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EXHIBIT 4(i)
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[LOGO]
FIRST NORTH AMERICAN LIFE
ASSURANCE COMPANY
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HOME OFFICE:
International Corporate Center at Rye
000 Xxxxxxxx Xxxxx Xxxxxx
Xxx, XX 00000
THIS IS A LEGAL CONTRACT - READ IT CAREFULLY.
WE AGREE to pay the benefits of this Contract in accordance with its terms.
THIS CONTRACT is issued in consideration of the Payment.
TEN DAY RIGHT TO REVIEW
THE CONTRACT OWNER MAY CANCEL THE CONTRACT BY RETURNING IT TO OUR ANNUITY
SERVICE OFFICE OR AGENT AT ANY TIME WITHIN 10 DAYS AFTER RECEIPT OF THE
CONTRACT. WITHIN 7 DAYS OF RECEIPT OF THE CONTRACT BY US, WE WILL REFUND THE
PAYMENT MADE TO THE CONTRACT OWNER.
WHEN THE CONTRACT IS ISSUED AS AN INDIVIDUAL RETIREMENT ANNUITY, DURING THE
FIRST 7 DAYS OF THIS 10 DAY PERIOD, WE WILL RETURN THE GREATER OF (i) THE
CONTRACT VALUE OR (ii) THE PAYMENT.
SIGNED FOR THE COMPANY at its Executive Office, Rye, New York, on the
Contract Date.
Secretary President
Single Payment Deferred Fixed Annuity
Non-Participating
AMOUNTS PAYABLE UNDER THIS CONTRACT ARE SUBJECT TO A MARKET VALUE ADJUSTMENT
PRIOR TO A DATE OR DATES SPECIFIED IN THIS CONTRACT. APPLICATION OF THE MARKET
VALUE ADJUSTMENT MAY RESULT IN BOTH UPWARD AND DOWNWARD ADJUSTMENTS IN CASH
WITHDRAWAL BENEFITS.
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INTRODUCTION
This is a single payment deferred fixed annuity. This Contract provides that
prior to the Maturity Date, the Contract Value for an Owner will accumulate
based on interest rates guaranteed by the Company for the period selected.
Amounts withdrawn prior to the end of the selected period are subject to a
market value adjustment and possible withdrawal charges which could reduce the
withdrawal amount below original payment.
You must allocate the Payment to one Initial Guarantee Period.
On the Maturity Date, if the Annuitant and Owner are still living, the Contract
will provide for annuity payments to the Annuitant based upon the Annuity Option
selected. Fixed annuity dollar amounts are guaranteed by the Company.
TABLE OF CONTENTS
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Contract Specifications Page Page
PART 1 - DEFINITIONS 1
PART 2 - GENERAL PROVISIONS 3
PART 3 - OWNERSHIP 4
PART 4 - BENEFITS 4
PART 5 - PAYMENTS 6
PART 6 - INVESTMENT PROVISIONS 6
PART 7 - ANNUITY PROVISIONS 7
PART 8 - TRANSFERS 7
PART 9 - WITHDRAWAL PROVISIONS 7
PART 10 - FEES AND DEDUCTIONS 9
PART 11 - PAYMENT OF CONTRACT BENEFITS 9
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CONTRACT SPECIFICATIONS PAGE
TYPE OF CONTRACT: [QUALIFIED] PLAN TYPE: [403B]
CONTRACT DATE: [01/07/1994] MATURITY DATE: [01/07/2044]
PAYMENT: [$ 10,000.00] CONTRACT NUMBER: [000000001]
GOVERNING LAW: NEW YORK INITIAL GUARANTEE PERIOD: [5 YEARS]
INITIAL GUARANTEED INTEREST RATE: [5.05%] INITIAL GUARANTEE PERIOD
EXPIRES: [01/07/1999]
THIS PLAN IS INTENDED TO QUALIFY UNDER THE INTERNAL REVENUE CODE FOR TAX-FAVORED
STATUS. LANGUAGE CONTAINED IN THIS CONTRACT REFERRING TO FEDERAL TAX STATUS OR
RULES IS INFORMATIONAL AND INSTRUCTIONAL AND THIS LANGUAGE IS NOT SUBJECT TO
APPROVAL OR DISAPPROVAL BY THE STATE OF NEW YORK. PLEASE SEEK THE ADVICE OF YOUR
OWN TAX ADVISOR REGARDING YOUR INDIVIDUAL TAX TREATMENT.
