PLEASE READ THIS CONTRACT CAREFULLY
Annuity payments and other values provided by this contract under the Variable
Income Options may increase or decrease and are not guaranteed as to fixed
dollar amount.
RIGHT TO EXAMINE CONTRACT
ACCUMULATED VALUE STATES:
You may return this contract within 90 days after you have received it (the
"Free Look Period"). It can be mailed or delivered either to us or the
representative who sold it. If you return the contract, we will pay to you the
Contract Value on the date the contract is returned to us plus any premium tax
deducted on the Issue Date. This amount may be more or less than the Single
Purchase Payment.
FULL REFUND STATES & IRAS FOR ALL STATES:
You may return this contract within 90 days after you have received it. It can
be mailed or delivered either to us or the representative who sold it. If you
return the contract within 10 days after you have received it ("the Free Look
Period"), we will refund the Single Purchase Payment less the total amount of
all annuity payments made or withdrawals taken. If you return the contract after
the expiration of the "Free Look Period" but within 90 days after the Issue
Date, we will pay to you the Contract Value on the date the contract is returned
to us plus any premium tax deducted on the Issue Date.
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
Home Office: Dover, Delaware
Principal Office: 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxxxxxxx 00000
Phone Number: [0-000-000-0000]
This is a legal contract between you and the Company and is issued in
consideration of the Single Purchase Payment shown on the Specifications page.
The Net Payment may be allocated to the Fixed Income Option or the Variable
Income Option or a combination of both. If you select the Variable Income
Option, you can allocate the Net Payment among the Variable Sub-Accounts.
President Secretary
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an Annuitant Dies prior to the Annuity
Income Date
This contract does not participate in the profits or surplus of the Company
Table of Contents
SPECIFICATIONS 3
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION 5
DEFINITIONS 6
OWNER, ANNUITANT AND BENEFICIARY 8
ANNUITY BENEFIT 10
OVERVIEW 10
VARIABLE INCOME OPTIONS 11
WITHDRAWALS 14
DEATH OF OWNER OR ANNUITANT 17
BEFORE THE ANNUITY INCOME DATE 17
AFTER THE ANNUITY INCOME DATE 17
GENERAL PROVISIONS 18
DEFINITIONS
Annuitant The person who must be alive for annuity payments to
be made (unless payments are guaranteed). Joint
Annuitants are permitted and unless otherwise
indicated, any reference to Annuitant shall
include joint Annuitants.
Annuity Income Date The date annuity payments begin. The Annuity Income
Date is shown on the Specifications Page.
Annuity Unit A measure used to calculate annuity payments under a
Variable Income Option.
Beneficiary The person, persons or entity entitled to the Death
Benefit upon the death of the Owner prior to the
Annuity Income Date or remaining annuity payments, if
any, upon the death of the Owner on or after the
Annuity Income Date.
Change Frequency How often changes (due to investment performance) will
be reflected in the dollar value of the variable
annuity payments. For example, if you choose an annual
Change Frequency, the dollar value of variable annuity
payments will remain constant within each one-year
period.
Company, we, us or Allmerica Financial Life Insurance and Annuity
our Company.
Contract Value The Present Value of all remaining annuity payments.
Contract Year A one-year period based on the Issue Date or an
anniversary thereof.
Date of First Change The date on which your variable annuity payment will
change in value for the first time.
Effective Valuation Date The Valuation Date on or immediately following the
day we receive the Single Purchase Payment, request
for transfer, withdrawal, or proof of death.
Fund Each separate investment company, investment series
or portfolio eligible for investment by a Sub-Account
of the Variable Account.
General Account All assets of the Company that are not allocated to a
Separate Account.
Net Payment The Single Purchase Payment less any premium tax.
Owner, you or your The person, persons or entity entitled to exercise the
rights and privileges under this contract. Joint
Owners are permitted and unless otherwise indicated,
any reference to you and your shall include Joint
Owners.
Premium Tax The amount of tax, if any, imposed by a State or other
governmental entity upon our receipt of the Single
Purchase Payment.
Pro Rata The way a withdrawal is deducted from the accounts.
To determine how the withdrawal is made, assume an
annuity payment is made on the date of the withdrawal.
Compare the value of the payment from each account to
the total annuity payment. The withdrawal from each
account will be made in the same proportion.
Request A request or notice made by you, in a manner
consistent with our current procedures, which is
received by us.
Separate Account A segregated account established by us. The assets in
a Separate Account are not commingled with our general
assets and obligations and are not subject to claims
arising out of any other business we may conduct.
State The state or jurisdiction in which this contract is
issued.
Sub-Account A Variable Account subdivision that invests
exclusively in shares of a corresponding Fund.
Valuation Date A day the values of all units are determined.
Valuation Dates occur on each day the New York Stock
Exchange is open for trading.
Valuation Period The period of time between two consecutive Valuation
Dates.
Variable Account The Company's Separate Account, consisting of
Sub-Accounts that invest in the underlying Funds.
OWNER, ANNUITANT AND BENEFICIARY
Owner The Owner is as shown on the Specifications Page.
Upon the death of an Owner prior to the Annuity Income
Date, a Death Benefit is paid.
You may exercise all rights and options granted in
this contract or by us, subject to the consent of any
irrevocable Beneficiary (where applicable). Where
there are joint Owners, the consent of both is
required in order to exercise any ownership rights.
Assignment You may not assign this contract.
Annuitant The Annuitant is as shown on the Specifications Page.
Upon the death of an Annuitant prior to the Annuity
Income Date, a Death Benefit is paid.
