Exhibit 4(a)(2)
THE CHAIRMAN-TM- COMBINATION FIXED AND VARIABLE ANNUITY CONTRACT
ISSUED BY
THE AMERICAN FRANKLIN LIFE INSURANCE COMPANY
Unless otherwise directed by the Owner, The American Franklin Life Insurance
Company ("American Franklin") will pay a monthly income to the Annuitant if
living on the Annuity Commencement Date. The dollar amounts of such payments
will be determined on the basis of the provisions of this Contract. The first
payment will be payable on the Annuity Commencement Date. Subsequent payments
will be payable on the corresponding day of each month thereafter or at other
intervals in accordance with the provisions of this Contract.
All payments and values provided by this Contract, when based on the investment
experience of the Separate Account, are variable, may increase or decrease and
are not guaranteed as to amount. See the "Separate Account" and "Variable
Annuity Payments" provisions in this Contract.
CANCELLATION RIGHT. This Contract may be returned for cancellation to
American Franklin at its Administrative Office within 10 days after delivery.
Upon surrender of this Contract within the 10 day period, American Xxxxxxxx
will refund the sum of the Owner's Account Value at the end of the Valuation
Period in which the request is received, plus any premium taxes and Annual
Contract Fee that have been deducted.
This is a FLEXIBLE PAYMENT VARIABLE and FIXED INDIVIDUAL DEFERRED ANNUITY
CONTRACT. NONPARTICIPATING -- NOT ELIGIBLE FOR DIVIDENDS.
SIGNED AT THE HOME OFFICE ON THE DATE OF ISSUE.
/s/ /s/
---------------------- --------------------
Secretary President
READ THIS CONTRACT CAREFULLY
[American Franklin Logo]
A STOCK COMPANY
A Subsidiary of American General Corporation
Home Office: Springfield, Illinois
Administrative Office: Houston, Texas
P.O. Box 4636 Houston, Texas 77210-4636 (000) 000-0000
FORM T1575Z
INDEX
Page
10% Free Withdrawal Privilege. . . . . . . . . . . . . . . . . . 18
Account Value. . . . . . . . . . . . . . . . . . . . . . . . . . 4
Allocation of Purchase Payments. . . . . . . . . . . . . . . . . 8
Annual Contract Fee. . . . . . . . . . . . . . . . . . . . . . . 18
Annuity Options. . . . . . . . . . . . . . . . . . . . . . . . . 22
Annuity Tables . . . . . . . . . . . . . . . . . . . . . . . . . 24
Annuity Units. . . . . . . . . . . . . . . . . . . . . . . . . . 21
Beneficiary. . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Change of Investment Advisor or
Investment Policy . . . . . . . . . . . . . . . . . . . . . 7
Death Benefit. . . . . . . . . . . . . . . . . . . . . . . . . . 19
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Division Accumulation Units. . . . . . . . . . . . . . . . . . . 12
Divisions. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Fixed Account. . . . . . . . . . . . . . . . . . . . . . . . . . 11
Full Surrender . . . . . . . . . . . . . . . . . . . . . . . . . 15
General Provisions . . . . . . . . . . . . . . . . . . . . . . . 7
Guarantee Periods. . . . . . . . . . . . . . . . . . . . . . . . 11
Guaranteed Interest Rates. . . . . . . . . . . . . . . . . . . . 12
Net Investment Factor. . . . . . . . . . . . . . . . . . . . . . 13
Ownership Provisions . . . . . . . . . . . . . . . . . . . . . . 9
Partial Withdrawals. . . . . . . . . . . . . . . . . . . . . . . 16
Payment of Benefits. . . . . . . . . . . . . . . . . . . . . . . 20
Premium Taxes. . . . . . . . . . . . . . . . . . . . . . . . . . 9
Purchase Payments. . . . . . . . . . . . . . . . . . . . . . . . 8
Schedule Page. . . . . . . . . . . . . . . . . . . . . . . . . . 3
Separate Account . . . . . . . . . . . . . . . . . . . . . . . . 12
Surrender Charge . . . . . . . . . . . . . . . . . . . . . . . . 16
Surrender Charge Exceptions. . . . . . . . . . . . . . . . . . . 17
Surrenders . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Tax Charge . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Transfers. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Variable Account Asset Rebalancing . . . . . . . . . . . . . . . 15
Variable Annuity Payments. . . . . . . . . . . . . . . . . . . . 21
FORM T1575Z
2
The American Franklin Life Insurance Company
SCHEDULE PAGE
INITIAL PURCHASE PAYMENT: $10,000
MINIMUM ADDITIONAL PURCHASE PAYMENTS
(Per Division or Guarantee Period): $ 100
ADDITIONAL BENEFITS: NONE
MAXIMUM ASSET CHARGE FACTORS (Separate Account Only) ANNUAL RATE: 1.40%
MAXIMUM ANNUAL CONTRACT FEE: $ 30
TRANSFER CHARGE: $ 25
ISSUE AGE: 35
ANNUITY COMMENCEMENT DATE: JANUARY 1, 2026
INITIAL ALLOCATION:
Net Dollar
Amount of
Percentage Allocations
VIP Money Market Portfolio 100% $10,000
VIP High Income Portfolio xx% $ xxx
VIP Investment Grade Bond Portfolio xx% $ xxx
VIP Equity-Income Portfolio xx% $ xxx
VIP Growth Portfolio xx% $ xxx
VIP Overseas Portfolio xx% $ xxx
VIP Asset Manager Portfolio xx% $ xxx
VIP Index 500 Portfolio xx% $ xxx
VIP II Contrafund Portfolio xx% $ xxx
MFS Emerging Growth Portfolio xx% $ xxx
MFS Research Portfolio xx% $ xxx
MFS Growth With Income Portfolio xx% $ xxx
MFS Total Return Portfolio xx% $ xxx
MFS Utilities Portfolio xx% $ xxx
MFS Value Portfolio xx% $ xxx
Fixed Account
1 Year Guarantee Period xx% $ xxx
3 Year Guarantee Period xx% $ xxx
5 Year Guarantee Period xx% $ xxx
------ -----------
Total Allocations 100% $10,000
ANNUITANT: XXXX XXX CONTRACT NUMBER: 123456
CONTRACT OWNER: XXXX XXX DATE OF ISSUE: JANUARY 1, 1996
CONTRACT JURISDICTION: (STATE NAME)
FORM T1575Z
3
DEFINITIONS
ACCOUNT. Any of the Divisions or the Fixed Account.
