a contract between
Aetna Life Insurance and Annuity Company
(herein called Aetna)
and
New York State United Teachers Benefit Trust
(Policyholder)
Policy Number: [ ] Signed at Aetna's Home Office in
Hartford, Connecticut
Date of issue: [ ] on the date of issue.
To take effect: [ ]
Policy delivered in: New York
This policy will be construed in [
line with the law of the State of delivery. President]
Based on timely premium payments
Aetna agrees with the New York State United
Teachers Benefit Trust, to pay benefits [
accordance with the policy terms. Secretary]
The duties and the rights of the
policyholder will be based solely on
the terms of this policy. This [
policy is non-participating. Registrar]
RIGHT OF EXAMINATION
This policy may be returned to Aetna or its representative within 10 days after
its receipt. Return this policy to Aetna at 000 Xxxxxxxxxx Xxxxxx, Xxxxxxxx,
Xxxxxxxxxxx 00000. Upon its return, all insurance under this Certificate will
then be deemed void from its beginning.
70262-97
INDEX
PART I
CONTRACT --
CERTIFICATES
PART II
ELIGIBILITY -- ELIGIBLE PERSONS
PART III
CANCELLATION OF POLICY --
CONVERSION OF CERTIFICATE
PART IV
PREMIUM PROVISIONS --
GRACE PERIOD PROVISIONS
PART V
POLICYHOLDER AND INSURANCE
COMPANY MATTERS
PART VI
MISCELLANEOUS PROVISIONS
COPY OF APPLICATION
2
PART I
CONTRACT --
CERTIFICATES
CONTRACT
This policy, any attached endorsements, the Policyholder's application and the
Certificate constitute the entire contract. A copy of the Policyholder's
application is attached. All statements made by the New York State United
Teachers Benefit Trust or an Insured shall be deemed representations and not
warranties. Aetna will not use such statements to void this contract or defend
against a claim unless it is contained in the initial application or subsequent
applications.
CERTIFICATES
Aetna will prepare a Certificate setting forth a description of coverage for
each Insured under this policy. All such Certificates are hereby incorporated
into and made a part of this policy. Certificates will be issued for delivery to
each Owner.
Each Certificate incorporated into and made a part of this policy will be
identified by:
The form number 70263-1997;
The name of the Insured.
If Aetna receives a request from the New York State United Teachers Benefit
Trust to change any of the provisions of a Certificate, such change(s) that is
agreed to by Aetna will be made on future Certificates and, if applicable, on
existing Certificates by formal amendment and in accordance with any applicable
laws or regulations and any written instructions from the New York State United
Teachers Benefit Trust. The Certificate Owner's consent is needed if such
change(s) results in a reduction in benefits or an increase in guaranteed
charges.
PART II
ELIGIBILITY -- ELIGIBLE PERSONS
ELIGIBILITY
The New York State United Teachers Benefit Trust and the eligible class or
classes of Members will be those which are: (a) designated to Aetna in writing;
(b) accepted by Aetna; and (c) placed on file with Aetna. With Aetna's consent,
any class or classes of eligible Members may be changed by formal amendment of
this policy by written notice from the New York State United Teachers Benefit
Trust to Aetna.
Aetna will keep, in a file set up for the New York State United Teachers Benefit
Trust, a copy of the rates that apply to its eligible class or classes of
Members.
3
The New York State United Teachers Benefit Trust may act on all policy matters.
Each such act, or agreement made between Aetna and the New York State United
Teachers Benefit Trust, or notice given by one to the other will be binding.
ELIGIBLE PERSONS
All Members of the New York State United Teachers Benefit Trust and their
Spouses are eligible to apply for coverage under this policy. An eligible person
may become insured under only one eligible class at a time, even if he/she is a
member of more than one class. An eligible person may only become covered for
that insurance which he/she elects and for which he/she pays the required
premium and provide evidence of insurability satisfactory to Aetna.
A Member is eligible on the latest of:
[bullet] the Issue Date of the policy; or
[bullet] the date he/she enters an eligible class of Members.
The Spouse of an eligible Member is eligible on the later of:
[bullet] the date the Member becomes insured under the Certificate; or
[bullet] the date he/she becomes the Spouse of an eligible Member;
but only if the Spouse is less than 80 years of age on that date.
