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Exhibit 4(a)
PROVIDENT MUTUAL LIFE INSURANCE COMPANY
Berwyn, Pennsylvania
ANNUITANT: XXXX XXX CONTRACT DATE: 01/01/2000
CONTRACT NO.: 0200000000 MATURITY DATE: 01/01/2055
In this Contract, Provident Mutual Life Insurance Company is referred to as
"We," "Us," "Our," or the "Company." "You" and "Your" refer to the Owner of the
Contract.
We agree to pay the benefits as described in this Contract in accordance with
its provisions.
PLEASE READ THIS CONTRACT CAREFULLY
It is a legal contract between You and Us.
NOTICE OF 10-DAY CANCELLATION PERIOD
If for any reason You are not satisfied with this Contract, You may return it to
Us for cancellation by delivering or mailing it to:
1. our Service Center, 000 Xxxxxxxxxxx Xxxxx, Xxxxxx, XX 00000-0000, X.X. Xxx
00000, Xxxxxxxxxx, XX 00000-0000, or
2. the agent through whom it was purchased.
To cancel this Contract, You must return it to Us no later than 10 days after
You first receive it. This Contract will be void as of the date We receive Your
Contract and Your request for cancellation. We will refund Your Contract Account
Value (as of the date the returned Contract is received by Us) minus any Credit
Amounts plus any charges that We have deducted from either premium payments or
Contract Account Value.
Signed for Provident Mutual Life Insurance Company in Berwyn, Pennsylvania.
/s/ X. Xxxxxx /s/ Xxxxxx X. Xxxxx
Designated Officer President
PRIOR TO THE MATURITY DATE, ANNUITY PAYMENTS AND OTHER VALUES PROVIDED BY THIS
CONTRACT INCLUDING ANY DEATH BENEFIT THAT MAY BE PAYABLE, WHEN BASED ON THE
INVESTMENT PERFORMANCE OF THE VARIABLE ACCOUNT, MAY INCREASE OR DECREASE DAILY
AS A FUNCTION OF THE INVESTMENT PERFORMANCE OF SUBACCOUNTS SELECTED BY THE OWNER
AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. NO MINIMUM CONTRACT ACCOUNT VALUE IS
GUARANTEED EXCEPT FOR ANY AMOUNTS IN THE GUARANTEED ACCOUNT. THE AMOUNT OF THE
ANNUITY PAYMENTS UNDER THIS CONTRACT WILL BE DETERMINED ON THE MATURITY DATE AND
WILL NOT CHANGE DURING THE PAYMENT PERIOD.
AN ANNUAL ANNUITY CHARGE WILL BE DEDUCTED FROM THE ASSETS OF THE VARIABLE
ACCOUNT. THIS CHARGE WILL NOT EXCEED AN ANNUAL RATE OF 1.40% OF SUCH ASSETS.
FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT
Flexible premiums as stated in the General Provisions.
Contract Account Values are variable, except for amounts in the
Guaranteed Account.
Non-participating Contract.
FOR INQUIRIES, INFORMATION AND RESOLUTION OF COMPLAINTS CALL: 0-000-000-0000
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CONTRACT SCHEDULE
OWNER: XXXX XXX
ANNUITANT: XXXX XXX
DATE OF BIRTH - SEX: 01/01/1965 - MALE CONTRACT DATE: 01/01/2000
CONTRACT NUMBER: 0200000000 MATURITY DATE: 01/01/2055
INITIAL PREMIUM PAYMENT: $10,000.00
CREDIT AMOUNT PERCENTAGES:
TOTAL PREMIUMS LESS WITHDRAWALS
(INCLUDING SURRENDER CHARGES) PERCENTAGES
From $10,000 to $24,999 1.5%
From $25,000 to $99,999 3.0%
From $100,000 to $499,999 4.0%
From $500,000 to $999,999 4.5%
$1,000,000 and more 5.0%
MINIMUM REQUIREMENTS:
Minimum Withdrawal Amount: $500
Minimum Transfer Amount: $500
Minimum Remaining Amount after Transfer: $500
Minimum Remaining Contract Account Value after Withdrawal: $10,000
Minimum Subsequent Premium Payment: $50
CHARGES AND FEES:
Annual Annuity Charge: 1.40%
Annual Administrative Fee: $30.00
This fee may be waived if the Contract Account Value, on the date
the fee is assessed, is at least $100,000
Transfer Processing Fee: $25.00
This fee is waived on the first twelve transfers in a Contract Year
Premium Tax Charge: 0% (See Section 9: Fees and Charges)
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CONTRACT SCHEDULE
(Continued)
SURRENDER CHARGE:
AGE OF EACH PREMIUM PAYMENT IN
CONTRACT YEARS CHARGE
-------------- ------
1 8.0%
2 8.0%
3 8.0%
4 8.0%
5 8.0%
6 6.5%
7 5.0%
8 3.5%
9 2.0%
10 and over 0.0%
RIDERS:
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SECTION 1: DEFINITIONS
ACCUMULATION UNIT: A unit of measure used to calculate Variable Account Value.
ACT: Investment Company Act of 1940, as amended.
ANNUITANT: The person or persons upon whose life (or lives) the Annuity Payments
payable under the Contract is determined.
ANNUITY DATE: The date as of which Surrender Value is applied to a Payment
Option. The Annuity Date will be the Maturity Date unless the Owner designates a
different date.
ANNUITY PAYMENT: One of several periodic payments made by Us to the Payee under
a Payment Option.
BENEFICIARY: The person(s) to whom the death benefit will be paid on the death
of an Owner or Annuitant. If the Contract has joint Owners, the surviving joint
Owner will be the designated Beneficiary.
CALCULATED CREDIT AMOUNT: The amount calculated on the first three Contract
Anniversaries to determine if an additional Credit Amount will be applied under
the Look-back provision of the Credits Section.