ACCOUNT VALUE. The sum of the Fixed Account Value and the Separate Account
Value. The Fixed Account Value is the accumulated value of Net Purchase
Payments, renewals and transfers into the Fixed Account and interest on such
amounts, minus the accumulated value of any withdrawals and transfers out of the
Fixed Account and any Annual Contract Fee allocated to the Fixed Account and
interest on such amounts. The Separate Account Value is the sum of the values
of the Separate Account Divisions. The value of a Separate Account Division is
the value of a Division's Accumulation Unit multiplied by the number of
Accumulation Units in that Division.
ACCUMULATION PERIOD. The period during which Net Purchase Payments are applied.
ACCUMULATION UNIT. An accounting unit of measure used to calculate the value of
a Division of this Contract before annuity payments begin.
ADMINISTRATIVE OFFICE. The AMFLIC Annuity Service Center, to which all Owner
premium payments, requests, directions and other communications should be
directed. The AMFLIC Annuity Service Center is currently located at 0000-X
Xxxxx Xxxxxxx, 0-00, Xxxxxxx, Xxxxx 00000-0000; mailing address - P.O. Box
4636, Houston, Texas 00000-0000; telephone numbers - (000) 000-0000 or (713)
831-3310.
ANNUITANT. The person upon whose date of birth income payments are based. The
Annuitant's name is shown on Page 3.
ANNUITY OPTION. One of the several forms in which the Owner can request
American Xxxxxxxx to make annuity payments.
ANNUITY UNIT. A unit of measurement to calculate variable annuity payments.
BENEFICIARY. The person entitled to receive benefits in the event the Owner or
Annuitant dies. If no designated Beneficiary is living at the time any payment
is to be made, the Owner shall be the Beneficiary, or if the Owner is not
living, the Owner's estate shall be the Beneficiary.
CONTINGENT ANNUITANT. A person named by the Owner of a Non-Qualified Contract
to become the Annuitant if: (1) the Annuitant dies before the Annuity
Commencement Date; and (2) the Contingent Annuitant is then living. A
Contingent Annuitant may not be named except at the time of application. Once
named, the choice may not be revoked or replaced. If a Contingent Annuitant
dies, a new Contingent Annuitant may not be named. After Annuity Payments start,
a Contingent Annuitant may not become the Annuitant.
CONTINGENT BENEFICIARY. A person named by the Owner to receive benefits in the
event a designated Beneficiary is not living at the time of the Owner's or
Annuitant's death.
CONTRACT ANNIVERSARY. Each anniversary of the Date of Issue of this Contract.
CONTRACT YEAR. A period of 12 consecutive months beginning on the Date of Issue
or any anniversary thereof.
DATE OF ISSUE. The date on which this Contract becomes effective as shown on
Page 3.
DIVISION. The subdivisions of the Separate Account which are used to determine
how the Owner's Account is allocated among the Variable Funds.
FIXED ACCOUNT. The name of the investment alternative under which payments are
allocated to American Franklin's General Account.
FIXED ANNUITY OPTION. An annuity option with payments which do not vary with
investment performance as to dollar amount.
FORM T1575Z
4
GUARANTEED INTEREST RATE. The minimum rate American Franklin may use to credit
interest on an effective annual basis during any Guarantee Period.
GUARANTEE PERIOD. The period for which a Guaranteed Interest Rate is credited.
HOME OFFICE. The American Franklin Life Insurance Company, #0 Xxxxxxxx Xxxxxx,
Xxxxxxxxxxx, Xxxxxxxx 00000; 000-000-0000.
INDIVIDUAL RETIREMENT ANNUITY. An annuity contract described in Section 408(b)
of the Internal Revenue Code, which may also qualify under Section 408(k) or
Section 408(p) of the Internal Revenue Code.
ISSUE AGE. The Annuitant's age as of his or her nearest birthday on the Date of
Issue.
NET ASSET VALUE PER SHARE. The net assets of a Variable Fund divided by the
number of shares in the Variable Fund.
NET PURCHASE PAYMENT. The gross amount of a Purchase Payment less any Premium
Taxes deducted at the time a Purchase Payment is made.
NON-QUALIFIED CONTRACT. A Contract that does not qualify for the special
federal income tax treatment applicable in connection with retirement plans or
deferred compensation plans.
OWNER. The Owner of this Contract. The "Owner" is the person, persons or
entity entitled to the ownership rights stated in this Contract. The Owner may
designate a trustee or custodian of a retirement plan which meets the
requirements of Section 401, Section 408(c), Section 408(k) or Section 408(p)
of the Internal Revenue Code to serve as legal owner of assets of a retirement
plan, but the term "Owner" as used herein, shall refer to the organization
entering into this Contract.
OWNER'S ACCOUNT. An account established for each Owner to which each Net
Purchase Payment is credited.
PAYOUT PERIOD. The period, starting with the Annuity Commencement Date, during
which Annuity Payments are made by the Company.
PREMIUM TAX. The amount of tax, if any, charged by a state or municipality on
Purchase Payments or Contract values.
PURCHASE PAYMENT. An amount paid to the Company as consideration for the
benefits described herein.
QUALIFIED CONTRACT. A Contract that is qualified for the special federal income
tax treatment applicable in connection with certain retirement plans.
SECTION 457 CONTRACT. A Contract that is issued in connection with a deferred
compensation plan established under Section 457 of the Internal Revenue Code.
SEPARATE ACCOUNT. A segregated investment account entitled "Separate Account
VA-1" established by American Xxxxxxxx to separate the assets funding the
variable benefits for the class of contracts to which this Contract belongs from
the other assets of American Franklin. That portion of the assets of the
Separate Account equal to the reserves and other contract liabilities with
respect to the Separate Account shall not be chargeable with liabilities arising
out of any other business American Franklin may conduct. Income, gains and
losses, whether or not realized, from assets allocable to the Separate Account,
are credited to or charged against such account without regard to American
Franklin's other income, gains or losses.
VALUATION DATE. Any day on which American Franklin's Administrative Office is
open for business except, with respect to any Division, a day on which the
related Variable Fund does not value its shares.
VALUATION PERIOD. The period that starts at the close of regular trading on the
New York Stock Exchange on a Valuation Date and ends at close of regular trading
on the Exchange on the next Valuation Date.