PART III
CANCELLATION OF POLICY --
CONVERSION OF CERTIFICATE
CANCELLATION OF POLICY
The New York State United Teachers Benefit Trust may cancel this policy with
respect to all or any class or classes of Members by giving Aetna written notice
31 days before the cancellation date. Coverage under the Certificate will
terminate or, at the option of the Certificate Owner, may be converted.
The New York State United Teachers Benefit Trust will provide each of its
Members and their Spouses with advance notice of policy cancellation or
discontinuance. Such notice must be mailed or delivered to such Member at the
last known address of record at least 15 days before the date plan cancellation
or discontinuance is to take effect.
Subject to any applicable laws or regulations, Aetna has the right to cancel
this policy as to all or any class of Members at any time after the end of the
Grace Period if the policy premium has not been paid. Written notice of the
termination date must be given by Aetna to the New York State United Teachers
Benefit Trust.
Aetna reserves the right to discontinue accepting new applications under this
policy or as to any or all coverage of all or any class or classes of Members by
giving the New York State United Teachers Benefit Trust advance written notice
of when new applications will
4
no longer be accepted. This date will not be earlier than 31 days after Aetna
has given written notice, unless another date is agreed to by the New York State
United Teachers Benefit Trust and Aetna.
CONVERSION OF CERTIFICATE
If a Certificate terminates because (a) an Insured ceases to be a member of the
New York State United Teachers Benefit Trust, or (b) the insured is no longer
eligible for coverage under the Certificate as a Spouse and declines membership
in the New York State United Teachers Benefit Trust, or (c) the New York State
United Teachers Benefit Trust discontinues the group policy, the amount of
insurance which ceases may be converted to any substantially comparable flexible
premium general account life insurance policy except term that We make available
for such purpose and according to the Certificate terms. Aetna will send notice
to the Certificate Owner at the last known address of record of this right to
convert within fifteen days before or after the date plan cancellation or
discontinuance is to take effect. If such notice is given more than fifteen
days, but less than ninety days after the date plan cancellation or
discontinuance is to take effect, the time allowed for conversion shall expire
at the end of such ninety days. No evidence of insurability will be required.
If the Insured dies during the time allowed for conversion, the amount that
could have converted will be payable as a death benefit to the Beneficiary
designated by the Insured. In the event there is no designated beneficiary, We
may pay from the Death Benefit payable at a sum not exceeding $500 to any person
appearing to Us to be equitably entitled to same by reason of having incurred
funeral expenses incident to the death of the Insured.
The new policy will be issued:
[bullet] based on the Insured's Attained Age and sex at Our current rates at the
time of conversion (Certificates issued to residents of the State of
New York and residents of the State of New York at the time of
conversion will be issued a sex-neutral policy based only on the
Insured's Attained Age at Our current rates at the time of conversion);
[bullet] with the same premium class as would have been assigned to the Insured
for the new policy had it been issued on this Certificate's Issue Date;
[bullet] effective the date coverage under the Certificate terminates;
[bullet] subject to any limitations of risk or assignments outstanding against
this Certificate.
PART IV
PREMIUM PROVISIONS --
GRACE PERIOD PROVISIONS
5
PAYMENT OF PREMIUMS
The amount and frequency of each Certificate Owner's premium is shown on his/her
Certificate Specifications. The amount may be adjusted by Aetna from time to
time, as described therein.
GRACE PERIOD FOR CERTIFICATE
The 61-day Grace Period granted to a Certificate Owner for payment of his/her
premium is described in his or her Certificate.
PAYMENT OF PREMIUM BY NEW YORK STATE UNITED TEACHERS BENEFIT TRUST
The total policy premium payable by the New York State United Teachers Benefit
Trust will be the sum of all premiums remitted for persons insured under this
policy, excluding premiums that are not payable by payroll deduction. The
initial policy premium will be due on the Issue Date of this policy. After that,
the New York State United Teachers Benefit Trust will remit premium payments to
Aetna's Home Office on a weekly basis.
If any policy premium is not paid when due, this policy will be canceled as of
the premium due date; except as provided in the section called Policy Grace
Period.
