FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT
THE COMPANY'S PROMISE
In consideration for the Purchase Payments and the attached application, First
Security Benefit Life Insurance and Annuity Company of New York (the "Company")
will pay the benefits of this Contract according to its provisions.
LEGAL CONTRACT
PLEASE READ YOUR CONTRACT CAREFULLLY. It is a legal Contract between the Owner
and the Company. The Contract's table of contents is on page 2.
FREE LOOK PERIOD-RIGHT TO CANCEL
IF FOR ANY REASON THE OWNER IS NOT SATISFIED WITH THIS CONTRACT, HE OR SHE MAY
RETURN IT TO THE COMPANY WITHIN 30 DAYS FROM THE DATE OF RECEIPT. IT MAY BE
RETURNED BY DELIVERING OR MAILING IT TO THE COMPANY. IF RETURNED, THIS CONTRACT
SHALL BE DEEMED VOID FROM THE CONTRACT DATE. THE COMPANY WILL REFUND (I) ANY
PURCHASE PAYMENTS MADE AND ALLOCATED TO THE FIXED ACCOUNT; AND (II) SEPARATE
ACCOUNT CONTRACT VALUE AS OF THE DATE THE RETURNED POLICY IS POSTMARKED FOR
RETURN TO THE COMPANY, INCREASED BY ANY FEES OR OTHER CHARGES PAID.
Signed for First Security Benefit Life Insurance and Annuity Company of New York
on the Contract Date.
XXXXX X. XXXXX XXXXXX X. XXXXXX
Secretary President
A BRIEF DESCRIPTION OF THIS CONTRACT
This is a FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT.
*Purchase Payments may be made until the earlier of the Annuity Payout Date or
termination of the Contract.
*A Death Benefit may be paid prior to the Annuity Payout Date according to the
Contract provisions.
*Annuity Payments begin on the Annuity Payout Date using the method specified
in this Contract.
*The smallest annual rate of investment return that would have to be earned on
the assets of the Separate Account so that the dollar amount of Variable
Annuity Payment will not decrease is 3 1/2%. A daily charge corresponding to an
annual charge of .55% is applied to the assets of the Separate Account by the
Company. Please refer to the "Contract Value and Expense Provisions" beginning
on page 10.
ALL PAYMENTS AND VALUES PROVIDED BY THIS CONTRACT, WHEN BASED ON THE INVESTMENT
EXPERIENCE OF THE SEPARATE ACCOUNT, ARE VARIABLE AND MAY INCREASE OR DECREASE IN
ACCORDANCE WITH THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT. THERE ARE NO
GUARANTEED MINIMUM PAYMENTS OR CASH VALUES. (SEE "CONTRACT VALUE AND EXPENSE
PROVISIONS" AND "ANNUITY PAYMENT PROVISIONS" FOR DETAILS.)
FIRST SECURITY BENEFIT LIFE INSURANCE AND ANNUITY COMPANY OF NEW YORK
00 Xxxx Xxx Xxx Xxxx, 0xx Xxxxx, Xxxxx Xxxxxx, Xxx Xxxx 00000
Form FSB201 (R11-96)U BP 2010Q1
--------------------------------------------------------------------------------
TABLE OF CONTENTS
--------------------------------------------------------------------------------
PAGE
CONTRACT SPECIFICATIONS ............................................... 3
DEFINITIONS ........................................................... 4-6
GENERAL PROVISIONS .................................................... 7, 8
The Contract ........................................................ 7
Compliance .......................................................... 7
Misstatement of Age ................................................. 7
Evidence of Survival ................................................ 7
Incontestability .................................................... 7
Assignment .......................................................... 7
Exchanges ........................................................... 8
Claims of Creditors ................................................. 8
Nonforfeiture Values ................................................ 8
Non-Participating ................................................... 8
Statements .......................................................... 8
OWNERSHIP, ANNUITANT AND BENEFICIARY PROVISIONS ....................... 9
Ownership ........................................................... 9
Joint Ownership ..................................................... 9
Annuitant ........................................................... 9
Primary and Secondary Beneficiaries ................................. 9
Ownership and Beneficiary Changes ................................... 9
PURCHASE PAYMENT PROVISIONS ........................................... 10
Flexible Purchase Payments .......................................... 10
Purchase Payment Limitations ........................................ 10
Purchase Payment Allocation ......................................... 10
Place of Payment .................................................... 10
CONTRACT VALUE AND EXPENSE PROVISIONS ................................. 10-12
Contract Value ...................................................... 10
Fixed Account Contract Value ........................................ 10
Fixed Account Interest Crediting .................................... 11
Separate Account Contract Value ..................................... 11
Accumulation Unit Value ............................................. 11
Determining Accumulation Units ...................................... 11
Mortality and Expense Risk Charge ................................... 12
Premium Tax Expense ................................................. 12
Mutual Fund Expenses ................................................ 12
WITHDRAWAL PROVISIONS ................................................. 12, 13
Withdrawals ......................................................... 12
Withdrawal Value .................................................... 13
Systematic Withdrawals .............................................. 13
Date of Request ..................................................... 13
Payment of Withdrawal Benefits ...................................... 13
DEATH BENEFIT PROVISIONS .............................................. 14, 15
Death Benefit ....................................................... 14
Proof of Death ...................................................... 14
Distribution Rules .................................................. 14, 15
ANNUITY PAYMENT PROVISIONS ............................................ 15-19
Annuity Payout Date ................................................. 15
Change of Annuity Payout Date ....................................... 15
Annuity Payout Amount ............................................... 15
Annuity Tables ...................................................... 16
Annuity Payments .................................................... 16
Change of Annuity Option ............................................ 16
Fixed Annuity Payments .............................................. 16
Variable Annuity Payments ........................................... 16
Annuity Units ....................................................... 16, 17
Net Investment Factor ............................................... 17
Alternate Annuity Option Rates ...................................... 17
Annuity Options ..................................................... 18, 19
ANNUITY TABLES ........................................................ 20
AMENDMENTS OR ENDORSEMENTS, IF ANY
-2- BP 2010Q1
--------------------------------------------------------------------------------
CONTRACT SPECIFICATIONS
--------------------------------------------------------------------------------
OWNER NAME: CONTRACT NUMBER:
OWNER DATE OF BIRTH: CONTRACT DATE:
JOINT OWNER NAME: ISSUE DATE:
JOINT OWNER DATE OF BIRTH: ANNUITY PAYOUT DATE:
ANNUITANT NAME: PLAN:
ANNUITANT DATE OF BIRTH: ASSIGNMENT:
ANNUITANT GENDER:
PRIMARY BENEFICIARY NAME: SECONDARY BENEFICIARY
NAME: See Application or subsequent change form
--------------------------------------------------------------------------------
INITIAL PURCHASE PAYMENT ....................