FORM T1575Z
5
VARIABLE ANNUITY OPTION. An Annuity Option under which American Xxxxxxxx
promises to pay the Annuitant or other properly-designated Payee one or more
payments which vary in amount in accordance with the net investment
experience of the applicable Divisions selected to measure the value of this
Contract.
VARIABLE FUND. An individual investment fund or series in which a Division
invests.
FORM T1575Z
6
GENERAL PROVISIONS
Entire Contract This Contract, and a copy of the Application
for the Contract, if attached, is the entire
Contract. All statements made by Owner or
Annuitant will be deemed representations and
not warranties. No statement will be used to
reduce a claim under this Contract unless it
is in writing and made a part of this Contract.
Not Contestable This Contract is not contestable.
Guarantees Subject to the Net Investment Factor provision
of this Contract, American Franklin guarantees
that the dollar amount of Variable Annuity
Payments made during the lifetime of the
payee(s) will not be adversely affected by
American Franklin's actual mortality experience
or by the actual expenses incurred by American
Xxxxxxxx in excess of expense deductions
provided for in this Contract.
Settlement All benefits under this Contract are payable
from the Administrative Office.
Nonparticipating This Contract is nonparticipating and does not
share in American Franklin's surplus or
earnings.
Change of Investment Unless otherwise required by law or regulation,
Adviser or Investment the investment adviser or any investment policy
Policy of Variable Funds of a Variable Fund may not be changed without
American Franklin's consent. If required,
approval or change of any investment objective
will be filed with the Insurance Department of
the state where this Contract is delivered.
Owners will be notified of any material
investment policy change which has been
approved. Notification of an investment
policy change will be given in advance to those
Owners who have the right to consent to or vote
on such change.
Any substitution of the underlying investments
of any Division will comply with all applicable
requirements of the Investment Company Act of
1940 and rules thereunder.
Modification Rights Reserved American Franklin reserves the right to modify
by American Xxxxxxxx the Contract, but only if such modification:
(1) Is necessary to make the Contract or the
Separate Account comply with any law or
regulation issued by a governmental agency
to which American Franklin is subject; or
(2) Is necessary to assure continued
qualification of the Contract under the
Internal Revenue Code or other federal or
state laws relating to retirement
annuities or Annuity contracts; or
(3) Is necessary to reflect a change in the
operation of the Separate Account or the
Division(s); or
(4) Provides additional Separate Account
options or
FORM T1575Z
7
(5) Withdraws Separate Account options.
In the event of any such modification, American
Xxxxxxxx will provide notice to the Owner or to
the payee(s) during the Annuity Period.
American Franklin may also make appropriate
endorsements in the Contract to reflect such
modification.
When required by law, American Xxxxxxxx will
obtain approval by Owners of changes and
American Xxxxxxxx will gain approval from any
appropriate regulatory authority.
Changing the Terms Any change in the Contract must be approved by
of the Contract one of American Franklin's officers. No agent
has the authority to make any changes or waive
any of the terms of the Contract.
Termination This Contract will remain in force until
surrendered for its full value, or all annuity
payments have been made, or the death benefit
has been paid, except as follows:
If the Owner's Account Value is less than $500,
American Xxxxxxxx may cancel this Contract upon
60 days' notice to the Owner. Such
cancellation would be considered a full
surrender of this Contract.
If the Owner's Account Value in any Division
(except the Money Market Division) falls below
$500, American Franklin reserves the right to
transfer the remaining balance, without charge,
to the Money Market Division.
PURCHASE PAYMENTS
Minimum Payments The minimum amounts acceptable as Purchase
Payments are shown on Page 3. American
Franklin reserves the right to modify these
minimums or to refuse a Purchase Payment for
any reason.
Allocation of The initial allocation for Net Purchase
Purchase Payments Payments is shown on Page 3 of this Contract
and will remain in effect until changed by
written notice. The percentage allocation for
future Net Purchase Payments may be changed at
any time by written notice.
Changes in the allocation will be effective on
the date American Xxxxxxxx receives the Owner's
notice at its Administrative Office. The
allocation may be 100% to any available
Division or Guarantee Period, or may be
divided among these options in whole
percentage points totaling 100%.
The initial Net Purchase Payment will be
credited to the Owner's Account not more than
two business days after American Xxxxxxxx
receives it, together with all other required
documentation, in good order at its
Administrative Office. Subsequent Net
Purchase Payments will be credited as of the
end of the Valuation Period in which they are
so received. American Franklin reserves the
right to limit the total number of Fixed
Account Guarantee Periods and Separate Account
Divisions that may be chosen during the life
of the Contract.
FORM T1575Z
8
Premium Taxes When applicable, American Franklin will deduct
an amount to cover Premium Taxes. Such
deduction will be made:
(1) From Purchase Payment(s) when received; or
(2) From the Account Value at the time annuity
payments are to commence; or
(3) From the amount of any partial withdrawal;
or
(4) From proceeds payable upon termination of
the Contract for any other reason,
including death of the Annuitant or Owner,
or surrender of the Contract.
If Premium Tax is paid, American Franklin may
reimburse itself for such tax when deduction is
being made under paragraphs 2, 3, or 4 above
calculated by multiplying the sum of Purchase
Payments being withdrawn by the applicable
Premium Tax percentage.
OWNERSHIP PROVISIONS
Exercise of Contract This Contract belongs to the Owner, who is
Rights entitled to exercise all rights and privileges
in connection with this Contract. Where a
Contract is jointly owned, both Owners must
join in any request to exercise the rights or
privileges of an Owner.
In any case, such rights and privileges can be
exercised without the consent of the
Beneficiary (other than an irrevocably -
designated Beneficiary) or any other person.
Such rights and privileges may be exercised
only during the lifetime of the Annuitant and
prior to the Annuity Commencement Date, except
as otherwise provided in this Contract.
Unless the Owner specifies otherwise, on the
Annuity Commencement Date the Annuitant will
become the payee. If the Owner or the
Annuitant dies prior to the Annuity
Commencement Date, the Beneficiary will become
the payee. Such payees may thereafter exercise
such rights and privileges of ownership which
continue.
Beneficiary The Owner designated the Beneficiary and any
Contingent Beneficiary when applying for this
Contract. By written notice to American
Franklin at its Administrative Office, a
non-irrevocable Beneficiary or Contingent
Beneficiary may be changed by the Owner prior
to the Annuity Commencement Date or by the
Annuitant or other properly-designated
payee after the Annuity Commencement Date.