CANCELLATION PERIOD: The period described on the cover page of this Contract
during which the Owner may return the Contract for a refund.
CODE: The Internal Revenue Code of 1986, as amended.
COMPANY, WE, US OR OUR: Provident Mutual Life Insurance Company, a Pennsylvania
corporation.
CONTRACT: This flexible premium deferred variable annuity contract, including
any attached endorsements or riders, and the attached copy of the application.
CONTRACT ANNIVERSARY: The same day and month in each Contract Year as the
Contract Date. Contract Years and Months are measured from the Contract Date
shown in the Contract Schedule.
CONTRACT DATE: The date on which We issue the Contract, shown in the Contract
Schedule, and upon which the Contract becomes effective. The Contract Date is
used to determine Contract Years and Contract Anniversaries.
CONTRACT ACCOUNT VALUE: The total amount invested under the Contract. It is the
sum of Variable Account Value and the Guaranteed Account Value.
CONTRACT YEAR: A twelve-month period beginning on the Contract Date or on a
Contract Anniversary.
CREDIT AMOUNT: An amount calculated in accordance with the percentages shown in
the Contract Schedule as further defined in the Credits Section.
DUE PROOF OF DEATH: Proof of death satisfactory to Us. Due Proof of Death may
consist of the following:
(a) a certified copy of the death record;
(b) a certified copy of a court decree reciting a finding of death; or
(c) any other proof satisfactory to Us.
FREE WITHDRAWAL AMOUNT: During the first Contract Year, an amount equal to 10%
of the premium payments in the first Contract Year. For all other Contract
Years, an amount equal to 10% of the Contract Account Value at the start of that
year.
FUND: Any open-end management investment company or investment portfolio thereof
or any unit investment trust or series thereof, in which a Subaccount invests.
GENERAL ACCOUNT: The assets of the Company other than those allocated to the
Variable Account or any other Separate Account of the Company.
GUARANTEED ACCOUNT: An allocation option available under the Contract as further
defined in the Guaranteed Account Section. Amounts allocated to the Guaranteed
Account are invested in the General Account.
GUARANTEED ACCOUNT VALUE: The total amount in the Guaranteed Account.
HOME OFFICE: Our office at 0000 Xxxxxxxxxxxx Xxxxxxxxx, Xxxxxx, Xxxxxxxxxxxx
00000-0000.
MATURITY DATE: The last date as of which Contract Account Value may be applied
to purchase a Payment Option. It is the Contract Anniversary on or following the
Annuitant's age 90.
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NET ASSET VALUE: The value per share of any Fund on any Valuation Day. The
method of computing the Net Asset Value is described in the prospectus for each
Fund.
NET PREMIUM PAYMENT: Your premium payment less any Premium Tax Charge deducted
from the premium payment.
NOTICE: A notice or request submitted by You in writing or otherwise to Us in a
form satisfactory to Us that is signed by the Owner and received at the Service
Center.
OWNER: The person (or persons) who owns (or own) the Contract and who is (are)
entitled to exercise all rights and privileges provided in the Contract, also
referred to herein as "You" or "Your." The maximum number of joint Owners is
two. Provisions relating to action by the Owner mean, in the case of joint
Owners, both Owners acting jointly under procedures acceptable to Us.
PAYEE: The person entitled to receive Annuity Payments under the Contract. The
Annuitant is the Payee unless the Owner designates a different person as Payee.
PAYMENT OPTION: An elected option resulting in a series of periodic payments
beginning on the Annuity Date as further defined in the Annuity Provisions and
Payment Option Section.
PROCEEDS: The amount, if any, that We pay when the first of the following events
occur: (1) the Maturity Date; (2) the Contract is surrendered; (3) We receive
Due Proof of Death of an Owner; or (4) the election of a Payment Option.
SEC: The U.S. Securities and Exchange Commission.
SEPARATE ACCOUNT: An account of the Company other than the General Account.
SERVICE CENTER: Any office designated by Us for the receipt of premium payments
and processing of Owner requests.
SUBACCOUNT: A subdivision of the Variable Account, the assets of which are
invested in a designated Fund.
SUBACCOUNT VALUE: For this Contract, the amount equal to that part of any Net
Premium Payment and Credit Amounts allocated to the Subaccount and any Contract
Account Value transferred to that Subaccount, adjusted by any interest income,
dividends, net capital gains or losses, realized or unrealized, and decreased by
withdrawals (including any applicable Surrender Charges and Premium Tax Charge),
charges and any Contract Account Value transferred out of that Subaccount.
Subaccount Value is determined by calculating the Accumulation Unit Value as
described in the Variable Account Section.
SURRENDER VALUE: The Contract Account Value less: (1) any applicable Surrender
Charges; (2) Premium Tax Charges not previously deducted; and (3) the Annual
Administrative Fee.
VALUATION DAY: For each Subaccount, each day on which the New York Stock
Exchange is open for business except for certain holidays listed in the
prospectus and days that a Subaccount's corresponding Fund does not value its
shares.
VALUATION PERIOD: The period that starts at the close of regular trading on the
New York Stock Exchange and ends at the close of regular trading on next
succeeding Valuation Date.
VARIABLE ACCOUNT: Provident Mutual Variable Annuity Separate Account.
VARIABLE ACCOUNT VALUE: The sum of all Subaccount Values.
SECTION 2: GENERAL PROVISIONS
THE CONTRACT: We have issued this Contract in consideration of Your application
and Your payment of the Initial Premium Payment. The entire Contract is made up
of this Contract, any attached endorsements or riders, and the attached copy of
the application. We consider statements made in the application to be
representations and not warranties. We will not use any statement in defense of
a claim or to void this Contract unless it is contained in the attached
application. Only Our President, a Vice President, or Secretary may modify this
Contract or waive any of Our rights or requirements under this Contract. Any
modification or waiver must be in writing. No agent may bind Us by making any
promise not contained in this Contract.