OWNER: XXXX XXX CO-OWNER:
ANNUITANT: XXXX XXX ANNUITANT AGE: 35
CO-ANNUITANT: BENEFICIARY: XXXX XXX
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CONTRACT SPECIFICATIONS PAGE
TYPE OF CONTRACT: [NON-QUALIFIED] PLAN TYPE:
CONTRACT DATE: [01/07/1994] MATURITY DATE: [01/07/2044]
PAYMENT: [$ 10,000.00] CONTRACT NUMBER: [000000001]
GOVERNING LAW: NEW YORK
INITIAL GUARANTEED INTEREST RATE: [5.05%] INITIAL GUARANTEE PERIOD: [5 YEARS]
INITIAL GUARANTEE PERIOD [01/07/1999]
EXPIRES:
OWNER: XXXX XXX CO-OWNER:
ANNUITANT: XXXX XXX ANNUITANT AGE: 35
CO-ANNUITANT: BENEFICIARY: XXXX XXX
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PART 1 DEFINITIONS
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WE AND YOU "We", "us" and "our" means First North
American Life Assurance Company. "You" or
"your" means the Owner of this Contract.
ANNUITANT Any individual person or persons whose life
is used to determine the duration of annuity
payments involving life contingencies. The
Annuitant is as designated on the Contract
Specifications Page and application, unless
changed.
ANNUITY OPTION The method selected by you for annuity
payments made by us.
ANNUITY SERVICE OFFICE Any office designated by us for the
receipt of Payments and processing of
Contract Owner requests.
BENEFICIARY The person, persons or entity to whom
certain benefits are payable following the
death of an Owner, or in certain
circumstances, an Annuitant.
CONTINGENT BENEFICIARY The person, persons or entity who becomes
the Beneficiary if the Beneficiary is not
alive.
CONTRACT ANNIVERSARY The anniversary of the Contract Date.
CONTRACT DATE The date of issue of this Contract as
specified on the Contract Specifications
Page.
CONTRACT VALUE The value of the Contract which is the sum
of the Net Payment and accrued interest,
less the sum of any Gross Withdrawal Values
and any annual Administration Fees deducted,
adjusted for any Transfer Market Value
Adjustments.
CONTRACT YEAR The period of twelve consecutive months
beginning on the Contract Date or any
anniversary thereafter.
FIXED ACCOUNT The FNAL Fixed Account, which is a Separate
Account of the First North American Life
Assurance Company.
GENERAL ACCOUNT All the assets of First North American Life
Assurance Company other than assets in
separate accounts.
GROSS WITHDRAWAL VALUE The portion of the Contract Value specified
by you for a full or partial withdrawal.
Such amount is determined prior to the
application of any withdrawal charge, annual
Administration Fee and Market Value
Adjustment.
INITIAL GUARANTEE PERIOD The period of time during which the Initial
Guaranteed Rate is in effect.
INITIAL GUARANTEED INTEREST RATE The compound annual rate used to determine
the interest earned on the Net Payment
during the Initial Guarantee Period.
ISSUE DATE The date on which the Contract becomes
effective.
INTERNAL REVENUE CODE (IRC) The Internal Revenue Code of 1986, as
amended from time to time, and any successor
statute of similar purposes.
MARKET VALUE ADJUSTMENT An adjustment to amounts that are withdrawn
or transferred prior to the end of the
Initial Guarantee Period or Renewal
Guarantee Period. It may increase or
decrease the amount available for transfer
or withdrawal.
MATURITY DATE The date on which annuity benefits commence.