MINIMUM SUBSEQUENT PURCHASE PAYMENTS ........ investment program
MINIMUM SYSTEMATIC WITHDRAWAL ............... $100
MORTALITY AND EXPENSE RISK CHARGE ........... .55% Annually
GUARANTEED RATE ............................. 3%
ANNUITY OPTION ..............................
SUBACCOUNTS:
New America Growth Subaccount
International Stock Subaccount
Mid-Cap Growth Subaccount
Equity Income Subaccount
Personal Strategy Balanced Subaccount
Limited-Term Bond Subaccount
Prime Reserve Subaccount
METHOD FOR DEDUCTIONS:
Deductions for any Premium Taxes will be allocated proportionately to the
Owner's Contract Value in the Subaccounts and the Fixed Account.
* The Annuity Payout Date and Annuity Option may be changed by the Owner prior
to the Annuity Payout Date. See "Change of Annuity Payout Date" and "Change
of Annuity Option."
FSB201 A (R9-96) -3- SBL90
--------------------------------------------------------------------------------
DEFINTIONS
--------------------------------------------------------------------------------
ACCOUNT
An Account is one of the Subaccounts or the Fixed Account.
ACCUMULATION UNIT
The Accumulation Unit is a unit of measure. It is used to compute the Separate
Account Contract Value prior to the Annuity Payout Date. It is also used to
compute the Variable Annuity Payments for Annuity Options 5 through 7.
ANNUITANT
The Annuitant is the person named by the Owner on whose life the Annuity
Payments depend for Annuity Options 1 through 4. The Annuitant receives Annuity
Payments under this Contract. Please see "Annuitant" provisions on page 9.
ANNUITY OPTION
An Annuity Option is a set of provisions that form the basis for making Annuity
Payments. The Annuity Option is set prior to the Annuity Payout Date. Please see
"Annuity Options" on pages 18 and 19.
ANNUITY PAYOUT DATE
The Annuity Payout Date is the date on which Annuity Payments are scheduled to
begin. This date may be changed by the Owner. The Annuity Payout date is shown
on page 3. Please see "Annuity Payout Date" on page 15.
ANNUITY UNIT
The Annuity Unit is a unit of measure used to compute Variable Annuity Payments
for Annuity Options 1 through 4.
AUTOMATIC EXCHANGES
Automatic Exchanges are Exchanges among the Subaccounts and the Fixed Account.
Such exchanges are made automatically on a periodic basis by the Company at the
written request of the Owner.
COMPANY
The Company is First Security Benefit Life Insurance and Annuity Company of New
York.
CONTRACT ANNIVERSARY
A Contract Anniversary is a 12-month anniversary of the Contract Date.
CONTRACT DATE
The Contract Date is the date the Contract begins. The Contract Date is shown on
page 3.
CONTRACT YEAR
Contract Years are measured from the Contract Date.
CURRENT INTEREST
The Company may in its discretion pay Current Interest on the Fixed Account at a
rate that exceeds the Guaranteed Rate shown on page 3. The Company will declare
the rate of Current Interest, if any, from time to time.
DESIGNATED BENEFICIARY
Upon the death of the Owner or Joint Owner, the Designated Beneficiary will be
the first person on the following list who is alive on the date of death:
1. Owner;
2. Joint Owner;
3. Primary Beneficiary;
4. Secondary Beneficiary;
5. Annuitant; and
6. the Owner's estate if no one listed above is alive.
FSB201 B (4-94) -4- 00-00000-00
--------------------------------------------------------------------------------
DEFINITIONS (Continued)
--------------------------------------------------------------------------------
DESIGNATED BENEFICIARY (Cont'd)
The Designated Beneficiary receives a death benefit upon the death of the Owner.
Please see "Ownership, Annuitant, and Beneficiary Provisions" on page 9 and
"Death Benefit Provisions" on pages 14 and 15.
FIXED ACCOUNT
The Fixed Account is part of the Company's general account. The Company manages
the general account and guarantees that it will credit interest on Fixed Account
Contract Value at an annual rate at least equal to the Guaranteed Rate. This
Rate is shown on page 3.
GUARANTEE PERIOD
Current Interest, if declared, is fixed for rolling periods of one year,
referred to as Guarantee Periods. The Guarantee Period that applies to any Fixed
Account Contract Value: (1) starts on the date that such Contract Value is
allocated to the Fixed Account pursuant to: (a) a Purchase Payment Received by
the Company; or (b) an Exchange to the Fixed Account; and (2) ends on the last
day of the same month in the year in which the Guarantee Period expires. When
any Guarantee Period expires, a new Guarantee Period shall start for such
Contract Value on the date that follows such expiration date. Such period shall
end on the immediately preceding date in the year in which the Guarantee Period
expires. For example, Contract Value exchanged to the Fixed Account on June 1
would have a Guarantee Period starting on that date and ending on June 30 of the
following year. A new Guarantee Period for such Contract Value would start on
July 1 of that year and end on June 30 of the following year.
HOME OFFICE
The address of the Company's Home Office is First Security Benefit Life
Insurance and Annuity Company of New York, 00 Xxxx Xxx Xxx Xxxx, 0xx Xxxxx,
Xxxxx Xxxxxx, Xxx Xxxx 00000.
ISSUE DATE
The Issue Date is the date the Company uses to determine the date the Contract
becomes incontestable. The Issue Date is shown on page 3. Please see
"Incontestability" on page 7.
JOINT OWNER
The Joint Owner, if any, shares an undivided interest in the entire Contract
with the Owner. The Joint Owner, if any, is named on page 3. Please see "Joint
Ownership" provisions on page 9.
NONNATURAL PERSON
Any group or entity that is not a living person, such as a trust or corporation.
OWNER
The Owner is the person who has all rights under the Contract. The Owner is
named on page 3. Please see "Ownership" provisions on page 9.
PREMIUM TAX
Any Premium Taxes levied by a state or other governmental entity will be charged
against this Contract. When Premium Tax is assessed after the Purchase Payment
is applied, it will be deducted as described on page 3.
PURCHASE PAYMENT
A Purchase Payment is money Received by the Company and applied to the Contract.
RECEIVED BY THE COMPANY
The phrase "Received by the Company" means receipt by the Company in good order
at its Home Office at the address indicated above or such other address
designated in writing by the Company.
