EXHIBIT 4(d)
-----GOLDEN
--------AMERICAN DEFERRED COMBINATION
----------LIFE INSURANCE VARIABLE AND FIXED
-------COMPANY ANNUITY CONTRACT
Golden American is a stock company domiciled in Delaware.
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| 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] |
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In this Certificate you or your refers to the Owner shown above. We,
our or us refers to Golden American Life Insurance Company. You may
allocate this Certificate's Accumulation Value among the Variable
Separate Account, the General Account and the Fixed Account shown in the
Schedule.
This Certificate describes the benefits and provisions of the group
contract. The group contract, as issued to the Contractholder by us with
any Riders or Endorsements, alone makes up the agreement under which
benefits are paid. The group contract may be inspected at the office of
the Contractholder. In consideration of any application for this
Certificate and the payment of premiums, we agree, subject to the terms
and conditions of the group contract, to provide the benefits described
in this Certificate to the Owner. The Annuitant under this Certificate
must be eligible under the terms of the group contract. If the group
contract and this Certificate are in force, we will make income payments
to the Owner starting on the Annuity Commencement Date as shown in the
Schedule. If the Owner dies prior to the Annuity Commencement Date, we
will pay a death benefit to the Beneficiary. The amount of such benefit
is subject to the terms of this Certificate.
The benefits of the Certificate will be paid according to the
provisions of the Certificate and group contract.
RIGHT TO EXAMINE THIS CERTIFICATE: YOU MAY RETURN THIS CERTIFICATE TO
US OR THE AGENT THROUGH WHOM YOU PURCHASED IT WITHIN 10 DAYS AFTER YOU
RECEIVE IT. IF SO RETURNED, WE WILL TREAT THE CERTIFICATE AS THOUGH IT
WERE NEVER ISSUED. UPON RECEIPT WE WILL PROMPTLY REFUND THE ACCUMULATION
VALUE, ADJUSTED FOR ANY MARKET VALUE ADJUSTMENT, PLUS ANY CHARGES WE HAVE
DEDUCTED AS OF THE DATE THE RETURNED CERTIFICATE IS RECEIVED BY US.
ALL PAYMENTS AND VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A
VARIABLE SEPARATE ACCOUNT DIVISION, MAY INCREASE OR DECREASE, DEPENDING
ON THE CERTIFICATE'S INVESTMENT RESULTS. ALL PAYMENTS AND VALUES BASED
ON THE FIXED ACCOUNT MAY BE SUBJECT TO A MARKET VALUE ADJUSTMENT, THE
OPERATION OF WHICH MAY CAUSE SUCH PAYMENTS AND VALUES TO INCREASE OR
DECREASE.
Customer Service Center Secretary:
0000 Xxxxxxxx Xxxxx
Xxxx Xxxxxxx, XX 00000
President:
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DEFERRED COMBINATION VARIABLE AND FIXED ANNUITY CERTIFICATE - NO DIVIDENDS
Variable Cash Surrender Values while the Annuitant and Owner are living
and prior to the Annuity Commencement Date. Death benefit subject to
guaranteed minimum. Additional Premium Payment Option. Partial
Withdrawal Option. Non-participating. Investment results reflected in
values.
GA-CA-1074
CONTRACT CONTENTS
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THE SCHEDULE YOUR CERTIFICATE BENEFITS..14
Payment and Investment Information... 3A Cash Value Benefit
The Variable Separate Accounts....... 3B Partial Withdrawal Option
The General Account.................. 3C Proceeds Payable to
Certificate Facts.................... 3D the Beneficiary
Charges and Fees..................... 3E
Income Plan Factors.................. 3F CHOOSING AN INCOME PLAN....16
IMPORTANT TERMS .......................... 4
INTRODUCTION TO THIS CERTIFICATE.......... 6 Annuity Benefits
Annuity Commencement Date
Selection
The Certificate Frequency Selection
The Owner The Income Plan
The Annuitant The Annuity Options
The Beneficiary Payment When Named Person
Change of Owner or Beneficiary Dies
OTHER IMPORTANT
PREMIUM PAYMENTS AND ALLOCATION CHANGES... 8 INFORMATION.............18
Sending Notice to Us
Initial Premium Payment Reports to Owner
Additional Premium Payment Option Assignment - Using this
Your Right to Change Allocation of Certificate as
Accumulation Value Collateral Security
What Happens if a Variable Changing this Certificate
Separate Account Certificate Changes -
Division is Not Available Applicable Tax Law
Misstatement of Age or Sex
Non-Participating
HOW WE MEASURE THE CERTIFICATE'S Payments We May Defer
ACCUMULATION VALUE.............. 9 Authority to Make Agreements
Required Note on Our
The Variable Separate Accounts Computations
The General Account
Valuation Period
Accumulation Value
Accumulation Value in each Division
Measurement of Investment Experience
Charges Deducted from Accumulation Value
on each Certificate Processing Date
Copies of any application and any additional Riders and
Endorsements are at the back of this Certificate.
THE SCHEDULE
The Schedule gives specific facts about this Certificate and its
coverage. Please refer to the Schedule while reading this
Certificate.
GA-CA-1074 2
THE SCHEDULE
PAYMENT AND INVESTMENT INFORMATION
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| 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] |
|----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] |
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INITIAL INVESTMENT
Initial Premium Payment received: [$10,000]
Your initial Accumulation Value has been invested as follows:
Percentage of
Divisions Accumulation Value
--------- ------------------
[Multiple Allocation 10%
Fully Managed 10%
Capital Appreciation 10%
Rising Dividends 10%
All-Growth 10%
Real Estate 10%
Value Equity 5%
Hard Assets 5%
Emerging Markets 5%
Managed Global 5%
Limited Maturity Bond 5%
Liquid Asset 5%
Strategic Equity 5%
Fixed Allocation - 1 Year 5%]
-------------------- ------------------
Total 100%
===== ====
ADDITIONAL PREMIUM PAYMENT INFORMATION
Except in the case of a contract issued as an IRA, we will accept
additional premium payments until either the Annuitant or Owner reaches
the Attained Age of 85. The minimum additional payment which may be made
is $500.00.
If this Certificate 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 $250.00.
GA-CA-1074 3A1
THE SCHEDULE
PAYMENT AND INVESTMENT INFORMATION (continued)
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| 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] |
|----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456] |
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ACCUMULATION VALUE ALLOCATION RULES
The maximum number of Divisions in which you may be invested at any one
time is twenty. You are allowed unlimited allocation changes per
Certificate Year without charge. We reserve the right to impose a charge
for any allocation change in excess of twelve per Certificate 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-CA-1074 3A2
THE SCHEDULE
THE VARIABLE SEPARATE ACCOUNTS
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| 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] |
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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
------ ------
[Multiple Allocation Real Estate
Fully Managed Hard Assets
Value Equity Emerging Markets
Small Cap Limited Maturity Bond
Capital Appreciation Liquid Assets
Rising Dividend Strategic Equity
Capital Growth Managed Global
Developing World Global Fixed Income
Large Cap Value Total Return
Growth All-Cap
Mid-Cap Growth Investors
Research Equity Income]
GA-CA-1074 3B
THE SCHEDULE
THE GENERAL ACCOUNT
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| 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] |
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GENERAL ACCOUNT
[Guaranteed Interest Division
A 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
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 date of
transfer.]
GA-CA-1074 3C
THE SCHEDULE
CERTIFICATE FACTS
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| 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] |
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CERTIFICATE FACTS
Certificate Processing Date
The Certificate Processing Date for your Certificate is [April 1] of each
year.
Specially Designated Divisions
When a distribution is made from an investment portfolio underlying a
Separate Account Division in which reinvestment is not available, we will
allocate the amount of the distribution to the [Liquid Asset Division]
unless you specify otherwise.
PARTIAL WITHDRAWALS
The maximum amount that can be withdrawn each Certificate Year without
being considered an Excess Partial Withdrawal is described below. We will
collect a Surrender Charge for Excess Partial Withdrawals and a charge for
any unrecovered premium taxes. In no event may a Partial Withdrawal be
greater than 90% of the Cash Surrender Value. After a Partial Withdrawal,
the remaining Accumulation Value must be at least $100 to keep the
Certificate in force.
Systematic Partial Withdrawals and Conventional Partial Withdrawals may not
be taken in the same Certificate Year.
To determine the Surrender Charge on Excess Partial Withdrawals, the
withdrawals will occur in the following order:
(1) Earnings;
(2) The Free Amount;
(3) Premium Payments which were received more than eight years prior
to the withdrawal; and,
(4) Premium Payments which were received less than eight years
prior to withdrawal.
Earnings and Free Amounts are not treated as withdrawals of Premium
Payments for purposes of calculating any Surrender Charge.
Conventional Partial Withdrawals
Minimum Withdrawal Amount: $100.
The maximum amount that can be taken as a Conventional Partial Withdrawal
each Certificate Year without being considered an Excess Partial Withdrawal
is the sum of the following:
(1) Earnings (defined below) not previously withdrawn, but not less
than zero; and
(2) The Free Amount, equal to 10% of Premium Payments not
previously withdrawn, which were received within eight years prior
to the date of withdrawal.
Earnings are equal to the Accumulation Value, less Premiums Payments
received, plus prior withdrawals.
Any Conventional Partial Withdrawal is subject to a Market Value
Adjustment unless withdrawn from a Fixed Allocation within 30 days prior
to the Maturity Date.
GA-CA-1074 3D1
THE SCHEDULE
CERTIFICATE FACTS (continued)
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| 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] |
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Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days
from the Certificate Issue Date and may be taken on a monthly, quarterly or
annual basis. You select the day withdrawals will be made, but no later
than the 28th day of the month. If you do not elect a day, the Certificate
Date will be used.
Maximum Withdrawal Amounts:
Variable Separate Account Divisions: .833% of Premium Payments
monthly, 2.5% of Premium Payments
quarterly or 10% of Premium Payments
annually.
Fixed Allocations and
Guaranteed Interest Divisions: Interest earned on a Fixed Allocation
or Guaranteed Interest Division for
the prior month, quarter or year
(depending on the frequency selected).
The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal
is 10% of Premium Payments not previously withdrawn. Systematic Partial
Withdrawals from Fixed Allocations are not subject to a Market Value
Adjustment. A Systematic Partial Withdrawal in excess of Earnings and the
Free Amount may be subject to a Surrender Charge.
IRA Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a contract issued as an IRA on a
monthly, quarterly or annual basis. A minimum withdrawal of $100.00 is
required. You select the day the withdrawals will be made, but no later
than the 28th day of the month. If you do not elect a day, the Contract
Date will be used. Systematic Partial Withdrawals and Conventional Partial
Withdrawals are not allowed when IRA Partial Withdrawals are being taken.
An IRA Partial Withdrawal in excess of the maximum amount allowed under the
Systematic Partial Withdrawal option may be subject to a Market Value
Adjustment.
DEATH BENEFITS
The Death Benefit is determined as follows:
If the Owner's Issue Age is 67 or less, the Death Benefit is the greatest
of:
(1) The sum of premiums paid less any withdrawals and taxes:
(2) The Accumulation Value less any taxes;
(3) The highest Accumulation Value (plus subsequent premiums less
subsequent withdrawals and taxes) on any Certificate Anniversary on or
before the Owner's death beginning with the 8th anniversary and
continuing through to the last anniversary prior to the Owner's
attained age 76; or
(4) The Cash Surrender Value.
If the Owner's Issue Age is greater than 67 but less than or equal to 75,
the Death Benefit is the greatest of:
(1) The sum of Premium Payments less any withdrawals and taxes;
GA-CA-1074 3D2
THE SCHEDULE
CERTIFICATE FACTS (continued)
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| 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] |
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(2) The Accumulation Value less any taxes;
(3) The Accumulation Value (plus subsequent premiums less
subsequent withdrawals and taxes) on the 8th Certificate anniversary
but on or before the Owner's death; or
(4) The Cash Surrender Value.
If the Owner's Issue Age is greater than 75:
The Death Benefit is equal to the greater of Accumulation Value or
Cash Surrender Value.
SPECIAL FUNDS
Where used in this Certificate, Special Funds are [the Liquid Asset
Division, the Limited Maturity Bond Division, the Fixed Allocations and
the Guaranteed Interest Division]. We may add newly available divisions
as Special Funds. We may also reclassify an existing division as a
Special Fund or remove such designation upon 30 days notice to you. Such
reclassification will apply to amounts transferred or otherwise added to
such division after the date of change. We may reduce the Mortality and
Expense Risk Charge (if applicable) for that portion of the Contract
invested in a Special Fund.
CHANGE OF OWNER
A change of Owner from a sole Owner to a sole Owner (where there have
never been multiple Owners designated) will result in recalculation of
the Death Benefit. If the new Owner's attained age at the time of the
change is less than [76], the Death Benefit in effect prior to the
change will remain in effect and the Death Benefit provision shall apply.
If the new Owner's attained age at the time of the change is [77] or
greater, but not greater than [85] and the contract has been in effect
less than 8 years, the death benefit on the eight anniversary will be
equal to the Accumulation Value on the eight anniversary. If more than
eight years have passed since Contract Date, no further increases on any
anniversary will be made to a death benefit. If the new Owner's attained
age is greater than [85], at the time of the change, the Death Benefit
will then be the greatest of (b) 1, (b) 2, (b) 3,or (b) 4, above.
If ownership changes result in multiple Owners or if there has ever been
multiple Owners, the Death Benefit shall be set to zero. If any Owner's
or oldest multiple Owners' attained age is [86] or greater at the time of
the change, the Guaranteed Death Benefit, the Minimum Death Benefit, and
the Maximum Guaranteed Death Benefit will be zero, and the Death Benefit
will then be the Cash Surrender Value.
SPOUSAL CONTINUATION UPON DEATH OF OWNER
If at the Owner's death, the surviving spouse of the deceased Owner is
the Beneficiary and such surviving spouse elects to continue the contract
as their own pursuant to Internal Revenue Code Section 72(s) or the
equivalent provisions of U.S. Treasury Department rules for qualified
plans, the following will apply:
If the greater of (ii) and (iv) in the Death Benefit provision as of the
date we receive due proof of death of the Owner minus the Accumulation
Value, also as of that date, is greater than zero, we will add such
difference to the Accumulation Value. Such addition will be
GA-CA-1074 3D3
THE SCHEDULE
CERTIFICATE FACTS (continued)
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| 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] |
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(A) allocated to the divisions of the Separate Account in the same
proportion as the Accumulation Value in each division bears to the
Accumulation Value in the Separate Account. If there is no Accumulation
Value in the Separate Account, the addition will be allocated to the
Liquid Asset division, or its successor.
(b) The Guaranteed Death Benefit and the Maximum Guaranteed Death
Benefit will continue to apply, using the surviving spouse's age as the
determining age.
(c) At subsequent surrender, any surrender charge applicable to premiums
paid prior to the date we receive due proof of death of the Owner will be
waived. Any premiums paid later will be subject to any applicable
surrender charge.
This addition to Accumulation Value is available only to the spouse of
the Owner as of the date of death of the Owner if such spouse under the
provisions of this Contract elects to continue the Contract as their own.
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no
later than April 1st of the calendar year following the calendar year in
which the Owner attains age 70 1/2. Otherwise, the Annuity Commencement
Date may be no later than the same date as the Contract Processing Date in
the month following the Annuitant's 90th birthday. In applying the
Accumulation Value, we may first collect any Premium Taxes due us. If, on
the Annuity Commencement Date, a Surrender Charge remains, your elected
Annuity Option must include a period certain of at least five years
duration.
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
Optional Benefit Riders - [None.]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full years
elapsed since the Certificate Date.