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INCONTESTABILITY: We will not contest this Contract after it has been in force
during the Owner's lifetime for two years from the Contract Date.
MISSTATEMENT OF AGE OR SEX: If the age or sex has been misstated, We will adjust
the benefits We pay under this Contract to the amount that would have been
payable at the correct age and sex. If We made any underpayments because of any
such misstatement, We shall pay the amount of such underpayment plus interest at
an annual effective rate of 3%, immediately to the Payee or Beneficiary in one
sum. If We make any overpayment because of a misstatement of age or sex, We
shall deduct from current or future payments due under this Contract, the amount
of such overpayment plus interest at an annual effective rate of 3%.
PERIODIC REPORTS: At least annually, or more often as required by law, We will
mail to Owners at their last known address a report showing the following items
as of a date shown on the report:
1. the number of Accumulation Units credited to this Contract and the dollar
value of such units;
2. the Contract Account Value and Surrender Value;
3. any premium payments, withdrawals, or surrenders made, Death Benefits paid
and charges deducted since the last report; and
4. any other information required by law.
MODIFICATION: Upon notice to the Owner, We may modify the Contract to:
1. conform the Contract, the operations of the Company, or the Variable
Account to the requirements of any law (or regulation or pronouncement
issued by a government agency) to which the Contract, the Company, or the
Variable Account is subject;
2. assure continued qualification of the Contract as an annuity contract
under the Code;
3. reflect a change (as permitted in this Contract) in the operation of the
Variable Account; or
4. provide additional Subaccounts.
In the event of any such modification, We may make appropriate endorsements to
the Contract. Any modification will be made only upon the approval of the
Superintendent of Insurance.
NON-PARTICIPATING: This Contract does not participate in the surplus or profits
of the Company and We do not pay dividends under this Contract.
PROTECTION OF PROCEEDS: To the extent permitted by applicable law, no right or
benefit payable under this Contract are subject to the claims of creditors
except as may be provided in an assignment in a form acceptable to Us. No
Beneficiary or Payee may commute, encumber, or alienate any payments under this
Contract before they are due.
DISCHARGE OF LIABILITY: Any payments made by Us under any Payment Option in
connection with the payment of any withdrawal, surrender or death benefit, shall
discharge Our liability to the extent of each such payment.
INITIAL PREMIUM PAYMENT: The Initial Premium Payment is shown on the Contract
Schedule and is payable on or before the Contract Date.
SUBSEQUENT PREMIUM PAYMENTS: Owners may make an additional premium payment not
less than the minimum amount shown on the Contract Schedule.
PROOF OF AGE, SEX AND SURVIVAL: We reserve the right to require proof of age,
sex or survival of any person upon whose age, sex or survival any payments
depend. In addition, for life contingent Payment Options, We reserve the right
to require proof of the Annuitant's survival before any Annuity Date.
INSTRUCTIONS AND REQUESTS: All instructions and requests are effective as of the
end of the Valuation Period in which We receive them in a form satisfactory to
Us, unless the event is scheduled to occur on a later date. We may require that
You provide signature guarantees or other safeguards for any instruction,
request or document You send to Our Service Center. We are not liable for any
loss, liability, cost or expense of any kind for acting on instructions or
requests submitted to Us that We reasonably believe to be genuine.
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SECTION 3: OWNERSHIP
OWNERSHIP: This Contract belongs to the Owner. The Owner, as shown on the
Contract Schedule, or as subsequently changed, may exercise all rights under
this Contract. Subject to more specific provisions elsewhere herein, these
rights include the right to: (1) select or change an Owner; (2) select or change
any Beneficiary; (3) select or change the Payee; (4) before the Annuity Date,
select or change the Payment Option; (5) before the Annuity Date and Maturity
Date, select or change the Annuity Date; (6) allocate Net Premium Payments among
and between the Subaccounts and Guaranteed Account, and (7) transfer amounts
among and between the Subaccounts and Guaranteed Account.
ASSIGNMENT: At any time before the Maturity Date, the Owner may assign this
Contract by Notice. We are not responsible for the validity or sufficiency of
any assignment. Your rights and the rights of any Beneficiary or Payee may be
affected by an assignment. We are not bound by the assignment until We receive a
copy of the assignment at the Service Center.
CHANGING THE BENEFICIARY OR OWNER: The Owner may change the Beneficiary or Owner
by Notice at any time before a death benefit is paid. If, however, the Owner
previously irrevocably named a Beneficiary, that Beneficiary's consent in a form
acceptable to Us, must be provided to the Service Center before the change is
effective. Any change of Beneficiary is effective as of the date Notice and the
Beneficiary's consent, if necessary, is received at the Service Center. We are
not liable for any payments made under the Contract prior to the effectiveness
of any Beneficiary change.
SECTION 4: THE VARIABLE ACCOUNT
VARIABLE ACCOUNT: The Variable Account is registered with the SEC as a unit
investment trust under the Act. The Variable Account is also subject to the laws
of the State of Pennsylvania and is also subject to the laws of the state where
the Contract is delivered.
Although We own the assets in the Variable Account, these assets are held
separately from Our other assets and are not part of Our General Account. The
assets in the Variable Account are used to support the operation of and provide
the variable values and benefits for this Contract and similar contracts. The
portion of the assets of the Variable Account equal to the reserves and other
contract liabilities of the Variable Account are not chargeable with liabilities
that arise from any other business that We conduct. We have the right to
transfer to Our General Account any assets of the Variable Account that are in
excess of such reserves and other liabilities.
