|||GOLDEN FLEXIBLE PREMIUM
|||||AMERICAN DEFERRED VARIABLE
||||||LIFE INSURANCE ANNUITY CONTRACT
||||COMPANY
Golden American is a stock company domiciled in Delaware.
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|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
This is a legal Contract between its Owner and us. Please read it carefully. In
this Contract you or your refers to the Owner shown above. We, our or us refers
to Golden American Life Insurance Company. You may allocate this Contract's
Accumulation Value among the Divisions of the Variable Separate Account and the
General Account shown in the Schedule.
If this Contract is in force, we will make income payments to you starting on
the Annuity Commencement Date. If the Owner dies prior to the Annuity
Commencement Date, we will pay a Death Benefit to the Beneficiary. The amount
of such benefits is subject to the terms of this Contract.
ALL PAYMENTS AND VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A VARIABLE
SEPARATE ACCOUNT, MAY INCREASE OR DECREASE, DEPENDING ON THE CONTRACT'S
INVESTMENT RESULTS.
RIGHT TO EXAMINE THIS CONTRACT: YOU MAY RETURN THIS CONTRACT TO US OR THE AGENT
THROUGH WHOM YOU PURCHASED IT WITHIN 10 DAYS AFTER YOU RECEIVE IT. IF SO
RETURNED, WE WILL TREAT THE CONTRACT AS THOUGH IT WERE NEVER ISSUED. UPON
RECEIPT WE WILL PROMPTLY REFUND THE ACCUMULATION VALUE PLUS ANY CHARGES WE HAVE
DEDUCTED AS OF THE DATE THE RETURNED CONTRACT IS RECEIVED BY US.
Customer Service Center Secretary: /s/ Xxxxx X. Xxxxxxx
0000 Xxxxxxxx Xxxxx
Xxxx Xxxxxxx, XX 00000 President: /s/ Xxxxxxx Xxxxxxx
1-800-366-0066
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FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT - NO DIVIDENDS
Variable Cash Surrender Values while the Annuitant and Owner are living and
prior to the Annuity Commencement Date. Death Benefit subject to guaranteed
minimum. Partial Withdrawal Option. Non-participating. Investment results
reflected in values.
GA-IA-1083
CONTRACT CONTENTS
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THE SCHEDULE YOUR CONTRACT BENEFITS........ 15
Payment and Investment Information. 3A Cash Value Benefit.
The Variable Separate Accounts..... 3B Partial Withdrawal Option
The General Account................ 3C Proceeds Payable to the Beneficiary
Contract Facts..................... 3D
Charges and Fees................... 3E CHOOSING AN INCOME PLAN...... .16
Income Plan Factors................ 3F Annuity Benefits
Annuity Commencement Date Selection
IMPORTANT TERMS...................... 4 Frequency Selection
The Income Plan
INTRODUCTION TO THIS CONTRACT........ 6 The Annuity Options
The Contract Payment When Named Person Dies
The Owner
The Annuitant OTHER IMPORTANT INFORMATION....18
The Beneficiary Sending Notice to Us
Change of Owner or Beneficiary Reports to Owner
Assignment - Using this Contract as
PREMIUM PAYMENTS AND ALLOCATION CHANGES. 8 Collateral Security
Initial Premium Payment Changing this Contract
Additional Premium Payments Contract Changes - Applicable Tax Law
Your Right to Change Allocation of Misstatement of Age or Sex
Accumulation Value Non-Participating
What Happens if a Variable Separate Account Contestability
Division is Not Available Payments We May Defer
Restricted Funds Authority to Make Agreements
Thresholds Required Note on Our Computations
Dollar Cap
Premium Threshold
Allocation Threshold
Thresholds - Effect on Withdrawals
Threshold Processing
HOW WE MEASURE THE CONTRACT'S
ACCUMULATION VALUE......................11
The Variable Separate Accounts
The General Account
Valuation Period
Accumulation Value
Accumulation Value in each Division
Measurement of Investment Experience
Charges Deducted from Accumulation Value on
each Contract Processing Date
Copies of any additional Riders and Endorsements are at the back of this
Contract.
THE SCHEDULE
The Schedule gives specific facts about this Contract and its
coverage. Please refer to the Schedule while reading this
Contract.
GA-IA-1083 2
THE SCHEDULE
PAYMENT AND INVESTMENT INFORMATION
-------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
|Annuitant Owner |
|[XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
|Annuitant's Issue Age Annuitant's Sex Owner's Issue Age |
| [55] [MALE] [35] |
|-----------------------------------------------------------------------------|
|Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|-----------------------------------------------------------------------------|
|Contract Date Issue Date Residence Status |
| [JANUARY 1, 1996] [JANUARY 1, 1996 ] [DELAWARE] |
|-----------------------------------------------------------------------------|
|Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
INITIAL INVESTMENT
Initial Premium Payment received: [$10,000]
Your initial Accumulation Value has been invested as follows:
Percentage of
Divisions Accumulation Value
--------- ------------------
[Equity Income 10%
Fully Managed 10%
Capital Appreciation 10%
Rising Dividends 10%
Growth 10%
Real Estate 10%
Value Equity 10%
Hard Assets 5%
Emerging Markets 5%
Managed Global 5%
Limited Maturity Bond 5%
Liquid Asset 5%
Strategic Equity 5%]
------------------------------ --------------------------
Total 100%
----- ----
GA-IA-1083 3A1
THE SCHEDULE
PAYMENT AND INVESTMENT INFORMATION (continued)
-------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
|Annuitant Owner |
|[XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
|Annuitant's Issue Age Annuitant's Sex Owner's Issue Age |
| [55] [MALE] [35] |
|-----------------------------------------------------------------------------|
|Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|-----------------------------------------------------------------------------|
|Contract Date Issue Date Residence Status |
| [JANUARY 1, 1996] [JANUARY 1, 1996 ] [DELAWARE] |
|-----------------------------------------------------------------------------|
|Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
ADDITIONAL PREMIUM PAYMENT INFORMATION
Except in the case of a Contract issued as an XXX, we will accept additional
Premium Payments until either the Annuitant or Owner reaches the Attained Age
of [86]. The minimum additional payment which may be made is $[500.00].
If this Contract is issued as an XXX, no contributions may be made for the
taxable year in which you attain age 70 1/2 and thereafter (except for rollover
contributions). The minimum additional payment which may be made to a Contract
issued as an XXX is $250.00.
ACCUMULATION VALUE ALLOCATION RULES
We reserve the right to impose a charge for any allocation change in excess of
twelve per Contract Year. The Excess Allocation Charge is shown in the
Schedule. Allocations into and out of the Guaranteed Interest Divisions
are subject to restrictions (see General Account).
ALLOCATION CHANGES BY TELEPHONE
You may request allocation changes by telephone during our telephone request
business hours. You may call our Customer Service Center at 1-800-366-0066 to
make allocation changes by using the personal identification number you will
receive. You may also mail any notice or request for allocation changes to our
Customer Service Center at the address shown on the cover page.
GA-IA-1083 3A2
THE SCHEDULE
THE VARIABLE SEPARATE ACCOUNTS
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|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND
Separate Account B (the "Account") is a unit investment trust Separate Account,
organized in and governed by the laws of the State of Delaware, our state of
domicile. The Account is divided into Divisions. Each Division listed below
invests in shares of the mutual fund portfolio (the "Series") designated. Each
portfolio is a part of The GCG Trust managed by Directed Services, Inc.
SERIES SERIES SERIES
------ ------ ------
[All Cap Capital Growth Liquid Asset
Equity Income Managed Global Strategic Equity
Fully Managed Asset Allocation Growth Research
Value Equity Diversified Mid-Cap Growth
Small Cap Investors Global Fixed Income
Capital Appreciation Large Cap Value Developing World
Rising Dividends Real Estate Equity Income
Mid-Cap Growth Hard Assets Growth and Income
Total Return Limited Maturity Bond Special Situations
The Division listed below invests in shares of the mutual fund portfolio
(the "Portfolio") designated. The portfolio is a part of the ING Variable
Insurance Trust managed by ING Investment Management.
PORTFOLIO
---------
ING Global Brand Names Fund
The Division listed below invests in shares of the mutual fund portfolio
(the "Portfolio") designated. The portfolios are a part of the Prudential
Series Fund, Inc. managed by Xxxxxxxx Associates, LLC.
PORTFOLIO
---------
Prudential Xxxxxxxx
The Division listed below invests in shares of the mutual fund portfolio
(the "Portfolio") designated. The portfolio is a part of the Warburg
Pincus Trust managed by Credit Suisse Asset Management, LLC.
PORTFOLIO
---------
International Equity
International Growth
The Division listed below invests in shares of the mutual fund portfolio
(the "Portfolio") designated. The portfolios are a part of the PIMCO Trust
managed by Pacific Investment Management Company.
PORTFOLIO
---------
PIMCO High Yield Bond
PIMCO StocksPlus Growth & Income]
GA-IA-1083 3B
THE SCHEDULE
THE GENERAL ACCOUNT
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|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
GENERAL ACCOUNT
[Guaranteed Interest Division
A Guaranteed Interest Division provides an annual minimum interest rate of 3%.
At our sole discretion, we may periodically declare higher interest rates for
specific Guarantee Periods. Such rates will apply to periods following the date
of declaration. Any declaration will be by class and will be based on our
future expectations.
Limitations of Allocations
We reserve the right to restrict allocations into and out of the General
Account. Such limits may be dollar restrictions on allocations into the
General Account or we may restrict reallocations into the General Account.
Guarantee Periods
Each allocation to a Guaranteed Interest Division will be guaranteed an
interest rate for the entire Initial Guarantee Period elected. We currently
offer Initial Guarantee Periods of one, three, five, seven and ten years.
The Initial Guarantee Period starts on the day an allocation is made to
a Guaranteed Interest Division and ends on the last day of the calendar
month following one, three, five, seven or ten year(s), as appropriate,
the Maturity Date.
At the end of a Guarantee Period, you may transfer the Accumulation Value in
such Guarantee Period to the Variable Separate Account Divisions or to a
Guarantee Period we then offer. If we do not receive notification by the
Maturity Date, your Accumulation Value in the maturing Guarantee Period will
automatically be transferred to a one-year Guarantee Period. Upon such
automatic transfer you will have thirty days to reallocate any of your
Accumulation Value to the Divisions.
Deduction for Charges
We do not deduct the Mortality and Expense Risk Charge and the Asset-Based
Administrative Charge with respect to the amount of the Accumulation Value
allocated to a Guaranteed Interest Division while such Accumulation Value
remains allocated to a Guaranteed Interest Division.
Transfers from the Guaranteed Interest Division
On a Maturity Date, 100% of the Accumulation Value in the maturing Guarantee
Period may be transferred.
We currently require that an amount allocated to a Guarantee Period not be
transferred until the Maturity Date, except pursuant to our published rules. We
reserve the right not to allow amounts previously transferred from a Guaranteed
Interest Division to the Variable Separate Account Divisions to be transferred
back to a Guaranteed Interest Division for a period of at least six months from
the date of transfer. We reserve the right to reduce the amount otherwise
available for transfer from a Guaranteed Interest Division by any amounts
previously withdrawn from that Guaranteed Interest Division.]
GA-IA-1083 3C
THE SCHEDULE (STANDARD)
CONTRACT FACTS
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|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
CONTRACT FACTS
Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each year.
Specially Designated Division
When a distribution is made from an investment portfolio underlying a Separate
Account Division in which reinvestment is not available, we will allocate the
amount of the distribution to the [Liquid Asset Division] unless you specify
otherwise.
PARTIAL WITHDRAWALS
The maximum amount that can be withdrawn each Contract Year without being
considered an Excess Partial Withdrawal is described below. We will collect a
Surrender Charge for Excess Partial Withdrawals and a charge for any
unrecovered Premium Taxes. In no event may a Partial Withdrawal be greater
than 90% of the Cash Surrender Value. After a Partial Withdrawal, the remaining
Accumulation Value must be at least $100 to keep the Contract in force.
Systematic Partial Withdrawals and Conventional Partial Withdrawals may not be
taken in the same Contract Year.
To determine the Surrender Charge on Excess Partial Withdrawals, the
withdrawals will occur in the following order:
(1) Earnings;
(2) The Free Amount;
(3) Premium Payments made [four] or more years prior to the
withdrawal; and
(4) Premium Payments made less than [four] years prior to
withdrawal.
Earnings and Free Amounts are not treated as withdrawals of Premium Payments
for purposes of calculating any Surrender Charge.
Conventional Partial Withdrawals
Minimum Withdrawal Amount: $100
The maximum amount that can be taken as a Conventional Partial Withdrawal each
Contract Year without being considered an Excess Partial Withdrawal is the
greater of:
(1) Earnings (defined below) not previously withdrawn, but not less than
zero; and
(2) The Free Amount, equal to 10% of Premium Payments not previously
withdrawn, which were received within [four] years prior to the date
of withdrawal.
Earnings are equal to the Accumulation Value, less Premium Payments, plus prior
withdrawals.
GA-IA-1083 3D1
THE SCHEDULE
CONTRACT FACTS (continued)
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|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days from
the Contract Issue Date and may be taken on a monthly, quarterly or annual
basis. You select the day withdrawals will be made, but no later than the
28th day of the month. If you do not elect a day, the Contract Date will
be used.
Maximum Withdrawal Amounts:
Variable Separate Account Divisions: .833% of Premium Payments monthly,
2.5% of Premium Payments
quarterly or 10% of Premium Payments
Annually.
Guaranteed Interest Divisions: Interest earned on the Guaranteed
Interest Divisions for the prior
month, quarter or year (depending on
the frequency selected).