GA-CA-1074 3D4
THE SCHEDULE
CERTIFICATE FACTS (continued)
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| 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] |
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FIXED ACCOUNT
Minimum Fixed Allocation
The minimum allocation to the Fixed Account in any one Fixed Allocation
is [$250.00].
Minimum Guaranteed Interest Rate - [3%.]
Guarantee Periods
We currently offer Guarantee Periods of [1,2,3,4,5,6,7,8,9 and 10]
year(s). We reserve the right to offer Guarantee Periods of durations
other than those available on the Certificate Date. We also reserve the
right to cease offering a particular Guarantee Period or Periods.
Index Rate
The Index Rate is the average of the Ask Yields for the U.S. Treasury
Strips as reported by a national quoting service for the applicable
maturity. The average is based on the period from the 22nd day of the
calendar month two months prior to the calendar month of Index Rate
determination to the 21st day of the calendar month immediately prior to
the month of determination. The applicable maturity date for these U.S.
Treasury Strips is on or next following the last day of the Guarantee
Period. If the Ask Yields are no longer available, the Index Rate will
be determined using a suitable replacement method.
We currently set the Index Rate once each calendar month. However, we
reserve the right to set the Index Rate more frequently than monthly, but
in no event will such Index Rate be based on a period less than 28 days.
GA-CA-1074 3D5
THE SCHEDULE
CHARGES AND FEES
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| 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] |
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DEDUCTIONS FROM PREMIUMS
[None.]
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
[None.]
Administrative Charge - [We charge [$30] to cover a portion of our ongoing
administrative expenses for each Certificate Processing Period. The charge
is incurred at the beginning of the Certificate Processing Period and
deducted on the Certificate Processing Date at the end of the period.
At the time of deduction, this charge will be waived if
(1) The Accumulation Value is at least $100,000; or
(2) The sum of premiums paid to date is at least $100,000]
Excess Allocation Charge
Currently none, however, we reserve the right to charge [$25] for a
change if you make more than [twelve] allocation changes per Certificate
Year. Any charge will be deducted in proportion to the amount being
transferred from each Division.
Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if
the Certificate is surrendered or an Excess Partial Withdrawal is taken.
The percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed since a Premium
Payment was made. The Surrender Charge expressed as a percentage of each
Premium Payment is as follows:
Complete Years Elapsed Surrender
Since Premium Payment Charges
---------------------- ---------
[0 8%
1 7%
2 6%
3 5%
4 4%
5 3%
6 2%
7 1%
8+ 0%]
Surrender of the Certificate is permitted at or before the commencement
of annuity payments.
GA-CA-1074 3E1
THE SCHEDULE
CHARGES AND FEES (continued)
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| 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] |
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[Premium Taxes
We deduct the amount of any premium or other state and local taxes levied
by any state or governmental entity when such taxes are incurred.
We reserve the right to defer collection of Premium Taxes until surrender
or until application of Accumulation Value to an Annuity Option. An
Excess Partial Withdrawal will result in the deduction of any Premium Tax
then due us on such amount. We reserve the right to change the amount we
charge for Premium Tax charges on future Premium Payments to conform with
changes in the law or if the Owner changes state of residence.]
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the assets in
each Separate Account division on a daily basis of not more than
[0.003585%] (equivalent to an annual maximum rate of [1.30%]) for
mortality and expense risks. The charge is not deducted from the Fixed
Account or General Account accumulation values.
Asset Based Administrative Charge - We deduct [0.000411%] of the assets
in each Variable Separate Account Division on a daily basis (equivalent
to an annual rate of [0.15%]) to compensate us for a portion of our
ongoing administrative expenses. This charge is not deducted from the
Fixed Account values.
CHARGE DEDUCTION DIVISION
All charges against the Accumulation Value in this Certificate will be
deducted from the [Liquid Asset Division].
GA-CA-1074 3E2
THE SCHEDULE
INCOME PLAN FACTORS
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| 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] |
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Values for other payment periods, ages or joint life combinations are
available on request. Monthly payments are shown for each $1,000
applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Fixed Fixed
Period Monthly Period Monthly Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years 20 Years Refund
Certain Certain Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
GA-CA-1074 3F
IMPORTANT TERMS
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ACCUMULATION VALUE - The amount that a Certificate provides for
investment at any time. Initially, this amount is equal to the
premium paid.
ANNUITANT - The person designated by the Owner to be the measuring life
in determining Annuity Payments.
ANNUITY COMMENCEMENT DATE - For each Certificate, the date on which
Annuity Payments begin.
ANNUITY OPTIONS - Options the Owner selects that determine the form and
amount of annuity payments.
ANNUITY PAYMENT - The periodic payment an Owner receives. It may be
either a fixed or a variable amount based on the Annuity Option
chosen.
ATTAINED AGE - The Issue Age of the Annuitant or Owner plus the number of
full years elapsed since the Certificate Date.
BENEFICIARY - The person designated to receive benefits in the case of
the death of the Owner.
BUSINESS DAY - Any day the New York Stock Exchange ("NYSE") is open for
trading, exclusive of federal holidays, or any day on which the
Securities and Exchange Commission ("SEC") requires that mutual funds,
unit investment trusts or other investment portfolios be valued.
CASH SURRENDER VALUE - The amount the Owner receives upon surrender of
the Certificate.
CERTIFICATE ANNIVERSARY - The anniversary of the Certificate Date.
CERTIFICATE DATE - The date we received the initial premium and upon
which we begin determining the Certificate values. It may not be the
same as the Certificate Issue Date. This date is used to determine
Certificate months, processing dates, years, and anniversaries.
CERTIFICATE ISSUE DATE - The date the Certificate is issued at our
Customer Service Center.
CERTIFICATE PROCESSING DATES - The days when we deduct certain charges
from the Accumulation Value. If the Certificate Processing Date is
not a Valuation Date, it will be on the next succeeding Valuation
date. The Certificate Processing Date will be on the Certificate
Anniversary of each year.
CERTIFICATE PROCESSING PERIOD - The period between successive Certificate
Processing Dates unless it is the first Certificate Processing Period.
In that case, it is the period from the Certificate Date to the first
Certificate Processing Date.
CERTIFICATE YEAR - The period between Certificate Anniversaries.
CHARGE DEDUCTION DIVISION - The Division from which all charges are
deducted if so designated or elected by the Owner.
CONTINGENT ANNUITANT - The person designated by the Owner who, upon the
Annuitant's death prior to the Annuity Commencement Date, becomes the
Annuitant.
CONTRACT ISSUE DATE - The date the group contract is issued at our
Customer Service Center.
CONTRACTHOLDER - the entity to whom the group contract is issued.
GA-CA-1074 4
IMPORTANT TERMS (continued)
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EXPERIENCE FACTOR - The factor which reflects the investment experience
of the portfolio in which a Variable Separate Account Division invests
and also reflects the charges assessed against the Division for a
Valuation Period.
FIXED ACCOUNT - This is the Separate Account established to support Fixed
Allocations.
FIXED ALLOCATION - An amount allocated to the Fixed Account that is
credited with a Guaranteed Interest Rate for a specified Guarantee
Period.
GUARANTEE PERIOD - The period of years a rate of interest is guaranteed
to be credited to a Fixed Allocation or allocations to a Guaranteed
Interest Division.
GUARANTEED INTEREST DIVISION - An investment option available in the
General Account, an account which contains all of our assets other
than those held in our Separate Accounts.
GUARANTEED INTEREST RATE - The effective annual interest rate which we
will credit for a specified Guarantee Period.
GUARANTEED MINIMUM INTEREST RATE - The minimum interest rate which can be
declared by us for Fixed Allocations or Guaranteed Interest Divisions.
INDEX OF INVESTMENT EXPERIENCE - The index that measures the performance
of a Variable Separate Account Division.
INITIAL PREMIUM - The payment amount required to put each Certificate in
effect.
ISSUE AGE - The Annuitant's or Owner's age on the last birthday on or
before the Certificate Date.
MARKET VALUE ADJUSTMENT - A positive or negative adjustment to a Fixed
Allocation. It may apply if all or part of a Fixed Allocation is
withdrawn, transferred, or applied to an Annuity Option prior to the
end of the Guarantee Period.
MATURITY DATE - The date on which a Guarantee Period matures.
OWNER - The person who owns a Certificate and is entitled to exercise all
rights of the Certificate. This person's death also initiates payment
of the death benefit.
RIDERS - Riders add provisions or change the terms of the Certificate.
SPECIALLY DESIGNATED DIVISION - Distributions from a portfolio underlying
a Division in which reinvestment is not available will be allocated to
this Division unless you specify otherwise.
VALUATION DATE - The day at the end of a Valuation Period when each
Division is valued.
VALUATION PERIOD - Each business day together with any non-business days
before it.
VARIABLE SEPARATE ACCOUNT DIVISION - An investment option available in
the Variable Separate Account shown in the Schedule.
GA-CA-1074 5
INTRODUCTION TO THIS CERTIFICATE
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THE CERTIFICATE
This is a legal Certificate between you and us. We provide benefits as
stated in this Certificate. In return, you supply us with the Initial
Premium Payment required to put this Certificate in effect.
This Certificate, together with any Riders or Endorsements, constitutes
the entire Certificate. Riders and Endorsements add provisions or change
the terms of the basic Certificate.
THE OWNER
You are the Owner of this Certificate. You are also the Annuitant unless
another Annuitant has been named by you and is shown in the Schedule.
You have the rights and options described in this Certificate, including
but not limited to the right to receive the Annuity Benefits on the
Annuity Commencement Date.
One or more people may own this Certificate. If there are multiple
Owners named, the age of the oldest Owner will be used to determine the
applicable death benefit. In the case of a sole Owner who dies prior to
the Annuity Commencement Date, we will pay the Beneficiary the death
benefit then due. If the sole Owner is not an individual, we will treat
the Annuitant as Owner for the purpose of determining when the Owner dies
under the death benefit provision (if there is no Contingent Annuitant),
and the Annuitant's age will determine the applicable death benefit
payable to the Beneficiary. The sole Owner's estate will be the
Beneficiary if no Beneficiary designation is in effect, or if the
designated Beneficiary has predeceased the Owner. In the case of a joint
Owner of the Certificate dying prior to the Annuity Commencement Date,
the surviving Owner(s) will be deemed as the Beneficiary(ies).
THE ANNUITANT
The Annuitant is the measuring life of the Annuity Benefits provided
under this Certificate. You may name a Contingent Annuitant. The
Annuitant may not be changed during the Annuitant's lifetime.
If the Annuitant dies before the Annuity Commencement Date, the
Contingent Annuitant becomes the Annuitant. You will be the Contingent
Annuitant unless you name someone else. The Annuitant must be a natural
person. If the Annuitant dies and no Contingent Annuitant has been
named, we will allow you sixty days to designate someone other than
yourself as an Annuitant. If all Owners are not individuals and, through
the operation of this provision, an Owner becomes Annuitant, we will pay
the death proceeds to the Beneficiary. If there are joint Owners, we
will treat the youngest of the Owners as the Contingent Annuitant
designated, unless you elect otherwise.
THE BENEFICIARY
The Beneficiary is the person to whom we pay death proceeds if any Owner
dies prior to the Annuity Commencement Date. See Proceeds Payable to the
Beneficiary for more information. We pay death proceeds to the primary
Beneficiary (unless there are joint Owners in which case the death
benefit proceeds are payable to the surviving Owner). If the primary
Beneficiary dies before the Owner, the death proceeds are paid to the
Contingent Beneficiary, if any. If there is no surviving Beneficiary, we
pay the death proceeds to the Owner's estate.
GA-CA-1074 6
INTRODUCTION TO THIS CERTIFICATE (continued)
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One or more persons may be named as primary Beneficiary or contingent
Beneficiary. In the case of more than one Beneficiary, we will assume
any death proceeds are to be paid in equal shares to the surviving
Beneficiaries. You can specify other than equal shares.
You have the right to change Beneficiaries, unless you designate the
primary Beneficiary irrevocable. When an irrevocable Beneficiary has
been designated, you and the irrevocable Beneficiary may have to act
together to exercise the rights and options under this Certificate.
CHANGE OF OWNER OR BENEFICIARY
During your lifetime and while this Certificate is in effect you can
transfer ownership of this Certificate or change the Beneficiary. To
make any of these changes, you must send us written notice of the change
in a form satisfactory to us. The change will take effect as of the day
the notice is signed. The change will not affect any payment made or
action taken by us before recording the change at our Customer Service
Center. A Change of Owner may affect the amount of death benefit payable
under this Certificate. See Proceeds Payable to Beneficiary.
GA-CA-1074 7
PREMIUM PAYMENTS AND ALLOCATION CHARGES
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INITIAL PREMIUM PAYMENT
The Initial Premium Payment is required to put this Certificate in
effect. The amount of the Initial Premium Payment is shown in the
Schedule.
ADDITIONAL PREMIUM PAYMENT OPTION
You may make additional Premium Payments under this Certificate after the
end of the Right to Examine period. Restrictions on additional Premium
Payments, such as the Attained Age of the Annuitant or Owner and the
timing and amount of each payment, are shown in the Schedule. We reserve
the right to defer acceptance of or to return any additional Premium
Payments.
As of the date we receive and accept your additional Premium Payment:
(1)The Accumulation Value will increase by the amount of the
Premium Payment less any premium deductions as shown in the
Schedule.
(2)The increase in the Accumulation Value will be allocated among
the Divisions of the Variable Separate Account and General Account
and allocations to the Fixed Account in accordance with your
instructions. If you do not provide such instructions, allocation
will be among the Divisions of the Variable Separate Account and
General Account and allocations to the Fixed Account in proportion
to the amount of Accumulation Value in each Division or Fixed
Allocation.
Where to Make Payments
Remit the Premium Payments to our Customer Service Center at the address
shown on the cover page. On request we will give you a receipt signed by
our treasurer.
YOUR RIGHT TO CHANGE ALLOCATION OF ACCUMULATION VALUE
You may change the allocation of the Accumulation Value among the
Divisions and Fixed Allocations after the end of the Right to Examine
period. The number of free allocation changes each year that we will
allow is shown in the Schedule. To make an allocation change, you must
provide us with satisfactory notice at our Customer Service Center. The
change will take effect when we receive the notice. Restrictions for
reallocation into and out of Divisions of the Variable Separate Account
and General Account and allocations to the Fixed Account are shown in the
Schedule. An allocation from the Fixed Account may be subject to a
Market Value Adjustment. See the Schedule.
WHAT HAPPENS IF A VARIABLE SEPARATE ACCOUNT DIVISION IS NOT AVAILABLE
When a distribution is made from an investment portfolio supporting a
unit investment trust Separate Account Division in which reinvestment is
not available, we will allocate the distribution to the Specially
Designated Division shown in the Schedule unless you specify otherwise.
Such a distribution may occur when an investment portfolio or Division
matures, when distribution from a portfolio or Division cannot be
reinvested in the portfolio or Division due to the unavailability of
securities, or for other reasons. When this occurs because of maturity,
we will send written notice to you thirty days in advance of such date.
To elect an allocation to other than the Specially Designated Division
shown in the Schedule, you must provide satisfactory notice to us at
least seven days prior to the date the investment matures. Such
allocations will not be counted as an allocation change of the
Accumulation Value for purposes of the number of free allocations
permitted.
GA-CA-1074 8
PREMIUM PAYMENTS AND ALLOCATION CHARGES (CONT.)
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RESTRICTED FUNDS
Restricted Funds are subject to limits as to amounts which may be
invested or transferred into such divisions. The designation of a
division as a Restricted Fund may be changed upon 30 days notice to the
Owner with regard to future transfers and premium payments into such
division. When a new division is made available it may be designated as
a Restricted Fund. If so designated, the rules regarding its
restrictions will be sent to the Owner. Also listed below are
he total Contract limits for Restricted Funds. Listed on the Schedule
Page are the total Contract limits for Restricted Funds.