SUBACCOUNTS: The Variable Account consists of Subaccounts. Each Subaccount
invests in shares of a corresponding Fund. Shares of a Fund are purchased and
redeemed for a Subaccount at their Net Asset Value. Any amounts of income,
dividends and gains distributed from the shares of a Fund are reinvested in
additional shares of that Fund at Net Asset Value. Income, gains and losses,
realized or unrealized, from the assets allocated to a Subaccount are credited
to or charged against that Subaccount without regard to other income, gains or
losses of the Company.
The dollar amounts of values and benefits of this Contract provided by the
Variable Account vary as a function of the investment performance of the Fund in
which the Subaccount that You have selected invests. We do not guarantee the
investment performance of the Funds or Subaccounts. You bear the full investment
risk for fluctuations in the Subaccount Value in the Subaccounts You have
selected.
CHANGES TO THE VARIABLE ACCOUNT: Where permitted by applicable law, We may:
1. create new Separate Accounts;
2. combine Separate Accounts, including the Variable Account;
3. add new Subaccounts to or remove existing Subaccounts from the Variable
Account or combine Subaccounts;
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4. make Subaccounts (including new Subaccounts) available to such classes of
Contracts or insurance contracts as We may determine;
5. add new Funds or remove existing Funds;
6. substitute new Funds for any existing Fund;
7. deregister the Variable Account under the Act if such registration is no
longer required; and
8. operate the Variable Account as a management investment company under the
Act or as any other form permitted by law.
CHANGE IN INVESTMENT POLICY: The investment policy of a Subaccount may not be
changed unless:
1. the change is approved, if required, by the Pennsylvania Insurance
Department and by the Insurance Department of the state in which the
Contract is delivered; and
2. a statement of such approval is filed, if required, with the insurance
department of the state in which this Contract is delivered.
VARIABLE ACCOUNT VALUE: The Variable Account Value is the sum of the Subaccount
Values, and reflects the investment experience of the Subaccounts, any Net
Premium Payments and Credit Amounts allocated to the Subaccounts, transfers in
or out of the Subaccounts, any charges deducted from the Subaccounts or any
withdrawals from the Subaccount. There is no guaranteed minimum Variable Account
Value.
ACCUMULATION UNITS: Net Premium Payments and Credit Amounts allocated to a
Subaccount or amounts of Contract Account Value transferred to a Subaccount are
converted into Accumulation Units. The number of Accumulation Units credited to
a Contract is determined by dividing the dollar amount allocated to each
Subaccount by the Accumulation Unit Value for that Subaccount for the Valuation
Day as of which the allocation or transfer is invested in the Subaccount.
Allocations and transfers to a Subaccount increase the number of Accumulation
Units of that Subaccount.
Certain events or fees reduce the number of Accumulation Units of a Subaccount
credited to a Contract which result in the cancellation of an appropriate number
of Accumulation Units of that Subaccount including (a) withdrawals or transfers
of Subaccount Value from a Subaccount; (b) surrender of the Contract; (c)
payment of a death benefit; (d) the application of Variable Account Value to a
Payment Option on the Annuity Date; and (e) the deduction of the Annual
Administrative Fee or other charges. The number of Accumulation Units cancelled
is determined by dividing the dollar amount of each event or fee deducted from
each Subaccount by the Accumulation Unit Value for that Subaccount for the
Valuation Day as of which the event or fee is deducted from the Subaccount.
ACCUMULATION UNIT VALUE: The Accumulation Unit Value for each Subaccount was set
initially when the Subaccount began operations. Thereafter, the Accumulation
Unit Value at the end of every Valuation Day is the Accumulation Unit Value at
the end of the previous Valuation Day multiplied by the Net Investment Factor,
as described below. Each Subaccount Value for a Contract is determined on any
day by multiplying the number of Accumulation Units attributable to the Contract
in that Subaccount by the Accumulation Unit Value for that Subaccount.
NET INVESTMENT FACTOR: The Net Investment Factor is an index applied to measure
the investment performance of a Subaccount from one Valuation Period to the
next. The Net Investment Factor for any Subaccount for any Valuation Period is
determined by dividing (1) by (2) and subtracting (3) from the result, where:
(1) is the result of:
a. the Net Asset Value of the Fund held in the Subaccount, determined
at the end of the current Valuation Period; plus
b. the per share amount of any dividend or capital gain distributions
made by the Fund held in the Subaccount, if the "ex-dividend" date
occurs during the current Valuation Period; plus or minus
c. a per share charge or credit for any taxes reserved for, which is
determined by Us to have resulted from the operations of the
Subaccount.
(2) is the Net Asset Value of the Fund held in the Subaccount, determined at
the end of the last prior Valuation Period.
(3) is a daily amount representing the Annual Annuity Charge deducted from the
Subaccount adjusted for the number of days in the Valuation Period.
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SECTION 5: GUARANTEED ACCOUNT
GUARANTEED ACCOUNT: The Guaranteed Account is part of Our General Account. The
Guaranteed Account is not part of and does not depend on the investment
performance of the Variable Account.
We credit interest to Contract Account Value allocated to the Guaranteed Account
at rates We determine. We guarantee that the effective annual interest rate will
not be less than 3%. We may credit a higher interest rate from time to time.
We may credit an annual effective rate in excess of 3% for 12 months. Such
excess interest rates are declared by Us from the date of deposit in advance.
GUARANTEED ACCOUNT VALUE: We determine Guaranteed Account Value for any
Valuation Period before the Annuity Date as: the initial allocation of Net
Premium Payments or Credit Amounts to the Guaranteed Account and transfers into
the Guaranteed Account, increased by credited interest, and decreased by any
transfers out of the Guaranteed Account and charges deducted. For purposes of
crediting interest and deducting charges, the Guaranteed Account uses a last-in,
first-out method of accounting for allocations of Net Premium Payments and
Credit Amounts and for transfers of Contract Account Value.
SECTION 6: ALLOCATIONS AND TRANSFERS
NET PREMIUM ALLOCATION: In the application, the Owner must select how the
initial Net Premium Payment is to be allocated among the Subaccounts and the
Guaranteed Account.
