----- GOLDEN SINGLE PREMIUM
-------- AMERICAN DEFERRED MODIFIED
---------- LIFE INSURANCE GUARANTEED
------- COMPANY ANNUITY CONTRACT
Golden American is a stock company domiciled in Delaware.
--------------------------------------------------------------------------------
|------------------------------------------------------------------------------|
|Annuitant Owner(s) |
|[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 |
|[THE MVA FIXED ACCOUNT] [123456] |
--------------------------------------------------------------------------------
This is a legal Contract between you 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 offered under the Separate Account, as
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 MAY BE SUBJECT TO A MARKET VALUE ADJUSTMENT, THE
OPERATION OF WHICH MAY CAUSE SUCH PAYMENTS AND VALUES TO INCREASE OR DECREASE.
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, ADJUSTED FOR ANY MARKET
VALUE ADJUSTMENT, PLUS ANY CHARGES WE HAVE DEDUCTED, AS OF THE DATE THE RETURNED
CONTRACT IS RECEIVED BY US.
Secretary: /S/ Xxxxx Xxxxxxx-Xxxxxxx
Customer Service Center
0000 Xxxxxxxx Xxxxx President: /S/ Xxxxx Xxxxxxxx
Xxxx Xxxxxxx, XX 00000
0-000-000-0000
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SINGLE PREMIUM DEFERRED MODIFIED GUARANTEED ANNUITY CONTRACT - NO DIVIDENDS
Annuity Benefit payable at Annuity Commencement Date. Death Benefit payable in
the event of the Owner's death prior to the Commencement Date. Cash Surrender
Values are based on a Market Value Adjustment formula if the Contract is held
for a period less than the currently elected Guarantee Period. Cash Surrender
Values may increase or decrease based on the Market Value Adjustment Formula.
Equity Index premium allocation option.
GA-IA-1100
CONTRACT CONTENTS
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THE SCHEDULE YOUR CONTRACT BENEFITS.....................13
Contract Facts.......................................3A Cash Surrender Value Benefit
Charges and Fees.....................................3B Partial Withdrawal Option
Income Plan Factors..................................3C Proceeds Payable to the Beneficiary
IMPORTANT TERMS........................................4 CHOOSING AN INCOME PLAN....................16
Annuity Benefits
INTRODUCTION TO THIS CONTRACT..........................6 Annuity Commencement Date Selection
The Contract Frequency Selection
The Owner The Annuity Options
The Annuitant Payment When Named Person Dies
The Beneficiary
Change of Owner or Beneficiary OTHER IMPORTANT INFORMATION................18
Sending Notice to Us
HOW WE MEASURE THE CONTRACT'S..........................8 Reports to Owner
ACCUMULATION VALUE Assignment - Using this Contract as
Single Premium Payment Collateral Security
Premium Payment Allocation Changing this Contract
Guarantee Periods Contract Changes - Applicable Tax Law
Contract Accumulation Value Misstatement of Age or Sex
Interest Division Accumulation Value Non-Participating
Term Indexed Division Accumulation Value Contestability
Annual Indexed Division Accumulation Value Payments We May Defer
Market Value Adjustment Authority to Make Agreements
MVA Index Rate Required Note on Our Computations
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-1100 2
THE SCHEDULE
CONTRACT FACTS
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|------------------------------------------------------------------------------|
| Annuitant Owner(s) |
| [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] |
|------------------------------------------------------------------------------|
| Initial Guarantee Period |
| [5 YEARS] |
|------------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [THE MVA FIXED ACCOUNT] [123456] |
--------------------------------------------------------------------------------
INITIAL INVESTMENT
Initial Premium Payment received: [$10,000]
Your initial Accumulation Value has been invested for the as follows:
Participation Index Return Initial Interest Percentage of
Divisions Rate Maximum Rate* Accumulation Value
--------- ---- ------- ---- ------------------
Interest N/A N/A [4.0%] [60%]
Term Indexed [90%] N/A [3.25%] [20%]
Annual Indexed [90%] [12%] [3.50%] [20%]
---------------------------------------- ----------------- ----------------- ------------------- --------------------------
Total 100%
For the Interest Division, the Initial Interest Rate reflected above applies to
the Initial Guarantee Period and, if the premium is paid in installments, the
initial installment payment only. Different interest rates may apply to each
subsequent Guarantee Period or premium installment as declared by us at the
beginning of the Guarantee Period or at the time the installment payment is
received by us.