It is the date specified on the Contract
Specifications Page, unless changed.
NET PAYMENT The Payment less the amount of premium tax,
if any, deducted from the Payment.
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NON-QUALIFIED CONTRACTS Contracts which are not issued under
Qualified Plans.
OWNER OR CONTRACT OWNER The person, persons or entity entitled to
the ownership rights under this Contract.
The Owner is as designated on the Contract
Specifications Page and application, unless
changed.
PAYMENT An amount paid to us by you as consideration
for the benefits provided by this Contract.
QUALIFIED CONTRACTS Contracts issued under Qualified Plans.
QUALIFIED PLANS Retirement plans which receive favorable tax
treatment under section 401, 403, 408 or
457, of the Internal Revenue Code of 1986,
as amended.
RENEWAL AMOUNT The Contract Value as of the end of the
Initial Guarantee Period or at the end of a
Renewal Guarantee Period.
RENEWAL GUARANTEE PERIOD The period of time during which a Renewal
Guaranteed Interest Rate is in effect.
RENEWAL GUARANTEED INTEREST RATE The compound annual rate used to determine
the interest earned on a Renewal Amount
during a Renewal Guarantee Period. In no
event shall this rate be less than 3%.
SEPARATE ACCOUNT A segregated account of First North American
Life Assurance Company that is not
commingled with our general assets and
obligations.
PART 2 GENERAL PROVISIONS
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ENTIRE CONTRACT The entire contract consists of this
Contract, any Contract endorsements, and a
copy of the application if one is attached
to this Contract when issued. Only our
President, Vice-President or Secretary may
agree to change or waive any provisions of
this Contract. The change or waiver must be
in writing.
We will not change or modify this Contract
without your consent except as may be
required to make it conform to any
applicable law or regulation or any ruling
issued by a government agency.
The benefits and values available under this
Contract are not less than the minimum
required by any statute of the state of New
York. We have filed a detailed statement of
the method used to calculate the benefits
and values with the Department of Insurance
in the state of New York, if required by
law.
BENEFICIARY The Beneficiary is as designated in the
Contract Specifications Page and
application, unless changed. However, if
there is a surviving Owner, that person will
be treated as the Beneficiary. If no such
Beneficiary is living, the Beneficiary is
the "Contingent Beneficiary". If no
Beneficiary or Contingent Beneficiary is
living, the Beneficiary is the estate of the
deceased Owner.
CHANGE OF MATURITY DATE Prior to the Maturity Date, you may request
in writing a change of the Maturity Date.
Any extension of the Maturity Date will be
subject to our prior approval and any
Governing Law regulations.
ASSIGNMENT You may assign this Contract at any time
prior to the Maturity Date. No assignment
will be binding on us unless it is written
in a form acceptable to us and received at
the Annuity Service Office. We will not be
liable for any payments made or actions we
take before the assignment is accepted by
us. An absolute assignment will revoke the
interest of any revocable Beneficiary. We
will not be responsible for the validity of
any assignment.
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CLAIMS OF CREDITORS To the extent permitted by law, no benefits
payable under this Contract will be subject
to the claims of your, the Beneficiary's or
the Annuitant's creditors.
MISSTATEMENT AND PROOF OF AGE, We may require proof of age, sex or survival
SEX OR SURVIVAL of any upon whose age, sex or survival any
payments depend. If the age or sex of the
Annuitant has been misstated, the benefits
will be those which the payment would have
provided for the correct age and sex. If we
have made incorrect annuity payments, the
amount of any underpayment, adjusted with
interest at 4% per annum, will be paid
immediately. The amount of any overpayment
will be deducted from future annuity
payments.
NON-PARTICIPATING Your Contract is non-participating and will
not share in our profits or surplus
earnings. We will pay no dividends on your
Contract.
REPORTS At least once each year we will send you a
report containing information required by
the applicable state law.
CURRENCY AND PLACE OF All payments made to or by us shall be made
in the lawful currency of the United States
PAYMENTS of America at the Annuity Service Office or
elsewhere if we consent.
