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Exhibit 4(a)
PROVIDENT MUTUAL LIFE INSURANCE COMPANY
Berwyn, Pennsylvania
ANNUITANT: XXXX XXX CONTRACT DATE: 01/01/2000
CONTRACT NO.: 9000000 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. Provident Mutual Life Insurance Company, Home Office, 0000 Xxxxxxxxxxxx
Xxxxxxxxx, Xxxxxx, Xxxxxxxxxxxx 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) 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.
[TO COME] /s/ Xxxxxx X. Xxxxx
Secretary 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 OPTIONS. 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 Options.
Non-participating Contract.
FOR INQUIRIES, INFORMATION AND RESOLUTION OF COMPLAINTS CALL: 0-000-000-0000
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CONTRACT SCHEDULE
OWNER: ALTERNATE OWNER NAME
ANNUITANT: XXXX XXX
DATE OF BIRTH - SEX: 01/ 01/ 1965 - MALE CONTRACT DATE: 01/ 01/ 2000
CONTRACT NUMBER: 9000000 MATURITY DATE: 01/ 01/ 2055
INITIAL PREMIUM PAYMENT: $10,000.00
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
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 8: Fees and Charges)
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CONTRACT SCHEDULE
(Continued)
SURRENDER CHARGE:
AGE OF EACH PREMIUM PAYMENT IN
CONTRACT YEARS CHARGE
1 7.0%
2 7.0%
3 6.0%
4 5.0%
5 4.0%
6 3.0%
7 2.0%
8 1.0%
9 and over 0.0%
RIDERS:
Renewal Credit Endorsement - Form R1210
Death Benefit Rider - Form R1547
Death Benefit Rider - Form R1548
Amendment of Contract Provisions - (For Unisex Contracts) Form PM470.13A
Qualified Plan Rider - Form PM471
403(b) Annuity Loan Rider - Form PM515
Amendment to Qualify Deferred Annuity Contract as a SIMPLE XXX - Form PM549
Amendment to Qualify Deferred Annuity Contract as a SIMPLE Employee Pension
(SEP) XXX - Form PM550
Amendment to Qualify Deferred Annuity Contract as an XXX - Form PM553
Amendment to Qualify Deferred Annuity Contract as a TSA Under Section
403(b) of the IRC Form - PM554
Charitable Remainder Trust Rider - Form PM558
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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.
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.
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, the Free Withdrawal Amount is a percentage of the Contract Account Value
at the start of the year less a Reduction Factor, which reflects the usage of
the Free Withdrawal Amount in prior Contract Years. The percentage is 20% in the
second Contract Year and increases by 10% per year until it reaches a maximum of
50% in the fifth Contract Year. The Reduction Factor for the second Contract
Year equals a fraction expressed as a percentage where the numerator equals the
free withdrawals made in the first Contract Year and the denominator is the
premium payments in the first Contract year. The Reduction Factor for each
subsequent Contract Year equals the Reduction Factor for the prior Contract Year
plus a fraction expressed as a percentage where the numerator equals the free
withdrawals made in the prior Contract Year and the denominator is the Contract
Account Value at the beginning of the prior Contract Year. The Free Withdrawal
Amount in any year will not be less than 10% of the Contract Account Value at
the start of the Contract 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 OPTION: An allocation option available under the Contract as
further defined in the Guaranteed Account Options Section. Amounts allocated to
the Guaranteed Account Options are invested in the General Account.
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GUARANTEED ACCOUNT VALUE: The total amount in all Guaranteed Account Options
being used under the Contract.
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 later of the Contract Anniversary on or
following the Annuitant's age 90, or 10 years after the Contract Date (unless We
consent to a later Maturity Date).
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 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: Providentmutual Variable Annuity Separate Account.
VARIABLE ACCOUNT VALUE: The sum of all Subaccount Values.
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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.
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 and/or Guaranteed Account Options.
In the event of any such modification, We may make appropriate endorsements to
the Contract.
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 of at
least the minimum amount shown in the current prospectus. Notwithstanding the
foregoing, We reserve the right to not accept additional premium payments at any
time for any reason.
PROOF OF AGE, SEX AND SURVIVAL: We reserve the right to require proof of age,
sex or survival of any
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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. You acknowledge and agree
that 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.
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 Options, and (7) transfer
amounts among and between the Subaccounts and Guaranteed Account Options.
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.
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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;
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 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 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
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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.