THRESHOLDS
Each Restricted Fund has one or more thresholds at which point no
further amounts may be allocated to that division. Compliance with a
threshold is verified whenever there is a transaction initiated which is
subject to such threshold (premium payments, transfers, withdrawals). A
threshold is applied to the total Accumulation Value of each Restricted
Fund. Thresholds may be changed by the Company for new premiums,
transfers or withdrawals by Restricted Fund upon 30 day notice.
DOLLAR CAP
The Dollar Cap is the dollar amount at which no further Accumulation
Value may be added to Restricted Funds.
PREMIUM THRESHOLD
The threshold for premium by Restricted Fund limits the amount of any
premium which may be allocated to that division. Should a request for
allocation to a Restricted Fund exceed the limit in effect for that
division or for the Contract, any excess over that amount shall be
allocated prorata to any non-Restricted Fund(s) in which the Contract is
then invested. Should the Contract not be invested in other non-
Restricted Funds, the excess will be invested in the Specially Designated
Division unless we receive written instructions to do otherwise. Premium
allocations must also satisfy the Allocation Threshold.
ALLOCATION THRESHOLD
Allocations into a Restricted Fund are limited to that amount such that
the Accumulation Value in that Restricted Fund after such allocation does
not exceed the threshold for that division and does not cause the
Contract's total limit on allocation to Restricted Funds to be exceeded.
If the amount of an allocation would cause either limit to be exceeded,
the allocation will only be executed to the extent the lower limit would
allow.
Allocations from a Restricted Fund will be allowed even if the amount
remaining in the Restricted Fund after an allocation exceeds the
Allocation Threshold. If a program of allocations over time is
authorized by us, verification of the threshold will be performed at the
initiation of such program. If such program is modified at a later date,
a testing of thresholds will be done at that time.
GA-CA-1074 9
PREMIUM PAYMENTS AND ALLOCATION CHARGES (CONT.)
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THRESHOLDS - EFFECT ON WITHDRAWALS
If a withdrawal is requested while any Accumulation Value is allocated to
Restricted Funds and the Allocation Threshold percentage is currently
exceeded, the percentage for funds invested in Restricted Funds for the
total Contract, after taking into account the withdrawal, may not be
higher than prior to the withdrawal. Should the calculated effect of a
withdrawal result in the total Contract threshold being exceeded, the
excess portion of the withdrawal will be processed prorata from all
variable divisions. Systematic withdrawals, while the Contract has
investments in Restricted Funds, if not withdrawn prorata from all
divisions, shall be monitored annually to assure threshold compliance.
Should the effect of such withdrawals cause a Restricted Fund to exceed
its threshold, the divisions from which the withdrawals are processed may
be adjusted to assure that the percentage of Accumulation Value in the
Restricted Funds does not increase.
THRESHOLD PROCESSING
For the purpose of calculating any thresholds, the values for the
divisions will be determined using the prior day's closing index of
investment experience.
GA-CA-1074 10
HOW WE MEASURE THE CERTIFICATE'S ACCUMULATION VALUE
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The variable Annuity Benefits under this Certificate are provided through
investments which may be made in our Separate Accounts.
THE VARIABLE SEPARATE ACCOUNTS
These accounts, which are designated in the Schedule, are kept separate
from our General Account and any other Separate Accounts we may have.
They are used to support Variable Annuity Certificates and may be used
for other purposes permitted by applicable laws and regulations. We own
the assets in the Separate Accounts. Assets equal to the reserves and
other liabilities of the accounts will not be charged with liabilities
that arise from any other business we conduct; but, we may transfer to
our General Account assets which exceed the reserves and other
liabilities of the Variable Separate Accounts. Xxxxxx and realized and
unrealized gains or losses from assets in these Variable Separate
Accounts are credited to or charged against the account without regard to
other income, gains or losses in our other investment accounts.
The Variable Separate Account will invest in mutual funds, unit
investment trusts and other investment portfolios which we determine to
be suitable for this Certificate's purposes. The Variable Separate
Account is treated as a unit investment trust under Federal securities
laws. It is registered with the Securities and Exchange Commission
("SEC") under the Investment Company Act of 1940. The Variable Separate
Account is also governed by state law as designated in the Schedule. The
trusts may offer non-registered series.
Variable Separate Account Divisions
A unit investment trust Separate Account includes Divisions, each
investing in a designated investment portfolio. The Divisions and the
investment portfolios designated may be managed by a separate investment
adviser. Such adviser may be registered under the Investment Advisers
Act of 1940.
Changes within the Variable Separate Accounts
We may, from time to time, make additional Variable Separate Account
Divisions available to you. These Divisions will invest in investment
portfolios we find suitable for the group contract. We also have the
right to eliminate Divisions from a Variable Separate Account, to combine
two or more Divisions or to substitute a new portfolio for the portfolio
in which a Division invests. A substitution may become necessary if, in
our judgment, a portfolio or Division no longer suits the purpose of the
group contract. This may happen due to a change in laws or regulations,
or a change in a portfolio's investment objectives or restrictions, or
because the portfolio or Division is no longer available for investment,
or for some other reason. We may get prior approval from the insurance
department of our state of domicile before making such a substitution.
We will also get any required approval from the SEC and any other
required approvals before making such a substitution.
Subject to any required regulatory approvals, we reserve the right to
transfer assets of the Variable Separate Account which we determine to be
associated with the class of contracts to which the group contract
belongs, to another Variable Separate Account or Division.
When permitted by law, we reserve the right to:
(1)deregister a Variable Separate Account under the Investment
Company Act of 1940;
(2)operate a Variable Separate Account as a management company
under the Investment Company Act of 1940, if it is operating as a
unit investment trust;
(3)operate a Variable Separate Account as a unit investment trust
under the Investment Company Act of 1940, if it is operating as a
managed Variable Separate Account;
(4)restrict or eliminate any voting rights of Owners, or other
persons who have voting rights to a Variable Separate Account; and,
(5)combine a Variable Separate Account with other Variable
Separate Accounts.
GA-CA-1074 11
HOW WE MEASURE THE CERTIFICATE'S ACCUMULATION VALUE (continued)
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THE GENERAL ACCOUNT
The General Account contains all assets of the Company other than those
in the Separate Accounts we establish. The Guaranteed Interest Divisions
available for investment are shown in the Schedule. We may, from time to
time, offer other Divisions where assets are held in our General Account.
VALUATION PERIOD
Each Division and Fixed Allocation will be valued at the end of each
Valuation Period on a Valuation Date. A Valuation Period is each
Business Day together with any non-Business Days before it. A Business
Day is any day the New York Stock Exchange (NYSE) is open for trading,
and the SEC requires mutual funds, unit investment trusts, or other
investment portfolios to value their securities.
ACCUMULATION VALUE
The Accumulation Value of this Certificate is the sum of the amounts in
each of the Divisions of the Variable Separate Account and General
Account and allocations to the Fixed Account. You select the Divisions
of the Variable Separate Account and General Account and the Fixed
Allocations of the Fixed Account to which to allocate the Accumulation
Value. The maximum number of Divisions and Fixed Allocations to which
the Accumulation Value may be allocated at any one time is shown in the
Schedule.
ACCUMULATION VALUE IN EACH DIVISION AND FIXED ALLOCATION
On the Certificate Date
On the Certificate Date, the Accumulation Value is allocated to each
Division and Fixed Allocation as elected by you, subject to certain terms
and conditions imposed by us. We reserve the right to allocate premium
to the Specially Designated Division during any Right to Examine period.
After such time, allocation will be made proportionately in accordance
with the initial allocation(s) as elected by you.
On each Valuation Date
At the end of each subsequent Valuation Period, the amount of
Accumulation Value in each Division and Fixed Allocation will be
calculated as follows:
(1)We take the Accumulation Value in the Division or Fixed
Allocation at the end of the preceding Valuation Period.
(2)We multiply (1) by the Variable Separate Account Division's Net
Rate of Return for the current Valuation Period or we calculate the
interest to be credited to a Fixed Allocation or to a Guaranteed
Interest Division for the current Valuation Period.
(3)We add (1) and (2).
(4)We add to (3) any additional Premium Payments (less any premium
deductions as shown in the Schedule) allocated to the Division or
Fixed Allocation during the current Valuation Period.
(5)We add or subtract allocations to or from that Division or
Fixed Allocation during the current Valuation Period.
(6)We subtract from (5) any Partial Withdrawals which are
allocated to the Division or Fixed Allocation during the current
Valuation Period.
(7)We subtract from (6) the amounts allocated to that Division or
Fixed Allocation for:
(a) any charges due for the Optional Benefit Riders as shown in
the Schedule;
(b) any deductions from Accumulation Value as shown in the
Schedule.
All amounts in (7) are allocated to each Division or Fixed Allocation in
the proportion that (6) bears to the Accumulation Value unless the Charge
Deduction Division has been specified (see the Schedule).
GA-CA-1074 12
HOW WE MEASURE THE CERTIFICATE'S ACCUMULATION VALUE (continued)
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FIXED ACCOUNT
The Fixed Account is a Separate Account under state insurance law and is
not required to be registered with the Securities and Exchange Commission
under the Investment Company Act of 1940. The Fixed Account includes
various Fixed Allocations which we credit with fixed rates of interest
for the Guarantee Period or Periods you select. We reset the interest
rates for new Fixed Allocations periodically based on our sole
discretion.
Guarantee Periods
Each Fixed Allocation is guaranteed an interest rate or rates for a
Guarantee Period. The Guaranteed Interest Rates for a Fixed Allocation
are effective for the entire period. The Maturity Date of a Guarantee
Period will be on the last day of the calendar month in which the
Guarantee Period ends. Withdrawals and transfers made during a Guarantee
Period may be subject to a Market Value Adjustment unless made within
thirty days prior to the Maturity Date.
Upon the expiry of a Guarantee Period, we will transfer the Accumulation
Value of the expiring Fixed Allocation to a Fixed Allocation with a
Guarantee Period equal in length to the expiring Guarantee Period, unless
you select another period prior to a Maturity Date. We will notify you
at least thirty days prior to a Maturity Date of your options for
renewal. If the period remaining from the expiry of the previous
Guarantee Period to the Annuity Commencement Date is less than the period
you have elected or the period expiring, the next shortest period then
available that will not extend beyond the Annuity Commencement Date will
be offered to you. If a period is not available, the Accumulation Value
will be transferred to the Specially Designated Division.
We will declare Guaranteed Interest Rates for the then available Fixed
Allocation Guarantee Periods. These interest rates are based solely on
our expectation as to our future earnings. Declared Guaranteed Interest
Rates are subject to change at any time prior to application to specific
Fixed Allocations, although in no event will the rates be less than the
Minimum Guaranteed Interest Rate (see the Schedule).
Market Value Adjustments
A Market Value Adjustment will be applied to a Fixed Allocation upon
withdrawal, transfer or application to an Income Plan if made more than
thirty days prior to such Fixed Allocation's Maturity Date, except on
Systematic Partial Withdrawals and IRA Partial Withdrawals. The Market
Value Adjustment is applied to each Fixed Allocation separately.
The Market Value Adjustment is determined by multiplying the amount of
the Accumulation Value withdrawn, transferred or applied to an Income
Plan by the following factor:
N/365
((1+I)/(1+J+.0050)) -1
Where I is the Index Rate for a Fixed Allocation on the first day of the
applicable Guarantee Period: J is the Index Rate for new Fixed
Allocations with Guarantee Periods equal to the number of years
(fractional years rounded up to the next full year) remaining in the
Guarantee Period at the time of calculation; and N is the remaining
number of days in the Guarantee Period at the time of calculation. (The
Index Rate is described in the Schedule.)
Market Value Adjustments will be applied as follows:
(1)The Market Value Adjustment will be applied to the amount
withdrawn before deduction of any applicable Surrender Charge.
(2)For a Partial Withdrawal, partial transfer or in the case where
a portion of an allocation is applied to an Income Plan, the Market
Value Adjustment will be calculated on the total amount that must be
withdrawn, transferred or applied to an Income Plan in order to
provide the amount requested.
GA-CA-1074 13
HOW WE MEASURE THE CERTIFICATE'S ACCUMULATION VALUE (continued)
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(3)If the Market Value Adjustment is negative, it will be assessed
first against any remaining Accumulation Value in the particular
Fixed Allocation. Any remaining Market Value Adjustment will be
applied against the amount withdrawn, transferred or applied to an
Income Plan.
(4)If the Market Value Adjustment is positive, it will be credited to
any remaining Accumulation Value in the particular Fixed Allocation. If
a cash surrender, full transfer or full application to an Income Plan has
been requested, the Market Value Adjustment is added to the amount
withdrawn, transferred or applied to an Income Plan.
MEASUREMENT OF INVESTMENT EXPERIENCE
Index of Investment Experience
The Investment Experience of a Variable Separate Account Division is
determined on each Valuation Date. We use an Index to measure changes in
each Division's experience during a Valuation Period. We set the Index
at $10 when the first investments in a Division are made. The Index for
a current Valuation Period equals the Index for the preceding Valuation
Period multiplied by the Experience Factor for the current Valuation
Period.
How We Determine the Experience Factor
For Divisions of a unit investment trust Separate Account the Experience
Factor reflects the Investment Experience of the portfolio in which the
Division invests as well as the charges assessed against the Division for
a Valuation Period. The factor is calculated as follows:
(1) We take the net asset value of the portfolio in which the
Division invests at the end of the current Valuation Period.
(2) We add to (1) the amount of any dividend or capital gains
distribution declared for the investment portfolio and reinvested in
such portfolio during the current Valuation Period. We subtract
from that amount a charge for our taxes, if any.
(3) We divide (2) by the net asset value of the portfolio at the
end of the preceding Valuation Period.
(4) We subtract the daily Mortality and Expense Risk Charge for
each Division shown in the Schedule for each day in the Valuation
Period.
(5) We subtract the daily Asset Based Administrative Charge shown
in the Schedule for each day in the Valuation Period.
Calculations for Divisions investing in unit investment trusts are on a
per unit basis.
Net Rate of Return for a Variable Separate Account Division
The Net Rate of Return for a Variable Separate Account Division during a
Valuation Period is the Experience Factor for that Valuation Period minus
one.
Interest Credited to a Guaranteed Interest Division
Accumulation Value allocated to a Guaranteed Interest Division will be
credited with the Guaranteed Interest Rate for the Guarantee Period in
effect on the date the premium or reallocation is applied. Once applied,
such rate will be guaranteed until the Maturity Date of that Guarantee
Period. Interest will be credited daily at a rate to yield the declared
annual Guaranteed Interest Rate. No Guaranteed Interest Rate will be
less than the Minimum Interest Rate shown in the Schedule.
GA-CA-1074 14
HOW WE MEASURE THE CERTIFICATE'S ACCUMULATION VALUE (continued)
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Interest Credited to a Fixed Allocation
A Fixed Allocation will be credited with the Guaranteed Interest Rate for
the Guarantee Period in effect on the date the premium or reallocation is
applied. Once applied, such rate will be guaranteed until that Fixed
Allocation's Maturity Date. Interest will be credited daily at a rate to
yield the declared annual Guaranteed Interest Rate.
We periodically declare Guaranteed Interest Rates for then available
Guarantee Periods. No Guaranteed Interest Rate will be less than the
Minimum Interest Rate shown in the Schedule.
CHARGES DEDUCTED FROM ACCUMULATION VALUE ON EACH CERTIFICATE PROCESSING
DATE
Expense charges and fees are shown in the Schedule.