NOTICES AND ELECTIONS To be effective, all notices and elections
you make under this Contract must be in
writing, signed by you and received by us at
the Annuity Service Office. Unless otherwise
provided in this Contract, all notices,
requests and elections will be effective
when received by us, complete with all
necessary information and your signature, at
the Annuity Service Office.
GOVERNING LAW This Contract will be governed by the laws
of the state of New York.
SECTION 72(s) The provisions of this Contract shall be
interpreted so as to comply with the
requirements of Section 72(s) of the
Internal Revenue Code.
PART 3 OWNERSHIP
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GENERAL Before the Maturity Date, the Owner of this
Contract shall be the person, persons or
entity designated on the Contract
Specifications Page and application or the
latest change filed with us. On the Maturity
Date, the Annuitant becomes the Owner of the
Contract. If amounts become payable to the
Beneficiary under the Contract, the
Beneficiary becomes the Owner of the
Contract.
CHANGE OF OWNER, ANNUITANT, Subject to the rights of an irrevocable
BENEFICIARY Beneficiary, you may change the Owner,
Annuitant, or Beneficiary by written request
in a form acceptable to us and which is
received at the Annuity Service Office. The
Annuitant may not be changed after the
Maturity Date. You need not send us the
Contract unless we request it. Any change
must be approved by us. If approved, any
change in Beneficiary will take effect on
the date you signed the request. If
approved, any change in Owner or Annuitant
will take effect on the date we received the
request at the Annuity Service Office. We
will not be liable for any payments or
actions taken before the change is approved.
If any Annuitant is changed and any Owner is
not an individual, the entire interest in
the Contract must be distributed to the
Owner within five years of the change.
PART 4 BENEFITS
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ANNUITY BENEFITS We will pay a monthly income to the
Annuitant, if living, on the Maturity Date.
Annuity benefits will commence on the
Maturity Date and continue for the period of
time provided for under the Annuity Option
selected.
We may pay the higher of Contract Value and
any annual Administration Fee or the amount
available upon total withdrawal on the
Maturity Date in one lump sum if the monthly
income is less than $20.
On or before the Maturity Date you must
select how the Contract Value will be used
to provide the monthly income. Unless you
indicate otherwise, we will provide a fixed
annuity with guaranteed fixed annuity
payments continuing for 10 years or the
lifetime of the Annuitant, if longer.
The portion of the Contract Value adjusted
by the Transfer Market Value Adjustment used
to effect a fixed annuity will be applied to
the appropriate guaranteed fixed annuity
payment table contained in this Contract. If
the table in use by us on the Maturity Date
is more favorable to you, we will use that
table. We guarantee the dollar amount of
fixed annuity payments.
DEATH BENEFIT BEFORE A Death Benefit will be determined as of
MATURITY DATE the date on which written notice and proof
of death and all required claim forms are
received at the Company's Annuity Service
Office.
DEATH OF ANNUITANT: On the death of the last
surviving Annuitant, the Owner becomes the
new Annuitant, if the Owner is an
individual. If any Owner is not an
individual the death of any Annuitant is
treated as the death of an Owner and the
Death Benefit will be determined by
substituting the Annuitant for the Owner as
described below.
DEATH OF OWNER: We will pay a Death Benefit
equal to the Contract Value to the
Beneficiary if any Owner dies prior to the
Maturity Date. This amount will not be
subject to a Market Value Adjustment. The
Death Benefit may be taken in one sum
immediately, in which case the Contract will
terminate. If the Death Benefit is not taken
in one sum immediately, the Contract will
continue subject to the following
provisions:
(a) The Beneficiary becomes the Contract
Owner.
(b) No additional Payments may be applied to
the Contract.
(c) If the Beneficiary is not the deceased
Owner's spouse, the entire interest
in the Contract must be distributed
under one of the following options:
(i) The entire interest in the
Contract must be
distributed over the life
of the Beneficiary, or
over a period not
extending beyond the life
expectancy of the
Beneficiary, with
distributions beginning
within one year of the
Owner's death; or
(ii) the entire interest in the
Contract must be
distributed within 5 years
of the Owner's Death.
