DEFERRED ANNUITY CONTRACT
- Flexible purchase payments.
- Optional fixed dollar or variable accumulation values and annuity payments.
- Annuity payments to begin on the settlement date.
- This contract is nonparticipating. Dividends are not payable.
- Death benefits provided herein will be reduced by any unamortized purchase
payment credits applied within 12 months of death.
Annuitant: Xxxx Xxx Contract Date: May 15, 2004
Contract Number: XXXX-XXXXXXXX Settlement Date: May 15, 2004
This is a deferred annuity contract. It is a legal contract between you, as the
owner, and us, IDS Life Insurance Company of New York, a Stock Company. PLEASE
READ YOUR CONTRACT CAREFULLY.
If the annuitant is living on the settlement date, upon your request, we will
begin to pay you monthly annuity payments. Any payments made by us are subject
to the terms of this contract.
We issue this contract in consideration of your application and the payment of
the purchase payments.
Signed for and issued by IDS Life Insurance Company of New York in Albany, New
York, as of the contract date shown above.
ACCUMULATION VALUES AND ANNUITY PAYMENTS, WHEN BASED ON THE INVESTMENT RESULTS
OF THE VARIABLE SUBACCOUNTS, ARE VARIABLE AND NOT GUARANTEED AS TO FIXED DOLLAR
AMOUNT. See the Fixed And Variable Accounts section for variable provisions. The
mortality and expense risk charge, contract administrative charge and charges
for any optional riders are shown under Contract Data.
In order for the dollar amount of variable annuity payments not to decrease, the
assets of the variable acconts must have an annual net rate of investment return
of 5%. This is equal to the gross investment return minus the mortality and
expense risk charge shown under Contract Data.
NOTICE OF YOUR RIGHT TO EXAMINE THIS CONTRACT FOR 10 DAYS.
If for any reason you are not satisfied with this contract, return it to us or
our representative within 10 days after you receive it. We will then cancel this
contract and refund all premiums which you have paid. This contract will then be
considered void from its start.
/s/ Xxxxxxx X. Xxxxxxxx
President
/s/ Xxxx X. Xxxxxxx
Secretary
139035A (09/2003)
GUIDE TO CONTRACT PROVISIONS
Contract Data..................................Pages 2A-2C
Important contract specifications, fund
allocations, fees and charges, surrender
charge schedule
Definitions......................................Pages 3-4
General Provisions..................................Page 5
Entire Contract
Modification of the Contract
Incontestable
Benefits Based on Incorrect Data
State Laws
Federal Laws
Reports to Owner
Evidence of Survival
Protection of Proceeds
Payments by Us
Voting Rights
Ownership, Annuitant
and Beneficiary.....................................Page 6
Owner's Rights
Change of Ownership
Naming a Beneficiary
Change of Beneficiary
Beneficiary's Rights
Change of Annuitant or successor annuitant
Assignment
Payments to Beneficiary.............................Page 7
Death Benefit Before the Settlement Date
Pre-election of an Annuity Payment Plan
Spouse Option to Continue Contract
Death Benefits After Settlement
Purchase Payments...................................Page 8
Purchase Payments
Amounts and Intervals
Payment Limits
Allocation of Purchase Payments
Purchase Payment Credits
Contract Value..................................Pages 9-10
Variable Account Contract Value
Fixed Account Contract Value
Interest to be Credited
Contract Administrative Charge
Premium Tax Charges
Transfers of Contract Values
Dollar Cost Averaging
Fixed and Variable Accounts....................Pages 11-12
The Fixed Account
The Variable Account
Investments of the Variable Account
Valuation of Assets
Variable Account Accumulation Units and Values
Net Investment Factor
Mortality and Expense Risk Charge
Annuity Unit Value
Surrender Provisions...........................Pages 13-15
Surrender of the contract for its surrender value
Rules for Surrender
Surrender Value
Surrender Charge
Waiver of Surrender Charges, Hospital or Nursing
Home Waiver, Terminal Illness Waiver
Suspension or Delay in Payment of Surrender
Annuity Provisions.............................Pages 16-17
When annuity payments begin
Different ways to receive annuity payments
Determination of payment amounts
Tables of Settlement Rates.....................Pages 18-19
Tables showing amount of first variable
annuity payment and the guaranteed fixed
annuity payments for the various payment
plans
139035A Page 2 (09/2003)
CONTRACT DATA
Annuitant: Xxxx Xxx Contract Date: May 15, 2004
Contract Number: XXXX-XXXXXXXX Settlement Date: May 15, 2004
Contract Owner: Xxxx Xxx Age at Issue: 35
Deferred Annuity Contract:
("American Express Retirement Advisor Select Plus(SM) Variable Annuity")
Federal Tax Status: Non-qualified
Cash Submitted With Application:* $10,000.00
* Exchanges and transfers from other accounts are not reflected and will
be confirmed separately.