POLICY GRACE PERIOD
A policy Grace Period of 61 days from the premium due date will be granted to
the New York State United Teachers Benefit Trust for the payment of premiums
required under this policy. The policy will be in force during such Grace
Period. If such premium is not paid in such Grace Period, this policy will
cancel at the end of that Grace Period. This policy will cancel before that date
if the New York State United Teachers Benefit Trust gives written notice of
cancellation in advance to Aetna. If this policy cancels, the New York State
United Teachers Benefit Trust will be jointly and severally liable to Aetna for
all unpaid premiums for insurance which was in force.
6
PART V
POLICYHOLDER AND INSURANCE COMPANY MATTERS
DECLARATIONS
The first "policy month" starts on [ ]. Each subsequent policy month
starts on the [ ] of a calendar month. The first "policy year" starts on
[ ] and ends on [ ]. Each subsequent policy year starts on a [ ]
and ends on a [ ].
DATA REQUIRED
The New York State United Teachers Benefit Trust must give Aetna all data
required as to policy matters. All data which may have a bearing on insurance or
premiums will be open for Aetna to inspect while this policy is in force. Also,
such data must be open until the final rights and duties under this policy have
been resolved.
CLERICAL ERROR
Any clerical error by anyone in keeping records, or a delay in making an entry,
will not be the sole determination of the coverage's validity. A fair change in
premiums will be made when the error or delay is found.
MISSTATEMENTS
If the Insured's age is misstated, the amount of the Death Benefit will be
adjusted to reflect the coverage that would have been purchased by the most
recent Monthly Deduction at the correct age.
INCONTESTABILITY
The validity of this policy shall not be contested, except for non-payment of
premiums, after it has been in force for 2 years. All statements made by or for
the Insured are representations and not warranties. Aetna will not use any such
statement to void the insurance or defend against a claim unless the statement
is attached to and made a part of the policy or Certificate.
NON-DISCRIMINATION
In the management of this policy, the New York State United Teachers Benefit
Trust will act so as not to discriminate unfairly between persons in like
situations at the time of the action.
7
POLICY CHANGES
This policy may be changed at any time by written agreement between Aetna and
the New York State United Teachers Benefit Trust provided all necessary
regulatory approvals have been received. The consent of any Certificate Owner is
needed if the change results in a reduction in benefits or an increase in
guaranteed charges. All agreements made by Aetna are signed by one of its
executive officers. No other person can change or waive any of the policy terms
or make any agreement binding Aetna. The New York State United Teachers Benefit
Trust will not have to give written approval of a change in the policy if:
the New York State United Teachers Benefit Trust asked for the change and
Aetna has agreed to it; and
the change is needed so that the policy will conform to any law, regulation
or ruling of:
a jurisdiction that affects a person covered under this policy; or
the federal government.
PART VI
MISCELLANEOUS PROVISIONS
COPY OF APPLICATION
DEATH BENEFIT
If the Insured dies while the Certificate is in force, Aetna will pay a death
benefit based upon the Death Benefit Option in effect on the date of death, less
the Loan Account Value plus any accrued interest less any outstanding payment
required keep the Certificate in force through the date of death. In the event
there is no designated beneficiary, We may pay from the Death Benefit payable at
a sum not exceeding $500 to any person appearing to Us to be equitably entitled
to same by reason of having incurred funeral expenses incident to the death of
the Insured.
The individual(s) or entity(ies) that will receive any Proceeds on the death of
the Insured is the Beneficiary named by the Certificate Owner. If no Beneficiary
has been named, or if no named Beneficiary is living at the time of the
Insured's death, all Proceeds will be paid to the Certificate Owner or the
Certificate Owner's executors, administrators or assigns.
NONFORFEITURE PROVISIONS
By Written Request the Certificate Owner may, at any time while the policy is in
force and according to the terms of the Certificate, elect to (a) surrender or
partially surrender his/her Certificate in exchange for payment of all or part
of its Surrender Value, (b) continue the coverage in effect as paid up or (c)
borrow up to 90% of the sum of the Certificate's Separate Account Value and
Fixed Account Value. Aetna reserves the right to defer payments as provided
under the Certificate's Right to Defer Payment provision.
8
THE SEPARATE ACCOUNT
The Separate Account established for the purpose of providing Variable Options
to fund this insurance is Variable Life Account B. Variable Life Account B was
established pursuant to a June 18, 1986, resolution of the Board of Directors of
Aetna. The Separate Account is registered with the SEC as a unit investment
trust under the Investment Company Act of 1940 and meets the definition of
separate account under the federal securities laws. Such registration does not
involve any approval or disapproval by the Commission of the Separate Account or
Aetna's management or investment practices or policies. Aetna does not guarantee
the Separate Account's investment performance.