If the Beneficiary dies before the
distributions required by (i) or
(ii) are complete, the entire
remaining Contract Value must be
distributed in a lump sum
immediately.
(d) If the Beneficiary is the deceased
Owner's spouse, the Contract will
continue with the surviving spouse
as the new Owner. The surviving
spouse may name a new Beneficiary
(and, if no Beneficiary is so
named, the surviving spouse's
estate will be the Beneficiary).
Upon the death of the surviving
spouse, the Death Benefit will
equal the Contract Value at the
time of the surviving spouse's
death, and the entire interest in
the Contract must be distributed to
the new Beneficiary in accordance
with the provisions of (c)
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(i) or (c) (ii) above.
If there is more than one Beneficiary, the
foregoing provisions will independently
apply to each Beneficiary.
DEATH BENEFIT ON OR If annuity payments have been selected based
AFTER MATURITY DATE on an Annuity Option providing for payments
for a guaranteed period, and the Annuitant
dies on or after the Maturity Date, we will
make the remaining guaranteed payments to
the Beneficiary. Any remaining payments will
be made as rapidly as under the method of
distribution being used as of the date of
the Annuitant's death. If no Beneficiary is
living, we will commute any unpaid
guaranteed payments to a single sum (on the
basis of the interest rate used in
determining the payments) and pay that
single sum to the estate of the last to die
of the Annuitant and the Beneficiary.
PROOF OF DEATH Proof of death is required upon the death of
the Annuitant or the Owner. Proof of death
is one of the following received at the
Annuity Service Office:
(a) A certified copy of a death certificate.
(b) A certified copy of a decree of a court
of competent jurisdiction as to the
finding of death.
(c) Any other proof satisfactory to us.
PART 5 PAYMENTS
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GENERAL The Payment under this Contract is payable
at the Annuity Service Office or such other
place as we may designate.
The minimum Payment will
be $5,000 and must be paid at the
time of application. The maximum
Payment without prior approval will
be $500,000. Payments may not be
made subsequent to issue.
Following the third Contract Anniversary and
prior to the Maturity Date, if both:
(a) the Payment made, less any partial
withdrawals, is less than $2,000;
and
(b) the higher of the Contract Value or the
amount available upon total
withdrawal is less than $2,000;
We may cancel the Contract and pay you the
higher of Contract Value and any annual
Administration Fee or the amount available
upon total withdrawal.
ALLOCATION OF NET PAYMENT When we receive the Payment, the Net Payment
will be allocated to the Initial Guarantee
Period as shown on the Contract
Specifications Page.
PART 6 INVESTMENT PROVISIONS
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GUARANTEE PERIODS You may allocate the Net Payment into any
one of the Initial Guaranteed Periods
offered under this Contract.
The Initial Guarantee Period and Renewal
Guarantee Period are measured from the date
either a Net Payment or Renewal Amount is
allocated to the guarantee period. Amounts
cannot be allocated to a guarantee period
that would extend beyond the Maturity Date.
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During the Initial Guarantee Period, amounts
will earn interest, compounded annually, at
the Initial Guaranteed Interest Rate.
RENEWALS A notice will be mailed at least 15 but not
more than 45 days prior to the end of any
Initial Guarantee Period or Renewal
Guarantee Period. We will automatically
renew the Renewal Amount into the same
guarantee period that it is renewing from,
unless you specify otherwise in writing. If
a particular Renewal Guarantee Period would
extend beyond the Maturity Date, the Renewal
Amount may not be renewed in that Renewal
Guarantee Period. The Renewal Amount will be
applied to the longest Renewal Guarantee
Period that does not extend beyond the
Maturity Date.
During the Renewal Guarantee Period, amounts
will earn interest, compounded annually, at
the Renewal Guaranteed Interest Rate.