Beneficiary The Beneficiary is as shown on the Specifications Page
unless subsequently changed. You may declare any
Beneficiary to be revocable or irrevocable. A
revocable Beneficiary may be changed at any time (a)
before the Annuity Income Date and before the death of
an Owner or an Annuitant; or (b) after the Annuity
Income Date and before the death of the Annuitant. An
irrevocable Beneficiary must consent in writing to any
change of beneficiary. Unless otherwise indicated, the
Beneficiary will be revocable.
A Beneficiary change must be made by Request. When we
receive the Request, the change will take place as of
the date it was signed, even if an Owner or an
Annuitant dies after the form is signed but prior to
our receipt of the Request. Any rights created by the
change will be subject to payments we made or actions
taken before the change was recorded.
All benefits payable to the Beneficiary under this
contract will be divided equally among the surviving
Beneficiaries of the same class (see your
Specifications Page), unless you direct otherwise. If
there is no surviving Beneficiary in a particular
class, then the benefit is divided equally among the
surviving Beneficiaries of the next class. If there is
no surviving Beneficiary, the deceased Beneficiary's
interest will pass to you or your estate. If your
contract has Joint Owners, and one Owner dies, the
surviving joint Owner is the primary Beneficiary. This
is confirmed on the Specifications Page.
Once entitled to benefits under this contract, the
Beneficiary may transfer or commute the annuity
payments or any values provided as long as he or she
has been given that right by you.
Protection of Proceeds To the extent allowed by law, this contract and any
payments made under it will be exempt from the claims
of creditors.
ANNUITY BENEFIT
OVERVIEW
Single Purchase The Single Purchase Payment is shown on the
Payment Specifications Page. No additional payments may be
made.
Net Payment The Net Payment is equal to the Single Purchase
Payment reduced by any applicable Premium Tax. The Net
Payment is allocated as shown on the Specifications
Page.
Income Options The Income Option you selected is shown on the
Specifications Page. Income Options may be Fixed,
Variable or combination Fixed and Variable.
The Fixed Income Option provides a guaranteed amount
of income. The Fixed Income Option is funded through
the General Account.
The Variable Income Option provides income that will
vary over time. The investment performance of the
selected Sub-Accounts causes changes in Annuity Unit
Values, which result in fluctuating payments.
A combination Fixed and Variable Income Option
provides a portion of income that is guaranteed in
amount and a portion that will vary in amount.
Any portion of your Net Payment allocated to the Fixed
Income Option will always remain allocated to the
Fixed Income Option. Similarly, any portion of your
Net Payment allocated to the Variable Income Option
will always remain allocated to the Variable Income
Option, but you can reallocate this variable portion
of your contract among the various Sub-Accounts. See
the "Transfers" provision for additional information.
Payment of Annuity Annuity Payments are paid to you. By Request you may
Payments direct that payments be made to another person,
persons or entity.
VARIABLE INCOME OPTIONS
Assumed Investment The Assumed Investment Return ("AIR") is used to
Return calculate the initial variable annuity payment and to
determine how the payment will change over time in
response to the investment performance of the selected
Sub-Accounts. If the actual performance of any
selected Sub-Account (as measured by the Net
Investment Factor) is equal to the AIR, the annuity
payment attributable to that Sub-Account will be
constant. If the actual performance is greater than
the AIR, the annuity payment will increase. If the
actual performance is less than the AIR, the annuity
payment will decrease.
Net Investment Factor The Net Investment Factor measures the investment
performance of a Sub-Account from one Valuation
Period to the next. This factor is equal to 1.000000
plus the result (which may be positive or negative)
from dividing (a) by (b) and subtracting (c) and (d)
where:
(a) is the investment income of a Sub-Account for
the Valuation Period, including realized or
unrealized capital gains and losses during
the Valuation Period, adjusted for provisions
made for taxes, if any;
(b) is the value of that Sub-Account's assets at
the beginning of the Valuation Period;
(c) is the Mortality and Expense Risk Charge
applicable to the current Valuation Period
(see the Specifications Page) plus any
adjustment for an optional feature; and
(d) is the Administrative Charge applicable to
the current Valuation Period (see the
Specifications Page).
We guarantee that the amount of each variable
annuity payment will not be affected by changes
in our mortality and expense experience. We
assume the risk that actual mortality experience
and expenses may exceed the amounts provided
under the contract. We guarantee that the
mortality and expense risk and administrative
charges will not be increased. Subject to
applicable State and federal laws, these charges
may be decreased or the method used to determine
the Net Investment Factor may be changed.
Annuity Unit Values A Sub-Account Annuity Unit Value on any Valuation Date
is equal to its value on the preceding Valuation Date
multiplied by the product of:
(a) a discount factor equivalent to the Assumed
Investment Return and
(b) the Net Investment Factor of the Sub-Account
for the applicable Valuation Period.
The value of an Annuity Unit as of any date other than
a Valuation Date is equal to its value as of the
preceding Valuation Date.
Determination of the We have annuity option rates that determine the dollar
Number of Annuity Units amount of the first periodic payment under each
Variable Income Option for each $1,000 of Net Payment.
We calculate this amount assuming there is no change
in the Annuity Unit Value. We then divide the amount
of the first annuity payment attributable to a
particular Sub-Account by the Annuity Unit Value of
that Sub-Account to determine the number of Annuity
Units. This number of Annuity Units remains fixed
under all annuity benefit options [except Joint Life
with a Survivor Benefit Options that reduce the
number of Annuity Units upon the first death.]
However, the number of variable annuity units under
any Annuity Benefit Option could change if transfers
or withdrawals are made.
Dollar Amount of First The dollar amount of the first variable annuity
Variable payment will Annuity Payment equal the number of
Annuity Units of each Sub-Account multiplied by the
value of an Annuity Unit of that Sub-Account on the
applicable Valuation Date. [The benefit of any
optional feature will be taken into account.]
