EXHIBIT 5
First SunAmerica Life Insurance Company
A STOCK COMPANY NEW YORK, NEW YORK
CONTRACT NUMBER P9999999999
OWNER XXXX XXX
EXECUTIVE OFFICE ANNUITY SERVICE CENTER
000 XXXXX XXXXXX, 0xx XXXXX XX XXX 00000
XXX XXXX, XXX XXXX 00000 XXX XXXXXXX, XX 00000-0000
FIRST SUNAMERICA LIFE INSURANCE COMPANY ("We", "Us", the "Company", or "First
SunAmerica ") agrees to provide benefits to the Owner in accordance with the
provisions set forth in this Contract and in consideration of the Application
and Purchase Payments We receive.
The value of amounts allocated to the Separate Account during the accumulation
and annuity periods is not guaranteed, and will increase or decrease based upon
the investment experience of the Variable Portfolios You choose.
The Separate Account Charge is charged against the assets of the Separate
Account. This charge includes fees for mortality and expense risk and the
distribution expense. On an annualized basis, the charge equals [1.55%]. These
charges are assessed, on a simple interest basis, as a percentage of the average
daily ending value of the assets attributable to the Accumulation Units of the
Variable Portfolios to which your Contract Value is allocated. The daily charge
is 1/365th of the annualized charge. Thus, the smallest annual effective rate of
the investment return that would have to be earned on assets of the Separate
Account so that the dollar amount of variable annuity payments will not decrease
is [5.12%], compounded daily. [The Contract's rate of return is based on
compound interest.]
RIGHT TO EXAMINE - If, within 10 days of receipt of this Contract (60 days if
the Contract replaces any other life insurance or annuity contract(s)) You are
not satisfied with it, You may return this Contract to Our Annuity Service
Center or to the agent through whom the Contract was purchased. The Company will
refund the Purchase Payment or the Contract Value, whichever is greater,
calculated as of the business day during which we receive the Contract. Upon
such refund, the Contract shall be void.
For Individual Retirement Annuities, or if a refund of the Purchase Payment(s)
is otherwise required We reserve the right to allocate Your Purchase Payment(s)
to the cash management portfolio until the end of the Right To Examine period.
Thereafter, allocations will be made as selected by You on Your Application.
THIS IS A LEGAL DOCUMENT. READ IT CAREFULLY.
/s/ XXX X. XXXXXXX
--------------------------------
Xxx X. Xxxxxxx
President
INDIVIDUAL FIXED AND VARIABLE
DEFERRED ANNUITY CONTRACT
Nonparticipating
FS-975 (7/04) 1
TABLE OF CONTENTS
Contract Data Page .......................................................Page 3
Definitions...............................................................Page 4
Purchase Payment Provisions...............................................Page 7
Accumulation Provisions...................................................Page 8
Charges and Deductions...................................................Page 10
Transfer Provision.......................................................Page 11
Withdrawal Provisions....................................................Page 11
Death Provisions.........................................................Page 13
Annuity Provisions.......................................................Page 16
General Provisions.......................................................Page 18
Annuity Payment Options .................................................Page 21
Fixed Annuity Payment Options Table......................................Page 22
Variable Annuity Payment Options Table...................................Page 25
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CONTRACT DATA PAGE
Contract Number: Annuity Service Center:
P9999999999 P. O. XXX 00000
XXX XXXXXXX, XX 00000-0000
Owner: Age at Issue:
XXXX XXX 35
Annuitant: Initial Purchase Payment:
XXXX XXX $10,000.00
Specified Annuity Date: Contract Date:
May 1, 2034 May 1, 2004
Latest Annuity Date: Fixed Account Options:
May 1, 2064 Minimum Guarantee Rate:
[1.50%]
Beneficiary:
As named by You
Separate Account Charge: Annual Contract Maintenance Fee:
[1.55%] $30.00
Separate Account:
[FS Variable Annuity Account 5]
Withdrawal Charge Schedule:
Number of Full Years Elapsed Withdrawal Charge as a
Between Purchase Payment Contribution Percentage of Withdrawn
And Date of Withdrawal Purchase Payment
------------------------------------- -----------------------
0 7%
1 6%
2 5%
3 0%
Optional Elections: Optional Election Charges:
Optional Death Benefit Elected:
Maximum Anniversary Death Benefit 0.20%
Optional Living Benefit Elected:
Guaranteed Minimum Account Value
For Inquiries
[Call 0-000-000-0000]
FS-975 (7/04) 3
DEFINITIONS
Defined in this section are some of the words and phrases used in this Contract.
These terms are capitalized when used in the Contract with the meaning set forth
below.
ACCUMULATION UNIT
A unit of measurement used to compute the Contract Value in a Variable Portfolio
prior to the Annuity Date.
AGE
Age as of last birthday.
ANNUITANT
The natural person(s) whose life (lives) is(are) used to determine the annuity
benefits under the Contract. If the Contract is in force and the Annuitant(s)
is(are) alive on the Annuity Date, We will begin payments to the Payee. This
Contract cannot have Joint Annuitants if it is issued in connection with a
tax-qualified retirement plan.
ANNUITY DATE
The date on which annuity payments ("income payments") to the Payee begin. This
date cannot be later than the Latest Annuity Date.
ANNUITY SERVICE CENTER
As specified on the Contract Data Page.
ANNUITY UNIT
A unit of measurement determined on or after the Annuity Date used to compute
annuity payments from the Variable Portfolio(s).
BENEFICIARY
The Beneficiary is as named by You at issue to receive the death benefit under
this Contract upon Your death. You may later change Your Beneficiary in a
written request to Us at Our Annuity Service Center.
CONTINUATION DATE
The Date on which We receive, at Our Annuity Service Center: (a) the Spousal
Beneficiary's satisfactory written request to continue the Contract, and (b) Due
Proof of Death of the Owner. If We receive (a) and (b) on different dates, the
Continuation Date will be the later date.
CONTRACT DATE
The date Your Contract is issued, as shown on the Contract Data Page. It is the
date from which Contract Years and Contract anniversaries are measured.
CONTRACT VALUE
The sum of: (1) Your share of the Variable Portfolios' Accumulation Unit Values
and (2) the value of amounts if any, allocated to any available Fixed Account
Options.
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CONTRACT YEAR
One year starting from the Contract Date in one calendar year and ending on the
day preceding the anniversary of such date in the succeeding calendar year.
DEATH BENEFIT ADJUSTMENT
Any increase or reduction to the amount of the death benefit payable to account
for Purchase Payment and/or Withdrawal activity after a specified point in time
which will equal (a), (b), or (c), which ever is applicable, as follows:
(a) Where only Purchase Payments are received after the specified
point in time, the dollar value of the Purchase Payments will be
added to the death benefit payable; or
(b) Where only Withdrawals are made after the specified point in
time, the Withdrawal will reduce the death benefit payable in
the same proportion that the Contract Value was reduced at the
time of the Withdrawal; or
(c) Where Purchase Payments have been received and Withdrawals made
after the specified point in time, the death benefit amount
payable will be increased by Purchase Payment(s) received after
that specified point in time and reduced by any Withdrawal made
after that specified point in time in the same proportion that
the Contract Value was reduced at the time of the Withdrawal.