MARKET VALUE ADJUSTMENT FACTOR Any amounts withdrawn or transferred from
the Contract at any other date other than
the end of either the Initial Guarantee
Period or a Renewal Guarantee Period will be
adjusted by
the Market Value Adjustment Factor described
below. The Market Value Adjustment Factor is
determined by the following formula:
((1+i)/(1+j)) (n/12 exponent)
Where i, j and n are defined as follows:
i - The Initial Guaranteed Interest Rate
or Renewal Guaranteed Interest Rate
currently being earned on this Contract.
j - The guaranteed interest rate available,
on the date the request is processed,
for a guarantee period with the same
length as the period remaining in the
Initial Guarantee Period or Renewal
Guarantee Period. If a guarantee period
of this length is not available, the
guarantee period with the next highest
duration which is maintained by the
Company will be chosen.
n - The number of complete months remaining
to the end of the Initial Guarantee
Period or Renewal Guarantee Period.
The amount of Market Value Adjustment, if
any, upon transfer is specified in Part 8,
Transfer Provisions, and upon withdrawal as
specified in Part 9, Withdrawal Provisions.
PART 7 ANNUITY PROVISIONS
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FIXED ANNUITY PAYMENTS The amount of each fixed annuity payment is
determined by applying the portion of the
Contract Value adjusted by the Transfer
Market Value Adjustment used to effect such
payments measured as of a date not more than
10 business days prior to the Maturity Date
(minus any applicable premium taxes) to the
appropriate table contained in this
Contract. If the table in use by us on the
Maturity Date is more favorable to you, we
will use that table.
We guarantee the dollar amount of fixed
annuity payments.
PART 8 TRANSFERS
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TRANSFERS Before the Maturity Date you may transfer
the entire Contract Value to a different
guarantee period then being offered by the
Company. There is no transaction charge for
transfers, however, Contract Value
transferred prior to the end of a guaranteed
period will be subject to a Transfer Market
Value Adjustment.
The maximum number of transfers you may make
per Contract Year is one.
You must transfer the entire Contract Value
each time you make a transfer. In addition,
the entire amount must be transferred into
one guarantee period.
TRANSFER MARKET VALUE ADJUSTMENT Amounts transferred will be subject to a
Market Value Adjustment. The amount
requested to be transferred will be
multiplied by the Market Value Adjustment
Factor to determine the actual transferred
amount.
PART 9 WITHDRAWAL PROVISIONS
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PAYMENT OF WITHDRAWALS You may withdraw part or all of the Contract
Value at any time before the earlier of your
death or the Maturity Date, by sending us a
written request. We will pay all withdrawals
within seven days of receipt at the Annuity
Service Office subject to postponement in
certain circumstances, as specified below.
SUSPENSION OF PAYMENTS We may defer the payment resulting from a
request for total or partial withdrawal for
not more than six months, or for the period
permitted by New York state law if shorter,
from the day we receive written request and
the Contract, if required. If such payments
are deferred 10 days or more, the amount
deferred will earn interest at a rate not
less than 4% per year or at a rate
determined by New York state law.
TOTAL WITHDRAWAL Upon receipt of your request to withdraw
all of your Contract Value, we will
terminate the Contract and pay you the
following amount:
C + [( A - B - C) x D] , where:
A = the Gross Withdrawal Value reduced
by any applicable annual
Administration Fee;
B = the Withdrawal Charge;
C = the amount available without
imposition of a withdrawal charge;
D = the Market Value Adjustment Factor.
PARTIAL WITHDRAWAL Partial withdrawals will use the formula
specified in Part 9 Total Withdrawal above
and the Gross Withdrawal Value to determine
the amount payable to you. Partial
withdrawals will be subject to Market Value
Adjustments and possible withdrawal charges.
We will deduct the Gross Withdrawal Value
from the Contract Value. The Gross
Withdrawal Value may not exceed the Contract
Value.