00-00000-00
-5- BP 2010A1
--------------------------------------------------------------------------------
DEFINITIONS (Continued)
--------------------------------------------------------------------------------
SEPARATE ACCOUNT
The X. Xxxx Price Variable Annuity Account of First Security Benefit Life
Insurance and Annuity Company of New York is a Separate Account established and
maintained by the Company under New York law. The Separate Account is registered
with the Securities and Exchange Commission under the Investment Company Act of
1940 as Unit Investment Trust. It was established by the Company to support
variable annuity contracts. The Company owns the assets of the Separate Account
and maintains them apart from the assets of its general account and its other
separate accounts. The assets held in the Separate Account equal to the reserves
and other Contract liabilities with respect to the Separate Account shall not be
chargeable with liabilities arising out of any other business of the Company.
Income and realized and unrealized gains and losses from assets in the Separate
Account are credited to, or charged against, the Separate Account without regard
to the income, gains or losses from the Company's general account or its other
separate accounts. The Separate Account is divided into Subaccounts shown on
page 3. Income and realized and unrealized gains and losses from assets in each
Subaccount are credited to, or charged against, the Subaccount without regard to
income, gains or losses in the other Subaccounts. The Company has the right to
transfer to its general account any assets of the Separate Account that are in
excess of the reserves and other Contract liabilities with respect to the
Separate Account. The value of the assets in the Separate Account on each
Valuation Date is determined at the end of each Valuation Date.
SUBACCOUNT NET ASSET VALUE
The Subaccount Net Asset Value is equal to: (1) the net asset value of all
shares of the underlying mutual fund held by the Subaccount; plus (2) any cash
or other assets; less (3) all liabilities of the Subaccount.
SUBACCOUNTS
The Separate Account is divided into Subaccounts which invest in shares of
open-end management investment companies, commonly known as mutual funds. Each
Subaccount may invest its assets in a separate class or series of a designated
mutual fund or funds. The Subaccounts are shown on page 3. Subject to the
regulatory requirements then in force, the Company reserves the right to:
1. change or add designated mutual funds or other investment vehicles;
2. add, remove or combine Subaccounts;
3. add, delete or make substitutions for securities that are held or
purchased by the Separate Account or any Subaccount;
4. operate the Separate Account as a management investment company;
5. combine the assets of the Separate Account with other Separate Accounts
of the Company or an affiliate thereof;
6. restrict or eliminate any voting rights of the Owner with respect to the
Separate Account or other persons who have voting rights as to the
Separate Account; and
7. terminate and liquidate any Subaccount.
If any of these changes result in a material change to the Separate Account or a
Subaccount, the Company will notify the Owner of the change. The Company will
not change the investment policy of any Subaccount in any material respect
without complying with the filing and other procedures of the insurance
regulators of the state of issue.
VALUATION DATE
A Valuation Date is each day the New York Stock Exchange and the Company are
open for business.
VALUATION PERIOD
A Valuation Period is the interval of time from one Valuation Date to the next
Valuation Date.
FSB201 C (4-94)U 00-00000-00
-6- BP 201011
--------------------------------------------------------------------------------
GENERAL PROVISIONS
--------------------------------------------------------------------------------
THE CONTRACT
The entire Contract between the Owner and the Company consists of this Contract,
the attached Application, and any Amendments, Endorsements or Riders to the
Contract. All statements made in the Application will, as ruled by a court of
competent jurisdiction, be deemed representations and not warranties. The
Company will use no statement made by or on behalf of the Owner or the Annuitant
to void this Contract unless it is in the written Application. Any change in the
Contract can be made only with the written consent of the President, a Vice
President, or the Secretary of the Company.
The Purchase Payment(s) and the Application must be acceptable to the Company
under its rules and practices. If they are not, the Company's liability shall be
limited to a return of the Purchase Payment(s).
COMPLIANCE
The Company reserves the right to make any change to the provisions of this
Contract to comply with or give the Owner the benefit of any federal or state
statute, rule or regulation. This includes, but is not limited to, requirements
for annuity contracts under the Internal Revenue Code or the laws of any state.
The Company will provide the Owner with a copy of any such change and will
obtain approval for such a change with the insurance regulatory officials of the
state in which the Contract is delivered.
MISSTATEMENT OF AGE
If the age of the Annuitant has been misstated, payments shall be adjusted, when
allowed by law, to the amount which would have been provided for the correct
age. Proof of the age of an Annuitant may be required at any time, in a form
suitable to the Company. If payments have already commenced and the misstatement
has caused an underpayment, the full amount due with interest at a rate of 3%
will be paid with the next scheduled payment. If the misstatement has caused an
overpayment, the amount due with interest at the rate of 3% will be deducted
from one or more future payments.
EVIDENCE OF SURVIVAL
When any payments under this Contract depend on the payee being alive on a given
date, proof that the payee is living may be required by the Company. Such proof
must be in a form accepted by the Company, and may be required prior to making
the payments.
INCONTESTABILITY
This Contract will not be contested after it has been in force for two years
from the Issue Date during the life of the Owner.
ASSIGNMENT
Please refer to page 3 to see if this Contract may be assigned. If it may be
assigned, no Assignment under this Contract is binding unless Received by the
Company in writing. The Company assumes no responsibility for the validity,
legality, or tax status of any Assignment. The Assignment will be subject to any
payment made or other action taken by the Company before the Assignment is
Received by the Company. Once filed, the rights of the Owner, Annuitant and
Beneficiary are subject to the Assignment. Any claim is subject to proof of
interest of the assignee.
00-00000-00
-7- BP 201011
--------------------------------------------------------------------------------
GENERAL PROVISIONS (Continued)
--------------------------------------------------------------------------------
EXCHANGES
The Owner may Exchange Contract Value among the Fixed Account and Subaccounts
subject to the following.
Exchanges are not allowed within 30 days of the Annuity Payout Date. After the
Annuity Payout Date, for Annuity Options 1 through 4, the Owner may Exchange
Contract Value only among Subaccounts. The Company reserves the right to: (1)
prohibit exchanges that would reduce an account to less than $500; (2) limit the
number of Exchanges allowed each Contract Year to six; and (3) subject to New
York Insurance Department approval, waive the limit on Exchanges allowed each
Contract Year. Exchanges must be at least $500 or, if less, the remaining
balance in the Fixed Account or a Subaccount.
Contract Value may be exchanged from the Fixed Account only: (1) during the
calendar month in which the applicable Guarantee Period expires; and (2)
pursuant to an Automatic Exchange. Exchanges of Fixed Account Value will be
made: (1) first from Fixed Account Contract Value for which the Guarantee Period
expires during the calendar month in which the Exchange is effected; (2) then in
the order that starts with Fixed Account Contract Value which has the longest
amount of time before its Guarantee Period expires; and (3) ends with that which
has the least amount of time before its Guarantee Period expires.