Change of Ownership Ownership of a Qualified Contract may not be
transferred except to: (1) the Annuitant; (2)
a trustee or successor trustee of a pension or
profit sharing trust which is qualified under
Section 401(a) of the Internal Revenue Code;
(3) the employer of the Annuitant, provided
that the Qualified Contract after transfer is
maintained under the terms of a retirement plan
qualified under Section 403(a) of the Internal
Revenue Code for the benefit of the Annuitant;
(4) the trustee of an individual
FORM T1575Z
9
retirement account plan qualified under Section
408 of the Internal Revenue Code; or (5) as
otherwise permitted from time to time by laws
and regulations governing the retirement or
deferred compensation plans for which a
Qualified Contract may be issued (including but
not limited to transfers pursuant to a
qualified domestic relations order within the
meaning of Section 414(p) of the Internal
Revenue Code). In no other case may a
Qualified Contract be sold, assigned,
transferred, discounted or pledged as
collateral.
During the lifetime of the Annuitant and prior
to the Annuity Commencement Date, the Owner may
change the ownership of a Non-Qualified
Contract.
A change of ownership will not be binding upon
American Xxxxxxxx until American Xxxxxxxx
receives written notification at its
Administrative Office. When such notification
is so received, the change will be effective
as of the date of the signed request for
change, but the change will be without
prejudice to American Franklin on account of
any payment made, or any action taken by it
prior to receiving the change, or on account
of any tax consequence.
Distribution of If an Owner (including the first to die in the
Death Benefit case of joint Owners) under a Non-Qualified
under Non-Qualified Contract dies prior to the Annuitant and before
Contracts the Annuity Commencement Date, the death
benefit must be distributed to the
designated Beneficiary either (1) within
five years after the date of death of the
Owner, or (2) over the life of the designated
Beneficiary or a period not greater than the
expected life of the designated Beneficiary,
with annuity payments beginning within one year
after the date of death of the Owner. The
Beneficiary shall be considered the designated
beneficiary for the purposes of Section 72(s)
of the Internal Revenue Code. In all cases,
any such designated beneficiary will not be
entitled to exercise any rights prohibited by
applicable federal income tax law.
These mandatory distribution requirements will
not apply when the designated Beneficiary is
the spouse of the deceased Owner, if the spouse
elects to continue this Contract in the
spouse's own name, as Owner. When the deceased
Owner of a Non-Qualified Contract was also the
Annuitant, the surviving spouse (if the
surviving spouse is the designated Beneficiary)
may elect to be named as both Owner and
Annuitant and continue this Contract.
If the payee under a Non-Qualified Contract
dies after the Annuity Commencement Date and
before all of the payments under the Annuity
Option have been distributed, the remaining
amount payable, if any, must be distributed at
least as rapidly as under the method of
distribution then in effect.
If the Owner prior to the Annuity Commencement
Date, or the payee thereafter, is not a natural
person, then the foregoing distribution
requirements shall apply upon the death of the
primary Annuitant within the meaning of the
Internal Revenue Code.
FORM T1575Z
10
Periodic Reports American Xxxxxxxx will send to each Owner, at
least once during each Contract Year, a statement
showing the Owner's Account Value as of a date not
more than two months prior to the date of mailing.
American Franklin will also send such statements
as may be required by applicable state and federal
laws, rules and regulations.
Owner's Account American Xxxxxxxx will establish an Owner's
Account for the Owner under this Contract and will
maintain such account during the Accumulation
Period. The Owner's Account Value for any
Valuation Period will be equal to the Owner's
Separate Account Value, if any, plus the Owner's
Fixed Account Value, if any, for that Valuation
Period.
FIXED ACCOUNT
Fixed Account Value That portion of a Net Purchase Payment which is
allocated to the Fixed Account will be credited to
the Owner's Account and allocated to the Guarantee
Period(s) selected. The Fixed Account Value of an
Owner's Account for any Valuation Period is equal
to the sum of the values in each of the Guarantee
Periods credited to the Owner's Account for such
Valuation Period.
The value in any one Guarantee Period on a
Valuation Date is the accumulated value of the Net
Purchase Payments, renewals and transfers
allocated to the Guarantee Period and interest on
such amounts at the Guaranteed Interest Rate,
minus the accumulated value of withdrawals and
transfers out of that Guarantee Period and any
Annual Contract Fee allocated to that Guarantee
Period, and interest on such amounts at the
Guaranteed Interest Rate.
Guarantee Periods The Owner may select one or more Guarantee
Period(s). The Guarantee Period(s) selected will
determine the Guaranteed Interest Rates(s). The
Net Purchase Payment or the portion thereof (or
amount transferred in accordance with the transfer
privilege provision described below) allocated to
a particular Guarantee Period will earn interest
at the Guaranteed Interest Rate during the
Guarantee Period. Guarantee Periods begin on the
date as of which American Xxxxxxxx credits the
Owner's Account Value to that Guarantee Period or,
in the case of a transfer, on the effective date
of the transfer. The Guarantee Period is the
number of years American Franklin credits the
Guaranteed Interest Rate. The expiration date of
any Guarantee Period is the last day of the
Guarantee Period. Subsequent Guarantee Periods
begin on the first day following the expiration
date. As a result of Guarantee Period renewals,
additional Purchase Payments and transfers of
portions of the Owner's Account Value, Guarantee
Periods of the same duration may have different
expiration dates and Guaranteed Interest Rates.
American Xxxxxxxx will notify the Owner in writing
at least 30 and no more than 60 days prior to the
expiration date of any Guarantee Period. A new
Guarantee Period of the same duration as the
previous Guarantee Period will begin automatically
unless American Xxxxxxxx receives written notice
at its Administrative Office to the contrary from
the Owner at least three Valuation
FORM T1575Z
11
Dates prior to the end of such Guarantee Period.
The Owner may elect to change to another Guarantee
Period or Division which American Franklin offers
at such time.
If the amount of an Owner's Account Value in a
Guarantee Period is less than $500 at the end of
such Guarantee Period, American Franklin reserves
the right to transfer such amount, without charge,
to the Money Market Division of the Separate
Account. However, American Franklin will transfer
such amount to another available Division at the
Owner's request.
Guaranteed Interest American Xxxxxxxx will periodically establish an
Rates applicable Guaranteed Interest Rate for each
Guarantee Period it offers. These rates will be
guaranteed for the duration of the respective
Guarantee Periods. The Guarantee Periods that
American Xxxxxxxx makes available at any time will
be determined in its discretion.
No Guaranteed Interest Rate shall be less than an
effective annual rate of 3.0% per year.