We allocate the initial Net Premium Payment to the Subaccounts and the
Guaranteed Account based on the premium allocation schedule in Your application.
You may change the allocation schedule from that shown in the application by
providing Notice to Us. Any additional Net Premium Payments and Credit Amounts
are allocated in accordance with the allocation schedule in effect when such Net
Premium Payments are received at the Service Center, unless it is accompanied by
Notice directing a different allocation for that premium payment. The portion of
a Net Premium Payment that may be applied to a Subaccount or the Guaranteed
Account must be a whole percentage.
TRANSFER PRIVILEGE: Before the Annuity Date, You may transfer all or part of any
Subaccount Value to another Subaccount(s) or the Guaranteed Account (subject to
its availability) or transfer a part of the Guaranteed Account Value to any
Subaccount(s), (subject to its availability) subject to these restrictions:
1. the Minimum Transfer Amount is shown in the Contract Schedule (or, the
entire Subaccount Value or amount in the Guaranteed Account, if less than
the Minimum Transfer Amount); and
2. a transfer request that would reduce a Subaccount Value or amount
remaining in the Guaranteed Account below the amount shown on the Contract
Schedule is treated as a transfer request for the entire amount in that
Subaccount or Guaranteed Account; and
3. additional restrictions on transfers from the Guaranteed Account described
below.
A Transfer Processing Fee will be deducted from the transferred amount for
certain transfers. See "Transfer Processing Fee" below. Transfers are made as of
the date that Your request is received at the Service Center.
RESTRICTIONS ON TRANSFERS FROM THE GUARANTEED ACCOUNT: You may transfer a part
of the amount in the Guaranteed Account to the Subaccounts, subject to these
additional restrictions:
1. We allow only one transfer each year and this transfer must be requested
within the period that is 30 days before and 30 days after the Contract
Anniversary. An unused transfer does not carry over to the next year; and
2. the maximum transfer amount from the Guaranteed Account is 25% of the
Guaranteed Account Value on the date of
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transfer, unless the balance after the transfer is less than $500.00.
We will make the transfer on the Contract Anniversary if Your Notice is received
prior to the Contract Anniversary; if Your Notice is received after the Contract
Anniversary, We will make the transfer as of the date We receive Your Notice at
Our Service Center.
TRANSFER PROCESSING FEE: The first twelve transfers during each Contract Year
are free. We will assess a Transfer Processing Fee for each transfer in excess
of twelve transfers during a Contract Year. The amount of the Transfer
Processing Fee is shown on the Contract Schedule. For the purpose of assessing
the Transfer Processing Fee, each Notice of transfer is considered to be one
transfer, regardless of the number of Subaccounts/Guaranteed Account affected by
the transfer. The Transfer Processing Fee is deducted from the amount being
transferred.
SECTION 7: CONTRACT ACCOUNT VALUES
SURRENDER: You may surrender this Contract for its Surrender Value at any time
before the Annuity Date. You may elect to have the Surrender Value paid in a
single sum or under a Payment Option. The Contract ends when We pay the
Surrender Value or apply such sum to a Payment Option. The Surrender Value is
determined as of the date We receive Your Notice for surrender and this Contract
at Our Service Center.
WITHDRAWALS: You may withdraw part of the Surrender Value at any time before the
Annuity Date, subject to these limits:
1. the minimum withdrawal amount is shown on the Contract Schedule;
2. the maximum withdrawal (including applicable Surrender Charges) is the
amount that would leave a minimum remaining Contract Account Value of the
amount shown on the Contract Schedule.
We withdraw the amount You request from the Contract Account Value as of the day
that We receive Your Notice, and send to You that amount. We then deduct any
applicable Surrender Charge and any applicable Premium Tax Charge from the
remaining Contract Account Value.
Your Notice must specify the amount to be withdrawn from each
Subaccount/Guaranteed Account. If the Notice does not specify this information,
or if any Subaccount Value or Guaranteed Account Value is inadequate to comply
with Your request, We will make the withdrawal based on the proportion that each
Subaccount Value and Guaranteed Account Value bears to the Contract Account
Value as of the day of the withdrawal.
TERMINATION: We may terminate this Contract and pay You the Surrender Value if,
before the Annuity Date, all of the following simultaneously exist:
1. You have not made any premium payment for at least three Contract Years;
2. Your Contract Account Value is less than $2,000; and
3. total premium payments paid less withdrawals (including Surrender Charges)
are less than $2,000.
We will mail You a notice of Our intent to terminate this Contract at least six
months in advance of such termination. This Contract will automatically
terminate on the date specified in the notice unless We receive an additional
premium payment before the termination date specified in the notice. This
additional premium payment must be for at least the minimum amount shown on the
Contract Schedule.
BASIS OF VALUES: Any paid-up annuity, surrender or Death Benefits that may be
available are at least equal to the minimum required by law in the jurisdiction
in which this Contract is delivered. A detailed statement of the method used to
compute the minimum values has been filed, where required, with the insurance
officials of the jurisdiction in which this Contract is delivered.
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SECTION 8: CREDITS
CREDIT AMOUNTS: We will credit your Contract Account Value with an additional
Credit Amount when a Net Premium Payment is applied to the Contract. A Credit
Amount would not be applied if You took a withdrawal, and then applied a Net
Premium Payment for an amount less than the withdrawal amount. The Credit Amount
will be applied on the date the Net Premium Payment is received. The Credit
Amount is a percentage of the premium payments that You pay, and these
percentages are shown in the Contract Schedule. The percentage is determined by
the total amount of premium payments received on this Contract less the total
amount of all withdrawals (including any Surrender Charges). The Credit Amount
is calculated by multiplying the percentage (expressed as a decimal) by the
excess of (a) over (b), where:
(a) equals total premium payments applied under this Contract
(including the current premium payment) less the total
withdrawals (including any Surrender Charges); and
(b) equals the amount computed under (a) above at the time that the
most recent previous credit calculation was made that resulted in
a Credit Amount being applied.