WITHDRAWAL CHARGE If a withdrawal is made from the Contract
before the Maturity Date, a Withdrawal
Charge (contingent deferred sales charge)
may be assessed during the first 7 Contract
Years. No Withdrawal Charge will be applied
after the 7th Contract Year. The amount of
the Withdrawal Charge and when it is
assessed
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are discussed below:
1. The amount available without imposition
of a withdrawal charge is defined as the
excess of (a) over (b), where:
(a) equals 10% of Payment,
(b) equals 100% of all prior
partial withdrawals, in that
Contract Year.
The amount available without imposition
of a withdrawal charge may be withdrawn
free of a Withdrawal Charge and is not
subject to a Market Value Adjustment.
2. If a withdrawal is made at the end of the
Initial Guarantee Period, no withdrawal
charge will be applied provided such
withdrawal occurs on or after the end of
the third Contract Year. If a withdrawal
is made at the end of any other guarantee
period, no withdrawal charge will be
applied provided such withdrawal occurs
on or after the end of the fifth Contract
Year. A request for withdrawal at the end
of a guarantee period must be received in
writing during the 30 day period
preceding the end of that guarantee
period.
3. The Withdrawal Charge is determined by
multiplying the Gross Withdrawal Value
less any annual Administration Fee and
the amount available without imposition
of a withdrawal charge by the applicable
Withdrawal Charge Percentage obtained
from the table below.
Number of Complete Contract Withdrawal Charge
--------------------------- -----------------
Years Percentage
----- ----------
0 7%
1 6
2 5
3 4
4 3
5 2
6 1
7+ 0
WITHDRAWAL MARKET VALUE Amounts withdrawn will be subject to a
ADJUSTMENT Market Value Adjustment. The Market Value
Adjustment will be determined in accordance
with the formula specified in Part 9 Total
Withdrawal above.
There will be no Market Value Adjustment on
withdrawals in the following situations: (a)
death of the Owner, (b) amounts withdrawn
within one month prior to the end of the
guarantee period, and (c) the amount
available without imposition of a withdrawal
charge.
FREQUENCY AND AMOUNT OF You may make as many partial withdrawals as
PARTIAL WITHDRAWAL you wish. Any withdrawal from the Contract
must be at least $300 or the entire balance
of the Contract Value if less. If a partial
withdrawal would reduce the Contract Value
to less than $300, then we will treat the
partial withdrawal request as a total
withdrawal of the Contract Value.
PART 10 FEES AND DEDUCTIONS
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TAXES We reserve the right to charge certain taxes
against your Payment (either at the time of
payment or liquidation), Contract Value,
payment of Death Benefit or annuity
payments, as appropriate. Such taxes may
include any premium taxes
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or other taxes levied by any government
entity which we, in our sole discretion,
determine to have resulted from the
establishment or maintenance of the Separate
Account, or from the receipt by us of
Payments, or from the issuance of this
Contract, or from the commencement or
continuance of annuity payments under this
Contract.
PART 12 PAYMENT OF CONTRACT BENEFITS
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GENERAL Benefits payable under this Contract may be
applied in accordance with one or more of
the Annuity Options described below, subject
to any restrictions of Internal Revenue Code
section 72(s).
ALTERNATE ANNUITY OPTIONS Instead of settlement in accordance with the
Annuity Options described below, you may
choose an alternate form of settlement
acceptable to us.
DESCRIPTION OF ANNUITY OPTIONS Option 1: Life Annuity
(a) Life Non-Refund. We will make payments
during the lifetime of the
Annuitant. No payments are due
after the death of the Annuitant.
(b) Life 10-Year Certain. We will make
payments for 10 years and after
that during the lifetime of the
Annuitant. No payments are due
after the death of the Annuitant
or, if later, the end of the
10-year period certain.
Option 2: Joint and Survivor Life Annuity
The second Annuitant named shall be referred
to as the Co-Annuitant.
(a) Joint and Survivor Non-Refund. We will
make payments during the joint
lifetime of the Annuitant and
Co-Annuitant. Payments will then
continue during the remaining
lifetime of the survivor. No
payments are due after the death of
the last survivor of the Annuitant
and Co-Annuitant.
