
Contract Value in the Variable Account to the
Fixed Account once during the first 24 months
after the contract is issued in order to
convert to a fixed-only product. If you do
so, future payments will be allocated to the
Fixed Account unless you specify otherwise.
All other transfers are subject to the
following rules and will be permitted with
our approval.
We will determine the minimum and maximum
amounts that may be transferred according to
the rules that are in effect at the time of
the transfer.
We also reserve the right to limit the number
of transfers that can be made in each
contract year and set other reasonable rules
controlling transfers.
If a transfer would reduce the Contract Value
in a Sub-Account to less than the current
minimum balance required for such accounts,
we reserve the right to include the remaining
value in the amount transferred.
You will not be charged for the first twelve
transfers in a contract year, but a transfer
charge of up to $25 may be made on each
additional transfer. Any transfer charge will
be deducted from the amount that is
transferred. There is no charge for transfers
that result from a contract loan or repayment
of a loan.
21
WHAT YOU SHOULD KNOW ABOUR BORROWING FROM
YOUR CONTRACT
To borrow form this contract, the only
collateral you will need is the contract
itself.
AMOUNT YOU MAY BORROW The maximum loan amount is 90%
of the Contract Value less the surrender
charge. You may borrow an amount subject to
the minimum shown on the Specifications Page,
up to the maximum loan amount minus any
Outstanding Loan.
If you do not specify from which accounts you
want to borrow, we will allocate the loan Pro
Rata. In order to secure the Outstanding
Loan, we will transfer the Contract Value in
each Sub-Account equal to the contract loan
allocated to each Sub-Account to the Fixed
Account.
LOAN INTEREST You will pay interest on your loan at an
annual rate indicated on the Specifications
Page. Interest accrues daily and is payable
at the end of each contract year. Any
interest that is not paid on time will be
added to the loan principal and bear interest
at the same rate. If this makes the principal
higher than the Contract Value in the Fixed
Account, we will offset this shortfall by
transferring funds from the Sub-Accounts to
the Fixed Account. We will allocate the
transferred amount among the Sub-Accounts in
the same proportion that the value in each
Sub-Account has to the total value in all of
them.
REPAYING THE You may repay the Outstanding Loan at any
OUTSTANDING LOAN time before this contract lapses. When you
repay it, we will transfer the Contract Value
that is securing the loan in the Fixed
Account to the various Sub-Accounts and
increase the value in them. You may tell us
how to allocate repayments. Otherwise, we may
allocate them according to the most recent
payment allocation choices you have made.
Loan repayments made to the Variable Account
cannot be higher than the amounts you
transferred to secure the Outstanding Loan.
FORECLOSURE If at any time the amount of the Outstanding
Loan is higher than the Contract Value minus
the surrender charge, we will terminate the
contract. We will mail a notice of this
termination to the last known address of you
and any Assignee. If the excess Outstanding
Loan is not paid within 62 days after this
notice is mailed, the contract will terminate
with no value. You may reinstate this
contract according to the Reinstatement
provision.
22
WHAT YOU SHOULD KNOW ABOUT SURRENDERS AND
PARTIAL WITHDRAWALS
SURRENDER You may cancel this contract and receive its
surrender value as long as the Insured is
living on the date we receive your Written
Request at our Principal Office. The contract
will be canceled on that day. You may choose
to receive the surrender value in a lump sum
or under a benefit option.
SURRENDER VALUE The surrender value equals the Contract
Value minus the Outstanding Loan and
surrender charge. You will find the surrender
charge on the Specifications Page.
PARTIAL WITHDRAWALS You may withdraw part of the
surrender value on Written Request. Each
withdrawal must be at least $1,000. We will
deduct a 2% withdrawal transaction charge
(maximum $25) from the Contract Value each
time you make a partial withdrawal.
We will not permit a partial withdrawal if it
reduces the Contract Value amount to less
than the minimum amount shown on the
Specifications Page.
The Face Amount will be reduced
proportionately based on the ratio of the
amount of the partial withdrawal and charges
to the Contract Value on the date of
withdrawal. The Contract Value will be
reduced by the amount of the partial
withdrawal, the partial withdrawal
transaction charge and any applicable
surrender charges.
If you do not allocate a partial withdrawal
and its charges between the Fixed Account and
each Sub-Account, we will automatically
allocate them Pro Rata.