The Company will effect an Exchange to or from a Subaccount on the basis of
Accumulation Unit Value (or, when appropriate, Annuity Unit Value) determined at
the end of the Valuation Period in which the Exchange is effected. The Company
will effect an Exchange from the Fixed Account on the basis of Fixed Account
Contract Value at the end of the Valuation Period in which the Exchange is
effected.
The Company reserves the right to delay Exchanges from the Fixed Account for up
to 6 months. The Company will inform you if there will be a delay.
CLAIMS OF CREDITORS
The Contract Value and other benefits under this Contract are exempt from the
claims of creditors of the Owner to the extent allowed by law.
NONFORFEITURE VALUES
The Death Benefits, Withdrawal Values and Annuity Payout Values will at least
equal the minimum required by law.
NON-PARTICIPATING
This Contract is not participating and will pay no dividend.
STATEMENTS
At least once each Contract Year the Owner will be sent a statement including
the current Contract Value and any other information required by law. The Owner
may send a written request for a statement at other intervals. The Company may
charge a reasonable fee for such statements.
FSB201 D(R9-96) -8- BP 2010N1
--------------------------------------------------------------------------------
OWNERSHIP, ANNUITANT AND BENEFICIARY PROVISIONS
--------------------------------------------------------------------------------
OWNERSHIP
During the Owner's lifetime, all rights and privileges under the Contract may be
exercised only by the Owner. If the purchaser names someone other than himself
or herself as Owner, the purchaser has no rights in the Contract. No Owner may
be older than age 85 on the Contract Date.
JOINT OWNERSHIP
If a Joint Owner is named in the application, then the Owner and Joint Owner
share an undivided interest in the entire Contract as joint tenants with rights
of survivorship. When an Owner and Joint Owner have been named, the Company will
honor only requests for changes and the exercise of other Ownership rights made
by both the Owner and Joint Owner. When a Joint Owner is named, all references
to "Owner" throughout this Contract should be construed to mean both the Owner
and Joint Owner, except for the final sentence of the "Annuitant" provision
below, the "Statements" provision on page 8 and the "Death Benefit Provisions"
on pages 14 and 15.
ANNUITANT
The Annuitant is named on page 3. The Owner may change the Annuitant prior to
the Annuity Payout Date. The request for this change must be made in writing and
Received by the Company at least 30 days prior to the Annuity Payout Date. No
Annuitant may be named who is more than 85 years old on the Contract Date. When
the Annuitant dies prior to the Annuity Payout Date, the Owner must name a new
Annuitant within 30 days or, if sooner, by the Annuity Payout Date, except where
the Owner is a Nonnatural Person. If a new Annuitant is not named, the Owner
becomes the Annuitant.
PRIMARY AND SECONDARY BENEFICIARIES
The Primary Beneficiary and any Secondary Beneficiary are named on page 3. The
Owner may change any Beneficiary as described in "Ownership and Beneficiary
Changes" below. If the Primary Beneficiary dies prior to the Owner, the
Secondary Beneficiary becomes the Primary Beneficiary. Unless the Owner directs
otherwise, when there are two or more Primary Beneficiaries, they will receive
equal shares.
OWNERSHIP AND BENEFICIARY CHANGES
Subject to the terms of any existing Assignment, the Owner may name a new Owner,
a new Primary Beneficiary or a new Secondary Beneficiary. Any new choice of
Owner, Primary Beneficiary or Secondary Beneficiary will revoke any prior
choice. Any change must be made in writing and recorded at the Home Office. The
change will become effective as of the date the written request is signed,
whether or not the Owner is living at the time the change is recorded. A new
choice of Primary Beneficiary or Secondary Beneficiary will not apply to any
payment made or action taken by the Company prior to the time it was recorded.
The Company may require the Contract be returned so these changes may be made.
-9- BP 2010N1
--------------------------------------------------------------------------------
PURCHASE PAYMENT PROVISIONS
--------------------------------------------------------------------------------
FLEXIBLE PURCHASE PAYMENTS
The Contract becomes in force when the initial Purchase Payment is applied. The
Owner is not required to continue Purchase Payments in the amount or frequency
originally planned. The Owner may: (1) increase or decrease the amount of
Purchase Payments; or (2) change the frequency of Purchase Payments. A change in
frequency or amount of Purchase Payments does not require a written request.
PURCHASE PAYMENT LIMITATIONS
Total Purchase Payments to the Contract may not be greater than $1,000,000
without prior approval by the Company. The Minimum Subsequent Purchase Payment
amount is shown on page 3.
PURCHASE PAYMENT ALLOCATION
Purchase Payments may be allocated among the Fixed Account and the Subaccounts.
The allocations may be a whole dollar amount or whole percentage. However, no
less than $25 per Purchase Payment may be allocated to any Account. The Owner
may change the allocations by written notice to the Company.
PLACE OF PAYMENT
All Purchase Payments under this Contract are to be paid to the Company.
Purchase Payments after the first Purchase Payment are applied as of the end of
the Valuation Period during which they are Received by the Company.
--------------------------------------------------------------------------------
CONTRACT VALUE AND EXPENSE PROVISIONS
--------------------------------------------------------------------------------
CONTRACT VALUE
On any Valuation Date, the Contract Value is the sum of: (1) the Separate
Account Contract Value; and (2) the Fixed Account Contract Value. At any time
after the first Contract Year and before the Annuity Payout Date, the Company
reserves the right to pay to the Owner the Contract Value as a lump sum if it is
below $2,000 and no Purchase Payments have been paid for three years.
FIXED ACCOUNT CONTRACT VALUE
On any Valuation Date, the Fixed Account Contract Value is equal to the first
Purchase Payment allocated under the Contract to the Fixed Account:
PLUS:
1. any other Purchase Payments allocated under the Contract to the Fixed
Account;
2. any Exchanges from the Separate Account to the Fixed Account; and
3. any interest credited to the Fixed Account.
LESS:
1. any Withdrawals deducted from the Fixed Account;
2. any Exchanges from the Fixed Account to the Separate Account;
3. any applicable Premium Taxes;
4. any Fixed Account Contract Value which is applied to any of Annuity
Options 1 through 4; and
5. any Annuity Payments made under Annuity Options 5 and 7.