The Credit Amount is allocated among the Subaccounts and Guaranteed Account
based on the premium allocation.
LOOK-BACK: When a Net Premium is applied to the Contract during the first three
Contract Years, We will determine a Calculated Credit Amount. To the extent that
the Calculated Credit Amount exceeds the actual Credit Amounts applied to this
Contract, We will increase the Contract Account Value by the amount of such
excess and allocate such excess as a Credit Amount based on the premium
allocation.
The Calculated Credit Amount is determined by multiplying (1) by (2) where:
(1) equals the amount of total premium payments received on this
Contract less the amount of withdrawals (including any Surrender
Charges).
(2) equals the credit percentage (expressed as a decimal) as shown on
the Contract Schedule for the amount calculated under (1) above.
SECTION 9: FEES AND CHARGES
SURRENDER CHARGE: The Surrender Charge is equal to the percentage of each
premium payment surrendered or withdrawn as specified in the table on the
Contract Schedule. The Surrender Charge is separately calculated and applied to
each premium payment at any time that the payment is surrendered or withdrawn.
No Surrender Charge applies to the portion of the Contract Account Value equal
to the Free Withdrawal Amount or to Contract Account Value in excess of
aggregate premium payments (less prior withdrawals of premium payments). The
Surrender Charge is calculated using the assumption that Contract Account Value
is withdrawn in the following order: (1) the Free Withdrawal Amount for the
Contract Year; (2) premium payments; and (3) any remaining Contract Account
Value. In addition, the Surrender Charge is calculated using the assumption that
premium payments are withdrawn on a first-in, first-out basis.
The Surrender Charge applicable to each premium payment diminishes as the
payment ages. A premium payment ages by Contract Year, such that it is in "year"
1 (on the table in the Contract Schedule) during the Contract Year in which it
is received and in "year" 2 throughout the subsequent Contract Year and in
"year" 3 throughout the Contract Year after that, etc.
In addition, there is no Surrender Charge on or after the Maturity Date.
ANNUAL ANNUITY CHARGE: We assess an Annual Annuity Charge on a daily basis
against the assets of the Variable Account. The amount of the charge is shown on
the Contract Schedule.
ANNUAL ADMINISTRATIVE FEE: We will assess the Annual Administrative Fee shown on
the Contract Schedule:
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1. for the prior Contract Year, as of the Contract Anniversary; or
2. for the current Contract Year (a) as of the date of any surrender, or (b)
as of the Annuity Date.
The fee is deducted from Subaccount Values and the Guaranteed Account Value
based on the proportion that each bears to the Contract Account Value.
When the Annual Administrative Fee is deducted from Subaccount Values, We will
cancel the appropriate number of Accumulation Units. Where the fee is deducted
from the Guaranteed Account, We will reduce the Guaranteed Account Value by the
amount of the fee.
TRANSFER PROCESSING FEE: We will assess a Transfer Processing Fee for each
transfer in excess of twelve transfers during a Contract Year. The amount of
this fee is shown on the Contract Schedule.
PREMIUM TAX CHARGE: We reserve the right to deduct any premium tax assessed
against Us from the Proceeds to the extent that the premium tax has not been
recovered from a deduction from premium payments.
OTHER TAXES: If a tax is assessed against the operation of the Variable Account,
We reserve the right to adjust the Net Investment Factor to provide for any
taxes attributable to the operation of the Variable Account.
CHARGE FOR OPTIONAL BENEFITS: If optional benefits have been added to this
Contract, the method and amount of the charges for the optional benefits shall
be as specified in the Rider, Endorsement or Contract Schedule.
SECTION 10: PAYMENT OF BENEFITS
PAYMENT OF BENEFITS: We usually pay the Proceeds of any surrender, withdrawals,
death benefit, or any Annuity Payments within 7 business days after receipt of
all applicable Notices and/or Due Proof of Death. However, We can postpone such
payments if:
1. the New York Stock Exchange is closed, other than customary weekend and
holiday closing, or trading on the exchange is restricted as determined by
the SEC; or
2. the SEC permits, by an order, the postponement of payment for the
protection of Owners; or
3. the SEC determines that an emergency exists that would make the disposal
of securities held in the Variable Account or the determination of their
value not reasonably practicable.
If a recent check or draft has been submitted, We have the right to defer
payment of surrenders, withdrawals, Death Benefits, or Annuity Payments until
such check or draft has been honored.
We have the right to defer payment of any surrender, withdrawal, or transfer of
Guaranteed Account Value for up to six months from the date We receive Your
Notice.
INTEREST ON DELAYED PAYMENTS: We will pay interest on the amount of any payment
that is delayed pursuant to this section.
This interest will accrue from the date that the payment becomes payable to the
date of payment at an annual rate of 3%, or the rate and time required by law,
if greater. The interest rate will always be at least equal to the rate provided
under the interest income Payment Option.
SECTION 11: DEATH BENEFITS
DEATH BENEFITS ON OR AFTER THE ANNUITY DATE: If an Owner dies on or after the
Annuity Date, any surviving joint Owner becomes the sole Owner. If there is no
surviving Owner, the Beneficiary becomes the new Owner. If an Owner dies on or
after the Annuity Date, any remaining payments
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must be distributed at least as rapidly as under the Payment Option in effect on
the date of such death.
DEATH BENEFIT BEFORE THE ANNUITY DATE:
1. DEATH OF AN OWNER:
If there are multiple Owners named, the age of the oldest Owner will be
used to determine the applicable death benefit. If a sole Owner dies prior
to the Annuity 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 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 dying prior to the
Annuity Date, the surviving Owner will be deemed as the Beneficiary.