[DOLLAR COST AVERAGING (DCA)
An optional program under which You authorize the systematic transfer of
specified amounts or percentages from any source account to any target account.]
FIXED ACCOUNT OPTIONS
The investment options, if available under this Contract, which become part of
the Company's general asset account and are credited with a fixed rate of
interest declared by the Company. The general asset account contains all the
assets of the Company except for the Separate Account and other segregated asset
accounts. The amount You have in any Fixed Account Option at any time is a
result of any Purchase Payment You have allocated to it or any part of Your
Contract Value You have transferred to it.
FIXED ANNUITIZATION
A series of periodic income payments of predetermined amounts that do not vary
with investment experience. Such payments are made from the Company's general
asset account. This Contract provides several fixed annuity payment options.
GUARANTEE PERIOD
The period for which interest is credited to amounts allocated to any available
Fixed Account Options. We determine in Our sole discretion the periods, if any,
that will be offered.
IRC
The Internal Revenue Code of 1986, as amended, or as it may be amended or
superseded.
JOINT OWNER
Any person named as Joint Owner on the Application and listed on the Contract
Data Page, unless subsequently changed. The Joint Owner, if any, possesses an
undivided interest in this Contract in conjunction with the Owner. All
references within this Contract to Owner will also apply to the Joint Owner. We
reserve Our right to require that Joint Owners be each others' spouse.
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LATEST ANNUITY DATE
The later of the Owner's [90th] birthday or ten years after the Contract Date.
NET PURCHASE PAYMENT
The sum of all Purchase Payment(s), reduced for each Withdrawal in the same
proportion that the Contract Value is reduced by each such Withdrawal.
NYSE
New York Stock Exchange.
OWNER
The person or entity named in the Contract who is entitled to exercise all
rights and privileges of ownership under the Contract. Owner means both Joint
Owners, if applicable.
PAYEE
The person receiving payment of annuity benefits under this Contract.
PURCHASE PAYMENTS
Payments in U.S. currency made by or on behalf of the Owner to the Company to
fund the Contract.
REQUIRED DOCUMENTATION
Is: (a) Due Proof of Death that the Owner or the Spousal Beneficiary died before
the Annuity Date; and (b) an election form specifying the payment options; and
(c) any other documentation We may require.
SEPARATE ACCOUNT
A segregated asset account named on the Contract Data Page. The Separate Account
consists of several Variable Portfolios, each investing in shares of the
Underlying Fund(s) of the trust(s). The assets of the Separate Account are not
commingled with the general assets and liabilities of the Company. The value of
amounts allocated to the Variable Portfolios of the Separate Account is not
guaranteed.
SPECIFIED ANNUITY DATE
The anticipated Annuity Date specified by You as shown on the Application. This
date may be changed by You in writing prior to the Annuity Date, but in no event
can it be later than the Latest Annuity Date. If this date is not specified, it
will be the Latest Annuity Date.
SPOUSAL BENEFICIARY
The original deceased Owner's surviving spouse who is designated as the primary
Beneficiary at the time of the Owner's death and may continue the Contract as
the Owner on the Continuation Date.
SUBSEQUENT PURCHASE PAYMENTS
Purchase Payments made after the initial Purchase Payment.
TOTAL INVESTED AMOUNT
The sum of all Purchase Payments less amounts previously withdrawn that incurred
a Withdrawal Charge, less Purchase Payments withdrawn that were no longer
subject to a Withdrawal Charge.
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UNDERLYING FUND
The variable investment options in which the corresponding Variable Portfolio(s)
invest.
VARIABLE ANNUITIZATION
A series of periodic income payments which vary in amount according to the
investment experience of one or more Variable Portfolios, as selected by You.
This Contract provides several variable annuity payment options.
VARIABLE PORTFOLIO
One or more divisions of the Separate Account which provides for the variable
investment options available under this Contract. Each Variable Portfolio has
its own investment objective and is invested in the Underlying Fund(s) of the
trusts. A Variable Portfolio is not chargeable with liabilities arising out of
any other Variable Portfolio. The available Variable Portfolios are shown on the
Application. Additional Variable Portfolios may become available in the future.
The Variable Portfolios may also be referred to as a Variable Subaccount and/or
Subaccount.
WE, OUR, US, THE COMPANY
First SunAmerica Life Insurance Company.
WITHDRAWAL(S)
Amount(s) withdrawn from the Contract Value including any charges and fees
applicable to each such withdrawal.
YOU, YOUR
The Owner.
PURCHASE PAYMENT PROVISIONS
PURCHASE PAYMENTS
Purchase Payments are flexible. This means that, subject to Company disclosed
restrictions, You may change the amounts, frequency and/or timing of Purchase
Payments. Purchase Payments will be allocated in accordance with instructions
from You to the Variable Portfolio(s) and/or Fixed Account Option(s), if
available. We reserve the right to specify the minimum or maximum Purchase
Payment that may be allocated to a Variable Portfolio or available Fixed Account
Option under the Contract.
DOLLAR COST AVERAGING PROGRAM
To facilitate a dollar cost averaging program, a source account and target
account(s) must be identified. Subject to Company disclosed restrictions, a
source account can be [any available 1-year fixed account, available fixed
accounts designed to facilitate Dollar Cost Averaging (DCA Fixed Account) or a
Variable Portfolio.] The target account must be a Variable Portfolio. Any
portion of a Purchase Payment allocated to any available DCA Fixed Account
Options must be transferred out to the Variable Portfolio(s) within the
specified DCA Fixed Account period. Upon termination of a DCA program using the
DCA Fixed Account as a source account, any amounts remaining in the DCA Fixed
Account will be transferred to the target allocation(s) for the program being
terminated. If money remains in a DCA Fixed Account at the time of
annuitization, that amount will be applied towards a Fixed Annuitization. The
unit values credited and applied to your Contract are
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determined on the date of transfer. We reserve the right to impose a minimum or
maximum contribution level on Purchase Payments allocated to a DCA Fixed Account
and/or change the terms and conditions of the DCA program at any time.
SUBSTITUTION OF VARIABLE PORTFOLIO
If the shares of an Underlying Fund should no longer be available for investment
by the Separate Account, then We may substitute shares of another Underlying
Fund, for shares already purchased, or to be purchased in the future.
Substitutions of securities will be carried out in accordance with any
applicable state and/or federal laws or regulations.
ACCUMULATION PROVISIONS
Prior to the Annuity Date, the Contract Value is the sum of the Separate Account
Accumulation Value and the Fixed Account Accumulation Value, if any.
SEPARATE ACCOUNT ACCUMULATION VALUE
The Separate Account Accumulation Value under the Contract shall be the sum of
the values of the Accumulation Units held in the Variable Portfolios for the
Owner.