For the Term Indexed Division, the Participation Rate reflected above applies to
the Initial Guarantee Period and, if the premium is paid in installments, the
initial installment payment only. Different Participation Rates may apply for
each subsequent Guarantee Period or premium installment as declared by us at the
beginning of the Guarantee Period or at the time the installment payment is
received by us.
For the Annual Indexed Division, the Participation Rate and Index Return Maximum
reflected above apply to the first Contract Year, and, if the premium is paid in
installments, the initial installment payment only. Different Participation
Rates and Interest Rates may apply to each subsequent Contract Year or premium
installment as declared by us at the beginning of the Contract Year or at the
time the installment payment is received by us. However, the Participation Rate
will never be less than 50% and the Index Return Maximum will never be less than
8%.
*The interest rates specified above for the Term Indexed and Annual Indexed
Divisions are used in calculating the Divisions' Minimum Guaranteed Value and
are guaranteed for all premium installments and all Guarantee Periods. See "How
We Measure the Contract's Accumulation Value," pp. 8-12.
OPTIONAL BENEFIT RIDERS
[NONE]
GA-IA-1100 3A
THE SCHEDULE
CHARGES AND FEES
|------------------------------------------------------------------------------|
| Annuitant Owner(s) |
| [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 |
| [THE MVA FIXED ACCOUNT] [123456] |
|------------------------------------------------------------------------------|
SURRENDER CHARGE
A Surrender Charge is imposed if the Contract is surrendered or an Excess
Partial Withdrawal is taken at any time other than during the 30-day period
immediately prior to the Maturity Date of a Guarantee Period. The Surrender
Charge is calculated as a percentage of the Accumulation Value surrendered or
withdrawn, adjusted by the Market Value Adjustment. Surrender Charges vary
according to the duration of the Guarantee Period. The Surrender Charges are 8%
in the first Contract Year and decrease by 1% per Contract Year thereafter until
the end of the Guarantee Period as shown in the following table.
YEAR IN GUARANTEE PERIOD 1 2 3 4 5 6 7 8 9+
-------------------------------------- -------- ------- -------- -------- -------- -------- ------- -------- --------
% 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0
Surrender Charges restart at the beginning of each Guarantee Period for the life
of the Contract. Surrender is permitted on or before the Annuity Commencement
Date. Surrender Charges are not assessed if the Contract is surrendered on the
Annuity Commencement Date.
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 deducted for Premium Tax
charges on future Premium Payments to conform with changes in the law or if you
change your state of residence.
GA-IA-1100 3B
THE SCHEDULE
INCOME PLAN FACTORS
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Annuitant Owner(s)
[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
[THE MVA FIXED ACCOUNT] [123456]
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Values for other payment periods, ages or joint life combinations are available
on request. Monthly payments are shown for each $1,000 applied. The basis for
determining such values is the Annuity 2000 Mortality Table at 3.0% interest. We
may pay a higher rate at our discretion.
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-1100 3C
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.
ANNUAL INDEXED DIVISION - An investment option available in the Separate
Account.
ANNUITANT - The person designated by you to be the measuring life in determining
Annuity Payments.
ANNUITY COMMENCEMENT DATE - The date on which Annuity Payments begin.
ANNUITY OPTIONS - Options you select that determine the form and amount of
Annuity Payments.
ANNUITY PAYMENT - The periodic payment you receive.
ATTAINED AGE - Your age, or that of the Annuitant, on the Contract Issue Date
plus the number of full years elapsed since the Contract Date.
BENEFICIARY - The person designated to receive benefits in the case of your
death.
BUSINESS DAY - Any day the New York Stock Exchange is open for trading,
exclusive of federal holidays, or any day on which the Securities and
Exchange Commission requires that mutual funds, unit investment
trusts or other investment portfolios be valued.
CASH SURRENDER VALUE - The amount you receive upon surrender of the Contract.
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, years
and anniversaries.
CONTRACT YEAR - The period between Contract Anniversaries.
CONTINGENT ANNUITANT - The person designated by you who, upon the Annuitant's
death prior to the Annuity Commencement Date, becomes the Annuitant.
CONTRACT ISSUE DATE - The date the Contract is issued at our Customer Service
Center.
GROSS WITHDRAWAL - The total amount of Accumulation Value withdrawn.
GUARANTEE PERIOD - A period for which the Contract's return is determined by a
declared interest rate (for values in the Interest Division) and the
greater of a Minimum Guaranteed Value or changes to the S&P 500 Index
during the period (for values in the Term and Annual Indexed Divisions).