The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal is
10% of Premium Payments not previously withdrawn. A Systematic Partial
Withdrawal in excess of Earnings and the Free Amount may be subject to a
Surrender Charge.
XXX Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a Contract issued as an XXX on a monthly,
quarterly or annual basis. A minimum withdrawal of $100.00 is required. You
select the day the withdrawals will be made, but no later than the 28th day of
the month. If you do not elect a day, the Contract Date will be used.
Systematic Partial Withdrawals and Conventional Partial Withdrawals are not
allowed when XXX Partial Withdrawals are being taken.
DEATH BENEFIT
The Death Benefit is the greatest of (i), (ii) and (iii) below, where:
(i) is the Accumulation Value;
(ii) is the Guaranteed Death Benefit;
(iii) is the Cash Surrender Value.
GA-IA-1083 3D2
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
GUARANTEED DEATH BENEFIT
The Guaranteed Death Benefit for the Contract is equal to the sum of I and II
below.
I. The Guaranteed Death Benefit for non-Special Funds
II. The Accumulation Value allocated to Special Funds
On the Contract Date, the Guaranteed Death Benefit Base for non-Special Funds
is the initial premium allocated to non-Special Funds. On subsequent Valuation
Dates, the Guaranteed Death Benefit Base for non-Special Funds is calculated as
follows:
(1) Start with the Guaranteed Death Benefit Base for non-Special Funds
from the prior Valuation Date.
(2) Add any additional premiums paid and allocated to non-Special Funds
during the current Valuation Period to (1).
(3) Adjust (2) for any transfers to or from Special Funds during
the current Valuation Period.
(4) Subtract from (3) any Prorata Partial Withdrawal Adjustments for any
Partial Withdrawal made from non-Special
Funds during the current Valuation Period.
The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds.
Transfers from Special Funds to non-Special Funds will reduce the Guaranteed
Death Benefit Base for Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for non-Special Funds will
equal the lesser of the reduction in the Guaranteed Death Benefit Base for
Special Funds and the net Accumulation Value transferred.
Transfers from non-Special Funds to Special Funds will reduce the Guaranteed
Death Benefit Base for non-Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for Special Funds will equal the
reduction in Guaranteed Death Benefit Base for non-Special Funds.
GA-IA-1083 3D3
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
SPECIAL FUNDS
Where used in this Contract, Special Funds are [the Liquid Asset Division, the
Limited Maturity Bond Division and the Guaranteed Interest Division]. We may
add newly available Divisions as Special Funds. We may also
reclassify an existing Division as a Special Fund
or remove such designation upon 30 days notice to
you. Such reclassification will apply to amounts transferred or otherwise added
to such Division after the date of change. We may reduce the Mortality and
Expense Risk Charge (if applicable) for that portion of the Contract
invested in a Special Fund.
PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS
For any partial withdrawal, the Death Benefit components will be reduced by
Prorata Partial Withdrawal Adjustments. The Prorata Partial Withdrawal
Adjustment to a Death Benefit component for a partial withdrawal is equal to
(1) divided by (2) multiplied by (3), where: (1) is the Accumulation Value
withdrawn; (2) is the Accumulation Value immediately prior to withdrawal; and
(3) is the amount of the applicable Death Benefit component immediately prior
to the withdrawal. Separate adjustments will apply to amounts in the Special
and non-Special Funds.
CHANGE OF OWNER
A change of Owner will result in recalculation of the Death Benefit and the
Guaranteed Death Benefit. If the Owner's or the oldest of multiple Owner's
Attained Age at the time of the change is less than [86], the Guaranteed Death
Benefit in effect prior to the change will remain in effect and the Death
Benefit provision shall apply.
If any Owner's or oldest multiple Owner's Attained Age is [86] or greater at
the time of the change, the Guaranteed Death Benefit will be zero, and the
Death Benefit will then be the Cash Surrender Value
GA-IA-1083 3D4
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
SPOUSAL CONTINUATION UPON DEATH OF OWNER
If at the Owner's death, the surviving spouse of the deceased Owner is the
Beneficiary and such surviving spouse elects to continue the Contract as their
own pursuant to Internal Revenue Code Section 72(s) or the equivalent
provisions of U.S. Treasury Department rules for qualified plans, the following
will apply:
(a) If the Guaranteed Death Benefit as of the date we receive due
proof of death of the Owner, minus the Accumulation Value, also as of
that date, is greater than zero, we will add such difference to the
Accumulation Value. Such addition will be allocated to the Divisions
of the Separate Account in the same proportion as the Accumulation
Value in each Division bears to the Accumulation Value in the Separate
Account. If there is no Accumulation Value in the Separate Account,
the addition will be allocated to the Liquid Asset Division, or its
successor.
(b) The Guaranteed Death Benefit will continue to apply, with all age
criteria using the surviving spouse's age as the determining age.
(c) At subsequent surrender, any Surrender Charge applicable to premiums
paid prior to the date we receive due proof of death of the Owner will
be waived. Any premiums paid later will be subject to any applicable
Surrender Charge.
This addition to Accumulation Value is available only to the spouse of the
Owner as of the date of death of the Owner if such spouse under the
provisions if this Contract elects to continue the Contract as their own.
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no later
than April 1st of the calendar year following the calendar year in which the
Owner attains age 70 1/2. Otherwise, the Annuity Commencement Date may be no
later than the same date as the Contract Processing Date in the month following
the Annuitant's 90th birthday. In applying the Accumulation Value, we may first
collect any Premium Taxes due us. If, on the Annuity Commencement Date, a
Surrender Charge remains, your elected Annuity Option must include a period
certain of at least five years duration.
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
GA-IA-1083 3D5
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
OPTIONAL BENEFIT RIDERS - [None]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full years elapsed
since the Contract Date.
RESTRICTED FUNDS - [None]
GA-IA-1083 3D6
THE SCHEDULE
CHARGES AND FEES
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
DEDUCTIONS FROM PREMIUMS
None
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
None
Administrative Charge
We charge a maximum of $30 to cover a portion of our ongoing administrative
expenses for each Contract Processing Period. The charge is incurred at the
beginning of the Contract Processing Period and deducted on the Contract
Processing Date at the end of the period.
At the time of deduction, this charge will be waived if:
(1) The Accumulation Value is at least $100,000; or
(2) The sum of premiums paid to date is at
least $100,000.
Excess Allocation Charge
Currently none, however, we reserve the right to charge $25 for a change if you
make more than twelve allocation changes per Contract Year. Any charge will be
deducted in proportion to the amount being transferred from each Division.
Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if the
Contract is surrendered or an Excess Partial Withdrawal is taken. The
percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed since a
Premium Payment was made. The Surrender Charge expressed as a percentage
of each Premium Payment is as follows:
Complete Years Elapsed Surrender
Since Premium Payment Charges
----------------------- ---------
[0 6%
1 5%
2 4%
3 3%
4+ 0%]
Surrender of the Contract is permitted at or before the commencement of Annuity
Payments.
GA-IA-1083 3E1
THE SCHEDULE
CHARGES AND FEES(continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Premium Taxes
We deduct the amount of any premium or other state and local taxes levied by
any state or governmental entity when such taxes are incurred.
We reserve the right to defer collection of Premium Taxes until surrender or
until application of Accumulation Value to an Annuity Option. An Excess Partial
Withdrawal will result in the deduction of any Premium Tax then due us on such
amount. We reserve the right to change the amount we charge for Premium Tax
charges on future premium payments to conform with changes in the law or if the
Owner changes state of residence.
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct charge from the assets in each
Variable Separate Account Division on a daily basis of not more than
[0.004558]% (equivalent to an annual maximum rate of [1.65]%) for mortality
and expense risks. This charge is not deducted from the General Account
Accumulation Values.
Asset Based Administrative Charge - We deduct a charge of not more than
[0.000411]% of the assets in each Variable Separate Account Division on a daily
basis (equivalent to an annual maximum rate of [0.15]%) to compensate us for a
portion of our ongoing administrative expenses. This charge is not deducted
from the General Account Accumulation Values.]
CHARGE DEDUCTION DIVISION
If elected by you, all charges against the Accumulation Value in this Contract
will be deducted from the [Liquid Asset Division].
GA-IA-1083 3E2
THE SCHEDULE
INCOME PLAN FACTORS
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Values for other payment periods, ages or joint life combinations are available
on request. Monthly payments are shown for each $1,000 applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Period Monthly Fixed Period Monthly Fixed Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years Certain 20 Years Certain Refund Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
GA-IA-1083 3F
IMPORTANT TERMS
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ACCUMULATION VALUE - The amount that a Contract provides for investment at any
time. Initially, this amount is equal to the premium paid.
ANNUITANT - The person designated by the Owner to be the measuring life in
determining Annuity Payments.
ANNUITY COMMENCEMENT DATE - For each Contract, the date on which Annuity
Payments begin.
ANNUITY OPTIONS - Options the Owner selects that determine the form and amount
of Annuity Payments.
ANNUITY PAYMENT - The periodic payment an Owner receives.
ATTAINED AGE - The Issue Age of the Annuitant or Owner plus the number of full
years elapsed since the Contract Date.
BENEFICIARY - The person designated to receive benefits in the case of the
death of the Owner.
BUSINESS DAY - Any day the New York Stock Exchange ("NYSE") is open for
trading, exclusive of federal holidays, or any day on which the Securities and
Exchange Commission ("SEC") requires that mutual funds, unit investment trusts
or other investment portfolios be valued.
CASH SURRENDER VALUE - The amount the Owner receives upon surrender of the
Contract.
CHARGE DEDUCTION DIVISION - The Division from which all charges are deducted if
so designated or elected by the Owner.
CONTINGENT ANNUITANT - The person designated by the Owner who, upon the
Annuitant's death prior to the Annuity Commencement Date, becomes the
Annuitant.
CONTRACT ANNIVERSARY - The anniversary of the Contract Date.
CONTRACT DATE - The date we received the initial premium and upon which we
begin determining the Contract values. It may not be the same as the
Contract Issue Date. This date is used to determine Contract months,
processing dates, years, and anniversaries.
CONTRACT ISSUE DATE - The date the Contract is issued at our Customer Service
Center.
CONTRACT PROCESSING DATES - The days when we deduct certain charges from the
Accumulation Value. If the Contract Processing Date is not a Valuation
Date, it will be on the next succeeding Valuation date. The Contract
Processing Date will be on the Contract Anniversary of each year.
CONTRACT PROCESSING PERIOD - The period between successive Contract Processing
Dates unless it is the first Contract Processing Period. In that case, it
is the period from the Contract Date to the first Contract Processing
Date.
CONTRACT YEAR - The period between Contract Anniversaries.
GA-IA-1083 4
IMPORTANT TERMS (continued)
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EXPERIENCE FACTOR - The factor which reflects the investment experience of the
portfolio in which a Variable Separate Account Division invests and also
reflects the charges assessed against the Division for a Valuation Period.
GUARANTEE PERIOD - The period of years a rate of interest is guaranteed to be
credited to a Guaranteed Interest Division.
GUARANTEED INTEREST DIVISION - An investment option available in the General
Account, an account which contains all of our assets other than those held
in our Variable Separate Accounts.
GUARANTEED INTEREST RATE - The effective annual interest rate which we will
credit for a specified Guarantee Period.
GUARANTEED MINIMUM INTEREST RATE - The minimum interest rate which can be
declared by us for allocations to a Guaranteed Interest Division.
INDEX OF INVESTMENT EXPERIENCE - The index that measures the performance of a
Variable Separate Account Division.
INITIAL PREMIUM - The payment amount required to put each Contract in effect.
ISSUE AGE - The Annuitant's or Owner's age on the last birthday on or before
the Contract Date.
MATURITY DATE - The date on which a Guarantee Period matures.
OWNER- The person who owns a Contract and is entitled to exercise all rights of
the Contract. This person's death also initiates payment of the Death
Benefit.
RIDERS - Riders add provisions or change the terms of the Contract.
SPECIALLY DESIGNATED DIVISION - Distributions from a portfolio underlying a
Division in which reinvestment is not available will be allocated to this
Division unless you specify otherwise.
VALUATION DATE - The day at the end of a Valuation Period when each Division is
valued.
VALUATION PERIOD - Each business day together with any non-business days before
it.
VARIABLE SEPARATE ACCOUNT DIVISION - An investment option available in the
Variable Separate Account shown in the Schedule.
GA-IA-1083 5
INTRODUCTION TO THIS CONTRACT
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THE CONTRACT
This is a legal contract between you and us. We provide benefits as stated in
this Contract. In return, you supply us with the Initial Premium Payment
required to put this Contract in effect.
This Contract, together with any attached application, Riders or Endorsements,
constitutes the entire Contract. Riders and Endorsements add provisions or
change the terms of the basic Contract.
THE OWNER
You are the Owner of this Contract. You are also the Annuitant unless another
Annuitant has been named in the application and is shown in the Schedule. You
have the rights and options described in this Contract, including but not
limited to the right to receive the Annuity Benefits on the Annuity
Commencement Date.
One or more people may own this Contract. If there are multiple Owners named,
the age of the oldest Owner will be used to determine the applicable Death
Benefit. In the case of a sole Owner who dies prior to the Annuity Commencement
Date, we will pay the Beneficiary the Death Benefit then due. If the sole Owner
is not an individual, we will treat the Annuitant as Owner for the purpose of
determining when the Owner dies under the Death Benefit provision (if there is
no Contingent Annuitant), and the Annuitant's age will determine the applicable
Death Benefit payable to the Beneficiary. The sole Owner's estate will be the
Beneficiary if no Beneficiary designation is in effect, or if the designated
Beneficiary has predeceased the Owner. In the case of a joint Owner of the
Contract dying prior to the Annuity Commencement Date, the surviving Owner(s)
will be deemed as the Beneficiary(ies).