Charge Deduction Division Option
We will deduct all charges against the Accumulation Value of this
Certificate from the Charge Deduction Division if you elected this option
on the application (see the Schedule). If you did not elect this Option
or if the charges are greater than the amount in the Charge Deduction
Division, the charges against the Accumulation Value will be deducted as
follows:
(1) If these charges are less than the Accumulation Value in the
Variable Separate Account Divisions, they will be deducted
proportionately from all Divisions.
(2) If these charges exceed the Accumulation Value in the Variable
Separate Account Divisions, any excess over such value will be
deducted proportionately from any Fixed Allocations and Guaranteed
Interest Divisions.
Any charges taken from the Fixed Account or the General Account will be
taken from the Fixed Allocations or the Guaranteed Interest Divisions
starting with the Guarantee Period nearest its Maturity Date until such
charges have been paid.
At any time while this Certificate is in effect, you may change your
election of this Option. To do this you must send us a written request
to our Customer Service Center. Any change will take effect within seven
days of the date we receive your request.
GA-CA-1074 15
YOUR CERTIFICATE BENEFITS
------------------------------------------------------------------------------
While this Certificate is in effect, there are important rights and
benefits that are available to you. We discuss these rights and benefits
in this section.
CASH VALUE BENEFIT
Cash Surrender Value
The Cash Surrender Value, while the Annuitant is living and before the
Annuity Commencement Date, is determined as follows:
(1) We take the Certificate's Accumulation Value;
(2) We adjust for any applicable Market Value Adjustment;
(3) We deduct any Surrender Charges;
(4) We deduct any charges shown in the Schedule that have been
incurred but not yet deducted, including:
(a) any administrative charge that has not yet been deducted;
(b) the pro rata part of any charges for Optional Benefit
Riders; and
(c) any applicable premium or other tax.
Cancelling to Receive the Cash Surrender Value
At any time while the Annuitant is living and before the Annuity
Commencement Date, you may surrender this Certificate to us. To do this,
you must return this Certificate with a signed request for cancellation
to our Customer Service Center.
The Cash Surrender Value will vary daily. We will determine the Cash
Surrender Value as of the date we receive the Certificate and your signed
request in our Customer Service Center. All benefits under this
Certificate will then end.
We will usually pay the Cash Surrender Value within seven days; but, we
may delay payment as described in the Payments We May Defer provision.
PARTIAL WITHDRAWAL OPTION
After the Certificate Date, you may make Partial Withdrawals. Partial
Withdrawals may be subject to a Partial Withdrawal Charge (see the
Schedule). The minimum amount that may be withdrawn is shown in the
Schedule. The maximum amount that may be withdrawn without Surrender
Charge is shown in the Schedule. To take a Partial Withdrawal, you must
provide us satisfactory notice at our Customer Service Center.
PROCEEDS PAYABLE TO THE BENEFICIARY
Prior to the Annuity Commencement Date
If the sole Owner dies prior to the Annuity Commencement Date, we will
pay the Beneficiary the death benefit. If there are joint Owners and any
Owner dies, we will pay the surviving Owners the death benefit. We will
pay the amount on receipt of due proof of the Owner's death at our
Customer Service Center. Such amount may be received in a single lump
sum or applied to any of the Annuity Options (see Choosing an Income
Plan). When the Owner (or all Owners where there are joint Owners) is
not an individual, the death benefit will become payable on the death of
the Annuitant prior to the Annuity Commencement Date (unless a Contingent
Annuitant survived the Annuitant). Only one death benefit is payable
under this Certificate. In all events, distributions under the
Certificate must be made as required by applicable law.
GA-CA-1074 16
YOUR CERTIFICATE BENEFITS (continued)
------------------------------------------------------------------------------
How to Claim Payments to Beneficiary
We must receive proof of the Owner's (or the Annuitant's) death before we
will make any payments to the Beneficiary. We will calculate the death
benefit as of the date we receive due proof of death. The Beneficiary
should contact our Customer Service Center for instructions.
GA-CA-1074 17
CHOOSING AN INCOME PLAN
------------------------------------------------------------------------------
ANNUITY BENEFITS
If the Annuitant and Owner are living on the Annuity Commencement Date,
we will begin making payments to the Owner. We will make these payment
under the Annuity Option (or Options) as chosen in the application or as
subsequently selected. You may choose or change an Annuity Option by
making a written request at least 30 days prior to the Annuity
Commencement Date. Unless you have chosen otherwise, Option 2 on a 10-
year period certain basis will become effective. The amounts of the
payments will be determined by applying the Accumulation Value on the
Annuity Commencement Date in accordance with the Annuity Options section
below (see Payments We Defer). Before we pay any Annuity Benefits, we
require the return of this Certificate. If this Certificate has been
lost, we require the applicable lost Certificate form.
ANNUITY COMMENCEMENT DATE SELECTION
You select the Annuity Commencement Date. You may select any date
following the fifth Certificate Anniversary but before the required date
of Annuity Commencement as shown in the Schedule. If you do not select a
date, the Annuity Commencement Date will be in the month following the
required date of Annuity Commencement.
FREQUENCY SELECTION
You may choose the frequency of the Annuity Payments. They may be
monthly, quarterly, semi-annually or annually. If we do not receive
written notice from you, the payments will be made monthly.
THE INCOME PLAN
While this Certificate is in effect and before the Annuity Commencement
Date, you may chose one or more Annuity Options for the payment of death
benefits proceeds. If, at the time of the Owner's death, no Option has
been chosen for paying the death benefit proceeds, the Beneficiary may
choose an Option within one year. You may also elect an Annuity Option
on surrender of the Certificate for its Cash Surrender Value. For each
Option we will issue a separate written agreement putting the Option into
effect.
Our approval is needed for any Option where:
(1) the person named to receive payment is other than the Owner or
Beneficiary; or
(2) the person named is not a natural person, such as a
corporation; or
(3) any income payment would be less than the minimum annuity
income payment shown in the Schedule.
THE ANNUITY OPTIONS
There are four Options to choose from. They are:
Option 1. Income for a Fixed Period
Payment is made in equal installments for a fixed number of years. We
guarantee each monthly payment will be at least the Income for Fixed
Period amount shown in the Schedule. Values for annual, semiannual or
quarterly payments are available on request.
GA-CA-1074 18
CHOOSING AN INCOME PLAN
------------------------------------------------------------------------------
Option 2. Income for Life
Payment is made to the person named in equal monthly installments and
guaranteed for at least a period certain. The period certain can be 10
or 20 years. Other periods certain are available on request. A refund
certain may be chosen instead. Under this arrangement, income is
guaranteed until payments equal the amount applied. If the person named
lives beyond the guaranteed period, payments continue until his or her
death.
We guarantee each payment will be at least the amount shown in the
Schedule. By age, we mean the named person's age on his or her nearest
birthday before the Option's effective date. Amounts for ages not shown
are available on request.
Option 3. Joint Life Income
This Option is available if there are two persons named to receive
payments. At least one of the persons named must be either the Owner of
Beneficiary of this Certificate. Monthly payments are guaranteed and are
made as long as at least one of the named persons is living. The monthly
payment amounts are available upon request. Such amounts are guaranteed
and will be calculated on the same basis as the Table for Income for
Life, however, the amounts will be based on two lives.
Option 4. Annuity Plan
An amount can be used to buy any single premium immediate annuity we
offer for the Option's effective date.
The minimum rates for Option 1 are based on 3% interest, compounded
annually. The minimum rates for Options 2 and 3 are based on 3%
interest, compounded annually, and the Annuity 2000 Mortality Table. We
may pay a higher rate at our discretion.
PAYMENT WHEN NAMED PERSON DIES
When the person named to receive payment dies, we will pay any amounts
still due as provided by the Option agreement. The amounts still due are
determined as follows:
(1)For Option 1 or for any remaining guaranteed payments in Option
2, payments will be continued.
(2)For Option 3, no amounts are payable after both named persons
have died.
(3)For Option 4, the annuity agreement will state the amount due,
if any.
GA-CA-1074 19
OTHER IMPORTANT INFORMATION
------------------------------------------------------------------------------
ENTIRE CONTRACT
The group contract, including any attached Rider, endorsement, amendment
and the application of the Contractholder, constitute the entire contract
between the Contractholder and us. All statements made by the
Contractholder, any Owner or any Annuitant will be deemed representations
and not warranties. No such statement will be used in any contest unless
it is contained in the application signed by the Owner, a copy of which
has been furnished to the Owner, the Beneficiary or to the
Contractholder.
SENDING NOTICE TO US
Whenever written notice is required, send it to our Customer Service
Center. The address of our Customer Service Center is shown on the cover
page. Please include your Certificate number in all correspondence.
REPORTS TO OWNER
We will send you a report at least once during each Certificate Year.
The report will show the Accumulation Value and the Cash Surrender Value
as of the end of the Certificate Processing Period. The report will also
show the allocation of the Accumulation Value as of such date and the
amounts deducted from or added to the Accumulation Value since the last
report. The report will also include any information that may be
currently required by the insurance supervisory official of the
jurisdiction in which the Certificate is delivered.
We will also send you copies of any shareholder reports of the portfolios
in which the Divisions of the Variable Separate Account invest, as well
as any other reports, notices or documents required by law to be
furnished to Owners.
ASSIGNMENT - USING THIS CERTIFICATE AS COLLATERAL SECURITY
You can assign this Certificate as collateral security for a loan or
other obligation. This does not change the ownership. Your rights and
any Beneficiary's right are subject to the terms of the assignment. To
make or release an assignment, we must receive written notice
satisfactory to us, at our Customer Service Center. We are not
responsible for the validity of any assignment.
CHANGING THIS CERTIFICATE
This Certificate or any additional benefit riders may be changed to
another annuity plan according to our rules at the time of the change.
CERTIFICATE CHANGES - APPLICABLE TAX LAW
We reserve the right to make changes in this Certificate or its Riders to
the extent we deem it necessary to continue to qualify this Certificate
as an annuity. Any such changes will apply uniformly to all Certificates
that are affected. You will be given advance written notice of such
changes.
MISSTATEMENT OF AGE OR SEX
If an age or sex has been misstated, the amounts payable or benefits
provided by this Certificate will be those that the Premium Payment made
would have bought at the correct age or sex.
NON-PARTICIPATING
This Certificate does not participate in the divisible surplus of Golden
American Life Insurance Company.
GA-CA-1074 20
OTHER IMPORTANT INFORMATION (continued)
------------------------------------------------------------------------------
PAYMENTS WE MAY DEFER
We may not be able to determine the value of the assets of the Variable
Separate Account Divisions because:
(1) The NYSE is closed for trading;
(2) the SEC determines that a state of emergency exists;
(3) an order or pronouncement of the SEC permits a delay for the
protection of Owners; or
(4) the check used to pay the premium has not cleared through the
banking system. This may take up to 15 days.
During such times, as to amounts allocated to the Divisions of the
Variable Separate Account, we may delay;
(1) determination and payment of the Cash Surrender Value;
(2) determination and payment of any death benefit if death occurs
before the Annuity Commencement Date;
(3) allocation changes of the Accumulation Value; or,
(4) application of the Accumulation Value under an income plan.
As to the amounts allocated to a Guaranteed Interest Division in the
General Account and as to amounts allocated to Fixed Allocations of the
Fixed Account, we may, at any time, defer payment of the Cash Surrender
Value for up to six months after we receive a request for it. We will
allow interest of at least 3.00% a year on any Cash Surrender Value
payment derived from the Fixed Allocations or Guaranteed Interest
Divisions that we defer 30 days or more.
AUTHORITY TO MAKE AGREEMENTS
All agreements made by us must be signed by one of our officers. No
other person, including an insurance agent or broker, can:
(1) change any of this Certificate's terms;
(2) extend the time for Premium Payments; or
(3) make any agreement binding on us.
REQUIRED NOTE ON OUR COMPUTATIONS
We have filed a detailed statement of our computations with the insurance
supervisory official in the jurisdiction where this Certificate is
delivered. The values are not less than those required by the law of
that state or jurisdiction. Any benefit provided by an attached Optional
Benefit Rider will not increase these values unless otherwise stated in
that Rider.
GA-CA-1074 21
DEFERRED COMBINATION VARIABLE AND FIXED ANNUITY CERTIFICATE - NO DIVIDENDS
------------------------------------------------------------------------------
Variable Cash Surrender Values while the Annuitant and Owner are living
and prior to the Annuity Commencement Date. Death benefit subject to
guaranteed minimum. Additional Premium Payment Option. Partial
Withdrawal Option. Non-participating. Investment results reflected in
values.
GA-CA-1074
SCHEDULE (7% DB)
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days
from the Certificate Issue Date and may be taken on a monthly, quarterly or
annual basis. You select the day withdrawals will be made, but no later
than the 28th day of the month. If you do not elect a day, the Certificate
Date will be used.
Maximum Withdrawal Amounts:
Variable Separate Account Divisions: .833% of Premium Payments
monthly, 2.5% of Premium Payments
quarterly or 10% of Premium Payments
annually.
Fixed Allocations and
Guaranteed Interest Divisions: Interest earned on a Fixed Allocation
or Guaranteed Interest Division for the
prior month, quarter or year (depending
on the frequency selected).
The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal
is 10% of Premium Payments not previously withdrawn. Systematic Partial
Withdrawals from Fixed Allocations are not subject to a Market Value
Adjustment. A Systematic Partial Withdrawal in excess of Earnings and the
Free Amount may be subject to a Surrender Charge.
IRA Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a contract issued as an IRA on a
monthly, quarterly or annual basis. A minimum withdrawal of $100.00 is
required. You select the day the withdrawals will be made, but no later
than the 28th day of the month. If you do not elect a day, the Contract
Date will be used. Systematic Partial Withdrawals and Conventional Partial
Withdrawals are not allowed when IRA Partial Withdrawals are being taken.
An IRA Partial Withdrawal in excess of the maximum amount allowed under the
Systematic Partial Withdrawal option may be subject to a Market Value
Adjustment.
DEATH BENEFIT
-------------
The Death Benefit is the greatest of (i), (ii), (iii) and (iv) below,
where:
(i) is the Accumulation Value;
(ii) is the lesser of (a) and (b), , where (a) is the Guaranteed Death
Benefit and (b) is the Maximum Guaranteed Death Benefit;
(iii)is the Cash Surrender Value; and
(iv) is the Minimum Death Benefit.
MINIMUM DEATH BENEFIT
---------------------
The Minimum Death Benefit shall be the sum of the following:
1. The Accumulation Value allocated to Special Funds; and
2. Adjusted Premium for non-Special Funds.
GA-CA-1074 3D2
SCHEDULE (7% DB)
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
Adjusted Premium for non-Special Funds shall mean all premium allocated
to non-Special Funds, plus an adjustment for any amounts transferred to
non-Special Funds, less a prorata adjustment for any amounts transferred
or withdrawn from non-Special Funds. The amount of the prorata
adjustment will equal (a) times (b) divided by (c), where: (a) is the
Adjusted Premium for non-Special Funds prior to the transfer or
withdrawal; (b) is the Accumulation Value of
the transfer or withdrawal; and (c) is the Accumulation Value allocated
to non-Special Funds before the transfer or withdrawal. Adjusted Premium
for Special Funds has the same definition, but with respect to amounts
allocated to Special Funds.
Transfers from Special Funds increase the Adjusted Premium for non-
Special Funds by the lesser of the reduction of the Adjusted Premium for
Special Funds and net Accumulation Value transferred. Transfers from non-
Special Funds increase the Adjusted Premium for Special Funds by the
reduction in the Adjusted Premium for non-Special Funds.