INITIAL PREMIUM - The payment amount required to put this Contract in effect.
INTEREST DIVISION - An investment option available in the Separate Account.
ISSUE AGE - Your age, or age of the Annuitant, on the last birthday on or before
the Contract Date.
MARKET VALUE ADJUSTMENT - A positive or negative adjustment. It may apply if
all or part of the Accumulation Value is withdrawn or applied to an Annuity
Option at any time other than during the 30-day period immediately prior
to the end of a Guarantee Period.
GA-IA-1100 4
IMPORTANT TERMS (continued)
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MATURITY DATE - The date on which a Guarantee Period ends. The Maturity Date is
the last day of the last Contract Year in the Guarantee Period.
NET WITHDRAWAL - The Gross Withdrawal amount, adjusted by any Market Value
Adjustment minus any Surrender Charges.
OWNER - The person (persons if there are Joint Owners or entity if the Owner is
not an individual) 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. "You" and "Your" refer to the Owner.
RIDERS - Riders add provisions or change the terms of the Contract.
SEPARATE ACCOUNT - A non-unitized Separate Account established by us under
Delaware Statutes, that holds assets for guaranteed terms. There are no
discrete units for this account.
TERM INDEXED DIVISION - An investment option available in the Separate Account.
GA-IA-1100 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 Premium Payment required to put
this Contract in effect.
This Contract, together with any attached enrollment form, 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 by you 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. 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). The estate of a
sole Owner 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 to be the Beneficiary(ies) and any other
Beneficiary(ies) on record will be treated as the contingent 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 Benefit 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 the Death Benefit if any Owner dies
prior to the Annuity Commencement Date. See "Proceeds Payable to the
Beneficiary" for more information. We pay Death Benefits to the primary
Beneficiary (unless there are Joint Owners in which case the Death Benefit is
payable to the surviving Owner). If the primary Beneficiary dies before the
Owner, the Death Benefit is paid to the Contingent Beneficiary, if any. If there
is no surviving Beneficiary, we pay the Death Benefit to the Owner's estate.
Unless otherwise provided, the Death Benefit will be paid as though the
Beneficiary died before the Owner if:
(1) The Beneficiary dies at the same time as the Owner; or
(2) The Beneficiary dies within 24 hours of the Owner's death.
.
GA-IA-1100 6
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INTRODUCTION TO THIS CONTRACT (continued)
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THE BENEFICIARY (CONT'D)
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
Benefit is to be paid in equal shares to the surviving Beneficiaries. You may
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 may 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. If there are Joint Owners, both must agree to the change. 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. See "Proceeds Payable to Beneficiary."
GA-IA-1100 7
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HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE
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SINGLE PREMIUM PAYMENT
This is a single premium annuity. However, the single premium may be paid in one
lump sum or in installments during the first Contract Year. Any such planned
installments must be identified at the time the Contract is issued and be
received by us at our Customer Service Center within 60 days after the Contract
Date. There is no penalty if a planned installment is not paid.
PREMIUM PAYMENT ALLOCATION
Premium will be allocated among the Divisions of the Separate Account as elected
by you. Any premium installments will be allocated in the same manner, unless
you specify otherwise.
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.
TRANSFERS
You may transfer Accumulation Value between Divisions of the Separate Account
only during the 30-day period immediately prior to the expiry of a Guarantee
Period. Such transfers will occur on the Maturity Date of the ending Guarantee
Period. Surrender Charges and Market Value Adjustments will not apply to such
transfers.
GUARANTEE PERIODS
We offer Guarantee Periods of 5, 7 and 10 years. From time to time, we may offer
Guarantee Periods of durations other than those available on the Contract Date.
We also reserve the right to cease offering a particular Guarantee Period or
Periods.
At the time the Contract is issued, you elect an Initial Guarantee Period from
among the durations then being offered by us. The Guarantee Period elected
applies to all Divisions of the Separate Account. Only one Guarantee Period will
be in effect at any one time.
Upon the expiry of a Guarantee Period (the Guarantee Period Maturity Date), a
subsequent Guarantee Period will begin. Guarantee Period Maturity Dates will
always coincide with a Contract Anniversary. The Initial Guarantee Period
Maturity Date applies to all installment payments received. Each subsequent
Guarantee Period will be the same length as the previous Guarantee Period,
unless: a) you elect a different duration from among those then being offered by
us; or b) the new Guarantee Period would extend beyond the Annuity Commencement
Date then in effect. If the period remaining from the expiry of the previous
Guarantee Period to the Annuity Commencement Date is less than the period you
have elected or the period expiring, the next shortest period then available
that will not extend beyond the Annuity Commencement Date will be offered to
you.