THE ANNUITANT
The Annuitant is the measuring life of the Annuity Benefits provided under this
Contract. You may name a Contingent Annuitant. The Annuitant may not be changed
during the Annuitant's lifetime.
If the Annuitant dies before the Annuity Commencement Date, the Contingent
Annuitant becomes the Annuitant. You will be the Contingent Annuitant unless
you name someone else. The Annuitant must be a natural person. If the
Annuitant dies and no Contingent Annuitant has been named, we will allow you
sixty days to designate someone other than yourself as an Annuitant. If all
Owners are not individuals and, through the operation of this provision, an
Owner becomes Annuitant, we will pay the death proceeds to the Beneficiary.
If there are joint Owners, we will treat the youngest of the Owners as the
Contingent Annuitant designated, unless you elect otherwise.
THE BENEFICIARY
The Beneficiary is the person to whom we pay death proceeds if any Owner dies
prior to the Annuity Commencement Date. See Proceeds Payable to the Beneficiary
for more information. We pay death proceeds to the primary Beneficiary (unless
there are joint Owners in which case the Death Benefit proceeds are payable to
the surviving Owner). If the primary Beneficiary dies before the Owner, the
death proceeds are paid to the Contingent Beneficiary, if any. If there is no
surviving Beneficiary, we pay the death proceeds to the Owner's estate.
GA-IA-1083 6
INTRODUCTION TO THIS CONTRACT (continued)
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One or more persons may be named as primary Beneficiary or contingent
Beneficiary. In the case of more than one Beneficiary, we will assume any death
proceeds are to be paid in equal shares to the surviving Beneficiaries. You can
specify other than equal shares.
You have the right to change Beneficiaries, unless you designate the primary
Beneficiary irrevocable. When an irrevocable Beneficiary has been designated,
you and the irrevocable Beneficiary may have to act together to exercise the
rights and options under this Contract.
CHANGE OF OWNER OR BENEFICIARY
During your lifetime and while this Contract is in effect you can transfer
ownership of this Contract or change the Beneficiary. To make any of these
changes, you must send us written notice of the change in a form satisfactory
to us. The change will take effect as of the day the notice is signed. The
change will not affect any payment made or action taken by us before recording
the change at our Customer Service Center. A Change of Owner may affect the
amount of Death Benefit payable under this Contract. See Proceeds Payable to
Beneficiary.
GA-IA-1083 7
PREMIUM PAYMENTS AND ALLOCATION CHANGES
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INITIAL PREMIUM PAYMENT
The Initial Premium Payment is required to put this Contract in effect. The
amount of the Initial Premium Payment is shown in the Schedule.
ADDITIONAL PREMIUM PAYMENTS
You may make additional Premium Payments under this Contract after the end of
the Right to Examine period. Restrictions on additional Premium Payments, such
as the Attained Age of the Annuitant or Owner and the timing and amount of each
payment, are shown in the Schedule. We reserve the right to defer acceptance of
or to return any additional Premium Payments.
As of the date we receive and accept your additional Premium Payment:
(1) The Accumulation Value will increase by the amount of the Premium
Payment less any premium deductions as shown in the Schedule.
(2) The increase in the Accumulation Value will be allocated among the
Divisions of the Variable Separate Account and General Account in
accordance with your instructions. If you do not provide such
instructions, allocation will be among the Divisions of the Variable
Separate Account and General Account in proportion to the amount of
Accumulation Value in each Division.
Where to Make Payments
Remit the premium payments to our Customer Service Center at the address shown
on the cover page. On request we will give you a receipt signed by our
treasurer.
YOUR RIGHT TO CHANGE ALLOCATION OF ACCUMULATION VALUE
You may change the allocation of the Accumulation Value among the Divisions
after the end of the Right to Examine period. Allocation changes in excess of
twelve in any Contract Year are subject to the Excess Allocation Charge as
stated in the Schedule. To make an allocation change, you must provide us with
satisfactory notice at our Customer Service Center. The change will take effect
when we receive the notice. Restrictions for reallocation into and out of
Divisions of the Variable Separate Account and General Account are shown in the
Schedule.
WHAT HAPPENS IF A VARIABLE SEPARATE ACCOUNT DIVISION IS NOT AVAILABLE
When a distribution is made from an investment portfolio supporting a unit
investment trust Separate Account Division in which reinvestment is not
available, we will allocate the distribution to the Specially Designated
Division shown in the Schedule unless you specify otherwise.
Such a distribution may occur when an investment portfolio or Division matures,
when distribution from a portfolio or Division cannot be reinvested in the
portfolio or Division due to the unavailability of securities, or for other
reasons. When this occurs because of maturity, we will send written notice to
you thirty days in advance of such date. To elect an allocation to other than
the Specially Designated Division shown in the Schedule, you must provide
satisfactory notice to us at least seven days prior to the date the investment
matures. Such allocations will not be counted as an allocation change of the
Accumulation Value for purposes of the number of free allocations permitted.
GA-IA-1083 8
PREMIUM PAYMENTS AND ALLOCATION CHANGES (continued)
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RESTRICTED FUNDS
Restricted Funds are subject to limits as to amounts which may be invested or
transferred into such Divisions. The designation of a Division as a Restricted
Fund may be changed upon 30 days notice to the Owner with regard to future
transfers and Premium Payments into such Division. When a new Division is made
available it may be designated as a Restricted Fund. If so designated, the
rules regarding its restrictions will be sent to the Owner. Restricted Funds
available under this Contract, if any, as well as applicable total Contract
limits, are shown in the Schedule.
THRESHOLDS
Each Restricted Fund has one or more thresholds at which point no further
amounts may be allocated to that Division. Compliance with a threshold is
verified whenever there is a transaction initiated which is subject to such
threshold (Premium Payments, transfers, withdrawals). A threshold is applied to
the total Accumulation Value of each Restricted Fund. Thresholds may be changed
by the Company for new premiums, transfers or withdrawals by Restricted Fund
upon 30 day notice.
DOLLAR CAP
The Dollar Cap is the dollar amount at which no further Accumulation Value may
be added to Restricted Funds.
PREMIUM THRESHOLD
The threshold for premium by Restricted Fund limits the amount of any premium
which may be allocated to that Division. Should a request for allocation to a
Restricted Fund exceed the limit in effect for that Division or for the
Contract, any excess over that amount shall be allocated prorata to any
non-Restricted Fund(s) in which the Contract is then invested. Should the
Contract not be invested in other non-Restricted Funds, the excess will be
invested in the Specially Designated Division unless we receive written
instructions to do otherwise. Premium allocations must also satisfy the
Allocation Threshold.
ALLOCATION THRESHOLD
Allocations into a Restricted Fund are limited to that amount such that the
Accumulation Value in that Restricted Fund after such allocation does not
exceed the threshold for that Division and does not cause the Contract's total
limit on allocation to Restricted Funds to be exceeded. If the amount of an
allocation would cause either limit to be exceeded, the allocation will only be
executed to the extent the lower limit would allow.
Allocations from a Restricted Fund will be allowed even if the amount remaining
in the Restricted Fund after an allocation exceeds the Allocation Threshold. If
a program of allocations over time is authorized by us, verification of the
threshold will be performed at the initiation of such program. If such program
is modified at a later date, a testing of thresholds will be done at that time.
GA-IA-1083 9
PREMIUM PAYMENTS AND ALLOCATION CHANGES (continued)
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THRESHOLDS - EFFECT ON WITHDRAWALS
If a withdrawal is requested while any Accumulation Value is allocated to
Restricted Funds and the Allocation Threshold percentage is currently exceeded,
the percentage for funds invested in Restricted Funds for the total Contract,
after taking into account the withdrawal, may not be higher than prior to the
withdrawal. Should the calculated effect of a withdrawal result in the total
Contract threshold being exceeded, the excess portion of the withdrawal will be
processed prorata from all variable Divisions. Systematic withdrawals, while
the Contract has investments in Restricted Funds, if not withdrawn prorata
from all Divisions, shall be monitored annually to assure threshold compliance.
Should the effect of such withdrawals cause a Restricted Fund to exceed its
threshold, the Divisions from which the withdrawals are processed may be
adjusted to assure that the percentage of Accumulation Value in the Restricted
Funds does not increase.
THRESHOLD PROCESSING
For the purpose of calculating any thresholds, the values for the Divisions
will be determined using the prior day's closing Index of Investment
Experience.
GA-IA-1083 10
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE
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The variable Annuity Benefits under this Contract are provided through
investments which may be made in our Separate Accounts.
THE VARIABLE SEPARATE ACCOUNTS
These accounts, which are designated in the Schedule, are kept separate from
our General Account and any other Separate Accounts we may have. They are used
to support Variable Annuity Contracts and may be used for other purposes
permitted by applicable laws and regulations. We own the assets in the Separate
Accounts. Assets equal to the reserves and other liabilities of the accounts
will not be charged with liabilities that arise from any other business we
conduct; but, we may transfer to our General Account assets which exceed the
reserves and other liabilities of the Variable Separate Accounts. Income and
realized and unrealized gains or losses from assets in these Variable Separate
Accounts are credited to or charged against the account without regard to other
income, gains or losses in our other investment accounts.
The Variable Separate Account will invest in mutual funds, unit investment
trusts and other investment portfolios which we determine to be suitable for
this Contract's purposes. The Variable Separate Account is treated as a unit
investment trust under Federal securities laws. It is registered with the
Securities and Exchange Commission ("SEC") under the Investment Company Act of
1940. The Variable Separate Account is also governed by state law as designated
in the Schedule. The trusts may offer non-registered series.
Variable Separate Account Divisions
A unit investment trust Separate Account includes Divisions, each investing in
a designated investment portfolio. The Divisions and the investment portfolios
designated may be managed by a separate investment adviser. Such adviser may be
registered under the Investment Advisers Act of 1940.
Changes within the Variable Separate Accounts
We may, from time to time, make additional Variable Separate Account Divisions
available to you. These Divisions will invest in investment portfolios we find
suitable for this Contract. We also have the right to eliminate Divisions from
a Variable Separate Account, to combine two or more Divisions or to substitute
a new portfolio for the portfolio in which a Division invests. A substitution
may become necessary if, in our judgment, a portfolio or Division no longer
suits the purpose of this Contract. This may happen due to a change in laws or
regulations, or a change in a portfolio's investment objectives or
restrictions, or because the portfolio or Division is no longer available for
investment, or for some other reason. We will get any required approval before
making such a substitution.
Subject to any required regulatory approvals, we reserve the right to transfer
assets of the Variable Separate Account which we determine to be associated
with the class of contracts to which this Contract belongs, to another Variable
Separate Account or Division.
When permitted by law, we reserve the right to:
(1) deregister a Variable Separate Account under the Investment Company
Act of 1940;
(2) operate a Variable Separate Account as a management company under the
Investment Company Act of 1940, if it is operating as a unit
investment trust;
(3) operate a Variable Separate Account as a unit investment trust under
the Investment Company Act of 1940, if it is operating as a managed
Variable Separate Account;
(4) restrict or eliminate any voting rights of Owners, or other persons
who have voting rights to a Variable Separate Account; and
(5) combine a Variable Separate Account with other Variable Separate
Accounts.
GA-IA-1083 11
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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THE GENERAL ACCOUNT
The General Account contains all assets of the Company other than those in the
Separate Accounts we establish. The Guaranteed Interest Divisions available for
investment are shown in the Schedule. We may, from time to time, offer other
Divisions where assets are held in our General Account.
VALUATION PERIOD
Each Division will be valued at the end of each Valuation Period on a Valuation
Date. A Valuation Period is each Business Day together with any non-Business
Days before it. A Business Day is any day the New York Stock Exchange (NYSE) is
open for trading, and the SEC requires mutual funds, unit investment trusts, or
other investment portfolios to value their securities.
ACCUMULATION VALUE
The Accumulation Value of this Contract is the sum of the amounts in each of
the Separate and General Account Divisions. You select the Divisions of the
Variable Separate Account and General Account to which to allocate the
Accumulation Value
ACCUMULATION VALUE IN EACH DIVISION
On the Contract Date
On the Contract Date, the Accumulation Value is allocated to each Division as
elected by you, subject to certain terms and conditions imposed by us. We
reserve the right to allocate premium to the Specially Designated Division
during any Right to Examine period. After such time, allocation will be made
proportionately in accordance with the initial allocation(s) as elected by you.
On each Valuation Date
At the end of each subsequent Valuation Period, the amount of Accumulation
Value in each Division will be calculated as follows:
(1) We take the Accumulation Value in the Division at the end of the
preceding Valuation Period.
(2) We multiply (1) by the Variable Separate Account Division's Net
Rate of Return for the current Valuation
Period or we calculate the interest to be credited to a Guaranteed
Interest Division for the current Valuation Period.
(3) We add (1) and (2).
(4) We add to (3) any additional Premium Payments (less any premium
deductions as shown in the Schedule) allocated to the Division during
the current Valuation Period.
(5) We add or subtract allocations to or from that Division during the
current Valuation Period.
(6) We subtract from (5) any Partial Withdrawals which are allocated to
the Division during the current Valuation Period.
(7) We subtract from (6) the amounts allocated to that Division for:
(a) any charges due for the Optional Benefit Riders as shown in
the Schedule;
(b) any deductions from Accumulation Value as shown in the
Schedule.
All amounts in (7) are allocated to each Division in the proportion that (6)
bears to the Accumulation Value unless the Charge Deduction Division has been
specified (see the Schedule).