Dollar Amount of The dollar amount of each subsequent variable annuity
Subsequent Variable payment will vary with the Annuity Unit Value of the
Annuity Payments selected Sub-Account(s) on certain dates. The dollar
amount of variable annuity payments remains level
until the Date of First Change and within each Change
Frequency cycle. On the Date of First Change and as
of the start of each Change Frequency cycle the dollar
amount of the variable annuity payment is determined
by multiplying the number of Annuity Units of each
Sub-Account by the Annuity Unit Value of that
Sub-Account on the applicable Valuation Date. [The
benefit of any optional feature will be taken into
account.]
Transfers You may make transfers among the Sub-Accounts by
Request to us. Transfers may be made (a) before the
Annuity Income Date and before the death of an Owner
or an Annuitant; or (b) after the Annuity Income
Date and as long as annuity payments are payable under
the Annuity Benefit Option selected.
Transfers may increase or decrease the number of
Annuity Units in each subsequent payment.
There is no charge for the first twelve transfers per
Contract year. A transfer charge of up to $25 may be
imposed on each additional transfer.
We reserve the right to establish and impose
reasonable rules restricting transfers. All transfers
are subject to our consent.
WITHDRAWALS
You have the right, based on the Annuity Benefit
Option selected, to make withdrawals. Withdrawals may
be made (a) before the Annuity Income Date and before
the death of an Owner or an Annuitant; or (b) after
the Annuity Income Date and as long as annuity
payments are payable under the Annuity Benefit Option
selected. If the Death Benefit is applied under an
Annuity Benefit Option, withdrawals may also be made
in accordance with this provision.
Amounts withdrawn that were applied under a Variable
Income Option will be paid within 7 days of the date
we receive your Request. We reserve the right to delay
payments subject to applicable laws, rules and
regulations governing variable annuities.
Amounts withdrawn that were applied under a Fixed
Income Option will normally be paid within 7 days of
the date we receive your Request. We may defer payment
for up to six months from the receipt date. If
deferred for 30 days or more, the amount payable will
be credited interest at a rate of at least 3% or the
appropriate rate mandated by the State.
Your Request must indicate the dollar amount to be
paid and we will withdraw that amount on a Pro-Rata
basis.
Only one Request for withdrawal under a provision(s)
may be made each calendar year:
Payment Withdrawal Each calendar year, you can request a withdrawal up to
Amount Option an amount equal to:
(a) the Payment Withdrawal Amount (see
Specifications Page) multiplied by the value
of an annuity payment, if one were to be
paid, on the date we receive your Request (if
the withdrawal is taken prior to the Annuity
Incom Date), or
(b) the Payment Withdrawal Amount (see
Specifications Page) multiplied by the
previous annuity payment (if the withdrawal
is taken after the Annuity Income Date).
Each withdrawal proportionately reduces the number of
Annuity Units (for Variable Income Options) and/or the
dollar amount (for Fixed Income Options) of each
future annuity payment. The proportionate reduction is
calculated by multiplying the number of Annuity Units
or the dollar amount (whichever is applicable) of each
future annuity payment by the following:
Amount of the variable or fixed withdrawal
------------------------------------------
Present Value of all remaining variable or fixed
annuity payments immediately prior to the withdrawal]
[Present Value Over the life of the contract, when there are
Withdrawal Option remaining guaranteed annuity payments, you may
request withdrawals which represent a percentage of
the Present Value of those remaining guaranteed
payments.
Each withdrawal proportionately reduces any remaining
guaranteed payments (for Variable Income Options)
and/or the dollar amount of each future annuity
payment (for Fixed Income Options). The proportionate
reduction is calculated by multiplying the number of
Annuity Units or the dollar amount (whichever is
applicable) of each future annuity payment by the
following:
Amount of the variable or fixed withdrawal
------------------------------------------
Present Value of all remaining variable or fixed
guaranteed annuity payments immediately prior to the
withdrawal
Whenever a withdrawal is taken under this provision,
we record the percentage withdrawn. (See proportionate
reduction calculation above.) The total percentage
withdrawn over the life of the contract cannot exceed
the Present Value Withdrawal Amount (see the
Specifications Page).
[If an Annuitant is still living after the guaranteed
payments have been paid, the number of Annuity Units
(for Variable Income Options) or dollars (for Fixed
Income Options) will increase to the number of Annuity
Units/dollars payable prior to any Present Value
Withdrawals, adjusted upon the death of the first
Annuitant, if applicable, or for transfers, or for any
withdrawals taken under the Payment Withdrawal Amount
Option.]]
Present Value For a variety of purposes, it is at times necessary to
determine the Present Value of either all future
annuity payments or of future guaranteed annuity
payments. Present Values are calculated based on the
Mortality Table used by us to determine your benefit
(see the Specifications Page), male, female or unisex
rates as appropriate, and the interest rate (for Fixed
Income Options) or AIR (for Variable Income Options)
used to determine the annuity payments increased by
the following adjustments:
Adjustment
Death of the Annuitant 0.00%
Withdrawals
5 or more years after Issue Date 0.00%
Within 5 years of Issue Date:
15 or more years of annuity payments
being valued 1.00%
10-14 years of payments being valued 1.50%
Less than 10 years of payments being valued 2.00%
Determination of Contract Value* 0.00%
*If an optional feature was selected, annuity payments
used in determining this Present Value will be the
amount that would have been payable had you not
selected the optional feature.
DEATH OF OWNER OR ANNUITANT
BEFORE THE ANNUITY INCOME DATE
Death Benefit If an Owner or an Annuitant dies, we will pay a Death
Benefit equal to the Contract Value. The Contract
Value will be determined as of the Effective Valuation
Date.
The Death Benefit will be paid to the Owner of the
contract. If there is no Owner or Joint Owner, we will
pay the Death Benefit to the Beneficiary.