A death benefit is determined as of the date on which Notice and Due Proof
of Death and all required claim or other forms are received at the Service
Center.
The following options are available to the Beneficiary:
(1) elect to receive the death benefit in a single lump sum within 5
years of the deceased Owner's death; or
(2) elect to receive the death benefit paid under a Payment Option
provided that: (a) Annuity Payments begin within 1 year of the
deceased Owner s death; and (b) Annuity Payments are made in
substantially equal installments over the life of the Beneficiary or
over a period not greater than the life expectancy of the
Beneficiary; or
(3) if the Beneficiary is the spouse of the deceased Owner, he or she
may by Written Notice within one year of the Owner's death, in lieu
of receiving the death benefit, elect to continue the Contract as
the new Owner. If the spouse so elects, all his or her rights as a
Beneficiary cease and if the deceased Owner was also the Annuitant,
he or she will become the Annuitant. The spouse will be deemed to
have elected to continue the Contract if he or she makes no election
before the expiration of the one year period after the Owner's death
or if he or she makes any premium payments under the Contract.
With regard to a Beneficiary who is not the spouse of the deceased Owner:
(a) options (1) and (2) apply even if the Annuitant is alive at the time
of the deceased Owner's death; (b) if the new Owner is a not natural
person, only option (1) is available; (c) if no election is made within 60
days of the deceased Owner's death, option (1) will be deemed to have been
elected.
If the Beneficiary dies before the payments required by options (1) or (2)
are complete, the entire remaining Contract Account Value must be
distributed in a lump sum immediately.
If there is more than one Beneficiary, the foregoing provisions will
independently apply to each Beneficiary.
2. DEATH OF THE ANNUITANT:
On the death of the Annuitant before the Annuity Date, the Owner becomes
the new Annuitant, if the Owner is an individual. If there is more than
one Owner, the youngest Owner will become the Annuitant. If any Owner is
not an individual, the death of an Annuitant will be treated as the death
of an Owner and the death benefit will be determined as if the Annuitant
were the Owner. If the Annuitant is changed and the Owner is not a natural
person, the entire interest in the Contract must be distributed to the
Owner within 5 years of the change.
3. THE DEATH BENEFIT:
If the Owner is less than age 90 on the date of death, the death benefit
during the first 9 Contract Years will be equal to the greater of:
(a) the Contract Account Value; or
(b) the premiums payments paid reduced by the amount of all withdrawals
(including any applicable Surrender Charge).
The death benefit after the first 9 Contract Years will be equal to the
greater of:
(1) (a) as defined above; or
(2) as of the end of Contract Year 9, the greater of (b) as defined
above or the Contract Account Value. This amount is subsequently
increased by premium payments and reduced by an amount for each
withdrawal (described below).
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REDUCTION FOR A WITHDRAWAL: When part of the Surrender Value is withdrawn, the
withdrawal will reduce the death benefit in the same proportion that the
Contract Account Value was reduced on the date of withdrawal. For each
withdrawal, the death benefit reduction is calculated by multiplying the death
benefit on the date of withdrawal by a fraction, the numerator of which is the
amount of the withdrawal including any applicable Surrender Charge and the
denominator of which is the Contract Account Value immediately prior to the
withdrawal.
If the Owner is at least age 90 on the date of death, the death benefit is equal
to the Contract Account Value.
Any excess of the death benefit over the Contract Account Value will be
allocated to the Subaccounts and the Guaranteed Account according to the premium
allocation schedule in effect at the time that the distribution option is chosen
or is deemed to have been chosen.
SECTION 12: ANNUITY PROVISIONS AND PAYMENT OPTIONS
ANNUITY DATE AND MATURITY DATE: The Surrender Value is applied to purchase a
Payment Option as of the Annuity Date. The Owner may designate or change the
Annuity Date. The latest Annuity Date is the Maturity Date.
ELECTION OF OPTION: The following Payment Options are available to You during
Your lifetime. They are also available to the Beneficiary after Your death, if
You have not selected an option for such Beneficiary.
You may elect to have the Proceeds paid in accordance with any one of the
options described below or in any other manner acceptable to us and permissible
under applicable law. If no election has been made, the automatic Payment Option
shall be Option B. The amount paid under these options is fixed and does not
depend on the investment performance of the Variable Account.
OPTION A - LIFE ANNUITY: An income payable during the lifetime of the Annuitant,
ceasing with the last payment due prior to the death of the Annuitant, according
to the Option Table, Life Only column.
OPTION B - LIFE ANNUITY WITH 10 YEARS PERIOD CERTAIN: An income payable during
the lifetime of the Annuitant with the guarantee that payments shall be made for
a period of not less than 10 years according to the Option Table, 10 Year Period
Certain column.
Under Option B, if any Payee dies while receiving payment, the present value of
the current dollar amount on the date of death of any remaining guaranteed
payments shall be paid in one sum to the executors or administrators of the
Payee unless otherwise provided in writing. Calculation of such present value
shall be at 3%, which is the rate of interest assumed in computing the amount of
Annuity Payments. If you die on or after the annuity starting date and before
the interest in the Contract has been distributed, the remaining payments will
be distributed at least as rapidly as under the method of distribution being
used as of the date of your death.
OPTION C - ALTERNATIVE INCOME OPTION: In lieu of one of the above options, You
may elect to settle Proceeds under an alternative income option acceptable to
Us.
GENERAL PROVISIONS: Annuity Payments shall commence and continue subject to the
following provisions:
1. We shall issue a supplementary contract stating the terms of payment under
the option elected. We may require the return of this Contract to Our
Service Center.
2. Proof satisfactory to us of the identity, birth date and sex of any
Annuitant and that the Annuitant is living.
3. Notice is received at least 30 days before the Maturity Date. The
requested option must begin at least 30 days after We receive Notice, on
or before the Maturity Date, and cannot be the 29th, 30th, or 31st day of
a calendar month.