GA-IA-1083 12
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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MEASUREMENT OF INVESTMENT EXPERIENCE
Index of Investment Experience
The Investment Experience of a Variable Separate Account Division is determined
on each Valuation Date. We use an Index to measure changes in each Division's
experience during a Valuation Period. We set the Index at $10 when the first
investments in a Division are made. The Index for a current Valuation Period
equals the Index for the preceding Valuation Period multiplied by the
Experience Factor for the current Valuation Period.
How We Determine the Experience Factor
For Divisions of a unit investment trust Separate Account the Experience Factor
reflects the Investment Experience of the portfolio in which the Division
invests as well as the charges assessed against the Division for a Valuation
Period. The factor is calculated as follows:
(1) We take the net asset value of the portfolio in which the Division
invests at the end of the current Valuation Period.
(2) We add to (1) the amount of any dividend or capital gains distribution
declared for the investment portfolio and reinvested in such portfolio
during the current Valuation Period. We subtract from that amount a
charge for our taxes, if any.
(3) We divide (2) by the net asset value of the portfolio at the end of
the preceding Valuation Period.
(4) We subtract the daily Mortality and Expense Risk Charge for each
Division shown in the Schedule for each day
in the Valuation Period.
(5) We subtract the daily Asset Based Administrative Charge shown in the
Schedule for each day in the Valuation Period.
Calculations for Divisions investing in unit investment trusts are on a per
unit basis.
Net Rate of Return for a Variable Separate Account Division
The Net Rate of Return for a Variable Separate Account Division during a
Valuation Period is the Experience Factor for that Valuation Period minus one.
Interest Credited to a Guaranteed Interest Division
Accumulation Value allocated to a Guaranteed Interest Division will be credited
with the Guaranteed Interest Rate for the Guarantee Period in effect on the
date the premium or reallocation is applied. Once applied, such rate will be
guaranteed until the Maturity Date of that Guarantee Period. Interest will be
credited daily at a rate to yield the declared annual Guaranteed Interest Rate.
No Guaranteed Interest Rate will be less than the Minimum Interest Rate shown
in the Schedule.
GA-IA-1083 13
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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CHARGES DEDUCTED FROM ACCUMULATION VALUE ON EACH CONTRACT PROCESSING DATE
Expense charges and fees are shown in the Schedule.
Charge Deduction Division Option
We will deduct all charges against the Accumulation Value of this Contract from
the Charge Deduction Division if you elected this option on the application
(see the Schedule). If you did not elect this Option or if the charges are
greater than the amount in the Charge Deduction Division, the charges against
the Accumulation Value will be deducted as follows:
(1) If these charges are less than the Accumulation Value in the Variable
Separate Account Divisions, they will be deducted proportionately from
all Divisions.
(2) If these charges exceed the Accumulation Value in the Variable
Separate Account Divisions, any excess over such value will be
deducted proportionately from the Guaranteed Interest Divisions.
Any charges taken from the General Account will be taken from the Guaranteed
Interest Divisions starting with the Guarantee Period nearest its Maturity Date
until such charges have been paid.
At any time while this Contract is in effect, you may change your election of
this Option. To do this you must send us a written request to our Customer
Service Center. Any change will take effect within seven days of the date we
receive your request.
GA-IA-1083 14
YOUR CONTRACT BENEFITS
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While this Contract is in effect, there are important rights and benefits that
are available to you. We discuss these rights and benefits in this section.
CASH VALUE BENEFIT
Cash Surrender Value
The Cash Surrender Value, while the Annuitant is living and before the Annuity
Commencement Date, is determined as follows:
(1) We take the Contract's Accumulation Value;
(2) We deduct any Surrender Charges;
(3) We deduct any charges shown in the Schedule that have been incurred
but not yet deducted, including: (a) any administrative charge that
has not yet been deducted; (b) the prorata part of any charges for
Optional Benefit Riders; and (c) any applicable premium or other tax.
Cancelling to Receive the Cash Surrender Value
At any time while the Annuitant is living and before the Annuity Commencement
Date, you may surrender this Contract to us. To do this, you must return this
Contract with a signed request for cancellation to our Customer Service Center.
The Cash Surrender Value will vary daily. We will determine the Cash Surrender
Value as of the date we receive the Contract and your signed request in our
Customer Service Center. All benefits under this Contract will then end.
We will usually pay the Cash Surrender Value within seven days; but, we may
delay payment as described in the Payments We May Defer provision.
PARTIAL WITHDRAWAL OPTION
After the Contract Date, you may make Partial Withdrawals. Partial Withdrawals
may be subject to a Partial Withdrawal Charge (see the Schedule). The minimum
amount that may be withdrawn is shown in the Schedule. The maximum amount that
may be withdrawn without Surrender Charge is shown in the Schedule. To take a
Partial Withdrawal, you must provide us satisfactory notice at our Customer
Service Center.
PROCEEDS PAYABLE TO THE BENEFICIARY
Prior to the Annuity Commencement Date
If the sole Owner dies prior to the Annuity Commencement Date, we will pay the
Beneficiary the Death Benefit. If there are joint Owners and any Owner dies, we
will pay the surviving Owners the Death Benefit. We will pay the amount on
receipt of due proof of the Owner's death at our Customer Service Center. Such
amount may be received in a single lump sum or applied to any of the Annuity
Options (see Choosing an Income Plan). When the Owner (or all Owners where
there are joint Owners) is not an individual, the Death Benefit will become
payable on the death of the Annuitant prior to the Annuity Commencement Date
(unless a Contingent Annuitant survived the Annuitant). Only one Death Benefit
is payable under this Contract. In all events, distributions under the Contract
must be made as required by applicable law.
How to Claim Payments to Beneficiary
We must receive proof of the Owner's (or the Annuitant's) death before we will
make any payments to the Beneficiary. We will calculate the Death Benefit as of
the date we receive due proof of death. The Beneficiary should contact our
Customer Service Center for instructions.
GA-IA-1083 15
CHOOSING AN INCOME PLAN
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ANNUITY BENEFITS
If the Annuitant and Owner are living on the Annuity Commencement Date, we will
begin making payments to the Owner. We will make these payments under the
Annuity Option (or Options) as chosen in the application or as subsequently
selected. You may choose or change an Annuity Option by making a written
request at least 30 days prior to the Annuity Commencement Date. Unless you
have chosen otherwise, Option 2 on a 10-year period certain basis will become
effective. The amounts of the payments will be determined by applying the
Accumulation Value on the Annuity Commencement Date in accordance with the
Annuity Options section below (see Payments We May Defer). Before we pay any
Annuity Benefits, we require the return of this Contract. If this Contract has
been lost, we require the applicable lost Contract form.
ANNUITY COMMENCEMENT DATE SELECTION
You select the Annuity Commencement Date. You may select any date following the
fifth Contract Anniversary but before the required date of Annuity Commencement
as shown in the Schedule. If you do not select a date, the Annuity Commencement
Date will be in the month following the required date of Annuity Commencement.
FREQUENCY SELECTION
You may choose the frequency of the Annuity Payments. They may be monthly,
quarterly, semi-annually or annually. If we do not receive written notice from
you, the payments will be made monthly.
THE INCOME PLAN
While this Contract is in effect and before the Annuity Commencement Date, you
may choose one or more Annuity Options for the payment of Death Benefits
proceeds. If, at the time of the Owner's death, no Option has been chosen for
paying the Death Benefit proceeds, the Beneficiary may choose an Option within
one year. You may also elect an Annuity Option on surrender of the Contract for
its Cash Surrender Value. For each Option we will issue a separate written
agreement putting the Option into effect.
Our approval is needed for any Option where:
(1) the person named to receive payment is other than the Owner or
Beneficiary; or
(2) the person named is not a natural person, such as a
corporation; or
(3) any income payment would be less than the minimum
annuity income payment shown in the Schedule.
THE ANNUITY OPTIONS
There are four Options to choose from. They are:
Option 1. Income for a Fixed Period
Payment is made in equal installments for a fixed number of years. We guarantee
each monthly payment will be at least the Income for Fixed Period amount shown
in the Schedule. Values for annual, semiannual or quarterly payments are
available on request.
GA-IA-1083 16
CHOOSING AN INCOME PLAN (continued)
-------------------------------------------------------------------------------
Option 2. Income for Life
Payment is made to the person named in equal monthly installments and
guaranteed for at least a period certain. The period certain can be
10 or 20 years. Other periods certain are available on request.
A refund certain may be chosen
instead. Under this arrangement, income is guaranteed until payments equal the
amount applied. If the person named lives beyond the guarantee period, payments
continue until his or her death.
We guarantee each payment will be at least the amount shown in the Schedule. By
age, we mean the named person's age on his or her nearest birthday before the
Option's effective date. Amounts for ages not shown are available on request.
Option 3. Joint Life Income
This Option is available if there are two persons named to receive payments. At
least one of the persons named must be either the Owner or Beneficiary of this
Contract. Monthly payments are guaranteed and are made as long as at least one
of the named persons is living. The monthly payment amounts are available upon
request. Such amounts are guaranteed and will be calculated on the same basis
as the Table for Income for Life, however, the amounts will be based on two
lives.
Option 4. Annuity Plan
Payment may be made under any other method mutually agreed upon by you and us.
The minimum rates for Option 1 are based on 3% interest, compounded annually.
The minimum rates for Options 2 and 3 are based on 3% interest, compounded
annually, and the Annuity 2000 Mortality Table. We may pay a higher rate at our
discretion.
PAYMENT WHEN NAMED PERSON DIES
When the person named to receive payment dies, we will pay any amounts still
due as provided by the Option agreement. The amounts still due are determined
as follows:
(1) For Option 1 or for any remaining guaranteed payments in Option 2,
payments will be continued.
(2) For Option 3, no amounts are payable after
both named persons have died.
(3) For Option 4, the annuity agreement will
state the amount due, if any.
GA-IA-1083 17
OTHER IMPORTANT INFORMATION
------------------------------------------------------------------------------
SENDING NOTICE TO US
Whenever written notice is required, send it to our Customer Service Center.
The address of our Customer Service Center is shown on the cover page. Please
include your Contract number in all correspondence.
REPORTS TO OWNER
We will send you a report at least once during each Contract Year. The report
will show the Accumulation Value and the Cash Surrender Value as of the end of
the Contract Processing Period. The report will also show the allocation of
the Accumulation Value as of such date and the amounts deducted from or added
to the Accumulation Value since the last report. The report will also include
any information that may be currently required by the insurance supervisory
official of the jurisdiction in which the Contract is delivered.
We will also send you copies of any shareholder reports of the portfolios in
which the Divisions of the Variable Separate Account invest, as well as any
other reports, notices or documents required by law to be furnished to Owners.
ASSIGNMENT - USING THIS CONTRACT AS COLLATERAL SECURITY
You can assign this Contract as collateral security for a loan or other
obligation. This does not change the ownership. Your rights and any
Beneficiary's right are subject to the terms of the assignment. To make or
release an assignment, we must receive written notice satisfactory to us, at
our Customer Service Center. We are not responsible for the validity of any
assignment.
CHANGING THIS CONTRACT
This Contract or any additional benefit riders may be changed to another
annuity plan according to our rules at the time of the change.
CONTRACT CHANGES - APPLICABLE TAX LAW
We reserve the right to make changes in this Contract or its Riders to the
extent we deem it necessary to continue to qualify this Contract as an annuity.
Any such changes will apply uniformly to all Contracts that are affected. You
will be given advance written notice of such changes.
MISSTATEMENT OF AGE OR SEX
If an age or sex has been misstated, the amounts payable or benefits provided
by this Contract will be those that the Premium Payment made would have bought
at the correct age or sex.
NON-PARTICIPATING
This Contract does not participate in the divisible surplus of Golden American
Life Insurance Company.
GA-IA-1083 18
OTHER IMPORTANT INFORMATION (continued)
-------------------------------------------------------------------------------
CONTESTABILITY
This Contract is incontestable from its date of issue.
PAYMENTS WE MAY DEFER
We may not be able to determine the value of the assets of the Variable
Separate Account Divisions because:
(1) The NYSE is closed for trading;
(2) the SEC determines that a state of emergency exists;
(3) an order or pronouncement of the SEC permits a delay for the
protection of Owners; or
(4) the check used to pay the premium has not cleared through the banking
system. This may take up to 15 days.
During such times, as to amounts allocated to the Divisions of the Variable
Separate Account, we may delay;
(1) determination and payment of the Cash Surrender Value;
(2) determination and payment of any Death Benefit if death occurs before
the Annuity Commencement Date;
(3) allocation changes of the Accumulation Value; or
(4) application of the Accumulation Value
under an income plan.
As to the amounts allocated to a Guaranteed Interest Division in the General
Account, we may, at any time, defer payment of the Cash Surrender Value for up
to six months after we receive a request for it. We will allow interest of at
least 3.00% a year on any Cash Surrender Value payment derived from the
Guaranteed Interest Divisions that we defer 30 days or more.
AUTHORITY TO MAKE AGREEMENTS
All agreements made by us must be signed by one of our officers. No other
person, including an insurance agent or broker, can:
(1) change any of this Contract's terms;
(2) extend the time for Premium Payments; or
(3) make any agreement binding on us.
REQUIRED NOTE ON OUR COMPUTATIONS
We have filed a detailed statement of our computations with the insurance
supervisory official in the jurisdiction where this Contract is delivered. The
values are not less than those required by the law of that state or
jurisdiction. Any benefit provided by an attached Optional Benefit Rider will
not increase these values unless otherwise stated in that Rider.