NUMBER OF ACCUMULATION UNITS
Your Contract is credited with Accumulation Units of the Separate Account when
amounts are allocated to the Variable Portfolio(s). For that portion of each
Purchase Payment and/or transfer amount allocated to a Variable Portfolio, the
number of Accumulation Units credited is equal to the sum of each Purchase
Payment and/or transfer amount allocated to the Variable Portfolio reduced by
premium taxes, if any:
Divided by
The Accumulation Unit value for that Variable Portfolio for the NYSE business
day in which the Purchase Payment or transfer amount is allocated.
The number of Accumulation Units will be reduced for Withdrawals of Contract
Value, annuitizations, amounts transferred out of a Variable Portfolio, the
Contract Maintenance Fee and applicable charges for optional features as set
forth on the Contract Data Page and in applicable endorsements to this Contract.
Reductions will be made as of the NYSE business day in which We receive all
requirements for the transaction, as appropriate.
ACCUMULATION UNIT VALUE (AUV)
The AUV of a Variable Portfolio for any NYSE business day is calculated by
subtracting (2) from (1) and dividing the result by (3) where:
(1) is the total value at the end of the given NYSE business day of the
assets attributable to the Variable Portfolio minus any applicable
liabilities other than those owed to the Contractholders;
(2) is the amount equal to the daily Separate Account Charge plus the daily
charge for any optional features that impose a daily charge;
(3) is the number of Accumulation Units outstanding at the end of the given
NYSE business day.
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FIXED ACCOUNT ACCUMULATION VALUE
The Fixed Account Accumulation Value, if any, shall be the sum of all monies
allocated or transferred to the Fixed Account Option(s), if available, reduced
by any applicable premium taxes, plus all interest credited on the Fixed Account
Option(s) during the period that You have Contract Value allocated to the Fixed
Account Options. This amount shall be adjusted for Withdrawals, annuitizations,
transfers, and the deduction of the Contract Maintenance Fee and applicable
charges for elected features as set forth in endorsements to this Contract. The
Fixed Account Accumulation Value shall not be less than the minimum values
required by law in the state where this Contract is issued.
FIXED ACCOUNT GUARANTEE PERIOD OPTIONS AND INTEREST CREDITING
The portion of Your Contract Value within the Fixed Account, if any, is credited
with interest at rates guaranteed by Us for the Guarantee Period(s) selected.
Interest is credited on a daily basis at the then applicable effective interest
rate for the applicable Guarantee Period. You may select from one or more
Guarantee Periods which We may offer at any particular time. We reserve the
right at any time to add or delete Guarantee Periods. If You have allocated any
part of Your initial Purchase Payment to a Guarantee Period, the amount
allocated, as well as the duration of the Guarantee Period is shown on the
Application as completed by You. The interest rate applicable to an allocation
of Purchase Payment or transfer of Contract Value to a Guarantee Period is the
rate in effect for that Guarantee Period at the time of the allocation or
transfer. If You have allocated or transferred amounts at different times to the
Fixed Account, each allocation or transfer may have a unique effective interest
rate associated with that amount. We guarantee that the effective annual rate of
interest for the Fixed Account, including any of the available Guaranteed
Periods, will not be less than the Minimum Guarantee Rate as mandated by Your
state, and shown on the Contract Data Page.
CHARGES AND DEDUCTIONS
We will deduct the following charges from the Contract:
CONTRACT MAINTENANCE FEE
The charge specified on the Contract Data Page will be deducted on each Contract
anniversary that occurs on or prior to the Annuity Date. It will also be
deducted when the Contract Value is withdrawn in full if the Withdrawal is not
on the Contract anniversary. We reserve the right to assess this charge on a
class basis that differs from the charge specified on the Contract Data Page. We
also reserve the right to waive the fee for Contracts with a value of
[$50,000.00] or greater on the Contract anniversary.
WITHDRAWAL CHARGE
The charge, if any, may be deducted upon withdrawal of any portion of the
Contract Value. See the Contract Data Page for the Withdrawal Charge.
SEPARATE ACCOUNT CHARGE
This charge, as shown on the Contract Data Page, on an annualized basis equals a
percentage of the average daily ending value of the assets attributable to the
Accumulation Units of the Variable Portfolio(s) to which the Contract is
allocated. This charge compensates Us for mortality and expense risks and
distribution expenses associated with the Contract. We subtract this charge
daily.
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We reserve the right to assess a charge on a class basis which is less
than the charge specified on the Contract Data Page.
TRANSFER PROVISIONS
Prior to the Annuity Date, You may transfer all or part of Your Contract Value
from any Variable Portfolio to any other Variable Portfolio(s) or available
Fixed Account Options [other than the DCA Fixed Account options] subject to
certain restrictions. The minimum amount that can be transferred and the amount
that can remain in a Variable Portfolio or available Fixed Account Option are
subject to Company limits. We reserve the right to charge a fee of [$25.00] for
transfers if the number of transfers exceeds a limit of [fifteen (15)] in any
Contract Year. [Automatic asset rebalancing and/or transfers arising out of the
DCA program are not counted against the 15 allowable free transfers.] We further
reserve the right to restrict Your transfer privileges, including possible
termination of those privileges in Our sole discretion.
TRANSFERS OF ACCUMULATION AND ANNUITY UNITS BETWEEN VARIABLE PORTFOLIOS AND
FIXED ACCOUNTS
Prior to the Annuity Date, you may transfer all or a portion of Your Contract
Value from one Variable Portfolio to another Variable Portfolio(s) or to any
available Fixed Account Option(s) [other than the DCA Fixed Account Options]. A
transfer from a Variable Portfolio will result in the redemption of Accumulation
Units in that Variable Portfolio and the purchase of Accumulation Units in the
other Variable Portfolio. Transfers will be effected at the end of the NYSE
business day in which We receive Your completed request for the transfer. You
may also transfer from any available Fixed Account Option(s) to the Variable
Portfolio(s) and/or to any available Fixed Account Option(s) of the Contract
[other than the DCA Account Options].
After the Annuity Date, transfers into and out of any available Fixed Account
Option(s) are not allowed. You may transfer all or a portion of Your Contract
Value from one Variable Portfolio to another Variable Portfolio(s). A transfer
will result in the redemption of Annuity Units in a Variable Portfolio and the
purchase of Annuity Units in the other Variable Portfolio. Transfers will be
effected for the last NYSE business day [of the month] in which We receive Your
request for the transfer.
WITHDRAWAL PROVISIONS
On or before the Annuity Date and while the Owner is living, You may withdraw
all or part of Your Contract Value under this Contract by informing Us at Our
Annuity Service Center. For a full withdrawal, this Contract must be returned to
Our Annuity Service Center. The minimum amount that can be withdrawn and the
minimum amount that must remain after withdrawal are subject to Company limits.
Unless You tell Us otherwise in writing, Withdrawals will be deducted from the
Contract Value in proportion to their allocation among any available Fixed
Account Options and the Variable Portfolios. Withdrawals will be based on values
for the NYSE business day in which the request for withdrawal and the Contract
(in the case of a full withdrawal), are received at Our Annuity Service Center.
Unless the SUSPENSION OF PAYMENTS or DEFERMENT OF PAYMENTS sections are in
effect, payment of withdrawals will be made within seven calendar days.