Income payable is guaranteed to equal or exceed the Contract Account Value
applied to the rates shown in the Option Table. Income payable is guaranteed to
equal or exceed income provided by the application of the Surrender Value to
purchase any single consideration immediate annuity contract offered by Us at
the time to the same class of annuitants. No election of any option may be made
under this Contract for any Annuitant unless such
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election would produce a periodic payment of at least $50 to that Annuitant. If
at any time payments to be made become less than $50 each:
1. We shall have the right to change the frequency of payment to such
interval as shall result in the payment of at least $50. Subject to this
condition, payments may be made annually, semi-annually, quarterly or
monthly; or
2. We may surrender this Contract for its Contract Account Value or We may
allow a periodic payment less than $50.
ANNUITY PAYMENT RATES
The annuity payment rates shown in the Option Table are based on the 1983 Table
A with interest at the rate of 3% per annum. The amount of each annuity payment
will depend on the sex and age of the Annuitant.
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OPTION TABLE
GUARANTEED AMOUNT OF MONTHLY PAYMENT FOR EACH $1,000 OF ANNUITY VALUE APPLIED
GUARANTEED MONTHLY PAYMENTS GUARANTEED MONTHLY PAYMENTS
-----------------------------------------------------------------------------------------------------------------------------------
10 Year 10 Year
Period Period
Age of Payee Life Only Certain Age of Payee Life Only Certain
--------------------------------- -------------------------------
Male Female (Option A) (Option B) Male Female (Option A) (Option B)
-----------------------------------------------------------------------------------------------------------------------------------
5* $2.70 $2.70 45 50 $3.59 $3.58
6 2.71 2.71 46 51 3.63 3.62
7 2.72 2.72 47 52 3.68 3.67
8 2.72 2.73 48 53 3.73 3.72
9 2.73 2.73 49 54 3.78 3.76
5* 10 2.74 2.74 50 55 3.83 3.82
6 11 2.75 2.75 51 56 3.89 3.87
7 12 2.76 2.76 52 57 3.95 3.93
8 13 2.77 2.77 53 58 4.01 3.99
9 14 2.78 2.78 54 59 4.07 4.05
10 15 2.79 2.79 55 60 4.14 4.11
11 16 2.80 2.80 56 61 4.21 4.18
12 17 2.81 2.81 57 62 4.29 4.25
13 18 2.82 2.83 58 63 4.37 4.33
14 19 2.83 2.84 59 64 4.46 4.41
15 20 2.85 2.85 60 65 4.55 4.50
16 21 2.86 2.86 61 66 4.64 4.58
17 22 2.87 2.88 62 67 4.75 4.68
18 23 2.89 2.89 63 68 4.86 4.78
19 24 2.90 2.90 64 69 4.97 4.88
20 25 2.92 2.92 65 70 5.09 4.99
21 26 2.93 2.93 66 71 5.22 5.10
22 27 2.95 2.95 67 72 5.36 5.21
23 28 2.96 2.97 68 73 5.51 5.34
24 29 2.98 2.98 69 74 5.67 5.46
25 30 3.00 3.00 70 75 5.83 5.60
26 31 3.02 3.02 71 76 6.01 5.73
27 32 3.04 3.04 72 77 6.19 5.87
28 33 3.06 3.06 73 78 6.39 6.02
29 34 3.08 3.08 74 79 6.60 6.17
30 35 3.10 3.10 75 80 6.82 6.32
31 36 3.13 3.13 76 81 7.06 6.48
32 37 3.15 3.15 77 82 7.31 6.64
33 38 3.18 3.18 78 83 7.58 6.80
34 39 3.20 3.20 79 84 7.87 6.97
35 40 3.23 3.23 80 85** 8.17 7.13
36 41 3.26 3.26 81 8.49 7.29
37 42 3.29 3.29 82 8.83 7.45
38 43 3.32 3.32 83 9.19 7.61
39 44 3.35 3.35 84 9.57 7.77
40 45 3.39 3.39 85** 9.96 7.92
41 46 3.42 3.42
42 47 3.46 3.46
43 48 3.50 3.50
44 49 3.54 3.54
-----------------------------------------------------------------------------------------------------------------------------------
* Payment shown applies to all younger ages.
** Payment shown applies to all older ages.
The dollar amount of Annuity Payment for any age not shown, any other frequency
of payment, or any other income option agreed to by us will be quoted on
request.
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A GUIDE TO THE PROVISIONS OF THIS CONTRACT
Page
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SECTION 1: DEFINITIONS ......................... 5
SECTION 2: GENERAL PROVISIONS .................. 6
SECTION 3: OWNERSHIP ........................... 8
SECTION 4: THE VARIABLE ACCOUNT ................ 8
SECTION 5: GUARANTEED ACCOUNT .................. 10
SECTION 6: ALLOCATIONS AND TRANSFERS ........... 10
SECTION 7: CONTRACT ACCOUNT VALUES ............. 11
SECTION 8: CREDITS ............................. 12
SECTION 9: FEES AND CHARGES .................... 12
SECTION 10: PAYMENT OF BENEFITS ................. 13
SECTION 11: DEATH BENEFITS ...................... 13
SECTION 12: ANNUITY PROVISION AND PAYMENT
OPTIONS.............................. 15
A COPY OF THE APPLICATION AND ANY ENDORSEMENTS OR RIDERS ARE INCLUDED BEFORE THE
LAST PAGE.
18
FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT
Flexible premiums
as stated in the General Provisions.
Contract Account Values are variable, except for amounts in the
Guaranteed Account.
Non-participating Contract.
PROVIDENT MUTUAL LIFE INSURANCE COMPANY
0000 Xxxxxxxxxxxx Xxxxxxxxx, Xxxxxx, Xxxxxxxxxxxx 00000-0000