SEPARATE ACCOUNT
Divisions The Separate Account has a number of Divisions,
each investing in a corresponding Variable Fund.
Net Purchase Payments will be allocated to the
Divisions and the Fixed Account as shown on
Page 3, unless the Owner changes the allocation.
American Franklin will use the Net Purchase
Payments and any transferred amounts to purchase
Variable Fund shares applicable to the Divisions
at their net asset value. American Xxxxxxxx will
be the owner of all Variable Fund shares purchased
with the Net Purchase Payments or transferred
amounts.
Division Net Purchase Payments and transferred amounts
Accumulation allocated to the Separate Account will be
Units credited to the Owner's Account in the form of
Division Accumulation Units. The number of
Division Accumulation Units will be determined by
dividing the amount allocated to a Division by the
Division Accumulation Unit value as of the end of
the Valuation Period as of which the transaction
is credited. The value of each Division
Accumulation Unit was arbitrarily set as of the
date the Division first purchased Variable Fund
shares. Subsequent values on any Valuation Date
are equal to the previous Division
Accumulation Unit value times the Net Investment
Factor for the Valuation Period ending on that
Valuation Date.
Net Investment The Net Investment Factor is an index applied to
Factor measure the investment performance of a Division
from one Valuation Period to the next. The Net
Investment Factor may be greater or less than or
equal to one; therefore, the value of an
Accumulation Unit may increase, decrease or remain
the same.
FORM T1575Z
12
The Net Investment Factor for a Division is
determined by dividing (1) by (2), and then
subtracting (3) from the result, where:
(1) Is the sum of:
(a) The Net Asset Value Per Share of the
Variable Fund shares held in the
Division, determined at the end of the
current Valuation Period; plus
(b) The per share amount of any dividend or
capital gain distributions made on the
Variable Fund shares held in the
Division during the current Valuation
Period;
(2) Is the Net Asset Value Per Share of the
Variable Fund shares held in the Division,
determined at the end of the previous
Valuation Period; and
(3) Is a factor representing the mortality risk,
expense risk, and administrative expense
charge. American Franklin will determine the
daily asset charge factor annually, but in no
event may it exceed the Maximum Asset Charge
Factor as specified on Page 3.
Separate Account The Owner's Separate Account Value for any
Value Valuation Period is the total of the values in
each Division credited to the Owner's Account for
such Valuation Period. The value for each
Division will be equal to:
(1) The number of Division Accumulation Units;
multiplied by
(2) The Division Accumulation Unit value for the
Valuation Period.
The Owner's Separate Account Value will vary from
Valuation Date to Valuation Date reflecting the
total value in the Divisions.
TRANSFERS
Transfers Transfers may be made at any time during the
Accumulation Period after the first 30 days
following the Date of Issue. A transfer will be
effective at the end of the Valuation Period in
which American Xxxxxxxx receives the written
request for a transfer at its Administrative
Office. Transfers will be subject to the
following restrictions:
(1) Prior to the Annuity Commencement Date, the
Owner may make up to 12 transfers each
Contract Year without charge.
(2) There will be a charge of $25.00 for each
transfer in excess of 12 in a Contract Year.
(3) Transfers under the Variable Account Asset
Rebalancing program will not count towards
the 12 free transfers each Contract Year.
The $25.00 charge will not apply to transfers
made through Variable Account Asset
Rebalancing. Transfers under any other asset
management arrangement approved by
FORM T1575Z
13
American Xxxxxxxx will be subject to the
$25.00 charge and will count towards the 12
free transfers unless waived by American
Xxxxxxxx.
(4) Not more than 25% of the Owner's Account
Value allocated to a Guarantee Period at its
inception may be transferred to the Variable
Account or another Guarantee Period during
any Contract Year. Transfers from a
Guarantee Period are made on a first in,
first out basis.
The 25% limit does not apply to:
(a) Transfers within 15 days before or after
the end of the applicable Guarantee
Period to the same or another Guarantee
Period; or
(b) A renewal at the end of a Guarantee
Period to the same Guarantee Period.
(5) If a transfer would cause the Account Value
in any Division or Guarantee Period to fall
below $500, American Franklin reserves the
right to also transfer the remaining balance
in that Division or Guarantee Period in the
same proportions as the transfer request.
(6) American Xxxxxxxx reserves the right to defer
any transfer from the Fixed Account to any of
the Divisions for up to six months.
American Franklin reserves the right to restrict
or terminate transfers.
After the Annuity Commencement Date, the Owner may
make one transfer among the Divisions or from a
Division to a Fixed Annuity Option during any 180
day period; such transfer is without charge. The
Owner may not make transfers from a Fixed Annuity
Option to a Division after the Annuity
Commencement Date.
Variable Account "Variable Account Asset Rebalancing" occurs when
Asset Rebalancing funds are transferred by American Franklin between
the Divisions so that the values in each Division
match the percentage allocation then in effect.
Variable Account Asset Rebalancing of the
Divisions will occur periodically:
(1) If selected by the Owner; and
(2) If the Owner's Account Value is equal to or
greater than $25,000 at the time of selection
by the Owner.
The Owner may select Variable Account Asset
Rebalancing when applying for this Contract, or it
may be selected at a later date. American
Franklin reserves the right to increase or lower
the minimum Account Value required for Variable
Account Asset Rebalancing.
FORM T1575Z
14
SURRENDERS
General Surrender The amount surrendered will normally be paid to
Provisions the Owner within five Valuation Dates following
American Franklin's receipt at its
Administrative Office of:
(1) The Owner's written request on a form
acceptable to American Xxxxxxxx; and
(2) This Contract, if required.
American Xxxxxxxx reserves the right to defer
payment of surrenders from the Fixed Account for
up to six months from the date American Xxxxxxxx
receives the request.
Full Surrender At any time prior to the Annuity Commencement Date
and during the lifetime of the Annuitant, the
Owner may surrender this Contract by sending
American Franklin a written request at its
Administrative Office. The amount payable
on surrender is:
(1) The Owner's Account Value at the end of the
Valuation Period in which American Franklin
receives at its Administrative Office the
Owner's request on a form acceptable to it;
(2) Minus any applicable Surrender Charge;
(3) Minus any applicable Annual Contract Fee; and
(4) Minus any applicable Premium Tax.
The amount payable upon surrender will not be less
than the amount required by state law.
Upon payment of the surrender amount, this
Contract will be terminated and American Xxxxxxxx
will have no further obligation to the Owner.