We will notify you prior to the Guarantee Period Maturity Date of your options
for renewal. In order to elect a different Guarantee Period, you must notify us
in writing before the Maturity Date of the Guarantee Period then ending. You may
not select a Guarantee Period that would extend beyond the Annuity Commencement
Date then in effect.
CONTRACT ACCUMULATION VALUE
The Contract's Accumulation Value is the sum of the Accumulation Value in each
of the Separate Account Divisions.
GA-IA-1100 8
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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INTEREST DIVISION ACCUMULATION VALUE
The Accumulation Value in the Interest Division on the Contract Date is the
premium allocated to the Division. Thereafter, the Interest Division
Accumulation Value equals the Accumulation Value on the Contract Date, plus any
premium installments allocated to the Division, plus or minus any transfers,
less Gross Withdrawals, accumulated with interest.
The rate of interest will be as we declare. An Initial Interest Rate will be
declared at the time the Contract is issued and applies to the Initial Guarantee
Period and, if the premium is paid in installments, to the first installment
only. Different interest rates may apply to each subsequent Guarantee Period or
premium installment as declared by us at the beginning of the Guarantee Period
or at the time the installment payment is received by us. Interest will be
credited daily at a rate to yield the declared annual Interest Rate.
In case of surrender, withdrawal or transfer, interest will be credited on the
portion of the Accumulation Value surrendered, withdrawn or transferred up to
the date the surrender, withdrawal or transfer is requested. Accumulation Value
at any date within a Contract Year will be determined by us with allowance for
the time elapsed in the Contract Year.
TERM INDEXED DIVISION ACCUMULATION VALUE
Accumulation Value at the Beginning of Each Guarantee Period In the Initial
Guarantee Period, the beginning Accumulation Value equals the premium allocated
to the Division. In all subsequent Guarantee Periods, the beginning Accumulation
Value equals the Accumulation Value as of the end of the prior Guarantee Period,
less Gross Withdrawals taken on the Maturity Date of the prior Guarantee Period,
plus or minus any transfers.
Accumulation Value During Each Guarantee Period
During the Initial Guarantee Period, the Accumulation Value equals the sum of
all premium installments allocated to the Division, less Gross Withdrawals.
During subsequent Guarantee Periods, the Accumulation Value equals the beginning
Accumulation Value less Gross Withdrawals
Accumulation Value at the End of Each Guarantee Period
At the end of the Initial Guarantee Period, the Accumulation Value, calculated
on the Maturity Date equals the greater
of:
(1) The sum of all premium installments allocated to the Division, less
Gross Withdrawals, multiplied by (1 + the Index Return) calculated
separately for each premium installment; or
(2) The Minimum Guaranteed Value.
At the end of all subsequent Guarantee Periods, the Accumulation Value,
calculated on the Maturity Date, equals the greater of:
(1) The beginning Accumulation Value, less Gross Withdrawals, multiplied by
(1 + the Index Return); or
(2) The Minimum Guaranteed Value.
Amounts surrendered or withdrawn prior to the end of the Guarantee Period do not
participate in the Index Return during that Guarantee Period.
Minimum Guaranteed Value
During the Initial Guarantee Period, the Term Indexed Division Minimum
Guaranteed Value equals:
(1) 90% of the premium allocated to the Division; plus
(2) Accrued interest as declared by us; minus
(3) Net Withdrawals.
For any subsequent Guarantee Period, the Term Indexed Division Minimum
Guaranteed Value equals:
(1) 90% of the Division's beginning Accumulation Value for that Guarantee
Period; plus
(2) Accrued interest as declared by us; minus
(3) Net Withdrawals.
GA-IA-1100 9
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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TERM INDEXED DIVISION ACCUMULATION VALUE (CONT'D)
The interest rate used in calculating the Term Indexed Division Minimum
Guaranteed Value is declared at the time the Contract is issued and is
guaranteed for all premium installments and all Guarantee Periods.
Index Return
The Index Return for the Term Indexed Division is equal to (a x b) where:
a is the Division's Index Growth, as described below, but not less than 0;
and
b is the Participation Rate for the Guarantee Period elected.