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WITHDRAWAL CHARGE
Withdrawals of all or a portion of the Contract Value may be subject to a
Withdrawal Charge as shown on the Contract Data Page. The Withdrawal Charge
percentage applied to any withdrawal will depend on how long the Purchase
Payment to which the withdrawal is attributed has been in the Contract. No
Withdrawal Charge is deducted on an amount which is considered a Penalty-Free
Withdrawal, except for full Surrenders.
For the purpose of determining the Withdrawal Charge, a withdrawal will be
attributed to amounts in the following order: (1) Penalty-Free earnings in the
Contract; (2) Purchase Payments which are no longer subject to the Withdrawal
Charge and not yet withdrawn; (3) any remaining Penalty-Free Withdrawal amount
(except in the case of a full surrender); and (4) Purchase Payments subject to a
Withdrawal Charge. Purchase Payments, when withdrawn, are assumed to be
withdrawn on a first-in-first-out (FIFO) basis. You will not receive the benefit
of a Penalty-Free Withdrawal in the case of a full surrender.
The Withdrawal Charge will be assessed against the Variable Portfolio(s) and the
available Fixed Account Option(s) in the same proportion as the remaining
Contract Value is allocated unless You request that the Withdrawal come from a
particular Variable Portfolio or available Fixed Account Option. After a
Withdrawal is taken, the remaining Contract Value must be sufficient to cover
any Withdrawal Charge remaining upon full surrender of the Contract.
PENALTY-FREE WITHDRAWALS
As of any day, You may make a withdrawal of up to the Penalty-Free Withdrawal
amount for that day without incurring a Withdrawal Charge. Any Penalty-Free
Withdrawal made in excess of penalty-free earnings in the Contract is considered
to be a withdrawal of future penalty-free earnings and is therefore not a
withdrawal of the Total Invested Amount. On any day, penalty-free earnings in
the Contract are calculated as the Contract Value at the end of that day less
the Total Invested Amount.
During the first Contract Year, the maximum Penalty-Free Withdrawal amount is
equal to the penalty-free earnings in the Contract as of the date of withdrawal.
Alternatively, during the first Contract Year, You may make withdrawals of the
Penalty-Free Withdrawal amount through the Systematic Withdrawal Program. The
maximum Penalty-Free Withdrawal amount as of any systematic withdrawal date is
[10%] of the Total Invested Amount less any withdrawals already made during the
Contract Year.
[After the first Contract Year,] the maximum Penalty-Free Withdrawal amount as
of the date of the withdrawal is the greater of:
(a) penalty-free earnings in the Contract as of that date; or
(b) [10%] of the Total Invested Amount, less any withdrawals already made
during the year.
Although amounts withdrawn free of a Withdrawal Charge reduce Contract Value,
they do not reduce the Total Invested Amount for purposes of calculating the
Withdrawal Charge or for the purposes of calculating penalty-free earnings in
the Contract. As a result, You will not receive the benefit of a Penalty-Free
Withdrawal in a full surrender.
SYSTEMATIC WITHDRAWAL PROGRAM
Prior to the Annuity Date, You may elect to participate in a Systematic
Withdrawal Program by informing Us at Our Annuity Service Center. The Systematic
Withdrawal Program allows You to
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make automatic withdrawals from Your Contract Value monthly, quarterly,
semiannually or annually. The minimum systematic withdrawal amount is [$100].
Any amount withdrawn through the Systematic Withdrawal Program may be subject to
a Withdrawal Charge as discussed in the WITHDRAWAL CHARGE and PENALTY-FREE
WITHDRAWALS provisions. You may terminate Your participation in the Systematic
Withdrawal Program at any time by sending Us a written request to Our Annuity
Service Center. We reserve the right to modify, suspend or terminate the
Systematic Withdrawal Program at any time.
Systematic withdrawals will be deducted first from the Penalty-Free Withdrawal
amount available each Contract Year.
DEATH PROVISIONS
Notwithstanding any provision of this Contract to the contrary, all payments of
benefits under this Contract will be made in a manner that satisfies the
requirements of IRC Section 72(s), as amended from time to time. If the Contract
is owned by a trust or other non-natural person, We will treat the death of any
Annuitant as the death of the "Primary Annuitant" and as the death of any Owner.
DUE PROOF OF DEATH
Due Proof of Death means:
1. a certified copy of a death certificate; or
2. a certified copy of a decree of a court of competent
jurisdiction as to the finding of death; or
3. a written statement by a medical doctor who attended the
deceased Owner at the time of death; or
4. any other proof satisfactory to Us.
DEATH OF OWNER BEFORE THE ANNUITY DATE
We will pay a death benefit to the Beneficiary upon Our receiving all Required
Documentation. Unless You have previously designated a payment option on behalf
of the Beneficiary, the Beneficiary must select one of the following options:
1. Immediately collect the death benefit in a lump sum payment. If
a lump sum payment is elected, payment will be in accordance
with any applicable laws and regulations governing payments on
death; or
2. Collect the death benefit in the form of one of the Annuity
Payment Options. If an Annuity Payment Option is desired, an
option must be elected within 60 days of Our receipt of Required
Documentation. The payments must be over the life of the
Beneficiary or over a period not extending beyond the life
expectancy of the Beneficiary. Payments under this option must
commence within one year after the Owner's death, otherwise, the
death benefit will be paid in accordance with option 1 above; or
3. If eligible, continue the Contract as the Spousal Beneficiary.
On the Continuation Date, We will contribute to the Contract any
amount by which the death benefit exceeds the Contract Value,
calculated as of the Owner's date of death. This amount is not
considered a Purchase Payment except in the calculation of
certain death
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benefits upon the death of the Spousal Beneficiary. If this
option is elected, no death benefit is paid.
Upon the Spousal Beneficiary's death, the entire interest of the Contract must
be distributed immediately under option 1 or 2 as provided under DEATH OF OWNER
BEFORE THE ANNUITY DATE
In any event, where a death benefit is due and payable, the entire interest in
the Contract will be distributed within five years from the date of the Owner's
death.
AMOUNT OF DEATH BENEFIT
If the Owner was age [82 or younger] on the Contract Date, [and death occurs
prior to the [90th] birthday,] upon Our receipt of all Required Documentation at
Our Annuity Service Center, We will calculate the death benefit and it will be
the greater of:
(1) [100% of] the Contract Value for the NYSE business day during
which We receive all Required Documentation at Our Annuity
Service Center; or
(2) [100% of] Net Purchase Payment(s) received prior to the Owner's
[86th] birthday.
If the Owner was at least age [83 but younger than age 86] on the Contract Date,
[and death occurs prior to the Owner's [90th] birthday,] upon Our receipt of all
Required Documentation at Our Annuity Service Center, We will calculate the
death benefit and it will be the greater of:
(1) [100% of] Contract Value for the NYSE business day during which
We receive all Required Documentation at Our Annuity Service
Center; or
(2) The lesser of:
a) [100% of] Net Purchase Payment(s) received prior to the
Owner's [86th ] birthday; or
b) [125% of] the Contract Value for the NYSE business day
during which We receive all Required Documentation at
Our Annuity Service Center.