Payment of the Unless you have specified otherwise, the Death Benefit
Death Benefit will be paid within 7 days of the Effective Valuation
Date. Alternatively, the person entitled to the Death
Benefit may, by Request, elect to receive an annuity
over his or her life expectancy (or over a period not
extending beyond such life expectancy), with
distributions beginning within one year from the date
of death.
If the sole Beneficiary is the deceased Owner's
spouse, the Beneficiary may elect to continue the
contract as the Owner and Annuitant. As of the date of
such election, annuity payments will be adjusted to
reflect any change of Annuitant and Annuity Income
Date. The new Annuity Income Date must be within
twelve months of the Issue Date (see Specifications
Page). Any subsequent spouse of the new Owner, if
named as the Beneficiary, may not continue this
contract.
AFTER THE ANNUITY INCOME DATE
Remaining Annuity If the Owner or Annuitant dies, we will pay remaining
Payments annuity payments, if any, in accordance with the
terms of the Annuity Benefit Option selected.
Any remaining annuity payments will be paid to the
Owner of the contract. If there is no Owner or Joint
Owner, then the Beneficiary will receive the payments
and become the Owner of the contract.
Lump Sum Option The Beneficiary may elect to receive the Present Value
of any remaining payments in one lump sum.
GENERAL PROVISIONS
Entire Contract The entire contract consists of this contract, any
application attached at issue, Specifications page and
endorsements.
Misstatement of Age If the age or sex of an individual is misstated, we
Or Sex will adjust all benefits payable to that which would
be available at the correct age or sex. Any
underpayments already made by us will be paid
immediately. Any overpayments will be deducted from
future annuity payments.
Failure to Notify Company After the Annuity Income Date and once notified of the
of Annuitant Death Annuitant's death, we reserve the right to recover any
overpaid annuity payments.
Modifications Only the President or Vice President of the Company
may modify or waive any provisions of this contract.
Agents or Brokers are not authorized to do so.
Incontestability We will not contest this Contract.
Minimums All values and benefits available under this contract
equal or exceed those required by the State in which
the contract is delivered.
Annual Report We will send you an annual report of the Sub-Accounts
and any other notices, reports or documents required
by law to be delivered to You.
Addition, Deletion, or We reserve the right, subject to compliance with
Substitution of applicable law, to add to, delete from, or substitute
Investments for the shares of a Fund that are held by the
Sub-Accounts or that the Sub-Accounts may purchase. We
also reserve the right to eliminate the shares of any
Fund no longer available for investment or if we
believe further investment in the Fund is no longer
appropriate for the purposes of the Sub-Accounts.
We will not substitute shares attributable to any
interest in a Sub-Account without notice to you and
prior approval of the Securities and Exchange
Commission as required by the Investment Company Act
of 1940. This will not prevent the Variable Account
from purchasing other securities for other series or
classes of contracts, or from permitting a conversion
between series or classes of contracts on the basis of
requests made by You.
We reserve the right, subject to compliance with
applicable laws, to establish additional Separate
Accounts and Sub-Accounts and to make them available
to any class or series of contracts as we consider
appropriate. Each new Separate Account or Sub-Account
will invest in a new investment company, or in shares
of another open-end investment company, or such other
investments as may be permitted under applicable law.
We also reserve the right to eliminate or combine
existing Sub-Accounts and to transfer the assets of
any Sub-Accounts to any other Sub-Accounts. In the
event of any substitution or change, we may, by
appropriate notice, make such changes in this and
other contracts as may be necessary or appropriate to
reflect the substitution or change. If we consider it
to be in the best interests of the owners, the
Variable Account or any Sub-Account may be operated as
a management company under the Investment Company Act
of 1940 or in any other form permitted by law, or may
be de-registered under the Act in the event
registration is no longer required, or may be combined
with our other accounts.
Changes in Law We reserve the right to make any changes to provisions
of the contract to comply with, or give you the
benefit of, any federal or State statute, rule, or
regulation.
Change of Name Subject to compliance with applicable law, we reserve
the right to change the names of the Variable Account
or the Sub-Accounts.
Federal Tax The Variable Account is not currently subject to tax,
Considerations but we reserve the right to assess a charge for taxes
if the Variable Account becomes subject to tax.
Splitting of Units We reserve the right to split the value of a unit,
either to increase or decrease the number of units.
Any splitting of units will have no material effect on
the benefits, provisions or investment return of this
contract or upon you, the Annuitant, any Beneficiary,
or us.
Insulation of Separate The investment performance of Separate Account assets
Account is determined separately from our other assets. The
assets of a Separate Account equal to the reserves and
liabilities of the contracts supported by the account
will not be charged with liabilities from any other
business that we may conduct.
Single Payment Immediate Variable and Fixed Annuity
Annuity Payments Payable on the Annuity Income Date
Death Benefit Payable if an Owner or an Annuitant Dies prior to the Annuity
Income Date This contract does not participate in the profits or surplus of
the Company
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Payment for a Certain Number of Years:
We will provide annuity payments, beginning on the Annuity Income Date, for
the period of time shown on the Specifications Page.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Payment for a Certain Number of Years, with a Ratchet:
We will provide annuity payments, beginning on the Annuity Income Date, for
the period of time shown on the Specifications Page.
The Ratchet is an optional feature you have selected which is applicable
only to the Variable Income Option. It guarantees that annuity payments
will never decrease as a result of investment performance.
Annuity payments made prior to the Date of First Change are guaranteed to
equal or exceed the Initial Ratchet Amount shown on the Specifications
Page. All other annuity payments are guaranteed to equal or exceed the
Current Ratchet Amount. The Current Ratchet Amount equals the amount of the
last annuity payment in the previous Change Frequency Cycle.
From one Change Frequency Cycle to the next, annuity payments are limited
so that they will not exceed the applicable ratchet amount by more than the
Ratchet Maximum Benefit Increase Percentage (see Specifications Page).