The Participation Rate declared at the time the Contract is issued applies to
the Initial Guarantee Period and, if the premium is paid in installments, to the
first installment payment only. Different Participation Rates may apply to each
subsequent Guarantee Period or premium installment as declared by us at the
beginning of the Guarantee Period or at the time the installment payment is
received by us.
Index Growth For the Initial Guarantee Period, the Division's Index Growth is
calculated on the Guarantee Period Maturity Date separately for each premium
installment and equals a minus b divided by b where:
a is the average of the S & P 500 Index Values determined on the same date
in each month of the last Contract Year
in the Guarantee Period as the Contract Date; and
b is the S & P 500 Index Value on the date the premium installment is
received by us
For all subsequent Guarantee Periods, the Division's Index Growth is calculated
on the Guarantee Period Maturity Date and equals a minus b divided by b where:
a is the average of the S & P 500 Index Values determined on the same date
in each month of the last Contract Year in the Guarantee Period as the
Contract Date; and
b is the S & P 500 Index Value on first day of the Guarantee Period.
If there is no such corresponding date, the last day of the month is used. If
any date falls on a day the New York Stock Exchange is not open, the S&P 500
Index will be determined as of the next business day.
ANNUAL INDEXED DIVISION ACCUMULATION VALUE
Accumulation Value at the Beginning of Each Contract Year
In the first Contract Year, the beginning Accumulation Value equals the premium
allocated to the Division. In all subsequent Contract Years, the beginning
Accumulation Value equals the Accumulation Value as of the end of the prior
Contract Year, less Gross Withdrawals as of the Contract Anniversary, plus or
minus any transfers, if applicable. (See "Transfers," p. 8.)
Accumulation Value During Each Contract Year
During the first Contract Year, the Accumulation Value equals the sum of all
premium installments allocated to the Division, less Gross Withdrawals. During
subsequent Contract Years, the Accumulation Value equals the beginning
Accumulation Value, less Gross Withdrawals.
Accumulation Value at the End of Each Contract Year
At the end of the first Contract Year, the Accumulation Value, calculated on the
Contract Anniversary, equals the sum of all premium installments allocated to
the Division, multiplied by (1 + the Index Return), calculated separately for
each premium installment. At the end of all subsequent Contract Years, the
Accumulation Value calculated on the Contract Anniversary, equals the beginning
Accumulation Value, less Gross Withdrawals, multiplied by (1 + the Index
Return). However, if on the Guarantee Period Maturity Date, the Minimum
Guaranteed Value exceeds the Accumulation Value, the ending Accumulation Value
for that Contract Year/Guarantee Period is set equal to the Minimum Guaranteed
Value.
Amounts surrendered or withdrawn prior to the end of each Contract Year do not
participate in the Index Return during that Contract Year.
GA-IA-1100 10
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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ANNUAL INDEXED DIVISION ACCUMULATION VALUE (CONT'D)
Minimum Guaranteed Value During the Initial Guarantee Period, the Annual Indexed
Division Minimum Guaranteed Value equals:
(1) 90% of the premium allocated to the Division; plus
(2) Accrued interest as declared by us; minus
(3) Net Withdrawals.
For any subsequent Guarantee Period, the Annual Indexed Division Minimum
Guaranteed Value equals:
(1) 90% of the Division's beginning Accumulation Value for that Guarantee
Period; plus
(2) Accrued interest as declared by us; minus
(3) Net Withdrawals.
The interest rate used in calculating the Annual Indexed Division Minimum
Guaranteed Value is declared at the time the Contract is issued and is
guaranteed for all premium installments and all Guarantee Periods.
Index Return
The Index Return for the Annual Indexed Division is calculated annually on the
Contract Anniversary and is equal to the lesser of (a x b) or c where:
a is the Division's Index Growth, as described below, but not less than 0;
b is the Guaranteed Period Participation Rate for the Contract Year then
ending; and
c is Guarantee Period Index Return Maximum for the Contract Year then
ending.
The Participation Rate and the Index Return Maximum declared at the time the
Contract is issued applies to the first Contract Year and, if the premium is
paid in installments, to the first installment payment only. Different
Participation Rates and Index Return Maximums may apply to each subsequent
Contract Year or premium installment as declared by us at the beginning of the
Contract Year or at the time the installment payment is received by us. However,
the Annual Indexed Division's Participation Rate will never be less than 50% and
the Index Return Maximum will never be less than 8%.