00-00000-00
FSB201 E (4-94) -10- BP 2010D1
--------------------------------------------------------------------------------
CONTRACT VALUE AND EXPENSE PROVISIONS (Continued)
--------------------------------------------------------------------------------
FIXED ACCOUNT INTEREST CREDITING
The Company will credit interest on Fixed Account Contract Value at an annual
rate at least equal to the Guaranteed Rate shown on page 3. Also, the Company
may in its sole judgment credit Current Interest at a rate in excess of the
Guaranteed Rate. The rate of Current Interest, if declared, will be fixed during
the Guarantee Period. Fixed Account Contract Value will earn Current Interest
during each Guarantee Period at the rate, if any, declared by the Company on the
first day of the Guarantee Period.
The Company may credit Current Interest on Contract Value that was allocated or
exchanged to the Fixed Account during one period at a different rate than
amounts allocated or exchanged to the Fixed Account in another period.
Therefore, at any time, portions of Fixed Account Contract Value may be earning
Current Interest at different rates based upon the period during which such
portions were allocated or exchanged to the Fixed Account.
SEPARATE ACCOUNT CONTRACT VALUE
On any Valuation Date, the Separate Account Contract Value is the sum of the
then current value of the Accumulation Units allocated to each Subaccount for
this Contract.
ACCUMULATION UNIT VALUE
The initial Accumulation Unit Value for each Subaccount was set at $10. Other
Accumulation Unit Values are found on each Valuation Date by dividing (1) by (2)
where:
1. is equal to:
a. the Subaccount Net Asset Value determined at the end of the current
Valuation Period; plus
b. any dividends declared by the Subaccount's underlying mutual fund that
are not part of the Subaccount Net Asset Value; less
c. the accrued Mortality and Expense Risk Charge; and
d. any taxes for which the Company has reserved which the Company deems to
have resulted from the operation of the Subaccount.
2. is the number of Accumulation Units at the start of the Valuation Period.
The Accumulation Unit Value may increase or decrease from one Valuation Period
to the next.
DETERMINING ACCUMULATION UNITS
The number of Accumulation Units allocated to a Subaccount under this Contract
is found by dividing: (1) the amount allocated to a Subaccount; by (2) the
Accumulation Unit Value for the Subaccount at the end of the Valuation Period
during which the amount is applied under the Contract. The number of
Accumulation Units allocated to a Subaccount under the Contract will not change
as a result of investment experience. Events that change the number of
Accumulation Units are:
1. Purchase Payments that are applied to the Subaccount;
2. Contract Value that is Exchanged into or out of the Subaccount
3. Withdrawals that are deducted from the Subaccount; and
4. Premium Taxes that are deducted from the Subaccount.
00-00000-00
-11- BP 2010D1
--------------------------------------------------------------------------------
CONTRACT VALUE AND EXPENSE PROVISIONS (Continued)
--------------------------------------------------------------------------------
MORTALITY AND EXPENSE RISK CHARGE
The Company will deduct the Mortality and Expense Risk Charge shown on page 3.
This charge will be computed and deducted from each Subaccount on each Valuation
Date. This charge is factored into the Accumulation Unit and Annuity Unit Value
on each Valuation Date.
PREMIUM TAX EXPENSE
The Company reserves the right to deduct Premium Tax when due or any time
thereafter. Any applicable Premium Taxes will be allocated as described on page
3.
MUTUAL FUND EXPENSES
Each Subaccount invests in shares of a mutual fund. The net asset value per
share of each underlying fund reflects the deduction of any investment advisory
and administration fees and other expenses of the fund. These fees and expenses
are not deducted from the assets of a Subaccount, but are paid by the underlying
funds. The Owner indirectly bears a pro rata share of such fees and expenses. An
underlying fund's fees and expenses are not specified or fixed under the terms
of this Contract.
--------------------------------------------------------------------------------
WITHDRAWAL PROVISIONS
--------------------------------------------------------------------------------
WITHDRAWALS
A full Withdrawal of the Contract Value or partial Withdrawal of Separate
Account Contract Value is allowed at any time. Partial Withdrawals of Fixed
Account Contract Value are, however, restricted as described below.
This provision is subject to any federal or state Withdrawal restrictions.
A partial Withdrawal of Fixed Account Contract Value may be made only: (1)
pursuant to Systematic Withdrawals; (2) during the calendar month in which the
applicable Guarantee Period expires; and (3) once per Contract Year in an amount
up to the greater of $5,000 or 10 percent of the Fixed Account Contract Value at
the time of the partial Withdrawal.
Upon the Owner's request for a full Withdrawal, the Company will pay the
Withdrawal Value in a lump sum.
All Withdrawals must meet the following conditions.
1. The request for Withdrawal must be Received by the Company in writing or
under other methods allowed by the Company.
2. The Owner must apply: (a) while this Contract is in force; and (b) prior
to the Annuity Payout Date.
3. The amount Withdrawn must be at least $500.00 except for Systematic
Withdrawals, as discussed below, or when terminating the Contract.
A partial Withdrawal request must state the allocations for deducting the
Withdrawal from each Account. If the Owner does not specify the allocation, the
Company will contact the Owner for instructions. The Withdrawal will be effected
as of the end of the Valuation Period in which such instructions are Received by
the Company. Withdrawals of Fixed Account Contract Value will be made: (1) first
from Fixed Account Contract Value for which the Guarantee Period expires during
the calendar month in which the Withdrawal is effected; (2) then in the order
that starts with Fixed Account Contract Value which has the longest amount of
time before its Guarantee Period expires; and (3) ends with that which has the
least amount of time before its Guarantee Period expires.
00-00000-00
FSB201 F (4-94) -12- BP 2010E1
--------------------------------------------------------------------------------
WITHDRAWAL PROVISIONS (Continued)
--------------------------------------------------------------------------------
WITHDRAWAL VALUE
The Withdrawal Value at any time will be: (1) the Contract Value; less (2) any
Premium Taxes due or paid by the Company.
SYSTEMATIC WITHDRAWALS
Systematic Withdrawals are automatic periodic distributions from the Contract in
substantially equal amounts prior to the Annuity Payout Date. In order to start
Systematic Withdrawals, the Owner must make the request in writing. The Minimum
Systematic Withdrawal is shown on page 3. The Owner must choose the type of
payment, and its frequency. The payment type may be: (1) a percentage of
Contract Value; (2) a specified dollar amount; (3) all earnings in the Contract;
or (4) based upon the life expectancy of the Owner or the Owner and a
Beneficiary. The payment frequency may be: (1) monthly; (2) quarterly; (3)
semiannually; or (4) annually. Systematic Withdrawals of Fixed Account Contract
Value must provide for payments over a period of not less than 36 months.
Systematic Withdrawals may be stopped by the Owner upon proper written request
Received by the Company at least 30 days in advance. The Company reserves the
right to stop, modify or suspend Systematic Withdrawals.