GUARANTEED DEATH BENEFIT
------------------------
The Guaranteed Death Benefit for the Contact is equal to the sum of I and
II below.
I. The Guaranteed Death Benefit Base for non-Special Funds
II. The Accumulation Value allocated to Special Funds
On the Contract Date, the Guaranteed Death Benefit Base for non-Special
Funds is the initial premium, if applicable, allocated to non-Special
Funds. On subsequent Valuation Dates, the Guaranteed Death Benefit Base
for non-Special Funds is calculated as follows:
(1)Start with the Guaranteed Death Benefit Base for non-Special Funds
on the prior Valuation Date.
(2)Calculate interest on (1) for the current Valuation Period at the
Guaranteed Death Benefit Interest Rate for non-Special Funds.
(3)Add (1) and (2).
(4)Add to (3) any additional premiums allocated to non-Special Funds
during the current Valuation Period.
(5)Add to (or subtract from) (4) adjustments for transfers from (to)
Special Funds made during the Valuation Period.
(6)Subtract from (5) the amount of any Special Partial Withdrawal
Adjustments and Prorata Partial Withdrawal Adjustments for any partial
withdrawals made from non-Special Funds during the current Valuation
Period.
The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds.
Transfers from Special Funds to non-Special Funds will reduce the
Guaranteed Death Benefit Base for Special Funds on a prorata basis. The
resulting increase in the Guaranteed Death Benefit Base for non-Special
Funds will equal the lesser of the reduction in the Guaranteed Death
Benefit Base for Special Funds and the net Accumulation Value
transferred.
GA-CA-1074 3D3
SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
Transfers from non-Special Funds to Special Funds will reduce the
Guaranteed Death Benefit Base for non-Special Funds on a prorata basis.
The resulting increase in the Guaranteed Death Benefit Base for Special
Funds will equal the reduction in Guaranteed Death Benefit Base for non-
Special Funds.
GUARANTEED DEATH BENEFIT INTEREST RATE
--------------------------------------
The Guaranteed Death Benefit Interest Rate is [7%] compounded annually,
except:
(a) For any portion of the Guaranteed Death Benefit Base for Special
Funds, the Guaranteed Death Benefit Interest Rate is [7%] (compounded
annually); and
(b) For any valuation period ending after the contract anniversary on
which the Owner attains age [80], or after the Maximum Guaranteed Death
Benefit has been reached, the Guaranteed Death Benefit Interest Rate is
[0%].
SPECIAL FUNDS
-------------
Where used in this Certificate, Special Funds are [the Liquid Asset
Division, the Limited Maturity Bond Division, the Fixed Allocations and
the Guaranteed Interest Division]. We may add newly available divisions
as Special Funds. We may also reclassify an existing division as a
Special Fund or remove such designation upon 30 days notice to you. Such
reclassification will apply to amounts transferred or otherwise added to
such division after the date of change. We may reduce the Mortality and
Expense Risk Charge (if applicable) for that portion of the Contract
invested in a Special Fund.
MAXIMUM GUARANTEED DEATH BENEFIT
--------------------------------
The Maximum Guaranteed Death Benefit is equal to [three] times premium
paid, reduced by the amount of any Partial Withdrawal Adjustments. The
Maximum Guaranteed Death Benefit is allocated proportionally based on the
Contract's allocation to Special and non-Special funds. Transfers and
withdrawals will affect the allocation of the Maximum Guaranteed Death
Benefit at the same proportion among the Special and non-Special Funds
that they bear to the Accumulation Value transferred or withdrawn. Any
addition due to spousal continuation will not affect the Maximum
Guaranteed Death Benefit or the Guaranteed Death Benefit Base.
SPECIAL AND PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS
--------------------------------------------------
For any partial withdrawal, the Death Benefit components will be reduced
by Prorata Partial Withdrawal Adjustments. A Prorata Partial Withdrawal
Adjustment will be made unless a Special Partial Withdrawal Adjustment
applies to the component for the withdrawal. Special Partial Withdrawal
Adjustments are made when partial withdrawals in any Contract Year do not
exceed [7%] of the sum of cumulative premiums, but only if partial
withdrawals in each prior year did not exceed [7%] of the sum of premiums
paid prior to that year. The Special Partial Withdrawal Adjustment
GA-CA-1074 3D4
SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
is equal to the amount of the Accumulation Value withdrawn. Special
Partial Withdrawal Adjustments are applicable only in the calculation of
the Maximum Guaranteed Death Benefit and the Guaranteed Death Benefit
Base, and in all other cases withdrawals are treated as Prorata Partial
Withdrawal Adjustments.
The Prorata Partial Withdrawal Adjustment to a Death Benefit component is
equal to (1) divided by (2), multiplied by (3), where: (1) is the
Accumulation Value withdrawn; (2) is the Accumulation Value immediately
prior to withdrawal; and (3) is the amount of the applicable Death
Benefit component immediately prior to the withdrawal. Separate
adjustments will apply to the amounts in the Special and non-Special
Funds.
CHANGE OF OWNER
---------------
A change of Owner from a sole Owner to a sole Owner (where there have
never been multiple Owners designated) will result in recalculation of
the Death Benefit, the Guaranteed Death Benefit, and the Maximum
Guaranteed Death Benefit. If the new Owner's attained age at the time of
the change is less than [80], the Guaranteed Death Benefit and the
Maximum Guaranteed Death Benefit in effect prior to the change will
remain in effect and the Death Benefit provision shall apply. If the new
Owner's attained age at the time of the change is [80] or greater, but
not greater than [85]:
(a)The Guaranteed Death Benefit and the Maximum Guaranteed Death
Benefit following the change will be zero; and
(b)The Death Benefit will then be the greatest of:
(c)the Cash Surrender Value;
(d)the Accumulation Value; and
(e)the Minimum Death Benefit.
If ownership changes result in multiple Owners or if there has ever been
multiple Owners, the Guaranteed Death Benefit and the Maximum Guaranteed
Death Benefit shall be set to zero. If the oldest Owner is age [85] or
younger at the time of the change, the Death Benefit will then be the
greatest of (b) 1, (b) 2 or (b) 3 above.
If any Owner's or oldest multiple Owners' attained age is [86] or greater
at the time of the change, the Guaranteed Death Benefit, the Minimum
Death Benefit, and the Maximum Guaranteed Death Benefit will be zero, and
the Death Benefit will then be the Cash Surrender Value.
When a change of Owner reduces the Guaranteed Death Benefit and the
Maximum Guaranteed Death Benefit to zero, there will be a reduction in
the mortality and expense risk charge.
GA-CA-1074 3D5
SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
SPOUSAL CONTINUATION UPON DEATH OF OWNER
----------------------------------------
If at the Owner's death, the surviving spouse of the deceased Owner is
the Beneficiary and such surviving spouse elects to continue the contract
as their own pursuant to Internal Revenue Code Section 72(s) or the
equivalent provisions of U.S. Treasury Department rules for qualified
plans, the following will apply:
(a)If the greater of (ii) and (iv) in the Death Benefit provision as of
the date we receive due proof of death of the Owner minus the
Accumulation Value, also as of that date, is greater than zero, we will
add such difference to the Accumulation Value. Such addition will be
allocated to the divisions of the Separate Account in the same proportion
as the Accumulation Value in each division bears to the Accumulation
Value in the Separate Account. If there is no Accumulation Value in the
Separate Account, the addition will be allocated to the Liquid Asset
division, or its successor.
(b)The Guaranteed Death Benefit and the Maximum Guaranteed Death
Benefit will continue to apply, using the surviving spouse's age as the
determining age.
(c)At subsequent surrender, any surrender charge applicable to premiums
paid prior to the date we receive due proof of death of the Owner will be
waived. Any premiums paid later will be subject to any applicable
surrender charge.
This addition to Accumulation Value is available only to the spouse of
the Owner as of the date of death of the Owner if such spouse under the
provisions of this Contract elects to continue the Contract as their own.
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no
later than April 1st of the calendar year following the calendar year in
which the Owner attains age 70 1/2. Otherwise, the Annuity Commencement
Date may be no later than the same date as the Contract Processing Date in
the month following the Annuitant's 90th birthday. In applying the
Accumulation Value, we may first collect any Premium Taxes due us. If, on
the Annuity Commencement Date, a Surrender Charge remains, your elected
Annuity Option must include a period certain of at least five years
duration.
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
Optional Benefit Riders - [None.]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full years
elapsed since the Certificate Date.
GA-CA-1074 3D6
SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
FIXED ACCOUNT
Minimum Fixed Allocation
The minimum allocation to the Fixed Account in any one Fixed Allocation
is [$250.00].
Minimum Guaranteed Interest Rate - [3%.]
Guarantee Periods
We currently offer Guarantee Periods of [1,2,3,4,5,6,7,8,9 and 10]
year(s). We reserve the right to offer Guarantee Periods of durations
other than those available on the Certificate Date. We also reserve the
right to cease offering a particular Guarantee Period or Periods.
Index Rate
The Index Rate is the average of the Ask Yields for the U.S. Treasury
Strips as reported by a national quoting service for the applicable
maturity. The average is based on the period from the 22nd day of the
calendar month two months prior to the calendar month of Index Rate
determination to the 21st day of the calendar month immediately prior to
the month of determination. The applicable maturity date for these U.S.
Treasury Strips is on or next following the last day of the Guarantee
Period. If the Ask Yields are no longer available, the Index Rate will
be determined using a suitable replacement method.
We currently set the Index Rate once each calendar month. However, we
reserve the right to set the Index Rate more frequently than monthly, but
in no event will such Index Rate be based on a period less than 28 days.
GA-CA-1074 3D7
SCHEDULE
CHARGES AND FEES
------------------------------------------------------------------------------
------------------------------------------------------------------------------
| 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] |
------------------------------------------------------------------------------
DEDUCTIONS FROM PREMIUMS
[None.]
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
[None.]
Administrative Charge - [We charge [$30] to cover a portion of our ongoing
administrative expenses for each Certificate Processing Period. The charge
is incurred at the beginning of the Certificate Processing Period and
deducted on the Certificate Processing Date at the end of the period.
At the time of deduction, this charge will be waived if
1. The Accumulation Value is at least $100,000; or
2. The sum of premiums paid to date is at least $100,000]
Excess Allocation Charge
Currently none, however, we reserve the right to charge [$25] for a
change if you make more than [twelve] allocation changes per Certificate
Year. Any charge will be deducted in proportion to the amount being
transferred from each Division.
Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if
the Certificate is surrendered or an Excess Partial Withdrawal is taken.
The percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed since a Premium
Payment was made. The Surrender Charge expressed as a percentage of each
Premium Payment is as follows:
Complete Years Elapsed Surrender
Since Premium Payment Charges
--------------------- ---------
[0 8%
1 7%
2 6%
3 5%
4 4%
5 3%
6 2%
7 1%
8+ 0%]
Surrender of the Certificate is permitted at or before the commencement
of annuity payments.
GA-CA-1074 3E1
SCHEDULE
CHARGES AND FEES (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] |
------------------------------------------------------------------------------
[Premium Taxes
We deduct the amount of any premium or other state and local taxes levied
by any state or governmental entity when such taxes are incurred.
We reserve the right to defer collection of Premium Taxes until surrender
or until application of Accumulation Value to an Annuity Option. An
Excess Partial Withdrawal will result in the deduction of any Premium Tax
then due us on such amount. We reserve the right to change the amount we
charge for Premium Tax charges on future Premium Payments to conform with
changes in the law or if the Owner changes state of residence.]
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the assets in
each Separate Account division on a daily basis of not more than
[0.004419%] (equivalent to an annual maximum rate of [1.60%]) for
mortality and expense risks. The charge is not deducted from the Fixed
Account or General Account accumulation values.
Asset Based Administrative Charge - We deduct [0.000411%] of the assets
in each Variable Separate Account Division on a daily basis (equivalent
to an annual rate of [0.15%]) to compensate us for a portion of our
ongoing administrative expenses. This charge is not deducted from the
Fixed Account values.
CHARGE DEDUCTION DIVISION
All charges against the Accumulation Value in this Certificate will be
deducted from the [Liquid Asset Division].
GA-CA-1074 3E2
THE SCHEDULE
INCOME PLAN FACTORS
------------------------------------------------------------------------------
------------------------------------------------------------------------------
| 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] |
------------------------------------------------------------------------------
Values for other payment periods, ages or joint life combinations are
available on request. Monthly payments are shown for each $1,000
applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Fixed Fixed
Period Monthly Period Monthly Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years 20 Years Refund
Certain Certain Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
GA-CA-1074 3F
THE SCHEDULE (RATCHET)
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days
from the Certificate Issue Date and may be taken on a monthly, quarterly or
annual basis. You select the day withdrawals will be made, but no later
than the 28th day of the month. If you do not elect a day, the Certificate
Date will be used.
Maximum Withdrawal Amounts:
Variable Separate Account Divisions: .833% of Premium Payments
monthly, 2.5% of Premium Payments quarterly
or 10% of Premium Payments annually.
Fixed Allocations and
Guaranteed Interest Divisions: Interest earned on a Fixed Allocation or
Guaranteed Interest Division for the prior
month, quarter or year (depending on the
frequency selected).
The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal
is 10% of Premium Payments not previously withdrawn. Systematic Partial
Withdrawals from Fixed Allocations are not subject to a Market Value
Adjustment. A Systematic Partial Withdrawal in excess of Earnings and the
Free Amount may be subject to a Surrender Charge.
IRA Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a contract issued as an IRA on a
monthly, quarterly or annual basis. A minimum withdrawal of $100.00 is
required. You select the day the withdrawals will be made, but no later
than the 28th day of the month. If you do not elect a day, the Contract
Date will be used. Systematic Partial Withdrawals and Conventional Partial
Withdrawals are not allowed when IRA Partial Withdrawals are being taken.
An IRA Partial Withdrawal in excess of the maximum amount allowed under the
Systematic Partial Withdrawal option may be subject to a Market Value
Adjustment.
DEATH BENEFITS
The Death Benefit is the greatest of (i), (ii), (iii) and (iv) below,
where:
(i) is the Accumulation Value;
(ii) is the Guaranteed Death Benefit;
(iii) is the Cash Surrender Value; and
(iv) is The Minimum Death Benefit.
MINIMUM DEATH BENEFIT
---------------------
The Minimum Death Benefit shall be the sum of the following:
GA-CA-1074 3D2
THE SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
1. The Accumulation Value allocated to Special Funds; and
2. Adjusted Premium for non-Special Funds.
Adjusted Premium for non-Special Funds shall mean all premium allocated
to non-Special Funds, plus an adjustment for any amounts transferred to
non-Special Funds, less a prorata adjustment for any amounts transferred
or withdrawn from non-Special Funds. The amount of the prorata
adjustment will equal (a) times (b) divided by (c), wher(a) is the
Adjusted Premium for non-Special Funds prior to the transfer or
withdrawal; (b) is the Accumulation Value of the transfer or withdrawal;
and (c) is the Accumulation Value allocated to non-Special Funds before
the transfer or e: withdrawal. Adjusted Premium for Special Funds has
the same definition, but with respect to amounts allocated to Special
Funds.
Transfers from Special Funds increase the Adjusted Premium for non-
Special Funds by the lesser of the reduction of the Adjusted Premium for
Special Funds and net Accumulation Value transferred. Transfers from non-
Special Funds increase the Adjusted Premium for Special Funds by the
reduction in the Adjusted Premium for non-Special Funds.
GUARANTEED DEATH BENEFIT
------------------------
The Guaranteed Death Benefit for the Contact is equal to the sum of I and
II below.