FREE WITHDRAWAL AMOUNT The free withdrawal amount
will not be subject to the surrender charge
as described on the Specifications Page. This
amount equals (a) minus (b), where:
(a) is the free withdrawal amount shown on
the Specifications Page, and
(b) is the total of the withdrawals (or
portions of them) made in the same
contract year that were exempt from the
surrender charge.
The free withdrawal amount is first deducted
from Earnings. Withdrawals in excess of the
free withdrawal amount are deducted from
payments not previously considered withdrawn
on a last-in, first-out basis. Surrender
charges applicable to the excess withdrawal
are described on the Specifications Page.
POSTPONEMENT OF We may postpone any transfer from the
PAYMENT Variable Account, or payment of any amount
payable on:
- surrender
- partial withdrawal
- transfer
- contract loan
- death of the Insured
The postponement will continue during any
period when:
- trading on the New York Stock Exchange
is restricted as determined by the
Securities and Exchange Commission, or
the New York Stock Exchange is closed
for days other than weekends and
holidays, or
23
- the Securities and Exchange Commission
by order has permitted such suspension,
or
- the Securities and Exchange Commission
has determined that such an emergency
exists that disposal of portfolio
securities or valuation of assets is not
reasonably practical.
We also may postpone any transfer from the
Fixed Account or payment of any portion of
the amount payable on a surrender, partial
withdrawal or contract loan from the Fixed
Account for not more than six months form the
day we receive your Written Request and your
contract, if it is required. If we postpone
those payments for 30 days or more, the
amount postponed will earn interest during
that period of not less than 3% per year or
such higher rate as required by law. We will
not postpone payments to make payments on our
policies.
24
WHAT YOU SHOULD KNOW ABOUT THE DEATH BENEFIT
NET DEATH BENEFIT If the Insured dies before the Final Payment
Date, we will pay the net death benefit upon
receipt at the Principal Office of proof of
the Insured's death. The net death benefit is
the Face Amount at the time of death or the
guideline minimum sum insured, if greater,
reduced by any Outstanding Loan, rider
charges and monthly deductions due and
unpaid through the contract month in which
the Insured dies, as well as any partial
withdrawals and surrender charges. We will
pay interest from the date of death to the
date the net death benefit is paid. If the
Insured dies after the Final Payment Date,
we will pay the Contract Value minus any
Outstanding Loans. We will pay interest
from the date we receive the death
certificate. If you choose a lump sum
payment, the interest rate will be at least
3% a year, or the minimum rate set by law,
if greater.
REQUIRED MINIMUM In order to qualify as "life insurance" under
AMOUNT OF DEATH BENEFIT the federal tax law, this contract must
provide a minimum death benefit.
This is called the "guideline minimum sum
insured" in the tax code. This is calculated
by multiplying the Contract Value by the
percentages shown on the Specifications Page.
The guideline minimum sum insured varies by
Age. The amounts shown in the Table are
determined according to federal tax law, and
will be adjusted according to any changes in
that law.
25
WHAT YOU SHOULD KNOW ABOUT THE BENEFIT
OPTIONS
BENEFIT OPTIONS You may choose one of the following
options for receiving the surrender value or
the net death benefit. We will give the payee
a certificate describing the benefit option
you selected. If you make no choice, we will
pay the benefits in a single, lump sum.
We will pay all benefits from the Fixed
Account. Benefits may not be allocated to the
Variable Account. The amounts payable under
these options, for each $1,000 applied, will
be:
(a) the rate per $1,000 of benefit based on
our non-guaranteed current benefit
option rates for this class of
contracts, or
(b) the rate in this contract for the
applicable benefit option, whichever
is greater.
If you choose a benefit option, the
beneficiary may, when filing a proof of
claim, pay us any amount that otherwise would
be deducted from the proceeds.
OPTION A: BENEFITS FOR A We will make equal payments for any selected
SPECIFIED NUMBER OF number of years up to 30 years. These
YEARS (TABLE A) payments may be made annually, semi-
annually, quarterly or monthly, whichever
your choose.
OPTION B: LIFETIME Benefits are based on the age of the person
MONTHLY BENEFIT (TABLE who receives the money (called the payee) on
B) the date the first paymentwill be made. You
may choose one of the three following
options to specify when benefits will cease:
- when the payee dies with no further
benefits due (Life Annuity);
- when the payee dies but not before the
total benefit payments made by us equals
the amount applied under this option
(Life Annuity with Installment Refund);
or
- when the payee dies but not before 10
years have elapsed from the date of the
first payment (Life Annuity with
Payments Guaranteed for 10 years).