Withdrawals, including systematic withdrawals, may: (1) subject the Owner to a
penalty tax if taken before age 59 1/2; and (2) may be restricted or limited if
made from an Individual Retirement Annuity qualified under Internal Revenue Code
(IRC) Section 408 or a Tax Sheltered Annuity qualified under IRC Section 403(b).
DATE OF REQUEST
The Company will effect a Withdrawal of Separate Account Contract Value on the
basis of Accumulation Unit Value determined at the end of the Valuation Period
in which all the required information is Received by the Company.
PAYMENT OF WITHDRAWAL BENEFITS
The Company reserves the right to suspend an Exchange or delay payment of a
Withdrawal from the Separate Account for any period:
1. when the New York Stock Exchange is closed; or
2. when trading on the New York Stock Exchange is restricted; or
3. when an emergency exists as a result of which: (a) disposal of securities
held in the Separate Account is not reasonably practicable; or (b) it is
not reasonably practicable to fairly value the net assets of the Separate
Account.
Rules and regulations of the Securities and Exchange Commission will govern as
to whether the conditions set forth above exist.
The Company further reserves the right to delay payment of a Withdrawal from the
Fixed Account for up to six months as required by most states. The Company will
notify you if there will be a delay.
00-00000-00
-13- BP 2010E1
--------------------------------------------------------------------------------
DEATH BENEFIT PROVISIONS
--------------------------------------------------------------------------------
DEATH BENEFIT
If any Owner dies prior to the Annuity Payout Date, a Death Benefit will be paid
to the Designated Beneficiary when due Proof of Death and instructions regarding
payment are Received by the Company. If an Owner is a Nonnatural Person, then
the Death Benefit will be paid in the event of the death of the Annuitant or any
Joint Owner that is a natural person prior to the Annuity Payout Date. Further,
if an Owner is a Nonnatural Person, the amount of the death benefit is based on
the age of the Annuitant or any joint Owner that is a natural person on the
Issue Date.
If the age of each Owner was 75 or younger on the Issue Date, the Death Benefit
will be the greatest of: (1) the sum of all Purchase Payments, less any Premium
Taxes due or paid by the Company and less the sum of all partial Withdrawals;
(2) the Contract Value on the date due Proof of Death and instructions regarding
payment are Received by the Company, less any Premium Taxes due or paid by the
Company; or (3) the Stepped-Up Death Benefit below.
The Stepped-Up Death Benefit is:
1. the largest Death Benefit on any Contract Anniversary that is both an
exact multiple of five and occurs prior to the oldest Owner reaching age
76; plus
2. any Purchase Payments received since the applicable fifth Contract
Anniversary; less
3. any reductions caused by Withdrawals since the applicable fifth Contract
Anniversary; less
4. any Premium Taxes due or paid by the Company.
If the age of any Owner on the Issue Date was 76 or older, the Death Benefit
will be: (1) the Contract Value on the date due Proof of Death and instructions
regarding payment are Received by the Company; less (2) any Premium Taxes due or
paid by the Company.
If a lump sum payment is requested, the payment will be made in accordance with
any laws and regulations that govern the payment of Death Benefits.
The value of the Death Benefit is determined as of the date that both Proof of
Death and instructions regarding payment are Received by the Company in good
order.
PROOF OF DEATH
Any of the following will serve as Proof of Death:
1. certified copy of the death certificate;
2. certified decree of a court of competent jurisdiction as to the finding
of death;
3. written statement by a medical doctor who attended the deceased Owner; or
4. any proof accepted by the Company.
DISTRIBUTION RULES
The entire Death Benefit with any interest shall be paid within 5 years after
the death of any Owner, except as provided below. In the event that the
Designated Beneficiary elects an Annuity Option, the length of time for the
payment period may be longer than 5 years if: (1) the Designated Beneficiary is
a natural person; (2) the Death Benefit is paid out under Annuity Options 1
through 7; (3) payments are made over a period that does not exceed the life or
life expectancy of the Designated Beneficiary; and (4) Annuity Payments begin
within one year of the death of the Owner. If the deceased Owner's spouse is the
sole Designated Beneficiary, the spouse shall become the sole Owner of the
Contract. He or she may elect to: (1) keep the Contract in force until the
sooner of the spouse's death or the Annuity Payout Date; or (2) receive the
Death Benefit.
FSB201 G (R9-96) -14- BP 2010O1
--------------------------------------------------------------------------------
DEATH BENEFIT PROVISIONS (Continued)
--------------------------------------------------------------------------------
DISTRIBUTION RULES (cont'd)
If any Owner dies after the Annuity Payout Date, Annuity Payments will continue
to be paid at least as rapidly as under the method of payment being used as of
the date of the Owner's death.
If the Owner is a Nonnatural Person, the distribution rules set forth above
apply in the event of the death of, or a change in, the Annuitant. This Contract
is deemed to incorporate any provision of Section 72(s) of the Internal Revenue
Code of 1986, as amended (the "Code"), or any successor provision. This Contract
is also deemed to incorporate any other provision of the code deemed necessary
by the Company, in its sole judgment, to qualify this Contract as an annuity.
The application of the distribution rules will be made in accordance with Code
section 72(s), or any successor provision, as interpreted by the Company in its
sole judgment.
The foregoing distribution rules do not apply to a Contract which is: (1)
provided under a plan described in Code section 401(a); (2) described in Code
section 403(b); (3) an individual retirement annuity or provided under an
individual retirement account or annuity; or (4) otherwise exempt from the Code
section 72(s) distribution rules.
--------------------------------------------------------------------------------
ANNUITY PAYMENT PROVISIONS
--------------------------------------------------------------------------------
ANNUITY PAYOUT DATE
The Owner may choose the Annuity Payout Date at the time of application. If no
Annuity Payout Date is chosen, the Company will use the later of: (1) the oldest
Annuitant's seventieth birthday; or (2) the fifth Contract Anniversary. The
Annuity Payout Date must be prior to the oldest Annuitant's ninetieth birthday.
The Annuity Payout Date is the date the first payment will be made to the
Annuitant under any of the Annuity Options.
CHANGE OF ANNUITY PAYOUT DATE
The Owner may change the Annuity Payout Date. A request for the change must be
made in writing. The written request must be Received by the Company at least 30
days prior to the new Annuity Payout Date as well as 30 days prior to the
previous Annuity Payout Date.
ANNUITY PAYOUT AMOUNT
The Annuity Payout Amount is applied to one of the Annuity Options listed on
pages 18 and 19. The Annuity Start Amount is: (1) the Contract Value on the
Annuity Payout Date; less (2) any Premium Taxes due or paid by the Company.