9
GUARANTEED MAXIMUM COST OF INSURANCE RATES
TABLE OF
GUARANTEED MAXIMUM INSURANCE RATES
PER $1,000 OF THE AMOUNT AT RISK
NonSmoker Smoker
Attained Preferred Substandard Substandard Attained Preferred Substandard Substandard
Age Standard Class 1 Class 2 Age Standard Class 1 Class 2
21 0.1117 0.27925 0.363025 21 0.1467 0.36675 0.476775
22 0.1117 0.27925 0.363025 22 0.1467 0.36675 0.476775
23 0.1108 0.27700 0.360100 23 0.1459 0.36475 0.474175
24 0.1108 0.27700 0.360100 24 0.1450 0.36250 0.471250
25 0.1083 0.27075 0.351975 25 0.1434 0.35850 0.466050
26 0.1083 0.27075 0.351975 26 0.1425 0.35625 0.463125
27 0.1075 0.26875 0.349375 27 0.1434 0.35850 0.466050
28 0.1092 0.27300 0.354900 28 0.1442 0.36050 0.468650
29 0.1108 0.27700 0.360100 29 0.1475 0.36875 0.479375
30 0.1117 0.27925 0.363025 30 0.1517 0.37925 0.493025
31 0.1142 0.28550 0.371150 31 0.1575 0.39375 0.511875
32 0.1167 0.29175 0.379275 32 0.1634 0.40850 0.531050
33 0.1208 0.30200 0.392600 33 0.1709 0.42725 0.555425
34 0.1258 0.31450 0.408850 34 0.1809 0.45225 0.587925
35 0.1317 0.32925 0.428025 35 0.1909 0.47725 0.620425
36 0.1392 0.34800 0.452400 36 0.2042 0.51050 0.663650
37 0.1475 0.36875 0.479375 37 0.2225 0.55625 0.723125
38 0.1584 0.39600 0.514800 38 0.2417 0.60425 0.785525
39 0.1692 0.42300 0.549900 39 0.2634 0.65850 0.856050
40 0.1825 0.45625 0.593125 40 0.2893 0.72325 0.940225
41 0.1967 0.49175 0.639275 41 0.3193 0.79825 1.037725
42 0.2125 0.53125 0.690625 42 0.3501 0.87525 1.137825
43 0.2276 0.56900 0.739700 43 0.3826 0.95650 1.243450
44 0.2442 0.61050 0.793650 44 0.4160 1.04000 1.352000
45 0.2634 0.65850 0.856050 45 0.4535 1.13375 1.473875
46 0.2826 0.70650 0.918450 46 0.4911 1.22775 1.596075
47 0.3043 0.76075 0.988975 47 0.5311 1.32775 1.726075
48 0.3268 0.81700 1.062100 48 0.5737 1.43425 1.864525
49 0.3518 0.87950 1.143350 49 0.6196 1.54900 2.013700
50 0.3793 0.94825 1.232725 50 0.6704 1.67600 2.178800
51 0.4102 1.02550 1.333150 51 0.7264 1.81600 2.360800
52 0.4469 1.11725 1.452425 52 0.7890 1.97250 2.564250
53 0.4877 1.21925 1.585025 53 0.8599 2.14975 2.794675
54 0.5319 1.32975 1.728675 54 0.9384 2.34600 3.049800
55 0.5812 1.45300 1.888900 55 1.0202 2.55050 3.315650
56 0.6337 1.58425 2.059525 56 1.1062 2.76550 3.595150
57 0.6888 1.72200 2.238600 57 1.1931 2.98275 3.877575
10
58 0.7464 1.86600 2.425800 58 1.2816 3.20400 4.165200
59 0.8090 2.02250 2.629250 59 1.3736 3.43400 4.464200
60 0.8799 2.19975 2.859675 60 1.4747 3.68675 4.792775
61 0.9618 2.40450 3.125850 61 1.5917 3.97925 5.173025
62 1.0561 2.64025 3.432325 62 1.7271 4.31775 5.613075
63 1.1689 2.92225 3.798925 63 1.8886 4.72150 6.137950
64 1.2984 3.24600 4.219800 64 2.0676 5.16900 6.719700
TABLE OF
GUARANTEED MAXIMUM INSURANCE RATES
PER $1,000 OF THE AMOUNT AT RISK
NonSmoker Smoker