Index Growth
For the first Contract Year, the Division's Index Growth is calculated
separately for each premium payment, and equals a minus b divided by b where:
a is the average of the S & P 500 Index Values determined on the same date
in each month of the Contract Year as the Contract Date; and
b is the S & P 500 Index Value on the date the premium payment is received
by us
For all subsequent Contract Years, the Division's Index Growth is calculated for
the Contract Year and equals a minus b divided by b where:
a is the average of the S & P 500 Index Values determined on the same date
in each month of the Contract Year as the Contract Date; and
b is the S & P 500 Index Value on first day of the Contract Year.
If there is no such corresponding date, the last day of the month is used. If
any date falls on a day the New York Stock Exchange is not open, the S&P 500
Index will be determined as of the next business day.
MARKET VALUE ADJUSTMENT
A Market Value Adjustment (MVA) will be applied to Excess Partial Withdrawals,
Surrenders and Accumulation Value applied to an Income Plan other than on, or
during the 30-day period immediately prior to, a Guarantee Period Maturity Date.
During the Initial Guarantee Period, the MVA applies to, and will be calculated
separately for, each premium installment payment, if any.
GA-IA-1100 11
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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MARKET VALUE ADJUSTMENT (CONT'D)
Market Value Adjustments will be applied as follows:
(1) The Market Value Adjustment will be applied to the amount withdrawn or
applied before deduction of any applicable Surrender Charge.
(2) For a Partial Withdrawal, or in the case where a portion of an
allocation is applied to an Income Plan, the Market Value Adjustment
will be calculated on the total amount that must be withdrawn or
applied to an Income Plan in order to provide the amount requested.
The Market Value Adjustment is determined by multiplying the amount of the
Accumulation Value withdrawn or applied to an Income Plan by the following
factor:
( 1 + I ) N/365
------------------------
( 1 + J + .0050 ) - 1
Where I is the MVA Index Rate on the first day of the applicable Guarantee
Period, or during the Initial Guarantee Period only, on the date the premium
installment payment, if any, is received by us: J is the Index Rate for
Guarantee Periods equal to the number of years (fractional years rounded up to
the next full year) remaining in the Guarantee Period at the time of
calculation; and N is the remaining number of days in the Guarantee Period at
the time of calculation.
MVA INDEX RATE
The MVA Index Rate is the average of the Ask Yields for the U.S. Treasury Strips
as reported by a national quoting service for the applicable maturity. The
average is based on the period from the 22nd day of the calendar month two
months prior to the calendar month of Index Rate determination to the 21st day
of the calendar month immediately prior to the month of determination. The
applicable maturity date for these U.S. Treasury Strips is on or next following
the last day of the Guarantee Period. If the Ask Yields are no longer available,
the Index Rate will be determined using a suitable replacement method.
We currently set the MVA Index Rate once each calendar month. However, we
reserve the right to set the Index Rate more frequently than monthly, but in no
event will such Index Rate be based on a period less than 28 days.
GA-IA-1100 12
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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.
NO SURRENDER CHARGE OR MARKET VALUE ADJUSTMENT IS ASSESSED ON SURRENDERS OR
WITHDRAWALS DURING THE 30-DAY PERIOD IMMEDIATELY PRIOR TO THE MATURITY DATE OF
ANY GUARANTEE PERIOD, PROVIDED WRITTEN NOTICE OF SURRENDER OR WITHDRAWAL IS
RECEIVED IN OUR CUSTOMER SERVICE CENTER BEFORE THE END OF SUCH 30-DAY PERIOD.
SURRENDER CHARGES AND THE MARKET VALUE ADJUSTMENT APPLY TO EACH SUBSEQUENT
GUARANTEE PERIOD. SURRENDER CHARGES FOR EACH SUBSEQUENT GUARANTEE PERIOD START
AT 8% FOR THE FIRST YEAR, THEN DECREASE BY 1% PER YEAR BEGINNING IN YEAR 2 UNTIL
THE MATURITY DATE OF THAT GUARANTEE PERIOD.
CASH SURRENDER VALUE BENEFIT
On or prior to the commencement of Annuity Income Payments if the Annuitant is
living, 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.
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.
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.
The Contract's Cash Surrender Value, while the Annuitant is living and on or
before the Annuity Commencement Date, is equal to the sum of the Cash Surrender
Value in each of the Divisions of the Separate Account.
In lieu of a lump sum payment, at the time of surrender you may elect to have
the Cash Surrender Value paid under an Annuity Option.