Unless otherwise directed by the Owner, Annuity Payout Amount derived from Fixed
Account Contract Value will be applied to purchase a Fixed Annuity Option; that
derived from Separate Account Contract Value will be applied to purchase a
Variable Annuity Option.
-15- BP 2010O1
--------------------------------------------------------------------------------
ANNUITY PAYMENT PROVISIONS (Continued)
--------------------------------------------------------------------------------
ANNUITY TABLES
The Annuity Tables show the guaranteed minimum amount of monthly Annuity Payment
that applies to the first payment for Variable Annuity Payments and to each
payment for Fixed Annuity Payments for each $1,000 of Annuity Payout Amount for
each of Annuity Options 1 through 4. The amount of each Annuity Payment for
Annuity Options 1 through 4 will depend on the Annuitant's age on the Annuity
Payout Date. The Annuity Tables state values for the exact ages shown. The
values will be interpolated based on the Annuitant's exact age on the Annuity
Payout Date. On request the Company will furnish the amount of monthly Annuity
Payment per $1,000 applied for any ages not shown.
The Company bases the Tables for Annuity Options 1 through 4 on: (1) the 1983
Table "A" Mortality Table projected for mortality improvement for 45 years using
Projection Scale G; and (2) an interest rate of 3 1/2% a year.
For Annuity Options 5 through 7, age is not considered. Annuity Payments for
these options are computed without reference to the Annuity Tables.
ANNUITY PAYMENTS
The Annuity Option is shown on page 3. The Owner may choose any form of Annuity
Option that is allowed by the Company. The Owner may choose an Annuity Option by
written request. This request must be Received by the Company at least 30 days
prior to the Annuity Payout Date. Several Annuity Options are listed on pages 18
and 19. No Annuity Option can be selected that requires the Company to make
periodic payments of less than $20.00. If no Annuity Option is chosen prior to
the Annuity Payout Date, the Company will use the Life with 10-Year Fixed Period
Option. Each Annuity Option allows for making Annuity Payments annually,
semiannually, quarterly or monthly.
CHANGE OF ANNUITY OPTION
Prior to the Annuity Payout Date, the Owner may change the Annuity Option
chosen. The Owner must request the change in writing. This request must be
Received by the Company at least 30 days prior to the Annuity Payout Date.
FIXED ANNUITY PAYMENTS
With respect to Fixed Annuity Payments, the amounts shown on the Tables are the
guaranteed minimum for each Annuity Payment for Annuity Options 1 through 4.
VARIABLE ANNUITY PAYMENTS
With respect to Fixed Annuity Payments, the amounts shown on the Tables are the
first Annuity Payment, based on the assumed interest rate of 3 1/2% for Annuity
Options 1 through 4. The amount of each Annuity Payment after the first for
these options is computed by means of Annuity Units. Neither expense actually
incurred (other than tax on investment return), nor mortality actually
experienced, shall adversely affect the dollar amount of annuity income already
commenced.
ANNUITY UNITS
The number of Annuity Units is found by dividing the first Annuity Payment by
the Annuity Unit Value for the selected Subaccount on the Annuity Payout Date.
The number of Annuity Units for the Subaccount then remains constant, unless an
Exchange of Annuity Units is made. After the first Annuity Payment, the dollar
amount of each subsequent Annuity Payment is equal to the number of Annuity
Units times the Annuity Unit Value for the Subaccount on the due date of the
Annuity Payment.
FSB201 H (4-94) 00-00000-00
-16- BP 201OM1
--------------------------------------------------------------------------------
ANNUITY PAYMENT PROVISIONS (Continued)
--------------------------------------------------------------------------------
ANNUITY UNITS (Cont'd)
The Annuity Unit Value for each Subaccount was first set at $1.00. The Annuity
Unit Value for any subsequent Valuation Date is equal to (a) times (b) times
(c), where:
(a) is the Annuity Unit Value on the immediately preceding Valuation Date;
(b) is the Net Investment Factor for the Valuation Date;
(c) is a factor used to adjust for an assumed interest rate of 3 1/2% per
year used to determine the Annuity Payment amounts. The assumed interest
rate is reflected in the Annuity Tables.
NET INVESTMENT FACTOR
The Net Investment Factor for any Subaccount at the end of any Valuation Period
is found by dividing (1) by (2) and subtracting (3) from the result, where:
1. is equal to:
a. the net asset value per share of the mutual fund held in the
Subaccount, found at the end of the current Valuation Period; plus
b. the per share amount of any dividend or capital gain distributions
paid by the Subaccount's underlying mutual fund that is not included
in the net asset value per share; plus or minus
c. a per share charge or credit for any taxes reserved for, which the
Company deems to have resulted from the operation of the Subaccount.
2. is the net asset value per share of the Subaccount's underlying mutual
fund as found at the end of the prior Valuation Period.
3. is a factor representing the Mortality and Expense Risk Charge deducted
from the Separate Account.
Underlying mutual funds may declare dividends on a daily basis and pay such
dividends once a month. The Net Investment Factor allows for the monthly
reinvestment of these daily dividends. As described above, the gains and losses
from each Subaccount are credited or charged against the Subaccount without
regard to the gains or losses in the Company or other Subaccounts.
ALTERNATE ANNUITY OPTION RATES
The Company may, at the time of election of an Annuity Option, offer more
favorable rates in lieu of the guaranteed rates shown in the Annuity Tables.
00-00000-00
-17- BP 2010M1
--------------------------------------------------------------------------------
ANNUITY PAYMENT PROVISIONS (Continued)
--------------------------------------------------------------------------------
ANNUITY OPTIONS
OPTION 1
LIFE OPTION: This option provides payments for the life of the Annuitant. Table
A shows some of the guaranteed rates for this option.
OPTION 2
LIFE WITH FIXED PERIOD OPTION: This option provides payments for the life of the
Annuitant. A fixed period of 5, 10, 15 or 20 years may be chosen. Payments will
be made to the end of this period even if the Annuitant dies prior to the end of
the period. If the Annuitant dies before receiving all the payments during the
fixed period, the remaining payments will be made to the Designated Beneficiary.
Table A shows some of the guaranteed rates for this option.
OPTION 3
LIFE WITH INSTALLMENT OR UNIT REFUND OPTION: This option provides payment for
the life of the Annuitant, with a period certain determined by dividing the
Annuity Payout Amount by the amount of the first payment. A fixed number of
payments will be made even if the Annuitant dies. If the Annuitant dies before
receiving the fixed number of payments, any remaining payments will be made to
the Designated Beneficiary. Table A shows some of the guaranteed rates for this
option.