Intended Optional Purchase Payments:
Annual Amount: N/A
Maximum Purchase Payments Permitted:
1st contract year: $1,000,000
Each contract year thereafter: $100,000
Special DCA Minimum Purchase Payment: $10,000
Purchase Payment Credit: 0%
Upon issuance of this contract your purchase payments have been scheduled to be
paid and applied to the fixed account and variable subaccounts as shown below.
You may change the amount, frequency and allocations as provided in this
contract. Refer to the Purchase Payments provision.
Variable Purchase Payments
Subaccounts Fund Allocation Percentage
CR AXP(R) VP - Capital Resource Fund 00.0%
CM AXP(R) VP - Cash Management Fund 00.0%
CB AXP(R) VP - Core Bond Fund 00.0%
BD AXP(R) VP - Diversified Bond Fund 00.0%
DE AXP(R) VP - Diversified Equity Income Fund 00.0%
EM AXP(R) VP - Emerging Markets Fund 00.0%
ES AXP(R) VP - Equity Select Fund 00.0%
GB AXP(R) VP - Global Bond Fund 00.0%
GR AXP(R) VP - Growth Fund 00.0%
EI AXP(R) VP - High Yield Bond Fund 00.0%
IE AXP(R) VP - International Fund 00.0%
MF AXP(R) VP - Managed Fund 00.0%
ND AXP(R) VP - New Dimensions Fund(R) 40.0%
FI AXP(R) VP - Short Duration U.S. Government Fund 20.0%
SC AXP(R) VP - Small Cap Advantage Fund 00.0%
IV AXP(R) VP - S&P 500 Index Fund 00.0%
ST AXP(R) VP - Stock Fund 00.0%
SA AXP(R) VP - Strategy Aggressive Fund 00.0%
PS AXP(R) VP Partners - Select Value Fund 00.0%
SV AXP(R) VP Partners - Small Cap Value Fund 00.0%
PV AXP(R) VP Partners - Value Fund 00.0%
AC AIM V.I. Capital Appreciation Fund, Series II 00.0%
AD AIM V.I. Capital Development Fund, Series II 00.0%
AL AllianceBernstein VP Growth & Income Portfolio (Class B) 00.0%
139035A Page 2A
CONTRACT DATA -(continued)
Variable Purchase Payments
Subaccounts Fund Allocation Percentage
AB AllianceBernstein VP Int'l Value Portfolio (Class B) 00.0%
AI American Century(R) VP International, Class II 00.0%
AV American Century(R) VP Value, Class II 00.0%
SR Xxxxxxx Variable Series, Inc. Social Balanced Portfolio 00.0%
HY Columbia High Yield Fund, Variable Series, Class B 00.0%
EE Evergreen VA International Equity Fund, Class 2 00.0%
FG Fidelity VIP Growth & Income Portfolio Service Class 2 10.00%
FM Fidelity VIP Mid Cap Portfolio Service Class 2 00.0%
FO Fidelity VIP Overseas Portfolio Service Class 2 00.0%
RE FTVIPT Franklin Real Estate Fund - Class 2 00.0%
SI FTVIPT Franklin Small Cap Value Securities Fund - Class 2 00.0%
MS FTVIPT Mutual Shares Securities Fund - Class 2 00.0%
UE Xxxxxxx Xxxxx VIT CORESM U.S. Equity Fund 00.0%
MC Goldman Xxxxx VIT Mid Cap Value Fund 00.0%
FS INVESCO VIF - Financial Services Fund 10.00%
TC INVESCO VIF - Technology Fund 00.0%
IP Lazard Retirement International Equity Portfolio 00.0%
MG MFS(R) Investors Growth Stock Series - Service Class 00.0%
MD MFS(R) New Discovery Series - Service Class 00.0%
TR MFS(R) Total Return Series - Service Class 00.0%
UT MFS(R) Utilities Series - Service Class 00.0%
XX Xxxxxxxxxxx Global Securities Fund/VA, Service Shares 00.0%
XX Xxxxxxxxxxx Main Street Small Cap Fund/VA, Service Shares 00.0%
XX Xxxxxxxxxxx Strategic Bond Fund/VA, Service Shares 00.0%
XX Xxxxxx VT Health Sciences Fund - Class IB Shares 00.0%
PI Xxxxxx VT International Equity Fund - Class IB Shares 00.0%
VS Xxxxxx VT Vista Fund - Class IB Shares 00.0%
SO Strong Opportunity Fund II - Advisor Class 00.0%
XX Xxx Xxxxxx Life Investment Trust Xxxxxxxx Portfolio Class II Shares 00.0%
IT Xxxxxx International Small Cap 00.0%
XX Xxxxxx U.S. Smaller Companies 00.0%
Fixed Account
FIX IDS Life of New York Fixed Account 20.00%
DCA IDS Life of New York Special DCA Account 00.0%
Fixed Account Minimum Interest Rate: 1.5% annual effective rate
Fixed Account Transfer Percentage: 30% (See Transfers of Contract Values
provision for limits on fixed
account transfers.)