(b) Joint and Survivor with 10-Year Certain.
We will make payments for 10 years
and after that during the joint
lifetime of the Annuitant and
Co-Annuitant. Payments will then
continue during the remaining
lifetime of the survivor. No
payments are due after the death of
the survivor of the Annuitant and
Co-Annuitant or, if later, the end
of the 10-year period certain.
ANNUITY PAYMENT RATES The annuity payment rates on the attached
tables show, for each $1,000 applied, the
dollar amount of the monthly fixed annuity
payment. These rates are based on the 1983
Table A projected at Scale G with interest
at the guaranteed rate of 3% per annum and
assume births in year 1942. The amount of
each annuity payment will depend upon the
sex and adjusted age of the Annuitant, the
Co-Annuitant, if any, or other payee. The
adjusted age is determined from the actual
age nearest birthday at the time the first
monthly annuity payment is due, as follows:
Calendar Year of Adjustment Calendar Year Adjustment
Birth to Actual Age of Birth to Actual Age
1899-1905 +6 1946-1951 -1
1906-1911 +5 1952-1958 -2
1912-1918 +4 1959-1965 -3
1919-1925 +3 1966-1972 -4
1926-1932 +2 1973-1979 -5
1933-1938 +1 1980-1986 -6
9
15
1939-1945 0 1987+ -7
The dollar amount of annuity payment for any
age or combination of ages not shown, for
any other form of Annuity Option agreed to
by us, or for payments made on a less
frequent basis (quarterly, semiannual or
annual) will be quoted on request.
10
16
AMOUNT OF MONTHLY PAYMENT
PER $1000 OF CONTRACT VALUE
OPTION 1: LIFE ANNUITY
Option 1(A): Non-Refund Option 1(B): 10-Year Certain
--------------------------------------------- ----------------------------------------------
Adjusted Age Adjusted Age
of Annuitant Male Female of Annuitant Male Female
--------------------------------------------- ----------------------------------------------
55 4.27 3.86 55 4.22 3.84
60 4.69 4.19 60 4.61 4.15
65 5.25 4.61 65 5.10 4.55
70 6.02 5.19 70 5.71 5.07
75 7.01 5.99 75 6.42 5.73
80 8.34 7.10 80 7.20 6.52
85 10.13 8.64 85 7.97 7.37
OPTION 2: JOINT AND SURVIVOR LIFE ANNUITY
Option 2(A): Non-Refund
Age of Co-Annuitant
-----------------------------------------------------------------------------------------------
Adjusted
Age of Male 10 Years 5 Years Same 5 Years 10 Years
Annuitant Younger Younger Age Older Older
-----------------------------------------------------------------------------------------------
55 3.25 3.39 3.55 3.72 3.87
60 3.41 3.60 3.81 4.02 4.21
65 3.62 3.87 4.14 4.41 4.67
70 3.89 4.21 4.57 4.95 5.29
75 4.24 4.67 5.17 5.67 6.11
80 4.71 5.30 5.97 6.63 7.19
85 5.35 6.15 7.05 7.92 8.60
Option 2(B): 10 Year Certain
Age of Co-Annuitant
-----------------------------------------------------------------------------------------------
Adjusted
Age of Male 10 Years 5 Years Same 5 Years 10 Years
Annuitant Younger Younger Age Older Older
-----------------------------------------------------------------------------------------------
55 3.25 3.39 3.55 3.72 3.87
60 3.41 3.60 3.80 4.01 4.21
65 3.62 3.86 4.13 4.41 4.66
70 3.89 4.21 4.56 4.92 5.24
75 4.24 4.66 5.13 5.58 5.95
80 4.69 5.25 5.85 6.39 6.78
85 5.28 6.00 6.71 7.27 7.67
-----------------------------------------------------------------------------------------------
Monthly installments for ages not shown will be furnished on request.
11
17
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FIRST NORTH AMERICAN LIFE
ASSURANCE COMPANY
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