EXHIBIT A
[GRAPHIC AILIFE] (R) American International Life Assurance
Company of New York
00 Xxxx Xxxxxx
Xxx Xxxx, Xxx Xxxx 00000
A capital stock company
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This Policy is a contract between American International Life Assurance Company
of New York ("We", "Us" or "Our") and the Policyholder ("You" or "Your") shown
on the Policy Schedule.
Subject to the terms of this Policy and the Certificates We issue to each
Certificate Owner, We will provide the benefits described in this Policy. We do
this in return for the application of the Policyholder, and the required
individual applications for life insurance coverage on the Insured Persons and
for the payment of the premiums.
This Policy becomes effective at 12:01 A.M. Standard Time on the Policy
Effective Date at the address of the Policyholder and will continue in force, in
accordance with the applicable provisions, unless terminated in accordance with
its provisions.
This Policy is non-participating and is not entitled to share in Our surplus
earnings.
/s/ Xxxxxxxxx X. Xxxx /s/ X. X. X'Xxxxxxx
Secretary President
GROUP FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE POLICY
Non-Participating
21GVULD997
INDEX
Policy Sections Page
Policy Schedule 2
Table Of Guaranteed Maximum Cost Of Insurance Rates 3
Policy Provisions 4
21GVULD997
2
POLICY SCHEDULE
POLICY NUMBER GVULD12345
POLICYHOLDER XYZ Trust
POLICY EFFECTIVE DATE September 1, 1997
ELIGIBLE PERSONS: Exempt Employees Of ABC Corporation
21GVULD997
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GUARANTEED MAXIMUM MONTHLY COST OF INSURANCE RATES
PER $1,000 OF NET AMOUNT AT RISK - STANDARD RATE CLASS
ATT. NONSMOKER SMOKER ATT. NONSMOKER SMOKER
AGE MALE FEMALE MALE FEMALE AGE MALE FEMALE MALE FEMALE
15 0.11334 0.07167 0.14668 0.08000 58 0.91249 0.64374 1.71209 0.96342
16 0.12334 0.07500 0.16336 0.08417 59 1.00517 0.68630 1.85844 1.01603
17 0.13085 0.07750 0.17503 0.08834 60 1.10872 0.73637 2.02157 1.07866
18 0.13585 0.08000 0.18420 0.09250 61 1.22399 0.79813 2.20568 1.15717
19 0.13918 0.08250 0.19003 0.09500 62 1.35683 0.87493 2.41330 1.25824
20 0.14001 0.08417 0.19337 0.09750 63 1.50726 0.96927 2.64531 1.38107
21 0.13835 0.08584 0.19337 0.09917 64 1.67446 1.07532 2.89921 1.51813
22 0.13585 0.08667 0.19003 0.10167 65 1.85761 1.18974 3.16834 1.66276
23 0.13251 0.08834 0.18670 0.10417 66 2.05588 1.30837 3.45019 1.80993
24 0.12918 0.09000 0.18169 0.10667 67 2.26846 1.42954 3.74228 1.95213
25 0.12501 0.09167 0.17586 0.10917 68 2.49956 1.55491 4.04882 2.09605
26 0.12251 0.09417 0.17252 0.11334 69 2.75590 1.69453 4.38161 2.25256
27 0.12084 0.09584 0.17086 0.11668 70 3.04591 1.85844 4.74911 2.43759
28 0.12001 0.09834 0.17086 0.12084 71 3.37720 2.05839 5.16234 2.67212
29 0.12001 0.10167 0.17336 0.12584 72 3.75991 2.30362 5.62985 2.95956
30 0.12084 0.10417 0.17753 0.13168 73 4.19334 2.59756 6.14840 3.30169
31 0.12334 0.10751 0.18336 0.13668 74 4.67004 2.93609 6.71732 3.69191
32 0.12668 0.11084 0.19086 0.14252 75 5.18002 3.31428 7.32577 4.11855
33 0.13168 0.11501 0.20087 0.15002 76 5.71918 3.72381 7.94851 4.57247
34 0.13751 0.12001 0.21254 0.15835 77 6.28340 4.16309 8.57456 5.04701
35 0.14418 0.12584 0.22671 0.16752 78 6.87612 4.63892 9.20818 5.54895
36 0.15168 0.13418 0.24339 0.18169 79 7.51606 5.16655 9.87149 6.09610
37 0.16169 0.14418 0.26423 0.19837 80 8.22374 5.76723 10.58673 6.70972
38 0.17252 0.15502 0.28758 0.21754 81 9.01809 6.45895 11.37459 7.40695
39 0.18420 0.16669 0.31426 0.23839 82 9.91568 7.25728 12.24905 8.20087
40 0.19837 0.18086 0.34511 0.26340 83 10.91280 8.15936 13.19603 9.11907
41 0.21337 0.19587 0.37847 0.29008 84 11.99039 9.15556 14.18421 10.11631
42 0.22921 0.21087 0.41517 0.31676 85 13.12417 10.23536 15.18033 11.17772
43 0.24672 0.22588 0.45520 0.34345 86 14.29993 11.39164 16.16033 12.29516
44 0.26590 0.24089 0.49941 0.37013 87 15.49991 12.62319 17.16810 13.45787
45 0.28758 0.25756 0.54613 0.39849 88 16.71909 13.93141 18.22020 14.67215
46 0.31092 0.27507 0.5945 0.42768 89 17.97489 15.32721 19.26842 15.93751
47 0.33594 0.29425 0.64708 0.45770 90 19.28573 16.82248 20.32834 17.34402