I The Guaranteed Death Benefit for non-Special Funds
II The Accumulation Value allocated to Special Funds
On the Contract Date, the Guaranteed Death Benefit Base for non-Special
Funds is the initial premium allocated to non-Special Funds. On
subsequent Valuation Dates, the Guaranteed Death Benefit Base for non-
Special Funds is calculated as follows:
(1)Start with the Guaranteed Death Benefit Base for non-Special Funds
on the prior Valuation Date.
(2)Add to (1) any additional premium allocated to the non-Special Funds
during the current Valuation Period and adjustments for transfers from
Special Funds during the current Valuation Period and subtract from (1)
any adjustment for transfers to Special Funds during the current
Valuation Period and any Prorata Partial Withdrawal Adjustments for any
Partial Withdrawals taken from non-Special Funds during the current
Valuation Period.
(3)On a Valuation Date that occurs on or prior to the Owner's attained
age [90], which is also a Contract Anniversary, we set the Guaranteed
Death Benefit Base for non-Special equal to the greater of (2) or the
Accumulation Value allocated to non-Special Funds as of such date. On
all other Valuation Dates, the Guaranteed Death Benefit Base for non-
Special Funds is equal to (2).
The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds.
GA-CA-1074 3D3
THE SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
Transfers from Special Funds to non-Special Funds will reduce the
Guaranteed Death Benefit Base for Special Funds on a prorata basis. The
resulting increase in the Guaranteed Death Benefit Base for non-Special
Funds will equal the lesser of the reduction in the Guaranteed Death
Benefit Base for Special Funds and the net Accumulation Value
transferred.
Transfers from non-Special Funds to Special Funds will reduce the
Guaranteed Death Benefit Base for non-Special Funds on a prorata basis.
The resulting increase in the Guaranteed Death Benefit Base for Special
Funds will equal the reduction in Guaranteed Death Benefit Base for non-
Special Funds.
SPECIAL FUNDS
Where used in this Certificate, Special Funds are [the Liquid Asset
Division, the Limited Maturity Bond Division, the Fixed Allocations and
the Guaranteed Interest Division]. We may add newly available divisions
as Special Funds. We may also reclassify an existing division as a
Special Fund or remove such designation upon 30 days notice to you. Such
reclassification will apply to amounts transferred or otherwise added to
such division after the date of change. We may reduce the Mortality and
Expense Risk Charge (if applicable) for that portion of the Contract
invested in a Special Fund.
SPECIAL AND PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS
For any partial withdrawal, the Death Benefit components will be reduced
by Prorata Partial Withdrawal Adjustments. The Prorata Partial
Withdrawal Adjustment to a Death Benefit component for a partial
withdrawal is equal to (1) divided by (2) multiplied by (3), where: (1)
is the Accumulation Value withdrawn; (2) is the Accumulation Value
immediately prior to withdrawal; and (3) is the amount of the applicable
Death Benefit component immediately prior to the withdrawal. Separate
adjustments will apply to amounts in the Special and non-Special Funds.
CHANGE OF OWNER
A change of Owner from a sole Owner to a sole Owner (where there have
never been multiple Owners designated) will result in recalculation of
the Death Benefit and the Guaranteed Death Benefit. If the new Owner's
attained age at the time of the change is less than [90], the Guaranteed
Death Benefit in effect prior to the change will remain in effect and the
Death Benefit provision will apply. If the new owner's attained age at
the time of the change is [90] or greater, but not greater than [95]:
(a) The Guaranteed Death Benefit following the change will be zero; and
(b) The Death Benefit will then be the greatest of:
(c) the cash surrender value;
(d) the Accumulation Value; and
(e) The Minimum Death Benefit.
GA-CA-1074 3D4
THE SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
If ownership changes result in multiple Owners or if there has ever been
multiple Owners, the Guaranteed Death Benefit shall be set to zero. If
the oldest Owner is age [95] or younger at the time of the change, the
Death Benefit will then be the greatest of (b) 1, (b) 2 or (b) 3 above.
If any Owner's or oldest multiple Owners' attained age is [86] or greater
at the time of the change, the Guaranteed Death Benefit will be zero, and
the Death Benefit will then be the Cash Surrender Value.
When a change of Owner reduces the Guaranteed Death Benefit to zero,
there will be a reduction in the mortality and expense risk charge.
SPOUSAL CONTINUATION UPON DEATH OF OWNER
If at the Owner's death, the surviving spouse of the deceased Owner is
the Beneficiary and such surviving spouse elects to continue the contract
as their own pursuant to Internal Revenue Code Section 72(s) or the
equivalent provisions of U.S. Treasury Department rules for qualified
plans, the following will apply:
(a) If the greater of (ii) and (iv) in the Death Benefit provision as of
the date we receive due proof of death of the Owner minus the
Accumulation Value, also as of that date, is greater than zero, we will
add such difference to the Accumulation Value. Such addition will be
allocated to the divisions of the Separate Account in the same proportion
as the Accumulation Value in each division bears to the Accumulation
Value in the Separate Account. If there is no Accumulation Value in the
Separate Account, the addition will be allocated to the Liquid Asset
division, or its successor.
(b) The Guaranteed Death Benefit and the Maximum Guaranteed Death
Benefit will continue to apply, using the surviving spouse's age as the
determining age.
(c) At subsequent surrender, any surrender charge applicable to premiums
paid prior to the date we receive due proof of death of the Owner will be
waived. Any premiums paid later will be subject to any applicable
surrender charge.
This addition to Accumulation Value is available only to the spouse of
the Owner as of the date of death of the Owner if such spouse under the
provisions of this Contract elects to continue the Contract as their own.
GA-CA-1074 3D5
THE SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no
later than April 1st of the calendar year following the calendar year in
which the Owner attains age 70 1/2. Otherwise, the Annuity Commencement
Date may be no later than the same date as the Contract Processing Date in
the month following the Annuitant's 90th birthday. In applying the
Accumulation Value, we may first collect any Premium Taxes due us. If, on
the Annuity Commencement Date, a Surrender Charge remains, your elected
Annuity Option must include a period certain of at least five years
duration.
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
Optional Benefit Riders - [None.]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full years
elapsed since the Certificate Date.
GA-CA-1074 3D6
THE SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
FIXED ACCOUNT
Minimum Fixed Allocation
The minimum allocation to the Fixed Account in any one Fixed Allocation
is [$250.00].
Minimum Guaranteed Interest Rate - [3%.]
Guarantee Periods
We currently offer Guarantee Periods of [1,2,3,4,5,6,7,8,9 and 10]
year(s). We reserve the right to offer Guarantee Periods of durations
other than those available on the Certificate Date. We also reserve the
right to cease offering a particular Guarantee Period or Periods.
Index Rate
The Index Rate is the average of the Ask Yields for the U.S. Treasury
Strips as reported by a national quoting service for the applicable
maturity. The average is based on the period from the 22nd day of the
calendar month two months prior to the calendar month of Index Rate
determination to the 21st day of the calendar month immediately prior to
the month of determination. The applicable maturity date for these U.S.
Treasury Strips is on or next following the last day of the Guarantee
Period. If the Ask Yields are no longer available, the Index Rate will
be determined using a suitable replacement method.
We currently set the Index Rate once each calendar month. However, we
reserve the right to set the Index Rate more frequently than monthly, but
in no event will such Index Rate be based on a period less than 28 days.
GA-CA-1074 3D7
THE SCHEDULE
CHARGES AND FEES
------------------------------------------------------------------------------
------------------------------------------------------------------------------
| 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] |
------------------------------------------------------------------------------
DEDUCTIONS FROM PREMIUMS
[None.]
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
[None.]
Administrative Charge - [We charge [$30] to cover a portion of our ongoing
---------------------
administrative expenses for each Certificate Processing Period. The charge
is incurred at the beginning of the Certificate Processing Period and
deducted on the Certificate Processing Date at the end of the period.
At the time of deduction, this charge will be waived if
(1) The Accumulation Value is at least $100,000; or
(2) The sum of premiums paid to date is at least $100,000]
Excess Allocation Charge
Currently none, however, we reserve the right to charge [$25] for a
change if you make more than [twelve] allocation changes per Certificate
Year. Any charge will be deducted in proportion to the amount being
transferred from each Division.
Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if
the Certificate is surrendered or an Excess Partial Withdrawal is taken.
The percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed since a Premium
Payment was made. The Surrender Charge expressed as a percentage of each
Premium Payment is as follows:
Complete Years Surrender
Elapsed Charges
Since Premium
Payment
-------------- ---------
[0 8%
1 7%
2 6%
3 5%
4 4%
5 3%
6 2%
7 1%
8+ 0%]
Surrender of the Certificate is permitted at or before the commencement
of annuity payments.
GA-CA-1074 3E1
THE SCHEDULE
CHARGES AND FEES (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] |
------------------------------------------------------------------------------
[Premium Taxes
We deduct the amount of any premium or other state and local taxes levied
by any state or governmental entity when such taxes are incurred.
We reserve the right to defer collection of Premium Taxes until surrender
or until application of Accumulation Value to an Annuity Option. An
Excess Partial Withdrawal will result in the deduction of any Premium Tax
then due us on such amount. We reserve the right to change the amount we
charge for Premium Tax charges on future Premium Payments to conform with
changes in the law or if the Owner changes state of residence.]
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the assets in
each Separate Account division on a daily basis of not more than
[0.004558%] (equivalent to an annual maximum rate of [1.65%]) for
mortality and expense risks. The charge is not deducted from the Fixed
Account or General Account accumulation values.
Asset Based Administrative Charge - We deduct [0.000411%] of the assets
in each Variable Separate Account Division on a daily basis (equivalent
to an annual rate of [0.15%]) to compensate us for a portion of our
ongoing administrative expenses. This charge is not deducted from the
Fixed Account values.
CHARGE DEDUCTION DIVISION
All charges against the Accumulation Value in this Certificate will be
deducted from the [Liquid Asset Division].
GA-CA-1074 3E1
THE SCHEDULE
INCOME PLAN FACTORS
------------------------------------------------------------------------------
------------------------------------------------------------------------------
| 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] |
------------------------------------------------------------------------------
Values for other payment periods, ages or joint life combinations are
available on request. Monthly payments are shown for each $1,000
applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Fixed Fixed
Period Monthly Period Monthly Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years 20 Years Refund
Certain Certain Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
------------------------------------------------------------------------------
GA-CA-1074 3F
THE SCHEDULE (STANDARD)
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days
from the Certificate Issue Date and may be taken on a monthly, quarterly or
annual basis. You select the day withdrawals will be made, but no later
than the 28th day of the month. If you do not elect a day, the Certificate
Date will be used.
Maximum Withdrawal Amounts:
Variable Separate Account Divisions: .833% of Premium Payments
monthly, 2.5% of Premium Payments
quarterly or 10% of Premium Payments
annually.
Fixed Allocations and
Guaranteed Interest Divisions: Interest earned on a Fixed Allocation
or Guaranteed Interest Division for
the prior month, quarter or year
(depending on the frequency selected).
The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal
is 10% of Premium Payments not previously withdrawn. Systematic Partial
Withdrawals from Fixed Allocations are not subject to a Market Value
Adjustment. A Systematic Partial Withdrawal in excess of Earnings and the
Free Amount may be subject to a Surrender Charge.
IRA Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a contract issued as an IRA on a
monthly, quarterly or annual basis. A minimum withdrawal of $100.00 is
required. You select the day the withdrawals will be made, but no later
than the 28th day of the month. If you do not elect a day, the Contract
Date will be used. Systematic Partial Withdrawals and Conventional Partial
Withdrawals are not allowed when IRA Partial Withdrawals are being taken.
An IRA Partial Withdrawal in excess of the maximum amount allowed under the
Systematic Partial Withdrawal option may be subject to a Market Value
Adjustment.
DEATH BENEFITS
The Death Benefit is the greatest of (i), (ii) and (iii) below, where:
(i) is the Accumulation Value;
(ii) is the Guaranteed Death Benefit;
(iii)is the Cash Surrender Value.
GA-CA-1074 3D2
THE SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
GUARANTEED DEATH BENEFIT
------------------------
The Guaranteed Death Benefit for the Contact is equal to the sum of I and
II below.
I The Guaranteed Death Benefit for non-Special Funds
II The Accumulation Value allocated to Special Funds
On the Contract Date, the Guaranteed Death Benefit Base for non-Special
Funds is the initial premium, allocated to non-Special Funds. On
subsequent Valuation Dates, the Guaranteed Death Benefit Base for non-
Special Funds is calculated as follows:
(1) Start with the Guaranteed Death Benefit Base for non-Special Funds
from the prior Valuation Date.
(2) Add any additional premiums paid and allocated to non-Special Funds
during the current Valuation Period to (1).
(3) Adjust (2) for any transfers to or from Special Funds during the
current Valuation Period.
(4) Subtract from (3) any Prorata Partial Withdrawal Adjustments for any
Partial Withdrawal made from non-Special Funds during the current
Valuation Period.
The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds.
Transfers from Special Funds to non-Special Funds will reduce the
Guaranteed Death Benefit Base for Special Funds on a prorata basis. The
resulting increase in the Guaranteed Death Benefit Base for non-Special
Funds will equal the lesser of the reduction in the Guaranteed Death
Benefit Base for Special Funds and the net Accumulation Value
transferred.
Transfers from non-Special Funds to Special Funds will reduce the
Guaranteed Death Benefit Base for non-Special Funds n a prorata basis.
The resulting increase in the Guaranteed Death Benefit Base for Special
Funds will equal the reduction in Guaranteed Death Benefit Base for non-
Special Funds.
GA-CA-1074 3D3
THE SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
SPECIAL FUNDS
Where used in this Certificate, Special Funds are [the Liquid Asset
Division, the Limited Maturity Bond Division, the Fixed Allocations and
the Guaranteed Interest Division]. We may add newly available divisions
as Special Funds. We may also reclassify an existing division as a
Special Fund or remove such designation upon 30 days notice to you. Such
reclassification will apply to amounts transferred or otherwise added to
such division after the date of change. We may reduce the Mortality and
Expense Risk Charge (if applicable) for that portion of the Contract
invested in a Special Fund.
SPECIAL AND PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS
For any partial withdrawal, the Death Benefit components will be reduced
by Prorata Partial Withdrawal Adjustments. The Prorata Partial
Withdrawal Adjustment to a Death Benefit component for a partial
withdrawal is equal to (1) divided by (2) multiplied by (3), where: (1)
is the Accumulation Value withdrawn; (2) is the Accumulation Value
immediately prior to withdrawal; and (3) is the amount of the applicable
Death Benefit component immediately prior to the withdrawal. Separate
adjustments will apply to amounts in the Special and non-Special Funds.
CHANGE OF OWNER
A change of Owner will result in recalculation of the Death Benefit and
the Guaranteed Death Benefit. If the Owner's or the oldest of multiple
Owners' attained age at the time of the change is less than [85], the
Guaranteed Death Benefit in effect prior to the change will remain in
effect and the Death Benefit provision shall apply.
If any owner's or oldest multiple owners attained age is [86] or greater
at the time of the change, the Guaranteed Death Benefit will be zero, and
the Death Benefit will then be the Cash Surrender Value.
GA-CA-1074 3D4
THE SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
SPOUSAL CONTINUATION UPON DEATH OF OWNER
If at the Owner's death, the surviving spouse of the deceased Owner is
the Beneficiary and such surviving spouse elects to continue the Contract
as their own pursuant to Internal Revenue Code Section 72(s) or the
equivalent provisions of U.S. Treasury Department rules for qualified
plans, the following will apply:
(i)If the Guaranteed Death Benefit as of the date we receive due proof
of death of the Owner, minus the Accumulation Value, also as of that
date, is greater than zero, we will add such difference to the
Accumulation Value. Such addition will be allocated to the divisions of
the Separate Account in the same proportion as the Accumulation Value in
each division bears to the Accumulation Value in the Separate Account.