[If the Owner was age [90] or older at the time of death, the death benefit will
be the Contract Value for the NYSE business day during which We receive all
Required Documentation at Our Annuity Service Center.]
Spousal Beneficiary Continuation
If the Spousal Beneficiary was age [82 or younger] on the Continuation Date,
upon Our receipt of all Required Documentation at Our Annuity Service Center, We
will calculate the death benefit and it will be the greater of:
(1) [100% of] the Contract Value for the NYSE business day during
which We receive all Required Documentation at Our Annuity
Service Center; or
(2) [100% of] the Contract Value on the Continuation Date, and a
death benefit adjustment for Purchase Payment(s) transacted
after the Continuation Date but prior to the Spousal
Beneficiary's [86th] birthday and/or Withdrawals transacted
after the Continuation Date.
If the Spousal Beneficiary was at least age [83 but younger than age 86] on the
Continuation Date, upon Our receipt of the all Required Documentation at Our
Annuity Service Center, We will calculate the death benefit and it will be the
greater of:
FS-975 (7/04) 13
(1) [100% of] the Contract Value for the NYSE business day during
which We receive all Required Documentation at Our Annuity
Service Center; or
(2) The lesser of:
a) [100% of] the Contract Value on the Continuation Date,
and a death benefit Adjustment for Purchase Payment(s)
transacted after the Continuation Date but prior to the
Spousal Beneficiary's [86th] birthday and/or Withdrawals
transacted after the Continuation Date; or
b) [125% of] the Contract Value for the NYSE business day
during which We receive all Required Documentation at
Our Annuity Service Center.
If the Spousal Beneficiary was age [86] or older on the Continuation Date and/or
their death occurs at age [90 or older], the death benefit will be [100% of]
Contract Value for the NYSE business day during which We receive all Required
Documentation at Our Annuity Service Center.
DEATH OF OWNER OR ANNUITANT ON OR AFTER THE ANNUITY DATE
If any Owner or Annuitant dies on or after the Annuity Date and before the
entire interest in the Contract has been distributed, We will pay the remaining
portion of the annuity payout to the Beneficiary upon Our receipt of Required
Documentation. For further information pertaining to death of the Annuitant, see
ANNUITY PAYMENT OPTIONS.
BENEFICIARY
The Beneficiary is selected by the Owner. While the Owner is living and before
the Annuity Date, the Owner may change the Beneficiary by written notice in a
form satisfactory to Us. A change in Beneficiary will take effect on the date We
receive the written notice at Our Annuity Service Center. If two or more persons
are named as Beneficiaries under the Contract those surviving the Owner will
share equally unless otherwise stated; and each must elect to receive their
respective portions of the death benefit according to the options listed under
DEATH OF OWNER BEFORE THE ANNUITY DATE. If the Annuitant survives the Owner, and
there are no surviving Beneficiaries, the Annuitant will be deemed the
Beneficiary.
Joint Owners, if applicable, shall be each other's primary Beneficiary. Joint
Annuitants, if any, when the Owner is a non-natural person, shall be each
other's primary Beneficiary. Any other Beneficiary designation will be treated
as a contingent Beneficiary.
If the Owner is also the Annuitant and dies before the Annuity Date with no
surviving Beneficiaries, then upon Our receipt of all Required Documentation We
will calculate the death benefit and we will pay the death benefit to the estate
of the Owner in accordance with option 1, under DEATH OF OWNER BEFORE THE
ANNUITY DATE.
ANNUITY PROVISIONS
ANNUITY DATE
The Owner specifies an anticipated Annuity Date on the Application. The Owner
may change the Annuity Date at any time, at least seven days prior to the
Annuity Date, by written notice to the Company at its Annuity Service Center.
The Annuity Date must always be the first day of the calendar month and must be
at least one year after the Contract Date, but not beyond the Latest
FS-975 (7/04) 14
Annuity Date. If no Annuity Date is specified on the Application, the Annuity
Date will be the Latest Annuity Date, as set by the Company.
PAYMENTS TO OWNER
Unless You request otherwise, We will make annuity payments to You. If You want
the annuity payments to be made to some other Payee, We will make such payments
subject to receipt of a written request filed at the Annuity Service Center no
later than thirty (30) days before the due date of the first annuity payment.
Any such request is subject to the rights of any assignee. No payments available
to or being paid to the Payee while the Annuitant is alive can be transferred,
commuted, anticipated or encumbered.
FIXED ANNUITIZATION
If a Fixed Annuitization has been elected, the proceeds payable under this
Contract less any applicable premium taxes, shall be applied to the payment of
the fixed annuity payment option elected at rates which are at least equal to
the annuity rates based upon the applicable tables in the Contract. In no event
will the Fixed Annuitization be changed once it begins.
BETTERMENT OF RATES
The amount of the Owner's monthly payment will be at least equal to the monthly
payment produced by the application of an amount equal to the Contract Value of
this Contract to purchase any single consideration immediate annuity contract
offered by the Company at the same time to the same class of annuitants. We are
not currently offering any single premium immediate annuity contracts.
AMOUNT OF FIXED ANNUITY PAYMENTS
The amount of each fixed annuity payment will be determined by applying the
portion of the Contract Value allocated by You for Fixed Annuitization, less any
applicable premium taxes, to the annuity table applicable to the fixed annuity
payment option chosen.
AMOUNT OF VARIABLE ANNUITY PAYMENTS
(a) FIRST VARIABLE ANNUITY PAYMENT: The dollar amount of the first Variable
Annuitization payment will be determined by applying the portion of the
Contract Value allocated to the Variable Portfolio(s), less any
applicable premium taxes, to rates which are at least equal to the
annuity rates based upon the annuity table applicable to the variable
annuity payment option chosen. If the Contract Value is allocated to
more than one Variable Portfolio, the value of Your interest in each
Variable Portfolio is applied separately to the variable annuity payment
option table to determine the amount of the first annuity payment
attributable to each Variable Portfolio.
(b) NUMBER OF VARIABLE ANNUITY UNITS: The number of Annuity Units for each
applicable Variable Portfolio is the amount of the first annuity payment
attributable to that Variable Portfolio divided by the value of the
applicable Annuity Unit for that Variable Portfolio as of the Annuity
Date. The number will not change as a result of investment experience.
(c) VALUE OF EACH VARIABLE ANNUITY UNIT: The value of an Annuity Unit may
increase or decrease from one month to the next. For any month, the
value of an Annuity Unit of a particular Variable Portfolio is the value
of that Annuity Unit as of the last NYSE
FS-975 (7/04) 15
business day of the preceding month, multiplied by the Net Investment
Factor for that Variable Portfolio for the last NYSE business day of the
current month.
The Net Investment Factor for any Variable Portfolio for a certain month is
determined by dividing (1) by (2) and multiplying by (3) where:
(1) is the Annuity Unit Value of the Variable Portfolio
determined as of the last business day at the end of
that month, and
(2) is the Annuity Unit Value of the Variable Portfolio
determined as of the last business day at the end of the
preceding month, and
(3) is a factor that neutralizes the assumed investment rate
of 3.5% per annum upon which the annuity payment tables
are based. The monthly factor that neutralizes the
assumed investment rate of 3.5% per annum is:
{1/[1.035(1/12)]=0.99713732}.