If you take a withdrawal from the contract, the Initial Ratchet Amount (if
the withdrawal is taken prior to the Date of First Change) or the Current
Ratchet Amount (if the withdrawal is taken at any other time) will be
reduced in the same manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a
result, the first annuity payment is lower than it would have been had this
feature not been selected. Future annuity payments will also be lower
except when the protection provided by this feature results in a greater
benefit.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Payment for a Certain Number of Years, with a Floor:
We will provide annuity payments, beginning on the Annuity Income Date, for
the period of time shown on the Specifications Page.
The Floor is an optional feature you have selected and is applicable only
to the Variable Income Option. While variable annuity payments may increase
or decrease, this feature guarantees that they will never fall below the
Floor Amount.
The Floor Amount is shown on the Specifications Page. If you take a
withdrawal from the contract, the Floor Amount will be reduced in the same
manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a
result, the first annuity payment is lower than it would have been had this
feature not been selected. Future annuity payments will also be lower
except when the protection provided by this feature results in a greater
benefit.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity:
We will provide annuity payments, beginning on the Annuity Income Date,
during the life of the sole Annuitant. We may require satisfactory proof
that the Annuitant is alive before any annuity payment is made.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity, with a Ratchet:
We will provide annuity payments, beginning on the Annuity Income Date,
during the life of the sole Annuitant. We may require satisfactory proof
that the Annuitant is alive before any annuity payment is made.
The Ratchet is an optional feature you have selected which is applicable
only to the Variable Income Option. It guarantees that annuity payments
will never decrease as a result of investment performance.
Annuity payments made prior to the Date of First Change are guaranteed to
equal or exceed the Initial Ratchet Amount shown on the Specifications
Page. All other annuity payments are guaranteed to equal or exceed the
Current Ratchet Amount. The Current Ratchet Amount equals the amount of the
last annuity payment in the previous Change Frequency Cycle.
From one Change Frequency Cycle to the next, annuity payments are limited
so that they will not exceed the applicable ratchet amount by more than the
Ratchet Maximum Benefit Increase Percentage (see Specifications Page).
If you take a withdrawal from the contract, the Initial Ratchet Amount (if
the withdrawal is taken prior to the Date of First Change) or the Current
Ratchet Amount (if the withdrawal is taken at any other time) will be
reduced in the same manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a
result, the first annuity payment is lower than it would have been had this
feature not been selected. Future annuity payments will also be lower
except when the protection provided by this feature results in a greater
benefit.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity, with a Floor:
We will provide annuity payments, beginning on the Annuity Income Date,
during the life of the sole Annuitant. We may require satisfactory proof
that the Annuitant is alive before any annuity payment is made.
The Floor is an optional feature you have selected and is applicable only
to the Variable Income Option. While variable annuity payments may increase
or decrease, this feature guarantees that they will never fall below the
Floor Amount.
The Floor Amount is shown on the Specifications Page. If you take a
withdrawal from the contract, the Floor Amount will be reduced in the same
manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a
result, the first annuity payment is lower than it would have been had this
feature not been selected. Future annuity payments will also be lower
except when the protection provided by this feature results in a greater
benefit.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit:
We will provide annuity payments, beginning on the Annuity Income Date,
during the joint lifetime of both Annuitants. Upon the death of an
Annuitant, the number of Annuity Units (for Variable Income Options) and/or
the dollar amount (for Fixed Income Options) of each payment will be
adjusted by the Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or
dollars of each payment paid during the survivor's life, which may be less
than or equal to that paid when both individuals are living. This
percentage is only applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit, with a Ratchet:
We will provide annuity payments, beginning on the Annuity Income Date,
during the joint lifetime of both Annuitants. Upon the death of an
Annuitant, the number of Annuity Units (for Variable Income Options) and/or
the dollar amount (for Fixed Income Options) of each payment will be
adjusted by the Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or
dollars of each payment paid during the survivor's life, which may be less
than or equal to that paid when both individuals are living. This
percentage is only applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
The Ratchet is an optional feature you have selected which is applicable
only to the Variable Income Option. It guarantees that annuity payments
will never decrease as a result of investment performance.
Annuity payments made prior to the Date of First Change are guaranteed to
equal or exceed the Initial Ratchet Amount shown on the Specifications
Page. All other annuity payments are guaranteed to equal or exceed the
Current Ratchet Amount. The Current Ratchet Amount equals the amount of the
last annuity payment in the previous Change Frequency Cycle. Upon the death
of the first Annuitant, the Current Ratchet Amount is adjusted by
multiplying it by the Survivor Benefit Percentage.
From one Change Frequency Cycle to the next, annuity payments are limited
so that they will not exceed the applicable ratchet amount by more than the
Ratchet Maximum Benefit Increase Percentage (see Specifications Page).
If you take a withdrawal from the contract, the Initial Ratchet Amount (if
the withdrawal is taken prior to the Date of First Change) or the Current
Ratchet Amount (if the withdrawal is taken at any other time) will be
reduced in the same manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a
result, the first annuity payment is lower than it would have been had this
feature not been selected. Future annuity payments will also be lower
except when the protection provided by this feature results in a greater
benefit.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit, with a Floor:
We will provide annuity payments, beginning on the Annuity Income Date,
during the joint lifetime of both Annuitants. Upon the death of an
Annuitant, the number of Annuity Units (for Variable Income Options) and/or
the dollar amount (for Fixed Income Options) of each payment will be
adjusted by the Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or
dollars of each payment paid during the survivor's life, which may be less
than or equal to that paid when both individuals are living. This
percentage is only applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
The Floor is an optional feature you have selected and is applicable only
to the Variable Income Option. While variable annuity payments may increase
or decrease, this feature guarantees that they will never fall below the
Floor Amount.