OPTION 4
JOINT AND LAST SURVIVOR OPTION: This option provides payments for the life of
the Annuitant and Joint Annuitant. Payments will be made as long as either is
living. Table B shows some of the guaranteed rates for this option.
OPTION 5
FIXED PERIOD OPTIONS: This option provides payments for a fixed number of years
between 5 and 20. If the Contract Value is held in the Fixed Account, then the
amount of the payments will vary as a result of the interest rate (as adjusted
periodically) credit on the Fixed Account. This rate is guaranteed to be no less
than the Guaranteed Rate shown on page 3. If the Contract Value is held in the
Separate Account, then the amount of the payments will vary as a result of the
investment performance of the Subaccounts chosen. If all the Annuitants die
before receiving the fixed number of payments, any remaining payments will be
made to the Designated Beneficiary.
OPTION 6
FIXED PAYMENT OPTION: This option provides a fixed payment amount. This amount
is paid until the amount applied, including daily interest adjustments, is paid.
If the Contract Value is held in the Fixed Account, then the number of payments
will vary as a result of the interest rate (as adjusted periodically) credited
on the Fixed Account. This rate is guaranteed to be no less than the Guaranteed
Rate shown on page 3. If the Contract Value is held in the Separate Account,
then the number of payments will vary as a result of the investment performance
of the Subaccounts chosen. If all the Annuitants die before receiving all the
payments, any remaining payments will be made to the Designated Beneficiary.
00-00000-00
FSB 201 1 (4-94) -18- BP 201041
--------------------------------------------------------------------------------
ANNUITY PAYMENT PROVISIONS (Continued)
--------------------------------------------------------------------------------
ANNUITY OPTIONS (cont'd)
OPTION 7
AGE RECALCULATION OPTION: This option provides payments based upon the
Annuitant's life expectancy, or the joint life expectancies of the Annuitant and
a beneficiary, at the Annuitant's attained age (and the Annuitant's
beneficiary's attained or adjusted age, if applicable) each year. The payments
are computed by reference to actuarial tables prescribed by the Treasury
Secretary. Payments are made until the amount applied is exhausted. If the
Contract Value is held in the Fixed Account, then the number of payments will
vary as a result of the interest rate (as adjusted periodically) credited on the
Fixed Account. This rate is guaranteed to be not less than the Guaranteed Rate
shown on page 3. If the Contract Value is held in the Separate Account, then the
number of payments will vary as a result of the investment performance of the
Subaccounts chosen. If all the Annuitants die before receiving the remaining
payments, such payments will be made to the Designated Beneficiary.
00-00000-00
-19- BP 2010H1
ANNUITY TABLES
--------------------------------------------------------------------------------
TABLE A
GUARANTEED MINIMUM AMOUNT
OF MONTHLY PAYMENT FOR
EACH $1,000 APPLIED
SINGLE LIFE ANNUITY
--------------------------------------------------------------------------------
AGE MONTHLY PAYMENTS CERTAIN INSTALLMENT
OF PAYEE 0 60 120 180 240 REFUND
--------------------------------------------------------------------------------
UNISEX
55 4.11 4.11 4.10 4.08 4.05 4.05
56 4.17 4.17 4.16 4.14 4.10 4.10
57 4.23 4.23 4.22 4.19 4.15 4.15
58 4.30 4.29 4.28 4.25 4.21 4.21
59 4.37 4.36 4.35 4.32 4.27 4.27
60 4.44 4.44 4.42 4.38 4.33 4.34
61 4.52 4.51 4.49 4.45 4.39 4.40
62 4.60 4.59 4.57 4.52 4.45 4.47
63 4.69 4.68 4.65 4.60 4.52 4.55
64 4.78 4.77 4.74 4.68 4.58 4.63
65 4.88 4.87 4.84 4.76 4.65 4.71
66 4.99 4.98 4.93 4.85 4.72 4.80
67 5.10 5.09 5.04 4.94 4.79 4.89
68 5.23 5.21 5.15 5.04 4.86 4.99
69 5.36 5.34 5.27 5.14 4.94 5.09
70 5.50 5.48 5.39 5.24 5.01 5.20
Rates not shown will be provided upon request. The guaranteed minimum monthly
payments shown apply to the initial payment for Variable Annuity Payments and to
each payment for Fixed Annuity Payments.
--------------------------------------------------------------------------------
JOINT & LAST AGE
SURVIVOR ANNUITY
TABLE B - MONTHLY
INSTALLMENTS AGE 55 60 62 65 70
--------------------------------------------------------------------------------
Until last Death 55 3.77 3.87 3.90 3.95 4.00
of Two Payees 60 3.87 4.01 4.06 4.13 4.24
per $1,000 of 62 3.90 4.06 4.12 4.21 4.34
benefit amount 65 3.95 4.13 4.21 4.32 4.49
70 4.00 4.24 4.34 4.49 4.75
Annual, semiannual, or quarterly payments can be determined from Table A or B by
multiplying the monthly payments by 11.812854, 5.9572233, and 2.9914201,
respectively.
00-00000-00
FSB201 J (4-94)U -20- BP 2010L
A BRIEF DESCRIPTION OF THIS CONTRACT
This is a FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT.
*Purchase Payments may be made until the earlier of the Annuity Payout Date or
termination of the Contract.
*A Death Benefit may be paid prior to the Annuity Payout Date according to the
Contract provisions.
*Annuity Payments begin on the Annuity Payout Date using the method as
specified in this Contract.
*The smallest annual rate of investment return that would have to be earned on
the assets of the Separate Account so that the dollar amount of Variable
Annuity Payments will not decrease is 3 1/2%. A daily charge corresponding to
an annual charge of .55% is applied to the assets of the Separate Account by
the Company. Please refer to the "Contract Value and Expense Provisions"
beginning on page 10.
ALL PAYMENTS AND VALUES PROVIDED BY THIS CONTRACT, WHEN BASED ON THE INVESTMENT
EXPERIENCE OF THE SEPARATE ACCOUNT, ARE VARIABLE AND MAY INCREASE OR DECREASE IN
ACCORDANCE WITH THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT. THERE ARE NO
GUARANTEED MINIMUM PAYMENTS OR CASH VALUES. (SEE "CONTRACT VALUE AND EXPENSE
PROVISIONS" AND "ANNUITY PAYMENT PROVISIONS" FOR DETAILS.)
FIRST SECURITY BENEFIT LIFE INSURANCE AND ANNUITY COMPANY OF NEW YORK
00 Xxxx Xxx Xxx Xxxx, 0xx Xxxxx, Xxxxx Xxxxxx, Xxx Xxxx 00000
BP 2010Q4