All collateral assignees must consent to any
surrender or partial withdrawal. American
Franklin may require that this Contract be
returned to its Administrative Office prior to
making payment.
Partial Withdrawals A portion of the Owner's Account Value may be
withdrawn at any time prior to the Annuity
Commencement Date. The Owner must send American
Franklin a written request at its Administrative
Office specifying the Divisions or Guarantee
Periods from which the partial withdrawal is to
be made. However, in cases where the Owner does
not so specify, or the withdrawal cannot be made
in accordance with the Owner's specification,
American Franklin reserves the right to implement
the withdrawal pro rata from each Division and
Guarantee Period based on the Owner's Account
Value in each. Partial withdrawals will be made
effective at the end of the Valuation Period in
which American Xxxxxxxx receives the written
request at its Administrative Office.
Partial withdrawals will be subject to the
following guidelines:
FORM T1575Z
15
(1) The partial withdrawal amount must be at
least $100 or, if less, the Owner's entire
Account Value.
(2) American Xxxxxxxx will surrender Division
Accumulation Units from the Separate Account
or interests in a Guarantee Period so that
the total amount withdrawn will be the sum
of:
(a) The amount payable to the Owner; and
(b) Any Surrender Charge and any applicable
Premium Tax.
(3) If a partial withdrawal would cause the
Owner's Account Value in any Division or
Guarantee Period (except the Money Market
Division) to fall below $500, American
Franklin reserves the right to transfer the
remaining balance without charge to the Money
Market Division.
(4) If the Owner's Account Value is less than
$500, American Xxxxxxxx may cancel this
Contract upon 60 days' notice to the Owner.
Such cancellation would be considered a full
surrender of this Contract.
(5) Partial withdrawals of amounts held under
Qualified Contracts are subject to certain
restrictions on withdrawals set forth in the
Internal Revenue Code.
Surrender Charge Except as noted under "Surrender Charge
for Partial Exceptions," a Surrender Charge will be applied
Withdrawals and to the amount of any Purchase Payment withdrawn
Full Surrenders during the first 7 years after it was first
credited, as follows:
Surrender Charge
Year of as a Percentage
Purchase Payment of Purchase
Withdrawal Payment Withdrawn
---------------- -----------------
1st 6%
2nd 6%
3rd 5%
4th 5%
5th 4%
6th 4%
7th 2%
Thereafter 0%
FORM T1575Z
16
For purposes of computing the Surrender Charge,
the oldest Purchase Payments are deemed to be
withdrawn first, and Purchase Payments are deemed
to be withdrawn before any amounts in excess of
Purchase Payments are withdrawn from an Owner's
Account. The following transactions will be
considered as withdrawals for purposes of
computing the Surrender Charge: total surrender,
partial withdrawal, commencement of an annuity
payment option and termination due to insufficient
Owner Account Value.
Surrender Charge The Surrender Charge will not apply:
Exceptions
(1) To any amounts in excess of Purchase Payments
that are withdrawn from an Owner's Account;
or
(2) To any amounts in excess of the amount
permitted by the 10% Free Withdrawal
Privilege if such amounts are required to be
withdrawn to obtain or retain favorable
federal tax treatment; (the granting of this
exception is subject to American Franklin's
approval);
(3) Upon the death of the Annuitant at any age
during the Payout Period;
(4) Upon the death of the Annuitant at any age
during the Accumulation Period if no
Contingent Annuitant survives;
(5) Upon the death of the Owner, including the
first to die in the case of joint Owners, of
a Non-Qualified Contract, unless the Contract
is being continued under the special rule for
a surviving spouse as defined under Internal
Revenue Code Section 72(s);
(6) Upon selection of an annuity payment option
involving payments for at least 10 years;
(7) Upon selection of an annuity payment option
based on life contingencies if life
expectancy is at least 10 years.
10% Free Withdrawal The Surrender Charge does not apply to that
Privilege portion of each withdrawal or a total surrender in
any Contract Year that does not exceed:
(1) Ten Percent (10%) of the amount of Purchase
Payments not previously withdrawn that have
been credited to this Contract for at least
one year, but not more than seven years; less
(2) The amount of any previous withdrawals during
such Contract Year.
For withdrawals under a systematic withdrawal
plan, Purchase Payments credited for 30 days or
more are eligible for the 10% Free Withdrawal
Privilege.
FORM T1575Z
17
If multiple withdrawals are made during a Contract
Year, the amount eligible for the free withdrawal
will be recalculated at the time of each partial
withdrawal. After the first Contract Year, non-
automatic and automatic withdrawals may be made in
the same Contract Year subject to the 10%
limitation.
A free withdrawal pursuant to any of the foregoing
Surrender Charge Exceptions is not deemed a
withdrawal of Purchase Payments except for
purposes of computing the 10% free withdrawal
privilege.
ANNUAL CONTRACT FEE
Manner of An Annual Contract Fee not to exceed $30.00 will
Deducting be deducted at the end of each Contract Year prior
to the Annuity Commencement Date. The fee will be
allocated among the Guarantee Periods and
Divisions in proportion to the Owner's Account
Value in each. The entire fee for the year will
be deducted from the proceeds of any full
surrender of this Contract.
TAX CHARGE
Right to Impose American Xxxxxxxx reserves the right to impose
additional charges or establish reserves for any
federal, state or local taxes incurred or that may
be incurred by American Xxxxxxxx, and that may be
deemed attributable to the Contracts.
DEATH BENEFIT
Death Benefit If the Annuitant dies before the Annuity
Commencement Date, and is survived by a Contingent
Annuitant, the Contract will be continued with the
Contingent Annuitant being named the Annuitant.
If this is a Non-Qualified Contract, this Contract
may qualify for continuation under the
"Distribution of Death Benefit under Non-Qualified
Contracts" provision. Otherwise, American
Xxxxxxxx will pay the death benefit to the
Beneficiary if one of the following dies prior to
the Annuity Commencement Date:
(1) The Annuitant (provided that no Contingent
Annuitant survives); or
(2) The Owner of a Non-Qualified Contract
(including the first to die in the case of
joint Owners).
If the Annuitant or such Owner dies, the amount of
the death benefit will be the greater of the
following amounts, less any applicable Premium
Tax:
(1) The sum of all Net Purchase Payments less any
prior partial withdrawals; or
FORM T1575Z
18
(2) The Owner's Account Value as of the end of
the Valuation Period in which American
Xxxxxxxx receives at its Administrative
Office proof of the Annuitant's or such
Owner's death and a written request from
the Beneficiary as to the form of payment.