SECTION 5: GUARANTEED ACCOUNT OPTIONS
GUARANTEED ACCOUNT OPTIONS: The Guaranteed Account Options are part of Our
General Account. The Guaranteed Account Options are not part of and do not
depend on the investment performance of the Variable Account. We may offer one
or more Guaranteed Account Options under the Contract at any time.
We credit interest to Contract Account Value allocated to the Guaranteed Account
Options 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 under one or
more Guaranteed Account Options from time to time.
We may credit an annual effective rate in excess of 3% for the lesser of: (a)
the time remaining for the Guaranteed Account Option selected; or (b) 12 months.
Such excess interest rates are declared by Us in advance for each Guaranteed
Account Option made available from time to time under the Contract. Generally,
We credit different rates of excess interest for different available Guaranteed
Account Options. Also, Guaranteed Account Options are generally available only
for specific periods of time and certain Guaranteed Account Options may only be
available subject to restrictions. At the expiration of any Guaranteed Account
Option, We will seek Your instructions as to the reallocation of Guaranteed
Account Value from that option. Nevertheless, We reserve the right to allocate
such Guaranteed Account Value to another available Guaranteed Account Option if
We do not receive Your instructions within a specified time period.
We may offer Guaranteed Account Options to be used solely for the systematic
transfer of Net Premium Payments and interest "Systematic Transfer Accounts"
thereon to Subaccounts and any other permitted Guaranteed Account Options. These
options would only be available for the allocation of a Net Premium Payment at
the time it was received by Us. Transfers of any portion of the Contract Account
Value into these options are not permitted. These options would require that a
systematic transfer be set up at the time of the allocation so that the Net
Premium Payments and associated interest be fully transferred by the end of a
specified period. If the systematic transfer is canceled or the amount to be
systematically transferred is reduced, the remaining balance will be transferred
to the Money Market Subaccount. You may transfer amounts allocated to these
Guaranteed Account Options to a Subaccount and any other permitted Guaranteed
Account Options at any time.
GUARANTEED ACCOUNT VALUE: We determine Guaranteed Account Value for any
Valuation Period before the Annuity Date, separately for each Guaranteed Account
Option as: the initial allocation of Net Premium Payments or Credit Amounts to
that Option and transfers into the Option, increased by credited interest, and
decreased by any transfers out of the Option and charges deducted. For purposes
of crediting interest and deducting charges, all Guaranteed Account Options use
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 Options.
We allocate the initial Net Premium Payment to the Subaccounts and the
Guaranteed Account Options based on the premium allocation schedule in Your
application.
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You may change the allocation schedule from that shown in the application by
providing Notice to Us. Any additional Net Premium Payments 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 a Guaranteed Account Option 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 a Guaranteed Account Option
(subject to its availability) or transfer a part of any 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 any Guaranteed Account Option, if less
than the Minimum Transfer Amount); and
2. a transfer request that would reduce a Subaccount Value or amount remaining
in a Guaranteed Account Option below the amount shown on the Contract
Schedule is treated as a transfer request for the entire amount in that
Subaccount or Guaranteed Account Option; and
3. additional restrictions on transfers from the Guaranteed Account Options
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 GUARANTEED ACCOUNT OPTIONS: You may transfer a
part of the amount in a Guaranteed Account Option 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 any Guaranteed Account Option is 25% of
the portion of the Guaranteed Account Value attributable to that Option on
the date of 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.
These restrictions do not apply to any Systematic Transfer Account.
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 or Guaranteed Account Options
affected by the transfer. Systematic transfers do not count towards the number
of transfers during a Contract Year. No fee will be assessed for a systematic
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
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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 or
Guaranteed Account Option. If the Notice does not specify this information, or
if any Subaccount Value or amount in a particular Guaranteed Account Option is
inadequate to comply with Your request, We will make the withdrawal based on the
proportion that each Subaccount Value and amount allocated to each Guaranteed
Account Option 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 two 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 additional premium
amount acceptable to Us.
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.
SECTION 8: 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:
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 Guaranteed Account Options based
on the
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Form VA111NY
12
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 a Guaranteed Account Option, 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. For the purposes of assessing the
Transfer Processing Fee, each Notice of transfer is considered to be one
transfer, regardless of the number of Subaccounts or Guaranteed Account Options
affected by the transfer. Systematic transfers do not count towards the number
of transfers during a Contract Year. No fee will be assessed for a systematic
transfer. The Transfer Processing Fee is deducted from the amount being
transferred.