GA-IA-1083 19
FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT - NO DIVIDENDS.
------------------------------------------------------------------------------
Variable Cash Surrender Values while the Annuitant and Owner are living
and prior to the Annuity Commencement Date. Death Benefit subject to
guaranteed minimum. Partial Withdrawal Option. Non-participating.
Investment results reflected in values.
GA-IA-1083
THE SCHEDULE (7% DB)
CONTRACT FACTS
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
CONTRACT FACTS
Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each year.
Specially Designated Division
When a distribution is made from an investment portfolio underlying a Separate
Account Division in which reinvestment is not available, we will allocate the
amount of the distribution to the [Liquid Asset Division] unless you specify
otherwise.
PARTIAL WITHDRAWALS
The maximum amount that can be withdrawn each Contract Year without being
considered an Excess Partial Withdrawal is described below. We will collect a
Surrender Charge for Excess Partial Withdrawals and a charge for any
unrecovered Premium Taxes. In no event may a Partial Withdrawal be greater than
90% of the Cash Surrender Value. After a Partial Withdrawal, the remaining
Accumulation Value must be at least $100 to keep the Contract in force.
Systematic Partial Withdrawals and Conventional Partial Withdrawals may not be
taken in the same Contract Year.
To determine the Surrender Charge on Excess Partial Withdrawals, the
withdrawals will occur in the following order:
(1) Earnings;
(2) The Free Amount;
(3) Premium Payments made [four] or more years prior to the
withdrawal; and
(4) Premium Payments made less than [four] years prior to
withdrawal.
Earnings and Free Amounts are not treated as withdrawals of Premium Payments
for purposes of calculating any Surrender Charge.
Conventional Partial Withdrawals
Minimum Withdrawal Amount: $100
The maximum amount that can be taken as a Conventional Partial Withdrawal each
Contract Year without being considered an Excess Partial Withdrawal is the
greater of:
(1) Earnings (defined below) not previously withdrawn, but not less than
zero; and
(2) The Free Amount, equal to 10% of Premium Payments not previously
withdrawn, which were received within [four] years prior to the date
of withdrawal.
Earnings are equal to the Accumulation Value, less Premium Payments, plus prior
withdrawals.
GA-IA-1083 3D1
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days from
the Contract Issue Date and may be taken on a monthly, quarterly or annual
basis. You select the day withdrawals will be made, but no later than the
28th day of the month. If you do not elect a day, the Contract Date will
be used.
Maximum Withdrawal Amounts:
Variable Separate Account Divisions: .833% of Premium Payments monthly,
2.5% of Premium Payments
quarterly or 10% of Premium
Payments Annually.
Guaranteed Interest Divisions: Interest earned on the Guaranteed
Interest Divisions for the prior
month, quarter or year (depending
on the frequency selected).
The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal is
10% of Premium Payments not previously withdrawn. A Systematic Partial
Withdrawal in excess of Earnings and the Free Amount may be subject to a
Surrender Charge.
XXX Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a Contract issued as an XXX on a monthly,
quarterly or annual basis. A minimum withdrawal of $100.00 is required. You
select the day the withdrawals will be made, but no later than the 28th day of
the month. If you do not elect a day, the Contract Date will be used.
Systematic Partial Withdrawals and Conventional Partial Withdrawals are not
allowed when XXX Partial Withdrawals are being taken.
DEATH BENEFIT
The Death Benefit is the greatest of (i), (ii), (iii) and (iv) below, where:
(i) is the Accumulation Value;
(ii) is the lesser of (a) and (b), where (a) is the Guaranteed Death
Benefit and (b) is the Maximum Guaranteed Death Benefit;
(iii) is the Cash Surrender Value; and
(iv) is the Minimum Death Benefit.
MINIMUM DEATH BENEFIT
The Minimum Death Benefit shall be the sum of the following:
1. The Accumulation Value allocated to Special Funds; and
2. Adjusted Premium for non-Special Funds.
GA-IA-1083 3D2
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Adjusted Premium for non-Special Funds shall mean all premium allocated to
non-Special Funds, plus an adjustment for any amounts transferred to
non-Special Funds, less a prorata adjustment for any amounts transferred or
withdrawn from non-Special Funds. The amount of the prorata adjustment will
equal (a) times (b) divided by (c), where: (a) is the Adjusted Premium for
non-Special Funds prior to the transfer or withdrawal; (b) is the Accumulation
Value of the transfer or withdrawal; and (c) is the Accumulation Value
allocated to non-Special Funds before the transfer or withdrawal. Adjusted
Premium for Special Funds has the same definition, but with respect to amounts
allocated to Special Funds.
Transfers from Special Funds increase the Adjusted Premium for non-Special
Funds by the lesser of the reduction of the Adjusted Premium for Special
Funds and net Accumulation Value transferred. Transfers from non-Special
Funds increase the Adjusted Premium for Special Funds by the reduction in
the Adjusted Premium for non-Special Funds.
GUARANTEED DEATH BENEFIT
The Guaranteed Death Benefit for the Contract is equal to the sum of I and II
below.
I. The Guaranteed Death Benefit Base for non-Special Funds.
II. The Accumulation Value allocated to Special Funds.
On the Contract Date, the Guaranteed Death Benefit Base for non-Special
Funds is the initial premium, if applicable, allocated to non-Special Funds.
On subsequent Valuation Dates, the Guaranteed Death Benefit Base for
non-Special Funds is calculated as follows:
(1) Start with the Guaranteed Death Benefit Base for non-Special Funds
on the prior Valuation Date.
(2) Calculate interest on (1) for the current Valuation Period at the
Guaranteed Death Benefit Interest Rate for non-Special Funds.
(3) Add (1) and (2).
(4) Add to (3) any additional premiums allocated to non-Special Funds
during the current Valuation Period.
(5) Add to (or subtract from) (4) adjustments for transfers from (to)
Special Funds made during the Valuation Period.
(6) Subtract from (5) the amount of any Special Partial Withdrawal
Adjustments and Prorata Partial Withdrawal Adjustments for any
partial withdrawals made from non-Special Funds during the current
Valuation Period.
The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds.
Transfers from Special Funds to non-Special Funds will reduce the Guaranteed
Death Benefit Base for Special Funds on a prorata basis. The resulting increase
in the Guaranteed Death Benefit Base for non-Special Funds will equal the
lesser of the reduction in the Guaranteed Death Benefit Base for Special Funds
and the net Accumulation Value transferred.
GA-IA-1083 3D3
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Transfers from non-Special Funds to Special Funds will reduce the Guaranteed
Death Benefit Base for non-Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for Special Funds will equal the
reduction in Guaranteed Death Benefit Base for non-Special Funds.
GUARANTEED DEATH BENEFIT INTEREST RATE
The Guaranteed Death Benefit Interest Rate is [7%] compounded annually, except:
(a) For any portion of the Guaranteed Death Benefit Base for Special
Funds, the Guaranteed Death Benefit Interest
Rate is [7%] (compounded annually); and
(b) For any valuation period ending after the Contract Anniversary on
which the Owner attains age [80], or after the Maximum
Guaranteed Death Benefit has been reached, the Guaranteed Death
Benefit Interest Rate is [0%].
SPECIAL FUNDS
Where used in this Contract, Special Funds are [the Liquid Asset Division, the
Limited Maturity Bond Division and the Guaranteed Interest Division]. We may
add newly available Divisions as Special Funds. We may also reclassify an
existing Division as a Special Fund or remove such designation upon 30 days
notice to you. Such reclassification will apply to amounts transferred or
otherwise added to such Division after the date of change. We may reduce the
Mortality and Expense Risk Charge (if applicable) for that portion of the
Contract invested in a Special Fund.
MAXIMUM GUARANTEED DEATH BENEFIT
The Maximum Guaranteed Death Benefit is equal to [three] times premium paid,
reduced by the amount of any Partial Withdrawal Adjustments. The Maximum
Guaranteed Death Benefit is allocated proportionally based on the Contract's
allocation to Special and non-Special funds. Transfers and withdrawals will
affect the allocation of the Maximum Guaranteed Death Benefit at the same
proportion among the Special and non-Special Funds that they bear to the
Accumulation Value transferred or withdrawn. Any addition due to spousal
continuation will not affect the Maximum Guaranteed Death Benefit or the
Guaranteed Death Benefit Base.
SPECIAL AND PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS
For any partial withdrawal, the Death Benefit components will be reduced by
Prorata Partial Withdrawal Adjustments. A Prorata Partial Withdrawal Adjustment
will be made unless a Special Partial Withdrawal Adjustment applies to the
component for the withdrawal. Special Partial Withdrawal Adjustments are made
when partial withdrawals in any Contract Year do not exceed [7%] of the sum of
cumulative premiums, but only if partial withdrawals in each prior year did not
exceed [7%] of the sum of premiums paid prior to that year. The Special Partial
Withdrawal Adjustment is equal to the amount of the Accumulation Value
withdrawn.
GA-IA-1083 3D4
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Special Partial Withdrawal Adjustments are applicable only in the calculation
of the Maximum Guaranteed Death Benefit and the Guaranteed Death Benefit Base,
and in all other cases withdrawals are treated as Prorata Partial Withdrawal
Adjustments.
The Prorata Partial Withdrawal Adjustment to a Death Benefit component is equal
to (1) divided by (2), multiplied by (3), where: (1) is the Accumulation Value
withdrawn; (2) is the Accumulation Value immediately prior to withdrawal; and
(3) is the amount of the applicable Death Benefit component immediately prior
to the withdrawal. Separate adjustments will apply to the amounts in the
Special and non-Special Funds.
CHANGE OF OWNER
A change of Owner from a sole Owner to a sole Owner (where there have never
been multiple Owners designated) will result in recalculation of the Death
Benefit, the Guaranteed Death Benefit and the Maximum Guaranteed Death Benefit.
If the new Owner's Attained Age at the time of the change is less than [80],
the Guaranteed Death Benefit and the Maximum Guaranteed Death Benefit in effect
prior to the change will remain in effect and the Death Benefit provision shall
apply. If the new Owner's Attained Age at the time of the change is [80] or
greater, but not greater than [85]:
(a) The Guaranteed Death Benefit and the Maximum Guaranteed Death Benefit
following the change will be zero; and
(b) The Death Benefit will then be the greatest of:
(1) the Cash Surrender Value;
(2) the Accumulation Value; and
(3) the Minimum Death Benefit.
If ownership changes result in multiple Owners or if there has ever been
multiple Owners, the Guaranteed Death Benefit and the Maximum Guaranteed Death
Benefit shall be set to zero. If the oldest Owner is age [85] or younger at the
time of the change, the Death Benefit will then be the greatest of (b) 1, (b) 2
or (b) 3 above.
If any Owner's or oldest multiple Owner's Attained Age is [86] or greater at
the time of the change, the Guaranteed Death Benefit, the Minimum Death
Benefit, and the Maximum Guaranteed Death Benefit will be zero, and the
Death Benefit will then be the Cash Surrender Value.
When a change of Owner reduces the Guaranteed Death Benefit and the Maximum
Guaranteed Death Benefit to zero, there will be a reduction in the Mortality
and Expense Risk Charge.
GA-IA-1083 3D5
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
SPOUSAL CONTINUATION UPON DEATH OF OWNER
If at the Owner's death, the surviving spouse of the deceased Owner is the
Beneficiary, and such surviving spouse elects to continue the Contract as their
own pursuant to Internal Revenue Code Section 72(s) or the equivalent
provisions of U.S. Treasury Department rules for qualified plans, the following
will apply:
(a) If the greater of (ii) and (iv) in the Death Benefit provision as of the
date we receive due proof of death of the Owner minus the Accumulation
Value, also as of that date, is greater than zero, we will add such
difference to the Accumulation Value. Such addition will be allocated to
the Divisions of the Separate Account in the same proportion as the
Accumulation Value in each Division bears to the Accumulation
Value in the Separate Account. If there is no Accumulation Value
in the Separate Account, the addition will be allocated to the
Liquid Asset Division, or its successor.
(b) The Guaranteed Death Benefit and the Maximum Guaranteed Death Benefit
will continue to apply, using the surviving spouse's age as the
determining age.
(c) At subsequent surrender, any Surrender Charge applicable to premiums
paid prior to the date we receive due proof of death of the Owner will
be waived. Any premiums paid later will be subject to any applicable
Surrender Charge.
This addition to Accumulation Value is available only to the spouse of the
Owner as of the date of death of the Owner if such spouse under the
provisions of this Contract elects to continue the Contract as their own.
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no later
than April 1st of the calendar year following the calendar year in which the
Owner attains age 70 1/2. Otherwise, the Annuity Commencement Date may be no
later than the same date as the Contract Processing Date in the month following
the Annuitant's 90th birthday. . In applying the Accumulation Value, we may
first collect any Premium Taxes due us. If, on the Annuity Commencement Date, a
Surrender Charge remains, your elected Annuity Option must include a period
certain of at least five years duration.
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
GA-IA-1083 3D6
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
OPTIONAL BENEFIT RIDERS - [None]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full years elapsed
since the Contract Date.
RESTRICTED FUNDS - [None]
GA-IA-1083 3D7
THE SCHEDULE
CHARGES AND FEES
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
DEDUCTIONS FROM PREMIUMS
None
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
None
Administrative Charge
We charge a maximum of $30 to cover a portion of our ongoing administrative
expenses for each Contract Processing Period. The charge is incurred at the
beginning of the Contract Processing Period and deducted on the Contract
Processing Date at the end of the period.
At the time of deduction, this charge will be waived if: (1) The Accumulation
Value is at least $100,000; or (2) The sum of premiums paid to date is at least
$100,000.