(d) SUBSEQUENT VARIABLE ANNUITY PAYMENTS: After the first Variable
Annuitization payment future payments will vary in amount according to
the investment performance of the applicable Variable Portfolio(s) to
which Your Purchase Payments are allocated as of the Annuity Date. The
amount may change from month to month. The amount of each subsequent
payment for each Variable Portfolio is:
The number of Annuity Units for each Variable Portfolio as determined
for the first annuity payment
Multiplied by
The value of an Annuity Unit for that Variable Portfolio at the end of
the month immediately preceding the month in which payment is due.
We guarantee that the amount of each Variable Annuitization payments will not be
affected by variations in expenses or mortality experience.
GENERAL PROVISIONS
ENTIRE CONTRACT
The Entire Contract between You and Us consists of this Contract, the
Application completed by You and attached to this Contract, and any attached
endorsement(s) or rider(s). An agent cannot change the terms or conditions of
this Contract. Any change must be in writing and approved by Us. Only Our
President, Secretary, or one of Our Vice-Presidents can give Our approval.
CHANGE OF ANNUITANT
If the Owner is an individual, the Owner may change the Annuitant(s) at any time
prior to the Annuity Date. To make a change, the Owner must send a written
notice to Us at Our Annuity Service Center at least 30 days before the Annuity
Date. If the Owner is a non-natural person, the Owner may not change the
Annuitant.
DEATH OF ANNUITANT
If the natural Owner and Annuitant are different, and the Annuitant dies before
the Annuity Date, the Owner becomes the Annuitant until the Owner elects a new
Annuitant. If there are Joint
FS-975 (7/04) 16
Annuitants, upon the death of any Annuitant prior to the Annuity Date, the Owner
may elect a new Joint Annuitant. However, if the Owner is a non-natural person,
We will treat the death of any Annuitant as the death of the "Primary Annuitant"
and as the death of the Owner, see DEATH PROVISIONS.
MISSTATEMENT OF AGE OR SEX
If the Age or sex of any Annuitant has been misstated, future annuity payments
will be adjusted using the correct Age and sex, according to Our rates in effect
on the date that annuity payments were determined. Any overpayment from the
fixed annuity payment options, plus interest at the rate required by Your state,
will be deducted from the next payment(s) due. Any underpayment from the fixed
annuity payment options, plus interest at the rate required by Your state, will
be paid in full with the next payment due. Any overpayment from the Variable
Portfolios will be deducted from the next payment(s) due. Any underpayment from
the Variable Portfolios will be paid in full with the next payment due.
With respect to Contract issue Age and other age driven features in the
Contract, should We discover a misstatement of Age, We reserve the right to
fully pursue Our remedies including possible termination of the Contract and/or
revocation of any Age driven benefits.
PROOF OF AGE, SEX, OR SURVIVAL
The Company may require satisfactory proof of correct Age or sex at any time. If
any payment under this Contract depends on the Annuitant being alive, the
Company may require satisfactory proof of survival.
DEFERMENT OF PAYMENTS
We may defer making payments from the available Fixed Account Options for up to
six (6) months. Interest, subject to state requirements, will be credited during
the deferral period.
SUSPENSION OF PAYMENTS
We may suspend or postpone any payments from the Variable Portfolios if any of
the following occur:
(a) the NYSE is closed;
(b) trading on the NYSE is restricted;
(c) an emergency exists such that it is not reasonably practical to dispose
of securities in the Variable Portfolios or to determine the value of
its assets; or
(d) the Securities and Exchange Commission, by order, so permits for the
protection of Owners.
Conditions in (b) and (c) will be decided by or in accordance with rules of the
Securities and Exchange Commission.
CONFORMITY WITH STATE LAWS
The provisions of this Contract will be interpreted by the laws of the state in
which the Application was signed or such other state as is required by law. Any
provision which, on the Contract Date, is in conflict with the law of such state
is amended to conform to the minimum requirements of such law.
FS-975 (7/04) 17
CHANGES IN LAW
If the laws governing this Contract or the taxation of benefits under the
Contract change, We reserve the right to amend this Contract, subject to New
York Insurance Department approval, to comply with any changes.
ASSIGNMENT
You may assign this Contract before the Annuity Date, but We will not be bound
by an assignment unless it is received by Us in writing. Your rights and those
of any other person referred to in this Contract will be subject to the
assignment. Certain assignments may be taxable. We do not assume any
responsibility for the validity or tax consequences of any assignment. We
reserve the right to not recognize assignments if it changes the risk profile of
the Owner of the Contract as determined in Our sole discretion.
CLAIMS OF CREDITORS
To the extent permitted by law, no right or proceeds payable under this Contract
will be subject to claims of creditors or legal process.
PREMIUM TAXES OR OTHER TAXES
The Company may deduct from Your Contract Value any premium tax or other taxes
payable to a state or other government entity, if applicable. Should We advance
any amount so due, We are not waiving any right to collect such amount at a
later date. The Company will deduct any withholding taxes required by applicable
law.
WRITTEN NOTICE
Any notice We send to You will be sent to Your address shown in the Application
unless You request otherwise. Any written request or notice to Us must be sent
to Our Annuity Service Center, as specified on the Contract Data Page.
PERIODIC REPORTS
At least once during each Contract Year, We will send You a statement of the
account activity of the Contract. The statement will include all transactions
which have occurred during the accounting period shown on the statement.
INCONTESTABILITY
This Contract shall be incontestable after it has been in force for a period of
two years from the Contract Date during Your lifetime or during the lifetimes of
each of the persons who are required to provide Us with information concerning
their age, sex and identity. The incontestability of this Contract applies to
any statements You make, except as otherwise stated in the Misstatement of Age
or Sex provision. Accurate statements as to Your age, sex and identity are
required as a condition of issuing this Contract.
NONPARTICIPATING
This Contract does not share in Our surplus.
WAIVER
Our waiver of any of the terms and conditions under this Contract will not be
deemed to constitute waiver of the right to enforce strict compliance.
FS-975 (7/04) 18
ANNUITY PAYMENT OPTIONS
During the Annuitant's life, upon written election and the return of this
Contract to the Company at its Annuity Service Center, the Contract Value may be
applied to provide one of the following options or any annuity payment option
that is mutually agreeable. After one year from the Contract Date, and prior to
the Annuity Date, You can choose one of the options described below. If no
option has been selected by the Annuity Date, You will automatically receive
Option 4, below, with payments for 10 years guaranteed.
OPTIONS 1 & 1v - LIFE ANNUITY, LIFETIME MONTHLY PAYMENTS GUARANTEED
Payments payable to the Payee during the lifetime of the Annuitant. No further
payments are payable after the death of the Annuitant.