The death benefit will not be less than the amount
payable on a full surrender at the date used to
value the death benefit. The death benefit will
be paid when American Xxxxxxxx receives at its
Administrative Office:
(1) Proof of the Owner's or Annuitant's death;
and
(2) A written request from the Beneficiary for
either a single sum or payment under an
Annuity Option.
If the Annuitant dies, and a Contingent Annuitant
was named but predeceased the Annuitant, American
Xxxxxxxx will require proof of the Contingent
Xxxxxxxxx's death in addition to proof of the
death of the Annuitant.
American Xxxxxxxx will pay a single sum to the
Beneficiary unless an Annuity Option is chosen.
If the Annuitant dies on or after the Annuity
Commencement Date, the Beneficiary will receive
the death benefit, if any, provided by the Annuity
Option in effect.
PAYMENT OF BENEFITS
Application of Owner's Unless directed otherwise, American Franklin will
Account Value apply the Fixed Account Value to provide a Fixed
Annuity, and the Separate Account Value to provide
a Variable Annuity.
The Owner must tell American Franklin in writing
at its Administrative Office at least 30 days
prior to the Annuity Commencement Date if Fixed
and Separate Account values are to be applied in
different proportions. Transfers and partial
withdrawals will be permitted within the 30-day
period.
Annuity The Annuity Commencement Date (Annuity Date) is
Commencement Date shown on page 3. Payments under a Qualified
Contract or a Section 457 Contract generally must
begin no later than April 1 following the calendar
year in which the Annuitant attains age 70-1/2 or
(except in the case of an Individual Retirement
Annuity) retires to comply with certain federal
tax requirements. The Annuity Date may be changed
by written notice to American Franklin's
Administrative Office from the Owner, subject to
the approval of American Franklin.
Annuity Options The Owner may elect to have annuity payments made
Available to a beginning on the Annuity Commencement Date under
Contract Owner any one of the Annuity Options described in this
Contract. American Xxxxxxxx will notify the Owner
60 to 90 days prior to the scheduled Annuity Date
that the Contract is scheduled to mature, and
request that an Annuity Option be selected. If
the Owner has not selected an Annuity Option 10
days prior to the Annuity Commencement Date,
American Xxxxxxxx will proceed as follows:
FORM T1575Z
19
If the scheduled Annuity Commencement Date is any
date prior to the Annuitant's 99th birthday,
American Xxxxxxxx will extend the Annuity
Commencement Date to the Annuitant's 99th
birthday, subject to various state limitations.
If the scheduled Annuity Commencement Date is the
Annuitant's 99th birthday, the Account Value less
any applicable Surrender Charges, Annual Contract
Fee and Premium Taxes will be paid in one sum to
the Owner.
Options Available The Owner may elect, in lieu of payment in one
to Beneficiary sum, that any amount or part thereof due under
this Contract be applied under any of the Annuity
Options described below. Within 60 days after the
death of the Annuitant or Owner, the Beneficiary
may make such election if the Owner has not done
so. In such case, the Beneficiary thereafter
shall have all the rights and options of the
Owner.
The first annuity payment under any Annuity Option
shall be made on the first day of the second month
after approval of the claim for settlement.
Subsequent payments shall be made periodically in
accordance with the manner of payment elected.
Payment Contract At such time as one of these Annuity Options
becomes effective, this Contract shall be
surrendered to American Franklin at its
Administrative Office in exchange for a
payment contract providing for the option elected.
Fixed Annuity Fixed Annuity Payments start on the Annuity
Payments Commencement Date. The amount of the first
monthly payment for the Annuity Option selected
will be at least as favorable as that produced by
the applicable annuity tables of this Contract for
each $1,000 applied as of the end of the Valuation
Period that contains the tenth day prior to the
Annuity Commencement Date.
The dollar amount of any payments after the first
payment is specified during the entire period of
annuity payments, according to the provisions of
the Annuity Option selected.
VARIABLE ANNUITY PAYMENTS
Annuity Units American Franklin converts the Division
Accumulation Units into Division Annuity Units at
the values determined at the end of the Valuation
Period which contains the tenth day prior to the
Annuity Commencement Date. The number of Division
Annuity Units remains constant as long as an
annuity remains in force and allocation among the
Divisions has not changed.
Each Division Annuity Unit Value was arbitrarily
set when the Division first converted Division
Accumulation Units into Division Annuity Units.
Subsequent values on any Valuation Date are equal
to the previous Division Annuity Unit Value times
the Net Investment Factor for that Division for
the Valuation Period ending on that Valuation
Date, with an offset for the 3-1/2% assumed
interest rate used in the
FORM T1575Z
20
annuity tables of this Contract.
Variable Annuity Payments start on the Annuity
Commencement Date. Payments will vary in amount
and are determined at the end of the Valuation
Period that contains the tenth day prior to each
payment. If the monthly payment under the Annuity
Option selected is based on a single Division, the
monthly payment is found by multiplying the
Division Annuity Unit Value on such date by the
number of Division Annuity Units.
If the monthly payment under the Annuity Option
selected is based upon more than one Division, the
above procedure is repeated for each applicable
Division. The sum of these payments is the
Variable Annuity Payment.
American Franklin guarantees that the amount of
each payment will not be affected by variations in
expense or mortality experience.
ANNUITY OPTIONS
First Option - Life Annuity. An annuity payable
monthly during the lifetime of the Annuitant,
ceasing with the last annuity payment due prior to
the death of the Annuitant.
Second Option - Life Annuity with 120, 180, or 240
Monthly Payments Certain. An annuity payable
monthly during the lifetime of the Annuitant
including the commitment that if, at the death of
the Annuitant, annuity payments have been made for
less than 120 months, 180 months, or 240 months
(as selected by the Owner in electing this
option), annuity payments shall be continued
during the remainder of the selected period to the
Beneficiary.
Third Option - Joint and Last Survivor Life
Annuity. An annuity payable monthly during the
joint lifetime of the Annuitant and a secondary
annuitant, and thereafter during the remaining
lifetime of the survivor, ceasing with the last
annuity payment due prior to the death of the
survivor.
Fourth Option - Payments for a Designated Period.
An amount payable monthly for a number of years
which may be from five to 40 (as selected by the
Owner in electing this option). If this option is
selected on a variable basis, the number of years
may not exceed the life expectancy of the
Annuitant or other properly-designated payee.