If there is no Accumulation Value in the Separate Account, the addition
will be allocated to the Liquid Asset division, or its successor.
(j)The Guaranteed Death Benefit will continue to apply, with all age
criteria using the surviving spouse's age as the determining age.
(k)At subsequent surrender, any surrender charge applicable to premiums
paid prior to the date we receive due proof of death of the Owner will be
waived. Any premiums paid later will be subject to any applicable
surrender charge.
This addition to Accumulation Value is available only to the spouse of
the Owner as of the date of death of the Owner if such spouse under the
provisions if this Contract elects to continue the Contract as their own.
GA-CA-1074 3D5
THE SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no
later than April 1st of the calendar year following the calendar year in
which the Owner attains age 70 1/2. Otherwise, the Annuity Commencement
Date may be no later than the same date as the Contract Processing Date in
the month following the Annuitant's 90th birthday. In applying the
Accumulation Value, we may first collect any Premium Taxes due us. If, on
the Annuity Commencement Date, a Surrender Charge remains, your elected
Annuity Option must include a period certain of at least five years
duration.
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
Optional Benefit Riders - [None.]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full years
elapsed since the Certificate Date.
GA-CA-1074 3D6
THE SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
FIXED ACCOUNT
Minimum Fixed Allocation
The minimum allocation to the Fixed Account in any one Fixed Allocation
is [$250.00].
Minimum Guaranteed Interest Rate - [3%.]
Guarantee Periods
We currently offer Guarantee Periods of [1,2,3,4,5,6,7,8,9 and 10]
year(s). We reserve the right to offer Guarantee Periods of durations
other than those available on the Certificate Date. We also reserve the
right to cease offering a particular Guarantee Period or Periods.
Index Rate
The Index Rate is the average of the Ask Yields for the U.S. Treasury
Strips as reported by a national quoting service for the applicable
maturity. The average is based on the period from the 22nd day of the
calendar month two months prior to the calendar month of Index Rate
determination to the 21st day of the calendar month immediately prior to
the month of determination. The applicable maturity date for these U.S.
Treasury Strips is on or next following the last day of the Guarantee
Period. If the Ask Yields are no longer available, the Index Rate will
be determined using a suitable replacement method.
We currently set the Index Rate once each calendar month. However, we
reserve the right to set the Index Rate more frequently than monthly, but
in no event will such Index Rate be based on a period less than 28 days.
GA-CA-1074 3D7
THE SCHEDULE
CHARGES AND FEES
------------------------------------------------------------------------------
------------------------------------------------------------------------------
| 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] |
------------------------------------------------------------------------------
DEDUCTIONS FROM PREMIUMS
[None.]
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
[None.]
Administrative Charge - [We charge [$30] to cover a portion of our ongoing
---------------------
administrative expenses for each Certificate Processing Period. The charge
is incurred at the beginning of the Certificate Processing Period and
deducted on the Certificate Processing Date at the end of the period.
At the time of deduction, this charge will be waived if
(1) The Accumulation Value is at least $100,000; or
(2) The sum of premiums paid to date is at least $100,000]
Excess Allocation Charge
Currently none, however, we reserve the right to charge [$25] for a
change if you make more than [twelve] allocation changes per Certificate
Year. Any charge will be deducted in proportion to the amount being
transferred from each Division.
Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if
the Certificate is surrendered or an Excess Partial Withdrawal is taken.
The percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed since a Premium
Payment was made. The Surrender Charge expressed as a percentage of each
Premium Payment is as follows:
Complete Years Surrender
Elapsed Charges
Since Premium
Payment
-------------- ---------
[0 8%
1 7%
2 6%
3 5%
4 4%
5 3%
6 2%
7 1%
8+ 0%]
Surrender of the Certificate is permitted at or before the commencement
of annuity payments.
GA-CA-1074 3E1
THE SCHEDULE
CHARGES AND FEES (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] |
------------------------------------------------------------------------------
[Premium Taxes
We deduct the amount of any premium or other state and local taxes levied
by any state or governmental entity when such taxes are incurred.
We reserve the right to defer collection of Premium Taxes until surrender
or until application of Accumulation Value to an Annuity Option. An
Excess Partial Withdrawal will result in the deduction of any Premium Tax
then due us on such amount. We reserve the right to change the amount we
charge for Premium Tax charges on future Premium Payments to conform with
changes in the law or if the Owner changes state of residence.]
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the assets in
---------------------------------
each Separate Account division on a daily basis of not more than
[0.003446%] (equivalent to an annual maximum rate of [1.40%]) for
mortality and expense risks. The charge is not deducted from the Fixed
Account or General Account accumulation values.
Asset Based Administrative Charge - We deduct [0.000411%] of the assets
---------------------------------
in each Variable Separate Account Division on a daily basis (equivalent
to an annual rate of [0.15%]) to compensate us for a portion of our
ongoing administrative expenses. This charge is not deducted from the
Fixed Account values.
CHARGE DEDUCTION DIVISION
All charges against the Accumulation Value in this Certificate will be
deducted from the [Liquid Asset Division].
GA-CA-1074 3E2
THE SCHEDULE
CHARGES AND FEES (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] |
------------------------------------------------------------------------------
Values for other payment periods, ages or joint life combinations are
available on request. Monthly payments are shown for each $1,000
applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Fixed Fixed
Period Monthly Period Monthly Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years 20 Years Refund
Certain Certain Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
GA-CA-1074 3F
SCHEDULE (COMBO DB)
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days
from the Certificate Issue Date and may be taken on a monthly, quarterly or
annual basis. You select the day withdrawals will be made, but no later
than the 28th day of the month. If you do not elect a day, the Certificate
Date will be used.
Maximum Withdrawal Amounts:
Variable Separate Account Divisions: .833% of Premium Payments
monthly, 2.5% of Premium Payments
quarterly or 10% of Premium Payments
annually.
Fixed Allocations and
Guaranteed Interest Divisions: Interest earned on a Fixed Allocation
or Guaranteed Interest Division for the
prior month, quarter or year (depending
on the frequency selected).
The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal
is 10% of Premium Payments not previously withdrawn. Systematic Partial
Withdrawals from Fixed Allocations are not subject to a Market Value
Adjustment. A Systematic Partial Withdrawal in excess of Earnings and the
Free Amount may be subject to a Surrender Charge.
IRA Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a contract issued as an IRA on a
monthly, quarterly or annual basis. A minimum withdrawal of $100.00 is
required. You select the day the withdrawals will be made, but no later
than the 28th day of the month. If you do not elect a day, the Contract
Date will be used. Systematic Partial Withdrawals and Conventional Partial
Withdrawals are not allowed when IRA Partial Withdrawals are being taken.
An IRA Partial Withdrawal in excess of the maximum amount allowed under the
Systematic Partial Withdrawal option may be subject to a Market Value
Adjustment.
DEATH BENEFIT
-------------
The Death Benefit is the greatest of (i), (ii), (iii), (iv) and (v)
below, where:
(i) is the Accumulation Value;
(ii) is the lesser of (a) and (b) where (a) is the Guaranteed Death
Benefit, and (b) is the Maximum Guaranteed Death Benefit;
(iii)is the Cash Surrender Value;
(iv) is the Minimum Death Benefit; and.
(v) the Alternate Guaranteed Death Benefit.
MINIMUM DEATH BENEFIT
---------------------
The Minimum Death Benefit shall be the sum of the following:
1. The Accumulation Value allocated to Special Funds; and
2. Adjusted Premium for non-Special Funds.
GA-CA-1074 3D2
SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
Adjusted Premium for non-Special Funds shall mean all premium allocated
to non-Special Funds, plus an adjustment for any amounts transferred to
non-Special Funds, less a prorata adjustment for any amounts transferred
or withdrawn from non-Special Funds. The amount of the prorata
adjustment will equal (a) times (b) divided by (c), where: (a) is the
Adjusted Premium for non-Special Funds prior to the transfer or
withdrawal; (b) is the Accumulation Value of
the transfer or withdrawal; and (c) is the Accumulation Value allocated
to non-Special Funds before the transfer or withdrawal. Adjusted Premium
for Special Funds has the same definition, but with respect to amounts
allocated to Special Funds.
Transfers from Special Funds increase the Adjusted Premium for non-
Special Funds by the lesser of the reduction of the Adjusted Premium for
Special Funds and net Accumulation Value transferred. Transfers from non-
Special Funds increase the Adjusted Premium for Special Funds by the
reduction in the Adjusted Premium for non-Special Funds.
GUARANTEED DEATH BENEFIT
------------------------
The Guaranteed Death Benefit for the Contact is equal to the sum of I and
II below.
I. The Guaranteed Death Benefit Base for non-Special Funds
II. The Accumulation Value allocated to Special Funds
On the Contract Date, the Guaranteed Death Benefit Base for non-Special
Funds is the initial premium, if applicable, allocated to non-Special
Funds. On subsequent Valuation Dates, the Guaranteed Death Benefit Base
for non-Special Funds is calculated as follows:
(1) Start with the Guaranteed Death Benefit Base for non-Special Funds
on the prior Valuation Date.
(2) Calculate interest on (1) for the current Valuation Period at the
Guaranteed Death Benefit Interest Rate for non-Special Funds.
(3) Add (1) and (2).
(4) Add to (3) any additional premiums allocated to non-Special Funds
during the current Valuation Period.
(5) Add to (or subtract from) (4) adjustments for transfers from (to)
Special Funds made during the Valuation Period.
(6) Subtract from (5) the amount of any Special Partial Withdrawal
Adjustments and Prorata Partial Withdrawal Adjustments for any partial
withdrawals made from non-Special Funds during the current Valuation
Period.
The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds.
Transfers from Special Funds to non-Special Funds will reduce the
Guaranteed Death Benefit Base for Special Funds on a prorata basis. The
resulting increase in the Guaranteed Death Benefit Base for non-Special
Funds will equal the lesser of the reduction in the Guaranteed Death
Benefit Base for Special Funds and the net Accumulation Value
transferred.
GA-CA-1074 3D3
SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
Transfers from non-Special Funds to Special Funds will reduce the
Guaranteed Death Benefit Base for non-Special Funds on a prorata basis.
The resulting increase in the Guaranteed Death Benefit Base for Special
Funds will equal the reduction in Guaranteed Death Benefit Base for non-
Special Funds.
GUARANTEED DEATH BENEFIT INTEREST RATE
--------------------------------------
The Guaranteed Death Benefit Interest Rate is [7%] compounded annually,
except:
(a) For any portion of the Guaranteed Death Benefit Base for Special
Funds, the Guaranteed Death Benefit Interest Rate is [7%] (compounded
annually); and
(b) For any valuation period ending after the contract anniversary on
which the Owner attains age [80], or after the Maximum Guaranteed
Death Benefit has been reached, the Guaranteed Death Benefit Interest
Rate is [0%].
SPECIAL FUNDS
-------------
Where used in this Certificate, Special Funds are [the Liquid Asset
Division, the Limited Maturity Bond Division, the Fixed Allocations and
the Guaranteed Interest Division]. We may add newly available divisions
as Special Funds. We may also reclassify an existing division as a
Special Fund or remove such designation upon 30 days notice to you. Such
reclassification will apply to amounts transferred or otherwise added to
such division after the date of change. We may reduce the Mortality and
Expense Risk Charge (if applicable) for that portion of the Contract
invested in a Special Fund.
MAXIMUM GUARANTEED DEATH BENEFIT
--------------------------------
The Maximum Guaranteed Death Benefit is equal to [three] times premium
paid, reduced by the amount of any Partial Withdrawal Adjustments. The
Maximum Guaranteed Death Benefit is allocated proportionally based on the
Contract's allocation to Special and non-Special funds. Transfers and
withdrawals will affect the allocation of the Maximum Guaranteed Death
Benefit at the same proportion among the Special and non-Special Funds
that they bear to the Accumulation Value transferred or withdrawn. Any
addition due to spousal continuation will not affect the Maximum
Guaranteed Death Benefit or the Guaranteed Death Benefit Base.
SPECIAL AND PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS
--------------------------------------------------
For any partial withdrawal, the Death Benefit components will be reduced
by Prorata Partial Withdrawal Adjustments. A Prorata Partial Withdrawal
Adjustment will be made unless a Special Partial Withdrawal Adjustment
applies to the component for the withdrawal. Special Partial Withdrawal
Adjustments are made when partial withdrawals in any Contract Year do not
exceed [7%] of the sum of cumulative premiums, but only if partial
withdrawals in each prior year did not exceed [7%] of the sum of premiums
paid prior to that year. The Special Partial Withdrawal Adjustment
GA-CA-1074 3D4
SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
is equal to the amount of the Accumulation Value withdrawn. Special
Partial Withdrawal Adjustments are applicable only in the calculation of
the Maximum Guaranteed Death Benefit and the Guaranteed Death Benefit
Base, and in all other cases withdrawals are treated as Prorata Partial
Withdrawal Adjustments.
The Prorata Partial Withdrawal Adjustment to a Death Benefit component is
equal to (1) divided by (2), multiplied by (3), where: (1) is the
Accumulation Value withdrawn; (2) is the Accumulation Value immediately
prior to withdrawal; and (3) is the amount of the applicable Death
Benefit component immediately prior to the withdrawal. Separate
adjustments will apply to the amounts in the Special and non-Special
Funds.
ALTERNATE GUARANTEED DEATH BENEFIT
The Alternate Guaranteed Death Benefit for the Contact is equal to the
sum of I and II below.
I. The Alternate Guaranteed Death Benefit Base for non-Special Funds
II. The Accumulation Value allocated to Special Funds
On the Contract Date, the Alternate Guaranteed Death Benefit Base for non-
Special Funds is the initial premium allocated to non-Special Funds . On
subsequent Valuation Dates, the Alternate Guaranteed Death Benefit Base
for non-Special Funds is calculated as follows:
(1) Start with the Alternate Guaranteed Death Benefit Base for non-
Special Funds from the prior Valuation Date.
(2) Add to (1) any additional premium allocated to the non-Special Funds
during the current Valuation Period and adjustments for transfers from
Special Funds during the current Valuation Period and subtract from (1)
any adjustment for transfers to Special Funds during the current
Valuation Period and any Prorata Partial Withdrawal Adjustments for any
Partial Withdrawals taken from non-Special Funds during the current
Valuation Period.
(3) On a Valuation Date that occurs on or prior to the Owner's attained
age [90], which is also a Contract Anniversary, we set the Alternate
Guaranteed Death Benefit Base for non-Special Funds equal to the greater
of (2) or the Accumulation Value as of such date. On all other Valuation
Dates, the Alternate Guaranteed Death Benefit Base for non-Special Funds
is equal to (2).
The Alternate Guaranteed Death Benefit Base for Special Funds has a
corresponding definition, but with respect to amounts allocated to
Special Funds.
Transfers from Special Funds to non-Special Funds will reduce the
Alternate Guaranteed Death Benefit Base for Special Funds on a prorata
basis. The resulting increase in the Alternate Guaranteed Death Benefit
Base for non-Special Funds will equal the lesser of the reduction in the
Alternate Guaranteed Death Benefit Base for Special Funds and the net
Accumulation Value transferred.
GA-CA-1074 3D5
SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
Transfers from non-Special Funds to Special Funds will reduce the
Alternate Guaranteed Death Benefit Base for non-Special Funds on a
prorata basis. The resulting increase in the Alternate Guaranteed Death
Benefit Base for Special Funds will equal the reduction in Alternate
Guaranteed Death Benefit Base for non-Special Funds.