OPTIONS 2 & 2v - JOINT AND SURVIVOR LIFE ANNUITY
Payments payable to the Payee during the lifetime of the Annuitant and during
the lifetime of a designated second person. No further payments are payable
after the deaths of both the Annuitant and the designated second person.
OPTIONS 3 & 3v - JOINT AND SURVIVOR LIFE ANNUITY - WITH PAYMENTS GUARANTEED FOR
10 YEARS OR 20 YEARS
Payments are payable to the Payee during the lifetime of the Annuitant and
during the lifetime of a designated second person. If, at the death of the
survivor, payments have been made for less than 10 or 20 years, as selected at
the time of Annuitization, the remaining guaranteed annuity payments will be
continued to the Beneficiary.
OPTIONS 4 & 4v - LIFE ANNUITY WITH PAYMENTS GUARANTEED FOR 10 YEARS OR 20 YEARS
Payments payable to the Payee during the lifetime of the Annuitant. If, at the
death of the Annuitant, payments have been made for less than 10 or 20 years, as
selected at the time of annuitization, the remaining guaranteed annuity payments
will be continued to the Beneficiary.
OPTIONS 5 & 5v - FIXED PAYMENTS FOR A SPECIFIED PERIOD CERTAIN
Payments are payable to the Payee for any specified period of time for [5] years
or more, but not exceeding [30] years, as selected at the time of annuitization.
The selection must be made for full twelve-month periods. In the event of death
of the Annuitant, any remaining annuity payments will be continued to the
Beneficiary. If Variable Annuity Payments are elected under this Annuity Payment
Option, any remaining guaranteed Variable Annuity payments may be redeemed for a
discounted value determined by Us. Any applicable Withdrawal Charges will be
deducted from the discounted value as if You fully surrendered Your Contract.
FS-975 (7/04) 19
FIXED ANNUITY PAYMENT OPTIONS TABLE
BASIS OF COMPUTATION
The actuarial basis for the Table of Annuity Rates is the 1983a Annuity
Mortality Table with projection and a guaranteed interest rate of 3%. The
mortality table is projected using Projection Scale G factors, assuming
annuitization in the year 2000. The Fixed Annuity Payment Options Table does not
include any applicable premium tax.
OPTIONS 1 & 4 - TABLE OF MONTHLY INSTALLMENTS PER $1,000.
(Monthly installments for ages not shown will be furnished upon request.)
Option 4 Option 4
Life Annuity Life Annuity
Age of Option 1 (w/120 payments (w/240 payments
Annuitant Life Annuity guaranteed) guaranteed)
Male Female Male Female Male Female
55 4.23 3.84 4.19 3.82 4.05 3.76
56 4.32 3.91 4.27 3.88 4.11 3.81
57 4.41 3.98 4.35 3.95 4.17 3.87
58 4.51 4.05 4.44 4.02 4.24 3.93
59 4.61 4.13 4.54 4.10 4.31 4.00
60 4.72 4.22 4.64 4.18 4.37 4.06
61 4.84 4.31 4.74 4.27 4.44 4.13
62 4.96 4.40 4.85 4.36 4.51 4.20
63 5.10 4.51 4.97 4.45 4.58 4.27
64 5.24 4.62 5.10 4.55 4.65 4.35
65 5.40 4.73 5.22 4.66 4.72 4.42
66 5.56 4.86 5.36 4.78 4.79 4.50
67 5.74 4.99 5.50 4.90 4.86 4.57
68 5.93 5.14 5.65 5.02 4.92 4.65
69 6.13 5.29 5.80 5.16 4.99 4.73
70 6.35 5.46 5.96 5.30 5.05 4.80
71 6.58 5.64 6.13 5.46 5.10 4.88
72 6.82 5.84 6.29 5.62 5.16 4.95
73 7.08 6.05 6.47 5.78 5.20 5.02
74 7.36 6.28 6.64 5.96 5.25 5.08
75 7.66 6.53 6.82 6.14 5.29 5.14
76 7.98 6.80 7.00 6.33 5.33 5.19
77 8.33 7.09 7.19 6.53 5.36 5.24
78 8.69 7.41 7.37 6.73 5.39 5.29
79 9.09 7.75 7.55 6.94 5.41 5.33
80 9.51 8.11 7.73 7.14 5.43 5.36
81 9.97 8.51 7.91 7.35 5.45 5.39
82 10.45 8.94 8.08 7.55 5.47 5.42
83 10.97 9.41 8.24 7.76 5.48 5.44
84 11.52 9.92 8.40 7.95 5.49 5.46
85 12.10 10.47 8.54 8.13 5.50 5.48
FS-975 (7/04) 20
OPTION 2 - TABLE OF MONTHLY INSTALLMENTS PER $1,000.
(Monthly installments for ages not shown will be furnished upon request.)
Joint & 100% Survivor Life Annuity
Age of
Male
Annuitant Age of Female Annuitant
--------- -----------------------
55 60 65 70 75 80 85
55 3.54 3.69 3.84 3.96 4.06 4.13 4.17
60 3.63 3.83 4.04 4.23 4.39 4.52 4.60
65 3.70 3.95 4.23 4.51 4.78 5.00 5.16
70 3.75 4.04 4.39 4.78 5.18 5.56 5.85
75 3.78 4.11 4.51 5.01 5.57 6.14 6.65
80 3.81 4.15 4.60 5.18 5.89 6.70 7.52
85 3.82 4.18 4.66 5.30 6.14 7.18 8.35
OPTION 3 - TABLE OF MONTHLY INSTALLMENTS PER $1,000.
(Monthly installments for ages not shown will be furnished upon request)
Joint & 100% Survivor Life Annuity (w/120 payments guaranteed)
Age of
Male
Annuitant Age of Female Annuitant
--------- -----------------------
55 60 65 70 75 80 85
55 3.54 3.69 3.83 3.96 4.05 4.12 4.16
60 3.63 3.83 4.03 4.22 4.38 4.50 4.57
65 3.70 3.95 4.22 4.50 4.76 4.97 5.10
70 3.75 4.04 4.38 4.76 5.15 5.48 5.72
75 3.78 4.10 4.50 4.98 5.50 6.00 6.40
80 3.80 4.14 4.58 5.13 5.78 6.46 7.04
85 3.81 4.16 4.62 5.22 5.97 6.80 7.55
(Monthly installments for ages not shown will be furnished upon request)
Joint & 100% Survivor Life Annuity (w/240 payments guaranteed)
Age of
Male
Annuitant Age of Female Annuitant
--------- -----------------------
55 60 65 70 75 80 85
55 3.53 3.68 3.81 3.92 3.99 4.03 4.04
60 3.62 3.81 4.00 4.16 4.27 4.34 4.37
65 3.68 3.92 4.16 4.39 4.56 4.66 4.71
70 3.72 3.99 4.39 4.58 4.81 4.96 5.03
75 3.74 4.03 4.58 4.70 4.99 5.17 5.26
80 3.75 4.05 4.70 4.77 5.09 5.30 5.40
85 3.76 4.06 4.77 4.80 5.13 5.35
4.80
FS-975 (7/04) 21
OPTION 5 - TABLE OF MONTHLY INSTALLMENTS PER $1,000.