Interest Division Cash Surrender Value
The Cash Surrender Value for the Interest Division is equal to the Division's
Accumulation Value, adjusted for any applicable Market Value Adjustment, less
any Surrender Charges or other charges that have been incurred but not yet
deducted, including any applicable Premium Tax.
Term Indexed Division Cash Surrender Value
The Cash Surrender Value for the Term Indexed Division is equal to the
greater of a and b minus c where:
a is the Division's Accumulation Value, adjusted for any applicable Market
Value Adjustment less any Surrender Charges;
b is the Division's Minimum Guaranteed Value, adjusted for any applicable
Market Value Adjustment; and
c is any other charges that have been incurred but not yet deducted,
including any applicable Premium Tax.
Amounts surrendered or withdrawn prior to the end of the Guarantee Period do not
participate in the Index Return during the Guarantee Period.
GA-IA-1100 13
YOUR CONTRACT BENEFITS (continued)
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CASH SURRENDER VALUE BENEFIT (CONT'D)
Annual Indexed Division Cash Surrender Value
The Cash Surrender Value for the Annual Indexed Division is equal to the greater
of a and b minus c where:
a is the Division's Accumulation Value, adjusted for any applicable Market
Value Adjustment less any Surrender Charges;
b is the Division's Minimum Guaranteed Value, adjusted for any applicable
Market Value Adjustment; and
c is any other charges that have been incurred but not yet deducted,
including any applicable Premium Tax.
Amounts surrendered or withdrawn prior to the end of each Contract Year do not
participate in the Index Return during that Contract Year.
PARTIAL WITHDRAWAL OPTION
You may make a Partial Withdrawal at any time by giving written notice to us.
Unless otherwise specified by you, any withdrawals will be taken first from the
Interest Division, then the Annual Interest Division and then the Term Index
Division. The maximum amount that can be withdrawn each Contract Year without
being considered an Excess Partial Withdrawal is described below. Excess Partial
Withdrawals taken at any time other than during the 30-day period immediately
prior to a Guarantee Period Maturity Date are subject to a Surrender Charge and
Market Value Adjustment, as well as a deduction of any Premium Taxes not
previously paid. The minimum Partial Withdrawal amount is $100. In no event may
a Partial Withdrawal be greater than 90% of the Contract's Cash Surrender Value.
After a Partial Withdrawal, the remaining Cash Surrender Value must be at least
$1000 to keep the Contract in force.
To determine the Surrender Charge on Excess Partial Withdrawals, the withdrawals
will occur in the following order:
(1) The Free Amount.
(2) Any remaining Accumulation Value.
The Free Amount
If the Contract is surrendered at any time other than during the 30-day period
immediately preceding a Guarantee Period Maturity Date, any withdrawal during
the same Contract Year will be considered an Excess Partial Withdrawal. Subject
to this limitation, during the first Contract Year, Systematic Partial
Withdrawals of interest earned in the Interest Division may be taken without
being considered an Excess Partial Withdrawal. In each Contract Year thereafter,
up to 10% of the Contract's total Accumulation Value, determined as of the date
of withdrawal, may be withdrawn from any one or any combination of the Divisions
without being considered an Excess Partial Withdrawal.
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.
.
GA-IA-1100 14
YOUR CONTRACT BENEFITS (continued)
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PARTIAL WITHDRAWAL OPTION (CONT'D)
Partial Withdrawals to Meet Minimum Distribution Requirements for
Qualified Plans
Partial Withdrawals may be taken from a Contract issued as a Qualified Plan to
meet Required Minimum Distribution Requirements 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. No Surrender Charge will
be assessed on Required Minimum Distribution Withdrawals; however, withdrawals
in excess of the Free Amount will be subject to a Market Value Adjustment.
Systematic Partial Withdrawals and Conventional Partial Withdrawals may not be
taken in the same Contract Year.
Systematic Partial Withdrawals and Conventional Partial Withdrawals are not
allowed when Required Minimum Distribution Withdrawals are being taken.
PROCEEDS PAYABLE TO THE BENEFICIARY
If you die prior to the Annuity Commencement Date, we will pay the Beneficiary
the Death Benefit, calculated as of the date of death. The Death Benefit varies
by Division. The Death Benefit for the Interest Division and the Annual Indexed
Division is equal to the Division Accumulation Value. The Death Benefit for the
Term Indexed Division is equal to the greater of:
(1) The Term Indexed Division's Minimum Guaranteed Value; and
(2) The Term Indexed Division's Accumulation Value calculated using the
Index Return as of the prior Contract Anniversary. For purposes of
this calculation, the S&P 500 Index Value as of the prior Contract
Anniversary is used as the ending value in determining the Index
Growth.