Attained Preferred Substandard Substandard Attained Preferred Substandard Substandard
Age Standard Class 1 Class 2 Age Standard Class 1 Class 2
58 0.7464 1.86600 2.425800 58 1.2816 3.20400 4.165200
59 0.8090 2.02250 2.629250 59 1.3736 3.43400 4.464200
60 0.8799 2.19975 2.859675 60 1.4747 3.68675 4.792775
61 0.9618 2.40450 3.125850 61 1.5917 3.97925 5.173025
62 1.0561 2.64025 3.432325 62 1.7271 4.31775 5.613075
63 1.1689 2.92225 3.798925 63 1.8886 4.72150 6.137950
64 1.2984 3.24600 4.219800 64 2.0676 5.16900 6.719700
65 1.4387 3.59675 4.675775 65 2.2626 5.65650 7.353450
66 1.5917 3.97925 5.173025 66 2.4610 6.15250 7.998250
67 1.7514 4.37850 5.692050 67 2.6663 6.66575 8.665475
68 1.9195 4.79875 6.238375 68 2.8649 7.16225 9.310925
69 2.1002 5.25050 6.825650 69 3.0811 7.70275 10.013575
70 2.3053 5.76325 7.492225 70 3.3109 8.27725 10.760425
71 2.5641 6.41025 8.333325 71 3.5836 8.95900 11.646700
72 2.8204 7.05100 9.166300 72 3.9027 9.75675 12.683775
73 3.1491 7.87275 10.234575 73 4.2732 10.68300 13.887900
74 3.5257 8.81425 11.458525 74 4.6902 11.72550 15.243150
75 3.9371 9.84275 12.795575 75 5.1506 12.87650 16.739450
76 4.3841 10.96025 14.248325 76 5.6332 14.08300 18.307900
77 4.8534 12.13350 15.773550 77 6.1290 15.32250 19.919250
78 5.3485 13.37125 17.382625 78 6.6295 16.57375 21.545875
79 5.8811 14.70275 19.113575 79 7.1558 17.88950 23.256350
80 6.4733 16.18325 21.038225 80 7.7293 19.32325 25.120225
81 7.1432 17.85800 23.215400 81 8.3729 20.93225 27.211925
82 7.9096 19.77400 25.706200 82 9.1021 22.75525 29.581825
83 8.7882 21.97050 28.561650 83 9.9301 24.82525 32.272825
84 9.7551 24.38775 31.704075 84 10.8745 27.18625 35.342125
85 10.8047 27.01175 35.115275 85 11.8300 29.57500 38.447500
86 11.9162 29.79050 38.727650 86 12.8830 32.20750 41.869750
87 13.0934 32.73350 42.553550 87 13.9031 34.75775 45.185075
88 14.3145 35.78625 46.522125 88 15.0644 37.66100 48.959300
89 15.6065 39.01625 50.721125 89 16.1827 40.45675 52.593775
90 16.9690 42.42250 55.149250 90 17.4484 43.62100 56.707300
91 18.4362 46.09050 59.917650 91 18.7977 46.99425 61.092525
92 20.0534 50.13350 65.173550 92 20.2876 50.71900 65.934700
11
93 21.9228 54.80700 71.249100 93 22.0116 55.02900 71.537700
94 24.2237 60.55925 78.727025 94 24.2237 60.55925 78.727025
95 27.4624 68.65600 89.252800 95 27.4624 68.65600 89.252800
96 32.5183 81.29575 90.909100 96 32.5183 81.29575 90.909100
97 41.3602 90.90910 90.909100 97 41.3602 90.90910 90.909100
98 57.8690 90.90910 90.909100 98 57.8690 90.90910 90.909100
99 90.9091 90.90910 90.909100 99 90.9091 90.90910 90.909100
The Guaranteed Maximum Cost of Insurance rates for Substandard Classes 1 and 2
reduce to the Preferred/Standard Cost of Insurance rates after 20 years, or at
attained age 65, whichever is later.
70262-97
12