Excess Allocation Charge
Currently none, however, we reserve the right to charge $25 for a change if you
make more than twelve allocation changes per Contract Year. Any charge will be
deducted in proportion to the amount being transferred from each Division.
Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if the
Contract is surrendered or an Excess Partial Withdrawal is taken. The
percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed since a Premium
Payment was made. The Surrender Charge expressed as a percentage of each
Premium Payment is as follows:
Complete Years Elapsed Surrender
Since Premium Payment Charges
---------------------- ----------
[0 6%
1 5%
2 4%
3 3%
4+ 0%]
Surrender of the Contract is permitted at or before the commencement of Annuity
Payments.
GA-IA-1083 3E1
THE SCHEDULE
CHARGES AND FEES (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Premium Taxes
We deduct the amount of any premium or other state and local taxes levied by
any state or governmental entity when such taxes are incurred.
We reserve the right to defer collection of Premium Taxes until surrender or
until application of Accumulation Value to an Annuity Option. An Excess Partial
Withdrawal will result in the deduction of any Premium Tax then due us on such
amount. We reserve the right to change the amount we charge for Premium Tax
charges on future premium payments to conform with changes in the law or if the
Owner changes state of residence.
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the assets in each
Variable Separate Account Division on a daily basis of not more than
[0.005535]% (equivalent to an annual maximum rate of [2.00]%) for mortality
and expense risks. This charge is not deducted from the General Account
Accumulation Values.
Asset Based Administrative Charge - We deduct a charge of not more than
[0.000411]% of the assets in each Variable Separate Account Division on a
daily basis (equivalent to an annual maximum rate of [0.15]%) to compensate
us for a portion of our ongoing administrative expenses. This charge is not
deducted from the General Account Accumulation Values.
CHARGE DEDUCTION DIVISION
If elected by you all charges against the Accumulation Value in this Contract
will be deducted from the [Liquid Asset Division].
GA-IA-1083 3E2
THE SCHEDULE
INCOME PLAN FACTORS
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Values for other payment periods, ages or joint life combinations are available
on request. Monthly payments are shown for each $1,000 applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Period Monthly Fixed Period Monthly Fixed Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years Certain 20 Years Certain Refund Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
GA-IA-1083 3F
THE SCHEDULE (RATCHET)
CONTRACT FACTS
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
CONTRACT FACTS
Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each year.
Specially Designated Divisions
When a distribution is made from an investment portfolio underlying a Separate
Account Division in which reinvestment is not available, we will allocate the
amount of the distribution to the [Liquid Asset Division] unless you specify
otherwise.
PARTIAL WITHDRAWALS
The maximum amount that can be withdrawn each Contract Year without being
considered an Excess Partial Withdrawal is described below. We will collect a
Surrender Charge for Excess Partial Withdrawals and a charge for any
unrecovered Premium Taxes. In no event may a Partial Withdrawal be greater
than 90% of the Cash Surrender Value. After a Partial Withdrawal, the
remaining Accumulation Value must be at least $100 to keep the Contract
in force.
Systematic Partial Withdrawals and Conventional Partial Withdrawals may not be
taken in the same Contract Year.
To determine the Surrender Charge on Excess Partial Withdrawals, the
withdrawals will occur in the following order:
(1) Earnings;
(2) The Free Amount;
(3) Premium Payments made [four] or more years prior to the
withdrawal; and
(4) Premium Payments made less than [four] years prior to
withdrawal.
Earnings and Free Amounts are not treated as withdrawals of Premium Payments
for purposes of calculating any Surrender Charge.
Conventional Partial Withdrawals
Minimum Withdrawal Amount: $100
The maximum amount that can be taken as a Conventional Partial Withdrawal each
Contract Year without being considered an Excess Partial Withdrawal is the
greater of:
(1) Earnings (defined below) not previously withdrawn, but not
less than zero; and
(2) The Free Amount, equal to 10% of Premium Payments not previously
withdrawn, which were received within [four] years prior to
the date of withdrawal.
Earnings are equal to the Accumulation Value, less Premium Payments, plus prior
withdrawals.
GA-IA-1083 3D1
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days from
the Contract Issue Date and may be taken on a monthly, quarterly or annual
basis. You select the day withdrawals will be made, but no later than the
28th day of the month. If you do not elect a day, the Contract Date will
be used.
Maximum Withdrawal Amounts:
Variable Separate Account Divisions: 833% of Premium Payments monthly,
2.5% of Premium Payments
quarterly or 10% of Premium Payments
Annually.
Guaranteed Interest Divisions: Interest earned on the Guaranteed
Interest Divisions for the prior
month, quarter or year (depending
on the frequency selected).
The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal is
10% of Premium Payments not previously withdrawn. A Systematic Partial
Withdrawal in excess of Earnings and the Free Amount may be subject to a
Surrender Charge.
XXX Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a Contract issued as an XXX on a monthly,
quarterly or annual basis. A minimum withdrawal of $100.00 is required. You
select the day the withdrawals will be made, but no later than the 28th day of
the month. If you do not elect a day, the Contract Date will be used.
Systematic Partial Withdrawals and Conventional Partial Withdrawals are not
allowed when XXX Partial Withdrawals are being taken.
DEATH BENEFIT
The Death Benefit is the greatest of (i), (ii), (iii) and (iv) below, where:
(i) is the Accumulation Value;
(ii) is the Guaranteed Death Benefit;
(iii) is the Cash Surrender Value; and (iv) is the Minimum Death Benefit.
GA-IA-1083 3D2
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
MINIMUM DEATH BENEFIT
The Minimum Death Benefit shall be the sum of the following:
1. The Accumulation Value allocated to Special Funds; and
2. Adjusted Premium for non-Special Funds.
Adjusted Premium for non-Special Funds shall mean all premium allocated
to non-Special Funds, plus an adjustment for any amounts transferred to
non-Special Funds, less a prorata adjustment for any amounts transferred or
withdrawn from non-Special Funds. The amount of the prorata adjustment will
equal (a) times (b) divided by (c), where: (a) is the Adjusted Premium for
non-Special Funds prior to the transfer or withdrawal; (b) is the
Accumulation Value of the transfer or withdrawal; and (c) is the Accumulation
Value allocated to non-Special Funds before the transfer or withdrawal.
Adjusted Premium for Special Funds has the same definition, but with respect
to amounts allocated to Special Funds.
Transfers from Special Funds increase the Adjusted Premium for non-Special
Funds by the lesser of the reduction of the Adjusted Premium for Special
Funds and net Accumulation Value transferred. Transfers from non-Special
Funds increase the Adjusted Premium for Special Funds by the reduction in
the Adjusted Premium for non-Special Funds.
GUARANTEED DEATH BENEFIT
The Guaranteed Death Benefit for the Contract is equal to the sum of I and II
below.
I. The Guaranteed Death Benefit for non-Special Funds.
II. The Accumulation Value allocated to Special Funds.
On the Contract Date, the Guaranteed Death Benefit Base for non-Special Funds
is the initial premium allocated to non-Special Funds. On subsequent Valuation
Dates, the Guaranteed Death Benefit Base for non-Special Funds is calculated as
follows:
(1) Start with the Guaranteed Death Benefit Base for non-Special Funds
on the prior Valuation Date.
(2) Add to (1) any additional premium allocated to the non-Special Funds
during the current Valuation Period and
adjustments for transfers from Special Funds during the current
Valuation Period and subtract from (1) any adjustment for transfers to
Special Funds during the current Valuation Period and any Prorata
Partial Withdrawal Adjustments for any Partial Withdrawals taken from
non-Special Funds during the current Valuation Period.
(3) On a Valuation Date that occurs on or prior to the Owner's
Attained Age [90], which is also a Contract Anniversary, we set the
Guaranteed Death Benefit Base for non-Special Funds equal to the
greater of (2) or the Accumulation Value allocated to non-Special
Funds as of such date. On all other Valuation Dates, the Guaranteed
Death Benefit Base for non-Special Funds is equal to (2).
The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds.
GA-IA-1083 3D3
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Transfers from Special Funds to non-Special Funds will reduce the Guaranteed
Death Benefit Base for Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for non-Special Funds will
equal the lesser of the reduction in the Guaranteed Death Benefit Base for
Special Funds and the net Accumulation Value transferred.
Transfers from non-Special Funds to Special Funds will reduce the Guaranteed
Death Benefit Base for non-Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for Special Funds will equal the
reduction in Guaranteed Death Benefit Base for non-Special Funds.
SPECIAL FUNDS
Where used in this Contract, Special Funds are [the Liquid Asset Division, the
Limited Maturity Bond Division and the Guaranteed Interest Division]. We may
add newly available Divisions as Special Funds. We may also reclassify an
existing Division as a Special Fund or remove such designation upon 30 days
notice to you. Such reclassification will apply to amounts transferred or
otherwise added to such Division after the date of change. We may reduce the
Mortality and Expense Risk Charge (if applicable) for that portion of the
Contract invested in a Special Fund.
PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS
For any partial withdrawal, the Death Benefit components will be reduced by
Prorata Partial Withdrawal Adjustments. The Prorata Partial Withdrawal
Adjustment to a Death Benefit component for a partial withdrawal is equal
to (1) divided by (2), multiplied by (3), where: (1) is the Accumulation Value
withdrawn; (2) is the Accumulation Value immediately prior to withdrawal; and
(3) is the amount of the applicable Death Benefit component immediately prior
to the withdrawal. Separate adjustments will apply to amounts in the Special
and non-Special Funds.
CHANGE OF OWNER
A change of Owner from a sole Owner to a sole Owner (where there have never
been multiple Owners designated) will result in recalculation of the Death
Benefit and the Guaranteed Death Benefit. If the new Owner's Attained Age at
the time of the change is less than [80], the Guaranteed Death Benefit in
effect prior to the change will remain in effect and the Death Benefit
provision will apply. If the new Owner's Attained Age at the time of the
change is [80] or greater, but not greater than [85]:
(a) The Guaranteed Death Benefit following the change will be zero; and
(b) The Death Benefit will then be the greatest of:
(1) the Cash Surrender Value;
(2) the Accumulation Value; and
(3) the Minimum Death Benefit.
GA-IA-1083 3D4
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
If ownership changes result in multiple Owners or if there has ever been
multiple Owners, the Guaranteed Death Benefit shall be set to zero. If the
oldest Owner is age [85] or younger at the time of the change, the Death
Benefit will then be the greatest of (b) 1, (b) 2 or (b) 3 above.
If any Owner's or oldest multiple Owner's Attained Age is [86] or greater at
the time of the change, the Guaranteed Death Benefit will be zero, and the
Death Benefit will then be the Cash Surrender Value.
When a change of Owner reduces the Guaranteed Death Benefit to zero, there will
be a reduction in the Mortality and Expense Risk Charge.
SPOUSAL CONTINUATION UPON DEATH OF OWNER
If at the Owner's death, the surviving spouse of the deceased Owner is the
Beneficiary and such surviving spouse elects to continue the Contract as their
own pursuant to Internal Revenue Code Section 72(s) or the equivalent
provisions of U.S. Treasury Department rules for qualified plans, the following
will apply:
(a) If the greater of (ii) and (iv) in the Death Benefit provision
as of the date we receive due proof of death of the Owner minus
the Accumulation Value, also as of that date, is greater than
zero, we will add such difference to the Accumulation
Value. Such addition will be allocated to the Divisions of the
Separate Account in the same proportion as the Accumulation Value
in each Division bears to the Accumulation Value in the Separate
Account. If there is no Accumulation Value in the Separate
Account, the addition will be allocated to the Liquid Asset
Division, or its successor.
(b) The Guaranteed Death Benefit and the Maximum Guaranteed Death
Benefit will continue to apply, using the surviving spouse's age
as the determining age.
(c) At subsequent surrender, any Surrender Charge applicable to
premiums paid prior to the date we receive due proof of death of
the Owner will be waived. Any premiums paid later will be subject
to any applicable Surrender Charge.
This addition to Accumulation Value is available only to the spouse of the
Owner as of the date of death of the Owner if such spouse under the provisions
of this Contract elects to continue the Contract as their own.
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no later
than April 1st of the calendar year following the calendar year in which the
Owner attains age 70 1/2. Otherwise, the Annuity Commencement Date may be no
later than the Contract Processing Date in the month following the Annuitant's
90th birthday. In applying the Accumulation Value, we may first collect any
Premium Taxes due us. If, on the Annuity Commencement Date, a Surrender Charge
remains, your elected Annuity Option must include a period certain of at least
five years duration.
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
GA-IA-1083 3D5
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
OPTIONAL BENEFIT RIDERS - [None]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full years elapsed
since the Contract Date.
RESTRICTED FUNDS - [None]
GA-IA-1083 3D6
THE SCHEDULE
CHARGES AND FEES
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
DEDUCTIONS FROM PREMIUMS
None
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
None
Administrative Charge
We charge a maximum of $30 to cover a portion of our ongoing administrative
expenses for each Contract Processing Period. The charge is incurred at the
beginning of the Contract Processing Period and deducted on the Contract
Processing Date at the end of the period.
At the time of deduction, this charge will be waived if:
(1) The Accumulation Value is at least $100,000; or
(2) The sum of premiums paid to date is at least $100,000.
Excess Allocation Charge
Currently none, however, we reserve the right to charge $25 for a change if you
make more than twelve allocation changes per Contract Year. Any charge will be
deducted in proportion to the amount being transferred from each Division.
Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if the
Contract is surrendered or an Excess Partial Withdrawal is taken. The
percentage imposed at time of surrender or Excess Partial Withdrawal depends
on the number of complete years that have elapsed since a Premium Payment
was made. The Surrender Charge expressed as a percentage of each Premium
Payment is as follows:
Complete Years Elapsed Surrender
Since Premium Payment Charges
---------------------- ---------
[0 6%
1 5%
2 4%
3 3%
4+ 0%]
Surrender of the Contract is permitted at or before the commencement of Annuity
Payments.
GA-IA-1083 3E1
THE SCHEDULE
CHARGES AND FEES (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Premium Taxes
We deduct the amount of any premium or other state and local taxes levied by
any state or governmental entity when such taxes are incurred.
We reserve the right to defer collection of Premium Taxes until surrender or
until application of Accumulation Value to an Annuity Option. An Excess Partial
Withdrawal will result in the deduction of any Premium Tax then due us on such
amount. We reserve the right to change the amount we charge for Premium Tax
charges on future Premium Payments to conform with changes in the law or if the
Owner changes state of residence.
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the assets in each
---------------------------------
Variable Separate Account Division on a daily basis of not more than
[0.005255]% (equivalent to an annual maximum rate of [1.90]%) for mortality
and expense risks. This charge is not deducted from the General Account
Accumulation Values.
Asset Based Administrative Charge - We deduct a charge of not more than
---------------------------------
[0.000411]% of the assets in each Variable Separate Account Division on a daily
basis (equivalent to an annual maximum rate of [0.15]%) to compensate us for a
portion of our ongoing administrative expenses. This charge is not deducted
from the General Account Accumulation Values.
CHARGE DEDUCTION DIVISION
If elected by you, all charges against the Accumulation Value in this Contract
will be deducted from the [Liquid Asset Division].
GA-IA-1083 3E2
THE SCHEDULE
INCOME PLAN FACTORS
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Values for other payment periods, ages or joint life combinations are available
on request. Monthly payments are shown for each $1,000 applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Period Monthly Fixed Period Monthly Fixed Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years Certain 20 Years Certain Refund Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
GA-IA-1083 3F
THE SCHEDULE (BASE)
CONTRACT FACTS
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
CONTRACT FACTS
Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each year.
Specially Designated Division
When a distribution is made from an investment portfolio underlying a Separate
Account Division in which reinvestment is not available, we will allocate the
amount of the distribution to the [Liquid Asset Division] unless you specify
otherwise.
PARTIAL WITHDRAWALS
The maximum amount that can be withdrawn each Contract Year without being
considered an Excess Partial Withdrawal is described below. We will collect a
Surrender Charge for Excess Partial Withdrawals and a charge for any
unrecovered Premium Taxes. In no event may a Partial Withdrawal be greater
than 90% of the Cash Surrender Value. After a Partial Withdrawal, the
remaining Accumulation Value must be at least $100 to keep the Contract in
force.
Systematic Partial Withdrawals and Conventional Partial Withdrawals may not be
taken in the same Contract Year.
To determine the Surrender Charge on Excess Partial Withdrawals, the
withdrawals will occur in the following order:
(1) Earnings;
(2) The Free Amount;
(3) Premium Payments made [four] or more years prior to the
withdrawal; and
(4) Premium Payments made less than [four] years prior to
withdrawal.
Earnings and Free Amounts are not treated as withdrawals of Premium Payments
for purposes of calculating any Surrender Charge.
Conventional Partial Withdrawals
Minimum Withdrawal Amount: $100
The maximum amount that can be taken as a Conventional Partial Withdrawal each
Contract Year without being considered an Excess Partial Withdrawal is the
greater of:
(1) Earnings (defined below) not previously withdrawn, but not less than
zero; and
(2) The Free Amount, equal to 10% of Premium Payments not previously
withdrawn, which were received within [four] years prior to the date
of withdrawal.
Earnings are equal to the Accumulation Value, less Premium Payments, plus prior
withdrawals.
GA-IA-1083 3D1
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days from
the Contract Issue Date and may be taken on a monthly, quarterly or annual
basis. You select the day withdrawals will be made, but no later than the 28th
day of the month. If you do not elect a day, the Contract Date will be used.
Maximum Withdrawal Amounts:
Variable Separate Account Divisions: .833% of Premium Payments monthly,
2.5% of Premium Payments
quarterly or 10% of Premium Payments
Annually.
Guaranteed Interest Divisions: Interest earned on the Guaranteed
Interest Divisions for the prior
month, quarter or year (depending
on the frequency selected).
The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal is
10% of Premium Payments not previously withdrawn. A Systematic Partial
Withdrawal in excess of Earnings and the Free Amount may be subject to a
Surrender Charge.
XXX Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a Contract issued as an XXX on a monthly,
quarterly or annual basis. A minimum withdrawal of $100.00 is required. You
select the day the withdrawals will be made, but no later than the 28th day of
the month. If you do not elect a day, the Contract Date will be used.
Systematic Partial Withdrawals and Conventional Partial Withdrawals are not
allowed when XXX Partial Withdrawals are being taken.
DEATH BENEFIT
The Death Benefit is the greatest of (i) and (ii) below, where:
(i) is the Accumulation Value; and
(ii) is the Cash Surrender Value.
GA-IA-1083 3D2
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
SPOUSAL CONTINUATION UPON DEATH OF OWNER
If at the Owner's death, the surviving spouse of the deceased Owner is the
Beneficiary and such surviving spouse elects to continue the Contract as their
own pursuant to Internal Revenue Code Section 72(s) or the equivalent
provisions of U.S. Treasury Department rules for qualified plans, on any
subsequent surrender, Surrender Charges applicable to premiums paid prior to
the date we receive due proof of death of the Owner will be waived. Any
premiums paid later will be subject to any applicable Surrender Charge.
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no later
than April 1st of the calendar year following the calendar year in which the
Owner attains age 70 1/2. Otherwise, the Annuity Commencement Date may be no
later than the same date as the Contract Processing Date in the month following
the Annuitant's 90th birthday. In applying the Accumulation Value, we may first
collect any Premium Taxes due us. If, on the Annuity Commencement Date, a
Surrender Charge remains, your elected Annuity Option must include a period
certain of at least five years duration.
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
GA-IA-1083 3D3
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
OPTIONAL BENEFIT RIDERS - [None]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full years elapsed
since the Contract Date.
RESTRICTED FUNDS - [None]
GA-IA-1083 3D1
THE SCHEDULE
CHARGES AND FEES
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
DEDUCTIONS FROM PREMIUMS
None
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
None.
Administrative Charge
We charge a maximum of $30 to cover a portion of our ongoing administrative
expenses for each Contract Processing Period. The charge is incurred at the
beginning of the Contract Processing Period and deducted on the Contract
Processing Date at the end of the period.
At the time of deduction, this charge will be waived if: (1) The Accumulation
Value is at least $100,000; or (2) The sum of premiums paid to date is at least
$100,000.
Excess Allocation Charge
Currently none, however, we reserve the right to charge $25 for a change if you
make more than twelve allocation changes per Contract Year. Any charge will be
deducted in proportion to the amount being transferred from each Division.
Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if the
Contract is surrendered or an Excess Partial Withdrawal is taken. The
percentage imposed at time of surrender or Excess Partial Withdrawal depends
on the number of complete years that have elapsed since a Premium Payment
was made. The Surrender Charge expressed as a percentage of each Premium
Payment is as follows:
Complete Years Elapsed Surrender
Since Premium Payment Charges
---------------------- ---------
[0 6%
1 5%
2 4%
3 3%
4+ 0%]
Surrender of the Contract is permitted at or before the commencement of Annuity
Payments.
GA-IA-1083 3E1
THE SCHEDULE
CHARGES AND FEES (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Premium Taxes
We deduct the amount of any premium or other state and local taxes levied by
any state or governmental entity when such taxes are incurred.
We reserve the right to defer collection of Premium Taxes until surrender or
until application of Accumulation Value to an Annuity Option. An Excess Partial
Withdrawal will result in the deduction of any Premium Tax then due us on such
amount. We reserve the right to change the amount we charge for Premium Tax
charges on future Premium Payments to conform with changes in the law or if the
Owner changes state of residence.
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the assets in each
Variable Separate Account Division on a daily basis of not more than
[0.004280]% (equivalent to an annual maximum rate of [1.55]%) for mortality
and expense risks. This charge is not deducted from the General Account
Accumulation Values.]
Asset Based Administrative Charge - We deduct a charge of not more than
[0.000411]% of the assets in each Variable Separate Account Division on a daily
basis (equivalent to an annual maximum rate of [0.15]%) to compensate us for a
portion of our ongoing administrative expenses. This charge is not deducted
from the General Account Qaccumulation Values.
CHARGE DEDUCTION DIVISION
If elected by you, all charges against the Accumulation Value in this Contract
will be deducted from the [Liquid Asset Division].
GA-IA-1083 3E2
THE SCHEDULE
INCOME PLAN FACTORS
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Values for other payment periods, ages or joint life combinations are
available on request. Monthly payments are shown for each $1,000 applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Period Monthly Fixed Period Monthly Fixed Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years Certain 20 Years Certain Refund Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
GA-IA-1083 3F
THE SCHEDULE (COMBO DB)
CONTRACT FACTS
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
CONTRACT FACTS
Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each year.
Specially Designated Division
When a distribution is made from an investment portfolio underlying a Separate
Account Division in which reinvestment is not available, we will allocate the
amount of the distribution to the [Liquid Asset Division] unless you specify
otherwise.
PARTIAL WITHDRAWALS
The maximum amount that can be withdrawn each Contract Year without being
considered an Excess Partial Withdrawal is described below. We will collect a
Surrender Charge for Excess Partial Withdrawals and a charge for any
unrecovered Premium Taxes. In no event may a Partial Withdrawal be greater
than 90% of the Cash Surrender Value. After a Partial Withdrawal, the
remaining Accumulation Value must be at least $100 to keep the Contract
in force.
Systematic Partial Withdrawals and Conventional Partial Withdrawals may not be
taken in the same Contract Year.
To determine the Surrender Charge on Excess Partial Withdrawals, the
withdrawals will occur in the following order: (1) Earnings; (2) The Free
Amount; (3) Premium Payments made [four] or more years prior to the
withdrawal; and (4) Premium Payments made less than [four] years prior to
withdrawal.
Earnings and Free Amounts are not treated as withdrawals of Premium Payments
for purposes of calculating any Surrender Charge.
Conventional Partial Withdrawals
Minimum Withdrawal Amount: $100
The maximum amount that can be taken as a Conventional Partial Withdrawal each
Contract Year without being considered an Excess Partial Withdrawal is the
greater of:
(1) Earnings (defined below) not previously withdrawn, but not less than
zero; and
(2) The Free Amount, equal to 10% of Premium Payments not previously
withdrawn, which were received within [four] years prior to the date
of withdrawal.
Earnings are equal to the Accumulation Value, less Premium Payments, plus prior
withdrawals.
GA-IA-1083 3D1
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days from
the Contract Issue Date and may be taken on a monthly, quarterly or annual
basis. You select the day withdrawals will be made, but no later than the
28th day of the month. If you do not elect a day, the Contract Date will
be used.
Maximum Withdrawal Amounts:
Variable Separate Account Divisions: .833% of Premium Payments monthly,
2.5% of Premium Payments
quarterly or 10% of Premium Payments
Annually.
Guaranteed Interest Divisions: Interest earned on the Guaranteed
Interest Divisions for the prior
month, quarter or year (depending
on the frequency selected).
The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal is
10% of Premium Payments not previously withdrawn. A Systematic Partial
Withdrawal in excess of Earnings and the Free Amount may be subject to a
Surrender Charge.
XXX Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a contract issued as an XXX on a monthly,
quarterly or annual basis. A minimum withdrawal of $100.00 is required. You
select the day the withdrawals will be made, but no later than the 28th day of
the month. If you do not elect a day, the Contract Date will be used.
Systematic Partial Withdrawals and Conventional Partial Withdrawals are
not allowed when XXX Partial Withdrawals are being taken.
DEATH BENEFIT
The Death Benefit is the greatest of (i), (ii), (iii) and (iv) below, where:
(i) is the Accumulation Value;
(ii) is the lesser of (a) and (b) where (a) is the Guaranteed
Death Benefit and (b) is the Maximum Guaranteed Death Benefit;
(iii) is the Cash Surrender Value;
(iv) is the Minimum Death Benefit; and
(v) the Alternate Guaranteed Death Benefit
MINIMUM DEATH BENEFIT
The Minimum Death Benefit shall be the sum of the following:
(1) The Accumulation Value allocated to Special Funds; and
(2) Adjusted Premium for non-Special Funds.
GA-IA-1083 3D2
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Adjusted Premium for non-Special Funds shall mean all premium allocated to
non-Special Funds, plus an adjustment for any amounts transferred to
non-Special Funds, less a prorata adjustment for any amounts transferred or
withdrawn from non-Special Funds. The amount of the prorata adjustment will
equal (a) times (b) divided by (c), where: (a) is the Adjusted Premium for
non-Special Funds prior to the transfer or withdrawal; (b) is the
Accumulation Value of the transfer or
withdrawal; and (c) is the Accumulation Value allocated to non-Special Funds
before the transfer or withdrawal. Adjusted Premium for Special Funds has the
same definition, but with respect to amounts allocated to Special Funds.
Transfers from Special Funds increase the Adjusted Premium for non-Special
Funds by the lesser of the reduction of the Adjusted Premium for Special
Funds and net Accumulation Value transferred. Transfers from non-Special
Funds increase the Adjusted Premium for Special Funds by the reduction in
the Adjusted Premium for non-Special Funds.
GUARANTEED DEATH BENEFIT
The Guaranteed Death Benefit for the Contract is equal to the sum of I and II
below.