The Floor Amount is shown on the Specifications Page. Upon the death of the
first Annuitant, the Floor Amount is adjusted by multiplying it by the
Survivor Benefit Percentage. If you take a withdrawal from the contract,
the Floor Amount will be reduced in the same manner that the withdrawal
reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a
result, the first annuity payment is lower than it would have been had this
feature not been selected. Future annuity payments will also be lower
except when the protection provided by this feature results in a greater
benefit.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity with Payment for a Certain Number of Years:
We will provide annuity payments, beginning on the Annuity Income Date,
during the life of the sole Annuitant with a guarantee that if, at the
Annuitant's death, annuity payments have been made for less than the number
of years elected, then annuity payments will continue thereafter to you (or
the payee you designate) for the remainder of the period. We may require
satisfactory proof that the Annuitant is alive before any annuity payment
is made.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity with Payment for a Certain Number of Years, with a Ratchet:
We will provide annuity payments, beginning on the Annuity Income Date,
during the life of the sole Annuitant with a guarantee that if, at the
Annuitant's death, annuity payments have been made for less than the number
of years elected, then annuity payments will continue thereafter to you (or
the payee you designate) for the remainder of the period. We may require
satisfactory proof that the Annuitant is alive before any annuity payment
is made.
The Ratchet is an optional feature you have selected which is applicable
only to the Variable Income Option. It guarantees that annuity payments
will never decrease as a result of investment performance.
Annuity payments made prior to the Date of First Change are guaranteed to
equal or exceed the Initial Ratchet Amount shown on the Specifications
Page. All other annuity payments are guaranteed to equal or exceed the
Current Ratchet Amount. The Current Ratchet Amount equals the amount of the
last annuity payment in the previous Change Frequency Cycle.
From one Change Frequency Cycle to the next, annuity payments are limited
so that they will not exceed the applicable ratchet amount by more than the
Ratchet Maximum Benefit Increase Percentage (see Specifications Page).
If you take a withdrawal from the contract, the Initial Ratchet Amount (if
the withdrawal is taken prior to the Date of First Change) or the Current
Ratchet Amount (if the withdrawal is taken at any other time) will be
reduced in the same manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a
result, the first annuity payment is lower than it would have been had this
feature not been selected. Future annuity payments will also be lower
except when the protection provided by this feature results in a greater
benefit.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity with Payment for a Certain Number of Years, with a Floor:
We will provide annuity payments, beginning on the Annuity Income Date,
during the life of the sole Annuitant with a guarantee that if, at the
Annuitant's death, annuity payments have been made for less than the number
of years elected, then annuity payments will continue thereafter to you (or
the payee you designate) for the remainder of the period. We may require
satisfactory proof that the Annuitant is alive before any annuity payment
is made.
The Floor is an optional feature you have selected and is applicable only
to the Variable Income Option. While variable annuity payments may increase
or decrease, this feature guarantees that they will never fall below the
Floor Amount.
The Floor Amount is shown on the Specifications Page. If you take a
withdrawal from the contract, the Floor Amount will be reduced in the same
manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a
result, the first annuity payment is lower than it would have been had this
feature not been selected. Future annuity payments will also be lower
except when the protection provided by this feature results in a greater
benefit.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Annuity with a Survivor Benefit, with Payment for a Certain Number of
Years:
We will provide annuity payments, beginning on the Annuity Income Date,
during the joint lifetime of both Annuitants with a guarantee that if, upon
the death of both Annuitants, annuity payments have been made for less than
the number of years elected, then annuity payments will continue thereafter
to you (or the payee you designate) for the remainder of the period. Upon
the death of an Annuitant, the number of Annuity Units (for Variable Income
Options) and/or the dollar amount (for Fixed Income Options) of each
payment will be adjusted by the Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or
dollars of each payment paid during the survivor's life, which may be less
than or equal to that paid when both individuals are living. This
percentage is only applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Annuity with a Survivor Benefit, with Payment for a Certain Number of
Years, with a Ratchet:
We will provide annuity payments, beginning on the Annuity Income Date,
during the joint lifetime of both Annuitants with a guarantee that if, upon
the death of both Annuitants, annuity payments have been made for less than
the number of years elected, then annuity payments will continue thereafter
to you (or the payee you designate) for the remainder of the period. Upon
the death of an Annuitant, the number of Annuity Units (for Variable Income
Options) and/or the dollar amount (for Fixed Income Options) of each
payment will be adjusted by the Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or
dollars of each payment paid during the survivor's life, which may be less
than or equal to that paid when both individuals are living. This
percentage is only applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
The Ratchet is an optional feature you have selected which is applicable
only to the Variable Income Option. It guarantees that annuity payments
will never decrease as a result of investment performance.
Annuity payments made prior to the Date of First Change are guaranteed to
equal or exceed the Initial Ratchet Amount shown on the Specifications
Page. All other annuity payments are guaranteed to equal or exceed the
Current Ratchet Amount. The Current Ratchet Amount equals the amount of the
last annuity payment in the previous Change Frequency Cycle. Upon the death
of the first Annuitant, the Current Ratchet Amount is adjusted by
multiplying it by the Survivor Benefit Percentage.
From one Change Frequency Cycle to the next, annuity payments are limited
so that they will not exceed the applicable Ratchet amount by more than the
Ratchet Maximum Benefit Increase Percentage (see Specifications Page).