48 0.36346 0.31426 0.70382 0.49024 91 20.68242 18.45266 21.43307 18.86254
49 0.39348 0.33678 0.76558 0.52610 92 22.21790 20.28062 22.71710 20.55222
50 0.42768 0.36179 0.83402 0.56448 93 24.04369 22.43825 24.36888 22.54367
51 0.46688 0.38931 0.91166 0.60536 94 26.50346 25.22305 26.62992 25.22305
52 0.51192 0.42101 0.99933 0.65209 95 30.20739 29.24955 30.20739 29.24955
53 0.56365 0.45604 1.09870 0.70382 96 36.35803 35.72205 36.35802 35.72205
54 0.62121 0.49190 1.20728 0.75640 97 47.21179 46.86829 47.21179 46.86829
55 0.68546 0.53028 1.32341 0.81065 98 66.20701 66.09429 66.20701 66.09429
56 0.75557 0.56865 1.44625 0.86407 99 83.33333 83.33333 83.33333 83.33333
57 0.82985 0.60620 1.57581 0.91416
21GVULD997
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POLICY PROVISIONS
Eligible Persons. Persons eligible to become Insured Persons under this Policy
are those described as Eligible Persons on the Policy Schedule.
Certificates. We will issue a Certificate to each Certificate Owner describing
each Insured Person's life insurance coverage under this Policy. The Certificate
will describe the benefits of this Policy, to whom the benefits will be paid,
and the limitations and conditions that apply.
A Certificate may be modified by rider or endorsement issued by Us to be
attached to the Certificate. The rider or endorsement will set forth the
modifications to the Certificate which affect the Insured Person.
Premiums. All premiums are payable in advance to Us. The planned premium for
each Insured Person is shown on that Insured Person's Certificate Information
Page.
Required Data. The Policyholder must give Us all data that We need to administer
this Policy.
Examination Of Records. We have the right to examine all records of the
Policyholder that pertain to the life insurance provided by this Policy.
Continuation Of This Policy. This Policy will continue in force, subject to the
Policy Termination provision.
Entire Contract. The entire contract ("Policy") consists of this Policy, the
Certificates, the Policyholder's application, each Insured Person's application
for life insurance coverage under this Policy, and any attached riders,
endorsements or amendments.
We rely on the Policyholder's application to issue this Policy and the
individual applications, if any, to issue certificates providing life insurance
coverage on each Insured Person. Statements made by the Policyholder or any
Insured Person or Certificate Owner are deemed to be representations and not
warranties. No such statement will be used to contest this Policy, a
Certificate, or a claim, unless a copy of the instrument is furnished to the
person making the statement or to his/her beneficiary.
Changing This Policy. This Policy may only be changed, in writing, by one of Our
executive officers. No other person, including an agent, has any authority to
change or reinstate this Policy or extend the time for paying a premium.
Conformity With State Statutes. Any provision of this Policy that, on the Policy
Effective Date, conflicts with state laws of the governing jurisdiction is
changed to meet the minimum requirements of those laws.
Policy Termination. This Policy may only be terminated with respect to the
issuance of new certificates. Either We or the Policyholder may terminate this
Policy upon giving at least 31 days written notice to the other. We will not
terminate this Policy prior to the end of the first year following the Policy
Effective Date.
Clerical Error. Clerical error will not void any Certificate issued under this
Policy which is otherwise validly in force, nor will it keep in force any
Certificate that otherwise would end.
Certificate Provisions Made Part Of This Policy. The remainder of this Policy
consists of provisions that appear in the Certificates, riders and endorsements.
A copy of the Certificates, riders and endorsements is added to and made a part
of this Policy.
21GVULD997
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[GRAPHIC AILIFE]
American International Life Assurance Company of New York
00 Xxxx Xxxxxx
Xxx Xxxx, Xxx Xxxx 00000
GROUP FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE POLICY
Non-Participating
21GVULD997