I. The Guaranteed Death Benefit Base for non-Special Funds.
II. The Accumulation Value allocated to Special Funds.
On the Contract Date, the Guaranteed Death Benefit Base for non-Special Funds
is the initial premium, if applicable, allocated to non-Special Funds. On
subsequent Valuation Dates, the Guaranteed Death Benefit Base for non-Special
Funds is calculated as follows:
(1) Start with the Guaranteed Death Benefit Base for non-Special Funds
on the prior Valuation Date.
(2) Calculate interest on (1) for the current Valuation Period at the
Guaranteed Death Benefit Interest Rate for non-Special Funds.
(3) Add (1) and (2).
(4) Add to (3) any additional premiums allocated to non-Special Funds
during the current Valuation Period.
(5) Add to (or subtract from) (4) adjustments for transfers from (to)
Special Funds made during the Valuation Period.
(6) Subtract from (5) the amount of any Special Partial Withdrawal
Adjustments and Prorata Partial Withdrawal Adjustments for any partial
withdrawals made from non-Special Funds during the current Valuation
Period.
The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds.
Transfers from Special Funds to non-Special Funds will reduce the Guaranteed
Death Benefit Base for Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for non-Special Funds will equal
the lesser of the reduction in the Guaranteed Death Benefit Base for Special
Funds and the net Accumulation Value transferred.
GA-IA-1083 3D3
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Transfers from non-Special Funds to Special Funds will reduce the Guaranteed
Death Benefit Base for non-Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for Special Funds will equal the
reduction in Guaranteed Death Benefit Base for non-Special Funds.
GUARANTEED DEATH BENEFIT INTEREST RATE
The Guaranteed Death Benefit Interest Rate is [7%] compounded annually, except:
(a) For any portion of the Guaranteed Death Benefit Base for Special
Funds, the Guaranteed Death Benefit Interest
Rate is [7%] (compounded annually); and
(b) For any valuation period ending after the Contract Anniversary on
which the Owner attains age [80], or after the Maximum Guaranteed
Death Benefit has been reached, the Guaranteed Death Benefit
Interest Rate is [0%].
SPECIAL FUNDS
Where used in this Contract, Special Funds are [the Liquid Asset Division, the
Limited Maturity Bond Division and the Guaranteed Interest Division]. We may
add newly available Divisions as Special Funds. We may also reclassify an
existing Division as a Special Fund or remove such designation upon 30 days
notice to you. Such reclassification will apply to amounts transferred or
otherwise added to such Division after the date of change. We may reduce
the Mortality and Expense Risk Charge (if applicable) for that portion of
the Contract invested in a Special Fund.
MAXIMUM GUARANTEED DEATH BENEFIT
The Maximum Guaranteed Death Benefit is equal to [three] times premium paid,
reduced by the amount of any Partial Withdrawal Adjustments. The Maximum
Guaranteed Death Benefit is allocated proportionally based on the Contract's
allocation to Special and non-Special funds. Transfers and withdrawals will
affect the allocation of the Maximum Guaranteed Death Benefit at the same
proportion among the Special and non-Special Funds that they bear to the
Accumulation Value transferred or withdrawn. Any addition due to spousal
continuation will not affect the Maximum Guaranteed Death Benefit or the
Guaranteed Death Benefit Base.
SPECIAL AND PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS
For any partial withdrawal, the Death Benefit components will be reduced by
Prorata Partial Withdrawal Adjustments. A Prorata Partial Withdrawal Adjustment
will be made unless a Special Partial Withdrawal Adjustment applies to the
component for the withdrawal. Special Partial Withdrawal Adjustments are made
when partial withdrawals in any Contract Year do not exceed [7%] of the sum of
cumulative premiums, but only if partial withdrawals in each prior year did not
exceed [7%] of the sum of premiums paid prior to that year. The Special Partial
Withdrawal Adjustment is equal to the amount of the Accumulation Value
withdrawn.
GA-IA-1083 3D4
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Special Partial Withdrawal Adjustments are applicable only in the calculation
of the Maximum Guaranteed Death Benefit and the Guaranteed Death Benefit Base,
and in all other cases withdrawals are treated as Prorata Partial Withdrawal
Adjustments.
The Prorata Partial Withdrawal Adjustment to a Death Benefit component is equal
to (1) divided by (2), multiplied by (3), where: (1) is the Accumulation Value
withdrawn; (2) is the Accumulation Value immediately prior to withdrawal; and
(3) is the amount of the applicable Death Benefit component immediately prior
to the withdrawal. Separate adjustments will apply to the amounts in the
Special and non-Special Funds.
ALTERNATE GUARANTEED DEATH BENEFIT
The Alternate Guaranteed Death Benefit for the Contact is equal to the sum of
I and II below.
I. The Alternate Guaranteed Death Benefit Base for non-Special Funds.
II. The Accumulation Value allocated to Special Funds.
On the Contract Date, the Alternate Guaranteed Death Benefit Base for
non-Special Funds is the initial premium allocated to non-Special Funds. On
subsequent Valuation Dates, the Alternate Guaranteed Death Benefit Base for
non-Special Funds is calculated as follows:
(1) Start with the Alternate Guaranteed Death Benefit Base for non-Special
Funds from the prior Valuation Date.
(2) Add to (1) any additional premium allocated to the non-Special Funds
during the current Valuation Period and
adjustments for transfers from Special Funds during the current
Valuation Period and subtract from (1) any adjustment for transfers to
Special Funds during the current Valuation Period and any Prorata
Partial Withdrawal Adjustments for any Partial Withdrawals taken from
non-Special Funds during the current Valuation Period.
(3) On a Valuation Date that occurs on or prior to the Owner's Attained
Age [90], which is also a Contract Anniversary, we set the Alternate
Guaranteed Death Benefit Base for non-Special Funds equal to the
greater of (2) or the Accumulation Value as of such date. On all other
Valuation Dates, the Alternate Guaranteed Death Benefit Base for
non-Special Funds is equal to (2).
The Alternate Guaranteed Death Benefit Base for Special Funds has a
corresponding definition, but with respect to amounts allocated to Special
Funds.
Transfers from Special Funds to non-Special Funds will reduce the Alternate
Guaranteed Death Benefit Base for Special Funds on a prorata basis. The
resulting increase in the Alternate Guaranteed Death Benefit Base for
non-Special Funds will equal the lesser of the reduction in the Alternate
Guaranteed Death Benefit Base for Special Funds and the net Accumulation Value
transferred.
GA-IA-1083 3D5
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Transfers from non-Special Funds to Special Funds will reduce the Alternate
Guaranteed Death Benefit Base for non-Special Funds on a prorata basis. The
resulting increase in the Alternate Guaranteed Death Benefit Base for Special
Funds will equal the reduction in Alternate Guaranteed Death Benefit Base for
non-Special Funds.
CHANGE OF OWNER
A change of Owner from a sole Owner to a sole Owner (where there have never
been multiple Owners designated) will result in recalculation of the Death
Benefit, the Guaranteed Death Benefit, the Alternate Guaranteed Death Benefit
and the Maximum Guaranteed Death Benefit. If the new Owner's Attained Age at
the time of the change is less than [80], the Guaranteed Death Benefit, the
Alternate Guaranteed Death Benefit and the Maximum Guaranteed Death Benefit
in effect prior to the change will remain in effect and the Death Benefit
provision shall apply. If the new Owner's Attained Age at the time of the
change is [80] or greater, but not greater than [85]:
(a) The Guaranteed Death Benefit, the Alternate Guaranteed Death Benefit
and the Maximum Guaranteed Death Benefit following the change will be
zero; and
(b) The Death Benefit will then be the greatest of:
(1) the Cash Surrender Value;
(2) the Accumulation Value; and
(3) the Minimum Death Benefit.
If an ownership changes result in multiple Owners or if there has ever been
multiple Owners, the Guaranteed Death Benefit, the Alternate Guaranteed Death
Benefit and the Maximum Guaranteed Death Benefit shall be set to zero. If the
oldest Owner is age [85] or younger at the time of the change, the Death
Benefit will then be the greatest of (b) 1, (b) 2 or (b) 3 above.
If any Owner's or oldest multiple Owner's Attained Age is [86] or greater at
the time of the change, the Guaranteed Death Benefit, the Minimum Death
Benefit, the Alternate Guaranteed Death Benefit and the Maximum Guaranteed
Death Benefit will be zero, and the Death Benefit will then be the Cash
Surrender Value.
When a change of Owner reduces the Guaranteed Death Benefit, the Alternate
Guaranteed death Benefit and the Maximum Guaranteed Death Benefit to zero,
there will be a reduction in the Mortality and Expense Risk Charge.
GA-IA-1083 3D6
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
SPOUSAL CONTINUATION UPON DEATH OF OWNER
If at the Owner's death, the surviving spouse of the deceased Owner is the
Beneficiary and such surviving spouse elects to continue the Contract as their
own pursuant to Internal Revenue Code Section 72(s) or the equivalent
provisions of U.S. Treasury Department rules for qualified plans, the following
will apply:
(a) If the greater of (ii), (iv), and (v) in the Death Benefit
provision as of the date we receive due proof of
death of the Owner, minus the Accumulation Value, also as of that date,
is greater than zero, we will add such difference to the Accumulation
Value. Such addition will be allocated to the Divisions of the Separate
Account in the same proportion as the Accumulation Value in each
Division bears to the Accumulation Value in the Separate Account. If
there is no Accumulation Value in the Separate Account, the addition
will be allocated to the Liquid Asset Division, or its successor.
(b) The Guaranteed Death Benefit, the Alternate Guaranteed Death Benefit,
the Minimum Death Benefit, and the Maximum Guaranteed Death Benefit
will continue to apply, with all age criteria using the surviving
spouse's age as the determining age.
(c) At subsequent surrender, any Surrender Charge applicable to premiums
paid prior to the date we receive due proof of death of the Owner will
be waived. Any premiums paid later will be subject to any applicable
Surrender Charge.
This addition to Accumulation Value is available only to the spouse of the
Owner as of the date of death of the Owner if such spouse under the provisions
of this Contract elects to continue the Contract as their own.
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no later
than April 1st of the calendar year following the calendar year in which the
Owner attains age 70 1/2. Otherwise, the Annuity Commencement Date may be no
later than the same date as the Contract Processing Date in the month following
the Annuitant's 90th birthday. In applying the Accumulation Value, we may first
collect any Premium Taxes due us. If, on the Annuity Commencement Date, a
Surrender Charge remains, your elected Annuity Option must include a period
certain of at least five years duration.
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
GA-IA-1083 3D7
THE SCHEDULE
CONTRACT FACTS (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
OPTIONAL BENEFIT RIDERS - [None]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full years elapsed
since the Contract Date.
RESTRICTED FUNDS - [None]
GA-IA-1083 3D8
THE SCHEDULE
CHARGES AND FEES
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
DEDUCTIONS FROM PREMIUMS
None
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
None
Administrative Charge
We charge a maximum of $30 to cover a portion of our ongoing administrative
expenses for each Contract Processing Period. The charge is incurred at the
beginning of the Contract Processing Period and deducted on the Contract
Processing Date at the end of the period.
At the time of deduction, this charge will be waived if:
(1) The Accumulation Value is at least $100,000; or
(2) The sum of premiums paid to date is at least $100,000.
Excess Allocation Charge
Currently none, however, we reserve the right to charge $25 for a change if you
make more than twelve allocation changes per Contract Year. Any charge will be
deducted in proportion to the amount being transferred from each Division.
Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if the
Contract is surrendered or an Excess Partial Withdrawal is taken. The
percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed since a Premium
Payment was made. The Surrender Charge expressed as a percentage of each
Premium Payment is as follows:
Complete Years Elapsed Surrender
Since Premium Payment Charges
---------------------- ---------
[0 6%
1 5%
2 4%
3 3%
4+ 0%]
Surrender of the Contract is permitted at or before the commencement of Annuity
Payments.
GA-IA-1083 3E1
THE SCHEDULE
CHARGES AND FEES (continued)
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Premium Taxes
We deduct the amount of any premium or other state and local taxes levied by
any state or governmental entity when such taxes are incurred.
We reserve the right to defer collection of Premium Taxes until surrender or
until application of Accumulation Value to an Annuity Option. An Excess Partial
Withdrawal will result in the deduction of any Premium Tax then due us on such
amount. We reserve the right to change the amount we charge for Premium Tax
charges on future premium payments to conform with changes in the law or if the
Owner changes state of residence.
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the assets in each
---------------------------------
Variable Separate Account Division on a daily basis of not more than
[0.005815]% (equivalent to an annual maximum rate of [2.10]%) for mortality
and expense risks. This charge is not deducted from the General Account
Accumulation Values.
Asset Based Administrative Charge - We deduct a charge of not more than
---------------------------------
[0.000411]% of the assets in each Variable Separate Account Division on a daily
basis (equivalent to an annual maximum rate of [0.15]%) to compensate us for a
portion of our ongoing administrative expenses. This charge is not deducted
from the General Account Accumulation Values.
CHARGE DEDUCTION DIVISION
If elected by you, all charges against the Accumulation Value in this Contract
will be deducted from the [Liquid Asset Division].
GA-IA-1083 3E2
THE SCHEDULE
INCOME PLAN FACTORS
------------------------------------------------------------------------------
|-----------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-----------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
| ----------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-----------------------------------------------------------------------------|
Values for other payment periods, ages or joint life combinations are available
on request. Monthly payments are shown for each $1,000 applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Period Monthly Fixed Period Monthly Fixed Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years Certain 20 Years Certain Refund Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
GA-IA-1083 3F