If you take a withdrawal from the contract, the Initial Ratchet Amount (if
the withdrawal is taken prior to the Date of First Change) or the Current
Ratchet Amount (if the withdrawal is taken at any other time) will be
reduced in the same manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a
result, the first annuity payment is lower than it would have been had this
feature not been selected. Future annuity payments will also be lower
except when the protection provided by this feature results in a greater
benefit.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Annuity with a Survivor Benefit, with Payment for a Certain Number of
Years,with a Floor:
We will provide annuity payments, beginning on the Annuity Income Date,
during the joint lifetime of both Annuitants with a guarantee that if, upon
the death of both Annuitants, annuity payments have been made for less than
the number of years elected, then annuity payments will continue thereafter
to you (or the payee you designate) for the remainder of the period. Upon
the death of an Annuitant, the number of Annuity Units (for Variable Income
Options) and/or the dollar amount (for Fixed Income Options) of each
payment will be adjusted by the Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or
dollars of each payment paid during the survivor's life, which may be less
than or equal to that paid when both individuals are living. This
percentage is only applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
The Floor is an optional feature you have selected and is applicable only
to the Variable Income Option. While variable annuity payments may increase
or decrease, this feature guarantees that they will never fall below the
Floor Amount.
The Floor Amount is shown on the Specifications Page. Upon the death of the
first Annuitant, the Floor Amount is adjusted by multiplying it by the
Survivor Benefit Percentage. If you take a withdrawal from the contract,
the Floor Amount will be reduced in the same manner that the withdrawal
reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a
result, the first annuity payment is lower than it would have been had this
feature not been selected. Future annuity payments will also be lower
except when the protection provided by this feature results in a greater
benefit.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity with Cash Back:
We will provide annuity payments, beginning on the Annuity Income Date,
during the life of the sole Annuitant with a guarantee that at the
Annuitant's death, you (or the payee you designate) will receive any excess
of the Net Payment applied over the total amount of annuity payments made
and withdrawals taken. We may require satisfactory proof that the Annuitant
is alive before any annuity payment is made.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life Annuity with Cash Back, with an Ratchet:
We will provide annuity payments, beginning on the Annuity Income Date,
during the life of the sole Annuitant with a guarantee that at the
Annuitant's death, you (or the payee you designate) will receive any excess
of the Net Payment applied over the total amount of annuity payments made
and withdrawals taken. We may require satisfactory proof that the Annuitant
is alive before any annuity payment is made.
The Ratchet is an optional feature you have selected which is applicable
only to the Variable Income Option. It guarantees that annuity payments
will never decrease as a result of investment performance.
Annuity payments made prior to the Date of First Change are guaranteed to
equal or exceed the Initial Ratchet Amount shown on the Specifications
page. All other annuity payments are guaranteed to equal or exceed the
Current Ratchet Amount. The Current Ratchet Amount equals the amount of the
last annuity payment in the previous Change Frequency Cycle.
From one Change Frequency Cycle to the next, annuity payments are limited
so that they will not exceed the applicable ratchet amount by more than the
Ratchet Maximum Benefit Increase Percentage (see Specifications Page).
If you take a withdrawal from the contract, the Initial Ratchet Amount (if
the withdrawal is taken prior to the Date of First Change) or the Current
Ratchet Amount (if the withdrawal is taken at any other time) will be
reduced in the same manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a
result, the first annuity payment is lower than it would have been had this
feature not been selected. Future annuity payments will also be lower
except when the protection provided by this feature results in a greater
benefit.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Single Life with Cash Back, with a Floor:
We will provide annuity payments, beginning on the Annuity Income Date,
during the life of the sole Annuitant with a guarantee that at the
Annuitant's death, you (or the payee you designate) will receive any excess
of the Net Payment applied over the total amount of annuity payments made
and withdrawals taken. We may require satisfactory proof that the Annuitant
is alive before any annuity payment is made.
The Floor is an optional feature you have selected and is applicable only
to the Variable Income Option. While variable annuity payments may increase
or decrease, this feature guarantees that they will never fall below the
Floor Amount.
The Floor Amount is shown on the Specifications page. If you take a
withdrawal from the contract, the Floor Amount will be reduced in the same
manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a
result, the first annuity payment is lower than it would have been had this
feature not been selected. Future annuity payments will also be lower
except when the protection provided by this feature results in a greater
benefit.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit, with Cash Back:
We will provide annuity payments, beginning on the Annuity Income Date,
during the joint lifetime of both Annuitants with a guarantee that, at the
surviving Annuitant's death, you (or the payee you designate) will receive
any excess of the Net Payment applied over the total amount of annuity
payments made and withdrawals taken. Upon the death of an Annuitant, the
number of Annuity Units (for Variable Income Options) and/or the dollar
amount (for Fixed Income Options) of each payment will be adjusted by the
Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or
dollars of each payment paid during the survivor's life, which may be less
than or equal to that paid when both individuals are living. This
percentage is only applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit, with Cash Back, with a Ratchet:
We will provide annuity payments, beginning on the Annuity Income Date,
during the joint lifetime of both Annuitants with a guarantee that, at the
surviving Annuitant's death, you (or the payee you designate) will receive
any excess of the Net Payment applied over the total amount of annuity
payments made and withdrawals taken. Upon the death of an Annuitant, the
number of Annuity Units (for Variable Income Options) and/or the dollar
amount (for Fixed Income Options) of each payment will be adjusted by the
Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or
dollars of each payment paid during the survivor's life, which may be less
than or equal to that paid when both individuals are living. This
percentage is only applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
The Ratchet is an optional feature you have selected which is applicable
only to the Variable Income Option. It guarantees that annuity payments
will never decrease as a result of investment performance.
Annuity payments made prior to the Date of First Change are guaranteed to
equal or exceed the Initial Ratchet Amount shown on the Specifications
page. All other annuity payments are guaranteed to equal or exceed the
Current Ratchet Amount. The Current Ratchet Amount equals the amount of the
last annuity payment in the previous Change Frequency Cycle. Upon the death
of the first Annuitant, the Current Ratchet Amount is adjusted by
multiplying it by the Survivor Benefit Percentage.