OPTIONC:INTEREST We will pay interest at a rate we determine
BENEFITS each year. It will not be less than 3% per
year. We will make payments annually,
semi-annually, quarterly, or monthly,
whichever is preferred. These benefits will
stop when the amount left has been withdrawn.
If the payee dies, any unpaid balance plus
accrued interest will be paid in a lump sum.
OPTION D: BENEFITS FOR A Interest will be credited to the unpaid
SPECIFIED AMOUNT balance and we will make payments until the
unpaid balance is gone. We will credit
interest at a rate we determine each year,
but no less
than 3%. We will make payments annually,
semi-annually, quarterly, or monthly,
whichever is preferred. The benefit level
chosen must provide for an annual benefit of
at least 8% of the amount applied.
OPTION E: LIFETIME We will pay a benefit jointly to two payees
MONTHLY BENEFITS FOR TWO during their joint lifetime. After one payee
PAYEES (TABLE E) dies, the benefits to the survivor will be:
- the same as the original amount, or
- in an amount equal beta of the original
amount.
26
Benefits are based on the payees' ages on the
date the first payment is due. Benefits will
end when the second payee dies.
SELECTING BENEFIT The amount we apply under any one option for
OPTIONS any one payee must be at least $5,000, and
the periodic payment for any one payee must
be at least $50.
You may change any option you select before
the net death benefit is paid, subject to the
Owner and Beneficiary provisions. If you make
no selection, the beneficiary may choose an
option when the benefits become payable.
If the amount of monthly income benefits
under Option B for the age of the payee is
the same for different periods certain, the
payee will be entitled to the longest period
certain for the payee's age.
You may give the beneficiary the right to
change from Option C or D to any other option
at any time. If Option C or D is chosen by
the payee when this contract becomes a claim,
the payee may reserve the right to change to
any other option. The payee who elects to
change options must be the payee under the
option selected.
ADDITIONAL DEPOSITS An additional deposit may be added
to any proceeds when they are applied under
Option B and E. We reserve the right to limit
the amount of any additional deposit. We may
levy a charge of no more than 3% on any
additional deposits.
RIGHTS AND LIMITATIONS A payee has no right to assign any amount
payable under any option, nor to demand a
lump sum benefit in place of any amount
payable under Options B or E. A payee will
have the right to receive a lump sum in place
of installments under Option A. The payee
must provide us with a Written Request to
reserve this right. If the right to receive a
lump sum is exercised, we will determine the
lump sum benefit at the same interest rates
used to calculate the installments. The
amount left under Option C and any unpaid
balance under Option D, may be withdrawn only
as noted in the Written Request selecting the
option.
A corporate or fiduciary payee may select
only Option A, C or D, subject to our
approval.
BENEFIT DATES The first payment under any option, except
Option C, will be due on the date this
contract matures, by death or otherwise,
unless another date is designated. Benefits
under Option C begin at the end of the first
benefit period.
The last payment under any option will be
made as stated in the option's description.
However, if a payee under Options B or E dies
before the due date of the second monthly
payment, the amount applied, minus the first
monthly payment, will be paid in a lump sum
or under any option other than Option E. This
payment will be made to the surviving payee
under Option E or the succeeding payee under
Option B.
BENEFIT RATES The Benefit Option Tables show benefit
amounts for Option A, B and E. If you choose
one of these options, either within five
years of the date of surrender or the date
the proceeds are otherwise payable, we will
apply either the benefit rates listed in the
Tables, or the rates we use on the date the
proceeds are paid, whichever is more
favorable. Benefits that begin more than five
years after that date, or as a result of
additional deposits, will be based on the
rates we use on the date the first benefit is
due.
27
BENEFIT OPTIONS
TABLE A
BENEFITS FOR SPECIFIED NUMBER OF
YEARS
Payment for Each $1,000 of Contract Value
Applied
[These tables are based on an annual interest rate of 3 1/2%.]