Fifth Option - Payments of a Specified Dollar
Amount. The amount due will be paid in equal
monthly annuity payments of a designated dollar
amount (not less than $125 nor more than $200 per
annum per $1,000 of the original amount due) until
the remaining balance is less than the amount of
one annuity payment, at which time such balance
will be paid and will be the final annuity payment
under this option. Payments under this option are
available on a fixed basis only. The remaining
balance at the end of any month is determined by
decreasing the balance at the end of the previous
month by the amount of any
FORM T1575Z
21
installment paid during the month and by adding to
the result interest at a rate not less than 3.5%
compounded annually. Upon the death of the payee
under this option, payments will be continued to
the Beneficiary until such remaining balance is
paid.
In lieu of monthly payments, payments may be
elected on a quarterly, semi-annual or annual
basis, in which cases the amount of each annuity
payment will be determined on a basis consistent
with that described in this Contract for monthly
payments.
No election of any Annuity Option may be made in
the case where a Fixed or Variable Annuity is
elected, unless a minimum initial annuity payment
of $100 will be provided. No election of any
Annuity Option may be made in the case where a
combination of a Fixed and a Variable Annuity is
elected, unless a minimum initial annuity payment
of $50 on each basis will be provided. If the
initial annuity payment does not meet the minimum
amount required for the Annuity Option elected,
American Franklin will provide a less frequent
payment schedule. If the minimum is still not
met, American Xxxxxxxx will make a lump-sum
payment of the Owner's Account Value (less any
Surrender Charge, uncollected Annual Contract Fee
and applicable Premium Tax) as of the date of this
determination to the Annuitant or other properly-
designated payee.
If the age of the Annuitant has been misstated to
American Franklin, any amount payable will be that
which would have been payable had the misstatement
not occurred. American Franklin will deduct any
overpayment from the next payment or payments due
and add any underpayments to the next payment due.
Interest at an effective annual rate of 3.5% will
be added to any such adjustment.
Annuity Tables The tables that follow show the dollar amount of
the first monthly payment for each $1,000 applied
under the Annuity Options. Under the First or
Second Options, the amount of each payment will
depend upon the Annuitant's adjusted age at the
time the first payment is due. Under the Third
Option, the amount of each payment will depend
upon the adjusted ages of both Annuitants at the
time the first payment is due.
In using the table of annuity payment rates, the
ages of the Annuitants must be reduced by one year
for Annuity Commencement Dates occurring during
the decade 2000-2009, reduced two years for
Annuity Commencement Dates occurring during the
decade 2010-2019, and reduced an additional year
for each decade that follows. The age 70 rate is
also used for ages above 70.
Alternate Amount of If a fixed life income option is elected, the
Installments Under Fixed Owner (or if the Owner has not elected a payment
Life Income Options option, the Beneficiary) may elect life income
payments equal to those provided by those fixed
single premium immediate annuity option rates in
use by American Xxxxxxxx when annuity payments
begin.
FORM T1575Z
22
ANNUITY TABLES
AMOUNT OF MONTHLY PAYMENT
FOR EACH $1,000 OF ANNUITY VALUE
Options 1 and 2 - Life Annuities
Adjusted Unisex Age Monthly Payments Guaranteed
Option 1 Option 2 Option 2 Option 2
None 120 180 240
50 4.18 4.15 4.12 4.07
51 4.24 4.21 4.18 4.12
52 4.31 4.28 4.24 4.17
53 4.38 4.34 4.30 4.23
54 4.45 4.41 4.36 4.28
55 4.53 4.48 4.43 4.34
56 4.61 4.56 4.50 4.40
57 4.70 4.64 4.57 4.46
58 4.79 4.73 4.65 4.52
59 4.89 4.82 4.72 4.59
60 5.00 4.91 4.81 4.65
61 5.11 5.02 4.89 4.71
62 5.23 5.12 4.98 4.78
63 5.36 5.23 5.07 4.85
64 5.49 5.35 5.17 4.91
65 5.64 5.48 5.26 4.98
66 5.80 5.61 5.36 5.04
67 5.96 5.74 5.46 5.10
68 6.14 5.88 5.57 5.16
69 6.34 6.03 5.67 5.21
70 and above 6.54 6.19 5.77 5.27
FORM T1575Z
23
Option 3 - Joint and Last Survivor Life Annuity
Adjusted Unisex
Age of Annuitant Adjusted Age of Secondary Annuitant
50 55 60 65 70
50 3.75 3.85 3.94 4.01 4.07
55 3.85 4.00 4.13 4.24 4.33
60 3.94 4.13 4.32 4.49 4.65
65 4.01 4.24 4.49 4.75 5.00
70 4.07 4.33 4.65 5.00 5.36
Option 4 - Payments for a Designated Period
Years of Amount of Monthly Years of Amount of Monthly
Payment Payment Payment Payment
5 $18.12 23 $5.24
6 15.35 24 5.09
7 13.38 25 4.96
8 11.90 26 4.84
9 10.75 27 4.73
10 9.83 28 4.63
11 9.09 29 4.53
12 8.46 30 4.45
13 7.94 31 4.37
14 7.49 32 4.29
15 7.10 33 4.22
16 6.76 34 4.15
17 6.47 35 4.09
18 6.20 36 4.03
19 5.97 37 3.98
20 5.75 38 3.92
21 5.56 39 3.88
22 5.39 40 3.83
FORM T1575Z
24
THE CHAIRMAN-TM- COMBINATION FIXED AND VARIABLE ANNUITY CONTRACT
ISSUED BY
THE AMERICAN FRANKLIN LIFE INSURANCE COMPANY
This is a FLEXIBLE PAYMENT VARIABLE and FIXED INDIVIDUAL DEFERRED ANNUITY
CONTRACT. NONPARTICIPATING -- NOT ELIGIBLE FOR DIVIDENDS.
All payments and values provided by this Contract, when based on the investment
experience of a separate account, are variable, may increase or decrease and are
not guaranteed as to amount. See the "Separate Account" and "Variable Annuity
Payments" provisions in this Contract.
For Information, Service or to make a Complaint
Contact a Registered Representative,
or the AMFLIC Annuity Service Center
AMFLIC Annuity Service Center
P.O. Box 4636
Houston, Texas 77210-4636
(000) 000-0000
(000) 000-0000
[American Franklin Logo]
A STOCK COMPANY
A Subsidiary of American General Corporation
FORM T1575Z