Fixed Payment for Specified Period
Number Monthly Number Monthly Number Monthly Number Monthly
of Years Payment of Years Payment of Years Payment of Years Payment
-------- ------- -------- ------- -------- ------- -------- -------
10 9.61 17 6.23 24 4.84
11 8.86 18 5.96 25 4.71
5 17.91 12 8.24 19 5.73 26 4.59
6 15.14 13 7.71 20 5.51 27 4.47
7 13.16 14 7.26 21 5.32 28 4.37
8 11.68 15 6.87 22 5.15 29 4.27
9 10.53 16 6.53 23 4.99 30 4.18
VARIABLE ANNUITY PAYMENT OPTIONS TABLE
BASIS OF COMPUTATION
The actuarial basis for the Table of Annuity Rates is the 1983a Annuity
Mortality Table with projection and an effective annual Assumed Investment Rate
of 3.5%. The mortality table is projected using Projection Scale G factors,
assuming annuitization in the year 2000. The Variable Annuity Payment Options
Table does not include any applicable premium tax.
OPTIONS 1v& 4v - TABLE OF MONTHLY INSTALLMENTS PER $1,000
(Monthly installments for ages not shown will be furnished upon request.)
Option 4v Option 4v
Life Annuity Life Annuity
Age of Option 1v (w/120 payments (w/240 payments
Annuitant Life Annuity guaranteed) guaranteed)
Male Female Male Female Male Female
55 4.53 4.13 4.48 4.11 4.33 4.05
56 4.62 4.20 4.56 4.18 4.39 4.10
57 4.71 4.27 4.64 4.24 4.45 4.16
58 4.80 4.34 4.73 4.31 4.52 4.22
59 4.90 4.42 4.82 4.39 4.58 4.28
60 5.01 4.51 4.92 4.47 4.65 4.34
61 5.13 4.60 5.03 4.55 4.71 4.41
62 5.26 4.69 5.14 4.64 4.78 4.48
63 5.39 4.80 5.25 4.74 4.85 4.55
64 5.54 4.91 5.38 4.84 4.92 4.62
65 5.69 5.02 5.51 4.94 4.99 4.69
66 5.86 5.15 5.64 5.06 5.05 4.77
67 6.03 5.28 5.78 5.18 5.12 4.84
68 6.22 5.43 5.93 5.30 5.18 4.92
69 6.43 5.58 6.08 5.44 5.24 4.99
70 6.64 5.75 6.23 5.58 5.30 5.06
71 6.87 5.93 6.40 5.73 5.36 5.14
72 7.12 6.13 6.56 5.89 5.41 5.21
FS-975 (7/04) 22
73 7.38 6.34 6.73 6.06 5.46 5.27
74 7.66 6.57 6.91 6.23 5.50 5.33
75 7.96 6.82 7.09 6.41 5.54 5.39
76 8.28 7.09 7.27 6.60 5.57 5.44
77 8.63 7.38 7.45 6.79 5.61 5.49
78 9.00 7.70 7.63 6.99 5.63 5.54
79 9.40 8.04 7.81 7.19 5.66 5.58
80 9.82 8.41 7.98 7.40 5.68 5.61
81 10.28 8.81 8.16 7.60 5.70 5.64
82 10.76 9.24 8.32 7.81 5.71 5.66
83 11.28 9.71 8.48 8.00 5.72 5.69
84 11.83 10.23 8.64 8.19 5.73 5.70
85 12.42 10.78 8.78 8.38 5.74 5.72
OPTION 2v - TABLE OF MONTHLY INSTALLMENTS PER $1,000.
(Monthly installments for ages not shown will be furnished upon request.)
Joint & 100% Survivor Life Annuity
Age of
Male
Annuitant Age of Female Annuitant
--------- -----------------------
55 60 65 70 75 80 85
55 3.83 3.98 4.12 4.24 4.34 4.42 4.46
60 3.92 4.11 4.32 4.51 4.67 4.80 4.89
65 3.99 4.23 4.50 4.79 5.05 5.28 5.44
70 4.04 4.33 4.67 5.05 5.46 5.83 6.13
75 4.07 4.39 4.79 5.28 5.84 6.41 6.93
80 4.10 4.44 4.88 5.45 6.16 6.97 7.79
85 4.11 4.47 4.94 5.57 6.41 7.45 8.61
OPTION 3v - TABLE OF MONTHLY INSTALLMENTS PER $1,000.
(Monthly installments for ages not shown will be furnished upon request)
Joint and 100% Survivor Life Annuity (w/120 payments guaranteed)
Age of
Male
Annuitant Age of Female Annuitant
--------- -----------------------
55 60 65 70 75 80 85
55 3.83 3.98 4.12 4.24 4.34 4.40 4.45
60 3.92 4.11 4.31 4.50 4.66 4.78 4.86
65 3.99 4.23 4.50 4.78 5.03 5.24 5.38
70 4.04 4.32 4.66 5.03 5.41 5.75 5.99
75 4.07 4.39 4.78 5.25 5.77 6.26 6.66
80 4.09 4.43 4.86 5.40 6.05 6.72 7.29
85 4.10 4.45 4.90 5.50 6.24 7.05 7.80
FS-975 (7/04) 23
OPTION 3v - TABLE OF MONTHLY INSTALLMENTS PER $1,000.
(Monthly installments for ages not shown will be furnished upon request)
Joint and 100% Survivor Life Annuity (w/240 payments guaranteed)
Age of
Male
Annuitant Age of Female Annuitant
--------- -----------------------
55 60 65 70 75 80 85
55 3.83 3.98 4.12 4.24 4.34 4.42 4.46
60 3.92 4.11 4.32 4.51 4.67 4.80 4.89
65 3.99 4.23 4.51 4.79 5.05 5.28 5.44
70 4.04 4.33 4.67 5.05 5.46 5.83 6.13
75 4.07 4.39 4.79 5.28 5.84 6.41 6.93
80 4.09 4.44 4.88 5.45 6.16 6.97 7.79
85 4.10 4.47 4.94 5.57 6.41 7.45 8.61
OPTION 5v - TABLE OF MONTHLY INSTALLMENTS PER $1,000.
Payments for a Specified Period
Number Monthly Number Monthly Number Monthly Number Monthly
of Years Payment of Years Payment of Years Payment of Years Payment
-------- ------- -------- ------- -------- ------- -------- -------
10 9.83 17 6.47 24 5.09
11 9.09 18 6.20 25 4.96
5 18.12 12 8.46 19 5.97 26 4.84
6 15.35 13 7.94 20 5.75 27 4.73
7 13.38 14 7.49 21 5.56 28 4.63
8 11.90 15 7.10 22 5.39 29 4.53
9 10.75 16 6.76 23 5.24 30 4.45
FS-975 (7/04) 24
First SunAmerica Life Insurance Company
A STOCK COMPANY NEW YORK, NEW YORK
INDIVIDUAL FIXED AND VARIABLE
DEFERRED ANNUITY CONTRACT
Nonparticipating
FS-975 (7/04) 25