As of the date this contract was issued, any purchase payments and
purchase payment credits allocated to the fixed account will earn
interest, for the first year, at the annual effective rate of time.
As of the date this contract was issued, any purchase payments and
purchase payment credits allocated to the Special DCA fixed account
will earn interest at the annual effective rate of time.
139035A Page 2B
Fees and Charges:
Contract Administrative Charge:
Initial Annual Charge $30
We reserve the right to adjust this charge after the first contract anniversary, but the
charge will never exceed $50.
Initial Annual Charge if contract value, or
purchase payments less purchase payments
surrendered, equals or exceeds $50,000 $0
We reserve the right to charge up to $20 after the first contract anniversary. See Contract
Administrative Charge provision.
Mortality and Expense Risk Charge: 1.20% prints for non-qualified contracts
1.00% prints for tax qualified contracts
.75% prints for initial purchase
payments over $1,000,000 and
employees
Return of Purchase Payment Death Benefit Rider Effective 5-15-2004
Initial Annual Charge* .20%
Maximum Five-Year Anniversary Value Death Benefit Rider Effective 5-15-2004
Initial Annual Charge* .10%
Maximum Anniversary Value Death Benefit Rider Effective 5-15-2004
Initial Annual Charge* .25%
*We reserve the right to adjust rider charges after the tenth rider
anniversary by a maximum of .10% for any rider.
Schedule of Surrender Charges
Contract Surrender Charge Percentage
Year Applied to Purchase Payments
1 7%
2 7%
3 7%
Thereafter 0%
Page 2C
DEFINITIONS
The following words are often used in this contract. When we use these words,
this is what we mean:
Accumulation Unit
An accumulation unit is an accounting unit of measure. It is used to calculate
the contract value prior to settlement.
Annuitant
The person or persons on whose life monthly annuity payments depend. The
annuitant may be changed as provided in this contract.
Annuity Unit
An annuity unit is an accounting unit of measure. It is used to calculate the
value of annuity payments from the variable subaccounts on and after the
settlement date.
Code
The Internal Revenue Code of 1986, as amended, its regulations thereunder and/or
promulgations of the Internal Revenue Service, as applicable.
Contract Anniversary
The same day and month as the contract date each year that the contract remains
in force.
Contract Date
The date from which contract anniversaries, contract years, and contract months
are determined. Your contract date is shown under Contract Data.
Contract Value
The sum of the Fixed Account Contract Value (which receives a declared interest
rate) and the Variable Account Contract Value (which varies with the investment
performance of the elected subaccounts) for this contract.
Fixed Account
The fixed account is made up of all our assets other than those in any separate
account.
Xxxxx Xxxxxxx
A fixed annuity is an annuity with payments which are guaranteed by us as to
dollar amount during the annuity payment period.
Nonqualified Contract
A contract used primarily for retirement purposes that is not intended to
qualify under 401(a), 403 or 408 of the Code.
Settlement
The application of the contract value of this contract to an Annuity Payment
Plan to provide annuity payments.
Settlement Date
The date shown under Contract Data on which annuity payments are scheduled to
begin. This date may be changed as provided in this contract. You will be
notified prior to the settlement date in order to select an appropriate annuity
payment plan.
Special DCA Fixed Account
The Special DCA fixed account is an option periodically available within the
fixed account whereby new purchase payments allocated will earn a specified rate
of interest if they are transferred monthly to the variable subaccounts within
specified time periods we declare.
Successor Annuitant
The person who becomes the annuitant when the current annuitant dies prior to
settlement.
Valuation Date
A valuation date is each day the New York Stock Exchange is open for trading.
Valuation Period
A valuation period is the interval of time commencing at the close of business
on each valuation date and ending at the close of business on the next valuation
date.
Variable Annuity
A variable annuity is an annuity with payments which: (1) are not predetermined
or guaranteed as to dollar amounts; and (2) vary in amount with the investment
experience of one or more of the variable subaccounts.
Variable Subaccounts
The portfolios of the Variable Account. The subaccounts available on the
contract date are named under Contract Data.
We, Our, Us
IDS Life Insurance Company of New York
139035A Page 3 (09/2003)
DEFINITIONS (Continued)
Written Request
A request in writing signed by you and delivered to us at our corporate office.
You, Your
The owner of this contract. If this is a nonqualified contract or an investment
in a Qualified Plan under section 401(a) of the Code, the owner may be someone
other than the annuitant. The owner may be changed as provided in this contract.