SEMI- QUAR-
YEARS ANNUAL ANNUAL TERLY MONTHLY
--------------------------------------------------------
[1 1000.00 504.30 253.23 84.65
2 508.60 256.49 128.79 43.05
3 344.86 173.91 87.33 29.19
4 263.04 132.65 66.61 22.27
5 213.99 107.92 54.19 18.12
6 181.32 91.44 43.92 15.35
7 158.01 79.69 40.01 13.38
8 140.56 70.88 35.59 11.90
9 127.00 64.05 32.16 10.75
10 116.18 58.59 29.42 9.83
11 107.34 54.13 27.18 9.09
12 99.98 50.42 25.32 8.46
13 93.78 47.29 23.75 7.94
14 88.47 44.62 22.40 7.49
15 83.89 42.31 21.24 7.10
16 79.89 40.29 20.23 6.76
17 76.37 38.51 19.34 6.47
18 73.25 36.94 18.55 6.20
19 70.47 35.54 17.85 5.97
20 67.98 34.28 17.22 5.75
21 65.74 33.15 16.65 5.56
22 63.70 32.13 16.13 5.39
23 61.85 31.19 15.66 5.24
24 60.17 30.34 15.24 5.09
25 58.62 29.56 14.85 4.96
26 57.20 28.85 14.49 4.84
27 55.90 28.19 14.15 4.73
28 54.69 27.58 13.85 4.63
29 53.57 27.02 13.57 4.53
30 52.53 26.49 13.3 4.45]
--------------------------------------------------------
28
LIFE INCOME OPTION TABLES
MONTHLY ANNUITY BENEFIT PAYMENT
FOR EACH $1,000 OF CONTRACT VALUE APPLIED
TABLE B
AGE LIFE ANNUITY WITH LIFE LIFE ANNUITY
NEAREST PAYMENTS GUARANTEED ANNUITY WITH INSTALLMENT
BIRTHDAY FOR 10 YEARS REFUND
-------------------------------------------------------------------------------------
[50 4.22 4.24 4.14
51 4.28 4.31 4.19
52 4.34 4.37 4.25
53 4.41 4.44 4.31
54 4.48 4.52 4.37
55 4.55 4.59 4.43
56 4.63 4.68 4.50
57 4.71 4.76 4.57
58 4.80 4.86 4.65
59 4.89 4.96 4.73
60 4.98 5.06 4.82
61 5.08 5.18 4.90
62 5.19 5.30 5.00
63 5.30 5.43 5.10
64 5.42 5.56 5.20
65 5.55 5.71 5.31
66 5.68 5.87 5.43
67 5.81 6.04 5.55
68 5.96 6.22 5.68
69 6.11 6.41 5.81
70 6.26 6.62 5.96
71 6.43 6.84 6.11
72 6.60 7.08 6.27
73 6.77 7.34 6.44
74 6.95 7.62 6.62
75 7.13 7.91 6.81]
---------------------------------------------------------------------------------------
[These tables are based on an annual interest rate of 3
1/2% and the 1983(a) Individual Mortality Table using a blend reflecting
40% of the male rate and 60% of the female rate.]
29
MONTHLY ANNUITY BENEFIT PAYMENT
FOR EACH $1,000 OF CONTRACT VALUE APPLIED
TABLE E1 TABLE E2
JOINT AND SURVIVOR LIFE ANNUITY JOINT AND TWO-THIRDS SURVIVOR LIFE ANNUITY
OLDER AGE OLDER AGE
50 55 60 65 70 75 80 50 55 60 65 70 75 80
Y [50 3.91 3.97 4.02 4.05 4.07 4.09 4.10 4.25 4.40 4.57 4.76 4.96 5.18 5.39
O
U 55 4.18 4.26 4.32 4.36 4.39 4.41 4.60 4.80 5.02 5.26 5.50 5.75
N
G 60 4.54 4.65 4.73 4.78 4.81 5.08 5.35 5.63 5.92 6.21
E
R 65 5.04 5.19 5.29 5.35 5.74 6.10 6.46 6.82
70 5.75 5.95 6.08 6.67 7.15 7.62
A
G 75 6.77 7.06 8.04 8.69
E
80 8.29 10.05]
[These tables are based on an annual interest rate of 3 1/2%
and the 1983(a) Individual Mortality Table using a proportional blend of
50% male and 50% female.]
MODIFIED SINGLE PAYMENT VARIABLE LIFE INSURANCE CONTRACT
NON-PARTICIPATING
30