CHANGE OF OWNER
A change of Owner from a sole Owner to a sole Owner (where there have
never been multiple Owners designated) will result in recalculation of
the Death Benefit, the Guaranteed Death Benefit the Alternate Guaranteed
Death Benefit, and the Maximum Guaranteed Death Benefit. If the new
Owner's attained age at the time of the change is less than [90], the
Guaranteed Death Benefit, the Alternate Guaranteed Death Benefit and the
Maximum Guaranteed Death Benefit in effect prior to the change will
remain in effect and the Death Benefit provision shall apply. If the new
Owner's attained age at the time of the change is [90] or greater, but
not greater than [95]:
(a) The Guaranteed Death Benefit, the Alternative Guaranteed Death
Benefit, and the Maximum Guaranteed Death Benefit following the change
will be zero; and
(b) The Death Benefit will then be the greatest of:
1) the cash surrender value;
2) the accumulation value; and
3) the Minimum Death Benefit.
If ownership change results in multiple Owners or if there has ever been
multiple Owners, the Guaranteed Death Benefit, the Alternate Guaranteed
Death Benefit and the Maximum Guaranteed Death Benefit shall be set to
zero. If the oldest owner is age [95] or younger at the time of the
change, the Death Benefit will then be the greatest of (b) 1, (b) 2 or
(b) 3 above.
If any Owner's or oldest multiple Owner's attained age is [86] or greater
at the time of the change, the Guaranteed Death Benefit, the Minimum
Death Benefit, the Alternate Guaranteed Death Benefit and the Maximum
Guaranteed Death Benefit will be zero, and the Death Benefit will then be
the cash surrender value.
When a change of Owner reduces the Guaranteed Death Benefit, the
Alternate Guaranteed Death Benefit and the Maximum Guaranteed Death
Benefit to zero, there will be a reduction in the mortality and expense
risk charge.
GA-CA-1074 3D6
SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
SPOUSAL CONTINUATION UPON DEATH OF OWNER
If at the Owner's death, the surviving spouse of the deceased Owner is
the Beneficiary and such surviving spouse elects to continue the contract
as their own pursuant to Internal Revenue Code Section 72(s) or the
equivalent provisions of U.S. Treasury Department rules for qualified
plans, the following will apply:
(a)If the greater of (ii) and (iv) in the Death Benefit provision as of
the date we receive due proof of death of the Owner minus the
Accumulation Value, also as of that date, is greater than zero, we will
add such difference to the Accumulation Value. Such addition will be
allocated to the divisions of the Separate Account in the same proportion
as the Accumulation Value in each division bears to the Accumulation
Value in the Separate Account. If there is no Accumulation Value in the
Separate Account, the addition will be allocated to the Liquid Asset
division, or its successor.
(b)The Guaranteed Death Benefit and the Maximum Guaranteed Death
Benefit will continue to apply, using the surviving spouse's age as the
determining age.
(c)At subsequent surrender, any surrender charge applicable to premiums
paid prior to the date we receive due proof of death of the Owner will be
waived. Any premiums paid later will be subject to any applicable
surrender charge.
This addition to Accumulation Value is available only to the spouse of
the Owner as of the date of death of the Owner if such spouse under the
provisions of this Contract elects to continue the Contract as their own.
GA-CA-1074 3D7
SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no
later than April 1st of the calendar year following the calendar year in
which the Owner attains age 70 1/2. Otherwise, the Annuity Commencement
Date may be no later than the same date as the Contract Processing Date in
the month following the Annuitant's 90th birthday. In applying the
Accumulation Value, we may first collect any Premium Taxes due us. If, on
the Annuity Commencement Date, a Surrender Charge remains, your elected
Annuity Option must include a period certain of at least five years
duration.
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
Optional Benefit Riders - [None.]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full years
elapsed since the Certificate Date.
GA-CA-1074 3D8
SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
FIXED ACCOUNT
Minimum Fixed Allocation
The minimum allocation to the Fixed Account in any one Fixed Allocation
is [$250.00].
Minimum Guaranteed Interest Rate - [3%.]
Guarantee Periods
We currently offer Guarantee Periods of [1,2,3,4,5,6,7,8,9 and 10]
year(s). We reserve the right to offer Guarantee Periods of durations
other than those available on the Certificate Date. We also reserve the
right to cease offering a particular Guarantee Period or Periods.
Index Rate
The Index Rate is the average of the Ask Yields for the U.S. Treasury
Strips as reported by a national quoting service for the applicable
maturity. The average is based on the period from the 22nd day of the
calendar month two months prior to the calendar month of Index Rate
determination to the 21st day of the calendar month immediately prior to
the month of determination. The applicable maturity date for these U.S.
Treasury Strips is on or next following the last day of the Guarantee
Period. If the Ask Yields are no longer available, the Index Rate will
be determined using a suitable replacement method.
We currently set the Index Rate once each calendar month. However, we
reserve the right to set the Index Rate more frequently than monthly, but
in no event will such Index Rate be based on a period less than 28 days.
GA-CA-1074 3D9
SCHEDULE
CHARGES AND FEES
------------------------------------------------------------------------------
------------------------------------------------------------------------------
| 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] |
------------------------------------------------------------------------------
DEDUCTIONS FROM PREMIUMS
[None.]
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
[None.]
Administrative Charge - [We charge [$30] to cover a portion of our ongoing
administrative expenses for each Certificate Processing Period. The charge
is incurred at the beginning of the Certificate Processing Period and
deducted on the Certificate Processing Date at the end of the period.
At the time of deduction, this charge will be waived if
(1) The Accumulation Value is at least $100,000; or
(2) The sum of premiums paid to date is at least $100,000]
Excess Allocation Charge
Currently none, however, we reserve the right to charge [$25] for a
change if you make more than [twelve] allocation changes per Certificate
Year. Any charge will be deducted in proportion to the amount being
transferred from each Division.
Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if
the Certificate is surrendered or an Excess Partial Withdrawal is taken.
The percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed since a Premium
Payment was made. The Surrender Charge expressed as a percentage of each
Premium Payment is as follows:
Complete Years
Elapsed
Since Premium Surrender
Payment Charges
-------------- ---------
[0 8%
1 7%
2 6%
3 5%
4 4%
5 3%
6 2%
7 1%
8+ 0%]
Surrender of the Certificate is permitted at or before the commencement
of annuity payments.
GA-CA-1074 3E1
SCHEDULE
CHARGES AND FEES (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] |
------------------------------------------------------------------------------
[Premium Taxes
We deduct the amount of any premium or other state and local taxes levied
by any state or governmental entity when such taxes are incurred.
We reserve the right to defer collection of Premium Taxes until surrender
or until application of Accumulation Value to an Annuity Option. An
Excess Partial Withdrawal will result in the deduction of any Premium Tax
then due us on such amount. We reserve the right to change the amount we
charge for Premium Tax charges on future Premium Payments to conform with
changes in the law or if the Owner changes state of residence.]
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the assets in
each Separate Account division on a daily basis of not more than
[0.005116%] (equivalent to an annual maximum rate of [1.85%]) for
mortality and expense risks. The charge is not deducted from the Fixed
Account or General Account accumulation values.
Asset Based Administrative Charge - We deduct [0.000411%] of the assets
in each Variable Separate Account Division on a daily basis (equivalent
to an annual rate of [0.15%]) to compensate us for a portion of our
ongoing administrative expenses. This charge is not deducted from the
Fixed Account values.
CHARGE DEDUCTION DIVISION
All charges against the Accumulation Value in this Certificate will be
deducted from the [Liquid Asset Division].
GA-CA-1074 3E2
THE SCHEDULE
INCOME PLAN FACTORS
------------------------------------------------------------------------------
------------------------------------------------------------------------------
| 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] |
------------------------------------------------------------------------------
Values for other payment periods, ages or joint life combinations are
available on request. Monthly payments are shown for each $1,000
applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Fixed Fixed
Period Monthly Period Monthly Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years 20 Years Refund
Certain Certain Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
GA-CA-1074 3F
SCHEDULE `(BASE)
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days
from the Certificate Issue Date and may be taken on a monthly, quarterly or
annual basis. You select the day withdrawals will be made, but no later
than the 28th day of the month. If you do not elect a day, the Certificate
Date will be used.
Maximum Withdrawal Amounts:
Variable Separate Account Divisions: .833% of Premium Payments
monthly, 2.5% of Premium Payments
quarterly or 10% of Premium Payments
annually.
Fixed Allocations and
Guaranteed Interest Divisions: Interest earned on a Fixed Allocation
or Guaranteed Interest Division for
the prior month, quarter or year
(depending on the frequency selected).
The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal
is 10% of Premium Payments not previously withdrawn. Systematic Partial
Withdrawals from Fixed Allocations are not subject to a Market Value
Adjustment. A Systematic Partial Withdrawal in excess of Earnings and the
Free Amount may be subject to a Surrender Charge.
IRA Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a contract issued as an IRA on a
monthly, quarterly or annual basis. A minimum withdrawal of $100.00 is
required. You select the day the withdrawals will be made, but no later
than the 28th day of the month. If you do not elect a day, the Contract
Date will be used. Systematic Partial Withdrawals and Conventional Partial
Withdrawals are not allowed when IRA Partial Withdrawals are being taken.
An IRA Partial Withdrawal in excess of the maximum amount allowed under the
Systematic Partial Withdrawal option may be subject to a Market Value
Adjustment.
DEATH BENEFITS
The Death Benefit is the greatest of (i) and (ii) below, where:
(i) is the Accumulation Value; and
(ii) is the Cash Surrender Value.
GA-CA-1074 3D2
THE SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
SPOUSAL CONTINUATION UPON DEATH OF OWNER
If at the Owner's death, the surviving spouse of the deceased Owner is
the Beneficiary and such surviving spouse elects to continue the Contract
as their own pursuant to Internal Revenue Code Section 72(s) or the
equivalent provisions of U.S. Treasury Department rules for qualified
plans, the following will apply:
(l)If the Guaranteed Death Benefit as of the date we receive due proof
of death of the Owner, minus the Accumulation Value, also as of that
date, is greater than zero, we will add such difference to the
Accumulation Value. Such addition will be allocated to the divisions of
the Separate Account in the same proportion as the Accumulation Value in
each division bears to the Accumulation Value in the Separate Account.
If there is no Accumulation Value in the Separate Account, the addition
will be allocated to the Liquid Asset division, or its successor.
(m)The Guaranteed Death Benefit will continue to apply, with all age
criteria using the surviving spouse's age as the determining age.
(n)At subsequent surrender, any surrender charge applicable to premiums
paid prior to the date we receive due proof of death of the Owner will be
waived. Any premiums paid later will be subject to any applicable
surrender charge.
This addition to Accumulation Value is available only to the spouse of
the Owner as of the date of death of the Owner if such spouse under the
provisions if this Contract elects to continue the Contract as their own.
GA-CA-1074 3D3
THE SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no
later than April 1st of the calendar year following the calendar year in
which the Owner attains age 70 1/2. Otherwise, the Annuity Commencement
Date may be no later than the same date as the Contract Processing Date in
the month following the Annuitant's 90th birthday. In applying the
Accumulation Value, we may first collect any Premium Taxes due us. If, on
the Annuity Commencement Date, a Surrender Charge remains, your elected
Annuity Option must include a period certain of at least five years
duration.
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
Optional Benefit Riders - [None.]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full years
elapsed since the Certificate Date.
GA-CA-1074 3D4
THE SCHEDULE
CERTIFICATE FACTS (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] |
------------------------------------------------------------------------------
FIXED ACCOUNT
Minimum Fixed Allocation
The minimum allocation to the Fixed Account in any one Fixed Allocation
is [$250.00].
Minimum Guaranteed Interest Rate - [3%.]
Guarantee Periods
We currently offer Guarantee Periods of [1,2,3,4,5,6,7,8,9 and 10]
year(s). We reserve the right to offer Guarantee Periods of durations
other than those available on the Certificate Date. We also reserve the
right to cease offering a particular Guarantee Period or Periods.
Index Rate
The Index Rate is the average of the Ask Yields for the U.S. Treasury
Strips as reported by a national quoting service for the applicable
maturity. The average is based on the period from the 22nd day of the
calendar month two months prior to the calendar month of Index Rate
determination to the 21st day of the calendar month immediately prior to
the month of determination. The applicable maturity date for these U.S.
Treasury Strips is on or next following the last day of the Guarantee
Period. If the Ask Yields are no longer available, the Index Rate will
be determined using a suitable replacement method.
We currently set the Index Rate once each calendar month. However, we
reserve the right to set the Index Rate more frequently than monthly, but
in no event will such Index Rate be based on a period less than 28 days.
GA-CA-1074 3D5
THE SCHEDULE
CHARGES AND FEES
------------------------------------------------------------------------------
------------------------------------------------------------------------------
| 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] |
------------------------------------------------------------------------------
DEDUCTIONS FROM PREMIUMS
[None.]
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
[None.]
Administrative Charge - [We charge [$30] to cover a portion of our ongoing
---------------------
administrative expenses for each Certificate Processing Period. The charge
is incurred at the beginning of the Certificate Processing Period and
deducted on the Certificate Processing Date at the end of the period.
At the time of deduction, this charge will be waived if
(1) The Accumulation Value is at least $100,000; or
(2) The sum of premiums paid to date is at least $100,000]
Excess Allocation Charge
Currently none, however, we reserve the right to charge [$25] for a
change if you make more than [twelve] allocation changes per Certificate
Year. Any charge will be deducted in proportion to the amount being
transferred from each Division.
Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if
the Certificate is surrendered or an Excess Partial Withdrawal is taken.
The percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed since a Premium
Payment was made. The Surrender Charge expressed as a percentage of each
Premium Payment is as follows:
Complete Years Surrender
Elapsed Charges
Since Premium
Payment
------------- ---------
[0 8%
1 7%
2 6%
3 5%
4 4%
5 3%
6 2%
7 1%
8+ 0%]
Surrender of the Certificate is permitted at or before the commencement
of annuity payments.
GA-CA-1074 3E1
THE SCHEDULE
CHARGES AND FEES (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] |
------------------------------------------------------------------------------
[Premium Taxes
We deduct the amount of any premium or other state and local taxes levied
by any state or governmental entity when such taxes are incurred.
We reserve the right to defer collection of Premium Taxes until surrender
or until application of Accumulation Value to an Annuity Option. An
Excess Partial Withdrawal will result in the deduction of any Premium Tax
then due us on such amount. We reserve the right to change the amount we
charge for Premium Tax charges on future Premium Payments to conform with
changes in the law or if the Owner changes state of residence.]
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the assets in
each Separate Account division on a daily basis of not more than
[0.003585%] (equivalent to an annual maximum rate of [1.30%]) for
mortality and expense risks. The charge is not deducted from the Fixed
Account or General Account accumulation values.
Asset Based Administrative Charge - We deduct [0.000411%] of the assets
in each Variable Separate Account Division on a daily basis (equivalent
to an annual rate of [0.15%]) to compensate us for a portion of our
ongoing administrative expenses. This charge is not deducted from the
Fixed Account values.
CHARGE DEDUCTION DIVISION
All charges against the Accumulation Value in this Certificate will be
deducted from the [Liquid Asset Division].
GA-CA-1074 3E2
THE SCHEDULE
INCOME PLAN FACTORS
------------------------------------------------------------------------------
------------------------------------------------------------------------------
| 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] |
------------------------------------------------------------------------------
Values for other payment periods, ages or joint life combinations are
available on request. Monthly payments are shown for each $1,000
applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Fixed Fixed
Period Monthly Period Monthly Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years 20 Years Refund
Certain Certain Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
GA-CA-1074 3F