From one Change Frequency Cycle to the next, annuity payments are limited
so that they will not exceed the applicable Ratchet amount by more than the
Ratchet Maximum Benefit Increase Percentage (see Specifications Page).
If you take a withdrawal from the contract, the Initial Ratchet Amount (if
the withdrawal is taken prior to the Date of First Change) or the Current
Ratchet Amount (if the withdrawal is taken at any other time) will be
reduced in the same manner that the withdrawal reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a
result, the first annuity payment is lower than it would have been had this
feature not been selected. Future annuity payments will also be lower
except when the protection provided by this feature results in a greater
benefit.
SPECIFICATIONS
DESCRIPTION OF YOUR ANNUITY BENEFIT OPTION
Joint Life Annuity with a Survivor Benefit, with Cash Back, with a Floor:
We will provide annuity payments, beginning on the Annuity Income Date,
during the joint lifetime of both Annuitants with a guarantee that, at the
surviving Annuitant's death, you (or the payee you designate) will receive
any excess of the Net Payment applied over the total amount of annuity
payments made and withdrawals taken. Upon the death of an Annuitant, the
number of Annuity Units (for Variable Income Options) and/or the dollar
amount (for Fixed Income Options) of each payment will be adjusted by the
Survivor Benefit Percentage.
The Survivor Benefit Percentage is the percentage of Annuity Units or
dollars of each payment paid during the survivor's life, which may be less
than or equal to that paid when both individuals are living. This
percentage is only applicable after the death of the first Annuitant.
We may require satisfactory proof that the Annuitants are alive before any
annuity payment is made.
The Floor is an optional feature you have selected and is applicable only
to the Variable Income Option. While variable annuity payments may increase
or decrease, this feature guarantees that they will never fall below the
Floor Amount.
The Floor Amount is shown on the Specifications Page. Upon the death of the
first Annuitant, the Floor Amount is adjusted by multiplying it by the
Survivor Benefit Percentage. If you take a withdrawal from the contract,
the Floor Amount will be reduced in the same manner that the withdrawal
reduces the Annuity Units.
There is no periodic charge for this feature. Instead, lower Income Option
Rates are used to determine your first variable annuity payment. As a
result, the first annuity payment is lower than it would have been had this
feature not been selected. Future annuity payments will also be lower
except when the protection provided by this feature results in a greater
benefit.
SPECIFICATIONS
Contract Type: [Non-qualified] Single Purchase Payment Amount: [ ]
Contract Number: [zz00600000] Net Payment: [ ]
Owner: [Xxxx Xxx ] Owner's Date of Birth: [10/25/1960]
Joint Owner: [Xxxx Xxx ] Joint Owner's Date of Birth: [07/12/1960]
Annuitant: [Xxxx Xxx ] Annuitant's Date of Birth: [03/19/1945]
Joint Annuitant: [Xxxxxxx Xxx ] Joint Annuitant's Date of Birth: [08/20/1954]
Annuitant's Sex: [Female ] Payee: [Xxxx Xxx ]
Joint Annuitant's Sex: [Male ] Payee's Address: [0 Xxxx Xx,
Xxxxxxxx, XXX ]
Primary Beneficiary: Surviving Joint Owner, if any
1st Contingent Beneficiary(ies): [Xxxxxxx Xxx ]
2nd Contingent Beneficiary(ies): [Xxxx Xxx]
Issue Date: [04/01/1999]
Annuity Income Date: [10/01/1999]
-----------------------------------------------------------------------------------------------------
Annuity Benefit Option: [Joint with a Survivor Benefit Option] (See
page [5])
[Survivor Benefit Percentage: [50%]]
Frequency of Annuity Payments: [Monthly]
Mortality Table: [Annuity 2000]
Percentage under a Fixed Income Option: [30%]
Dollar Amount of Fixed Income: [ $]
Percentage under a Variable Income Option: [70%]
Assumed Investment Return: [5%]
Change Frequency: [Monthly]
Date of First Change: [xx/xx/xxxx]
Income Option Rate: [ 4.5]
[Optional Feature:]
[The Ratchet:
Initial Ratchet Amount: [$100]
Ratchet Maximum Benefit Increase Percentage: [10%]
If you had not selected this feature, the Income Option Rate
above would have been [5.0].]
[The Floor:
Floor Amount: [$100]
If you had not selected this feature, the Income Option Rate
above would have been [5.0].]
SPECIFICATIONS (continued)
Owner: [Xxxx Xxx] Contract Number:
[zz00600000]
Joint Owner: [Xxxx Xxx]
Single Purchase Amount: [$25,000.00]
--------------------------------------------------------------------------------
[Payment Withdrawal Amount: [10 times the previous annuity payment.]
[[But not more than the remaining
guaranteed payments.]]
[Present Value Withdrawal Amount: [[75%] of Present Value of remaining
guaranteed annuity payments.]
Mortality and Expense Risk Charge: [[1.25%] on an annual basis of the daily
value of the Sub-Account assets.]
Administrative Charge: [[.20%] on an annual basis of the daily
value of the Sub-Account assets.]
Variable Allocation of Net Payment on Issue Date:
Sub-Account Name Percentage of Number of Units
---------------- Net Payment ---------------
-----------
[Select Aggr. Growth
Select Capital Appr.
Select Value Opp.
Select Emerging Market
Select Int'l Equity
DGPF Int'l Equity Series
Fidelity VIP Overseas
X. Xxxx Price Int'l
Select Growth
Select Strategic Growth
Growth Fund
Fidelity VIP Growth
Equity Index Fund
Select Gr. & Inc.
Fidelity VIP Eq. Inc.
Fidelity VIP Asset Mgr
Fidelity VIP High Inc
Investment Grade Income Fund
Government Bond Fund
Allmerica Money Market]