The Contract Death Benefit is equal to the sum of each Division's Death Benefit.
No Surrender Charge or Market Value Adjustment will be applied. If there are
Joint Owners and any Owner dies, we will pay the surviving Owner(s) 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, 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 Benefit
proceeds. If, at the time of your death, no Option has been chosen for paying
the Death Benefit proceeds, the Beneficiary may choose an Option within one
year.
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
Spousal Continuation upon Death of Owner
If at the Owner's death, the surviving spouse of the deceased Owner is the
Beneficiary, then such surviving spouse may elect to continue the Contract as
their own, pursuant to Internal Revenue Code Section 72(s) or the equivalent
provisions of the U.S. Treasury Department rules for Qualified Plans.
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-1100 15
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CHOOSING AN INCOME PLAN
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ANNUITY BENEFITS
If you and the Annuitant are living on the Annuity Commencement Date, we will
begin making payments to you. We will make these payments under the Annuity
Option (or Options) elected by you. You may elect to apply any portion of the
Accumulation Value (minus any applicable premium tax) to any Annuity Option by
making a written request at least 30 days prior to the Annuity Commencement
Date. 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. If no Annuity Option has been elected by the Required Annuity
Commencement Date shown in the Schedule, payments will be made under Option 2 on
a 10-year Period Certain basis. The amount of the payments will be determined by
applying the Accumulation Value adjusted by a Market Value Adjustment, if
applicable, on the Annuity Commencement Date in accordance with the Annuity
Options section below. (see "Payments We May Defer") A Market Value Adjustment
may apply if the Annuity Commencement Date is other than on, or during the
30-day period prior to, a Guarantee Period Maturity Date. Any Surrender Charges
otherwise applicable will be waived.
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 you or the
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 stated below. (see "Frequency Selection")
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
first Contract Anniversary. 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 you attain age 70 1/2. Otherwise, the Annuity
Commencement Date may be no later than the same date as the Contract Date in the
month following the later of the Annuitant's 90th birthday or the 10th Contract
Anniversary. In applying the Accumulation Value, we may first collect any
Premium Taxes due us.
On the Annuity Commencement Date, the age of the Annuitant plus the number of
years payments are guaranteed must not exceed 100. If you do not select a date,
the Annuity Commencement Date will be in the month following the later of the
Annuitant's 90th birthday or the 10th Contract Anniversary.
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. However, the minimum monthly annuity
income payment that we will make is $50. The minimum total income payments in
any one year is $250. We have the right to increase these minimums based upon
increases reflected in the Consumer Price Index - Urban (CPI-U) since July 1,
1993. If the Annuity Option or frequency of payments elected do not meet these
minimums, we have the right to make payments at such frequency as necessary to
meet these minimum requirements.
GA-IA-1100 16
CHOOSING AN INCOME PLAN (continued)
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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.
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 guaranteed 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.
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.
GA-IA-1100 17
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OTHER IMPORTANT INFORMATION
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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 Report
Date. 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.
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 rights are subject to the terms of the assignment. The
Beneficiary's rights may be subordinate to those of an assignee unless the
Beneficiary was designated as an irrevocable Beneficiary prior to 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.
GA-IA-1100 18
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OTHER IMPORTANT INFORMATION (continued)
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NON-PARTICIPATING
This Contract does not participate in our divisible surplus.
CONTESTABILITY
This Contract is incontestable from its date of issue.
PAYMENTS WE MAY DEFER
We may, at any time, defer payment of the Contract's 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 or greater if required by state law, on any Cash Surrender
deferred 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, has the authority to:
(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-1100 19
SINGLE PREMIUM DEFERRED MODIFIED GUARANTEED ANNUITY CONTRACT - NO DIVIDENDS
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Annuity Benefit payable at Annuity Commencement Date. Death Benefit payable in
the event of the Owner's death prior to the Commencement Date. Cash Surrender
Values are based on a Market Value Adjustment formula if the Contract is held
for a period less than the currently elected Guarantee Period. Cash Surrender
Values may increase or decrease based on the Market Value Adjustment Formula.
Equity Index premium allocation option.
GA-IA-1100