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 9: 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 10: 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
Page 13
Form VA111NY
13
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 8 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 8 Contract Years will be equal to the
greater of:
(1) (a) as defined above; or
(2) as of the end of Contract Year 8, the greater of (b) as defined above
or the Contract Account Value. This amount is subsequently increased
by premium
Form VA111NY Page 14
14
payments and reduced by an amount for each withdrawal (described
below).
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 Guaranteed Account Options 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 11: 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 Beneficiary 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 Beneficiary 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 be equal or exceed the Contract Account Value
applied to the rates shown in the Option Table. Income payable is guaranteed to
be equal or exceed income provided by the application of the Surrender Value to
Form VA111NY Page 15
15
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 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.
Form VA111NY Page 16
16
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.
Form VA111NY Page 17
17
PROVIDENT MUTUAL LIFE INSURANCE COMPANY
RIDER
DEATH BENEFIT
OWNER: ALTERNATE OWNER NAME
CONTRACT NUMBER: 9000000
The following Death Benefit provision replaces THE DEATH BENEFIT provision found
under the DEATH BENEFITS Section of your Contract. Capitalized terms are defined
in the Contract.
PROCEEDS ON DEATH BEFORE ANNUITY DATE. If the Owner dies before the Annuity
Date, the Proceeds we will pay to the Beneficiary is the Death Benefit.
If the Owner dies during the first Contract Year, the Death Benefit will equal
the greater of:
1. the premium payments, less any withdrawals including any applicable
Surrender Charge; or
2. the Contract Account Value less any Death Benefit Charge, if
applicable.
If the Owner dies after the end of the first Contract Year and prior to the
Annuity Date, the Death Benefit will equal the greatest of:
1. the Guaranteed Minimum Death Benefit described below, plus subsequent
premium payments, less any reduction for a subsequent withdrawal
described below; or
2. the premium payments less any withdrawals including any applicable
Surrender Charge; or
3. the Contract Account Value less any Death Benefit Charge, if
applicable.
The Proceeds will be paid in a lump sum or under a Payment Option. The Proceeds
must be distributed in accordance with the rules set forth in the provision
entitled "Death Benefit Before the Annuity Date: Death of an Owner". No Death
Benefit is payable if this Contract is surrendered before the Owner's death.
GUARANTEED MINIMUM DEATH BENEFIT. On each Contract Anniversary on or before the
Owner's 85th birthday, the Guaranteed Minimum Death Benefit is recalculated and
will equal the greater of:
(a) the Guaranteed Minimum Death Benefit as of the previous Contract
Anniversary less any reduction for a subsequent withdrawal described
below; or
(b) the Contract Account Value on the current Contract Anniversary.
After the Contract Anniversary on or before the Owner's 85th birthday, the
Guaranteed Minimum Death Benefit will not be recalculated under this provision.
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.
FORM R1547
18
RIDER CHARGE. A separate monthly charge is made for this rider. On the Contract
Date and the same day of each month thereafter, a charge is deducted from the
Contract Account Value. The monthly charge is equal to the Contract Account
Value multiplied by 0.25% (expressed as a decimal) divided by 12. The charge is
deducted from each Subaccount Value and Guaranteed Account Options based on the
proportion that each account bears to the Contract Account Value. The monthly
charge for this rider will cease upon payment of Proceeds.
This Rider does not change any other provisions of the Contract except as stated
above.
Attached by the Company on the issue date of the Contract.
/s/ Xxxxxx X. Xxxxx
-------------------
President
FORM R1547
19
A GUIDE TO THE PROVISIONS OF THIS CONTRACT
Page
----
SECTION 1: DEFINITIONS 5
SECTION 2: GENERAL PROVISIONS 7
SECTION 3: OWNERSHIP 8
SECTION 4: THE VARIABLE ACCOUNT 8
SECTION 5: GUARANTEED ACCOUNT OPTIONS 10
SECTION 6: ALLOCATIONS AND TRANSFERS 10
SECTION 7: CONTRACT ACCOUNT VALUES 11
SECTION 8: FEES AND CHARGES 12
SECTION 9: PAYMENT OF BENEFITS 13
SECTION 10: DEATH BENEFITS 13
SECTION 11: ANNUITY PROVISION AND PAYMENT OPTIONS 15
A COPY OF THE APPLICATION AND ANY ENDORSEMENTS OR RIDERS ARE INCLUDED BEFORE THE
LAST PAGE.
FORM VA111NY
20
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 Options.
Non-participating Contract.
PROVIDENT MUTUAL LIFE INSURANCE COMPANY
0000 Xxxxxxxxxxxx Xxxxxxxxx, Xxxxxx, Xxxxxxxxxxxx 00000-0000
FORM VA111NY