139035A Page 4 (09/2003)
GENERAL PROVISIONS
Entire Contract
This contract form and any endorsements or riders attached to it are the entire
contract between you and us.
No one except one of our corporate officers (President, Vice President,
Secretary or Assistant Secretary) can change or waive any of our rights or
requirements under this contract. That person must do so in writing. None of our
other representatives or other persons has the authority to change or waive any
of our rights or requirements under this contract.
Modification of the contract
This contract may be modified at any time by written agreement between you and
us. The modification must be signed by one of our corporate officers (President,
Vice President, Secretary or Assistant Secretary).
Incontestable
This contract is incontestable from its date of issue.
Benefits Based on Incorrect Data
If the amount of benefits is determined by data as to a person's age or sex that
is incorrect, benefits will be recalculated on the basis of the correct data.
Any underpayments made by us will promptly be paid in a single sum with an
interest credit of 6% per annum. Any overpayments made by us will be subtracted
from the future payments together with an interest charge of 6% per annum.
State Laws
This contract is governed by the laws of the state in which it is delivered. The
values and benefits of this contract are at least equal to those required by
such state.
Federal Laws
This contract is intended to qualify as an annuity contract under Section 72 of
the Internal Revenue Code for Federal income tax purposes. To that end, the
provisions of this contract are to be interpreted to ensure or maintain such tax
qualification, despite any other provisions to the contrary. We reserve the
right to unilaterally amend this contract to reflect any clarifications that may
be needed or are appropriate to maintain such tax qualification. We will send
you a copy of any such amendments.
Reports to Owner
At least once a year we will send you a statement showing the contract value,
the cash surrender value and death benefit of this contract as of a date not
more than two months prior to the statement. This statement will be based on any
laws or regulations that apply to contracts of this type. It will be mailed to
your last known post office address.
Evidence of Survival
Where any payments under this contract depend on the recipient or annuitant
being alive on a given date, proof that such condition has been met may be
required by us. Such proof may be required prior to making the payment.
Protection of Proceeds
Payments under this contract are not assignable by any beneficiary prior to the
time they are due.
Payments by Us
All sums payable by us are payable from our corporate office. Any payment or
surrender from a variable annuity is based on the variable contract value.
Voting Rights
So long as federal law requires, we will give certain voting rights to contract
owners. As contract owner, if you have voting rights we will send a notice to
you telling you the time and place of the shareholder meeting. The notice will
also explain matters to be voted upon and how many votes you have.
139035A Page 5 (09/2003)
OWNERSHIP, ANNUITANT AND BENEFICIARY
Owner's Rights
Unless otherwise stated in this contract, you may exercise all rights and
privileges provided in this contract or allowed by us.
Change of Ownership
You can change the ownership of this contract by written request on a form
approved by us. The change must be made while the annuitant is living. Once we
receive the change, it will take effect as of the date of your request, subject
to any action taken or payment made by us before receipt.
Naming a Beneficiary
Unless designated otherwise, beneficiaries are those you name, in a form
satisfactory to us, to receive benefits of this contract if you die while this
contract is in force. We must receive the form in our corporate office prior to
the date of death.
For joint spousal ownership with right of survivorship, the surviving spouse is
deemed the sole beneficiary superseding any other beneficiary designation. This
permits the surviving spouse to use the spousal continuation at death option
described in the "Payments to Beneficiary" section of the contract. (The deemed
surviving spouse sole beneficiary designation may only be overridden if
specifically requested in writing and signed by both joint spousal owners.)
If the annuity is jointly owned by non-spousal owners, then the annuity balance
will be paid to the beneficiary at the death of the first joint owner.
If the owner is other than a natural person (e.g., a trust or corporation), and
the annuitant dies before settlement, death benefits are payable to the
beneficiary.
Only those beneficiaries who are living when death benefits become payable may
share in the benefits, if any. Benefits will be paid to all primary
beneficiaries surviving you, in accordance with your last beneficiary
designation on file. If none survive, proceeds will be paid to all surviving
contingent beneficiaries. If no beneficiary survives, we will pay the benefits
as follows:
- if the owner is other than a natural person, we will pay the owner,
otherwise;
- to your spouse, if living;
- if no spouse is living, to your lawful children per stirpes;
- if you have no spouse or direct descendents, to your parents equally or
the survivor; if living, otherwise to your estate.
The owner may change the beneficiary as provided below.
Change of Beneficiary
If the annuitant is still living, you may change the beneficiary anytime by
satisfactory written request to us. Once we receive the change, it will take
effect as of the date of your request, subject to any action taken or payment
made by us before the receipt.
Beneficiary's Rights
If the death benefit under this contract becomes payable to a beneficiary
(payee) under an Annuity Payment Plan, that payee shall have the right to name a
beneficiary. Any such request from the payee must be made on a form satisfactory
to us.
Change of annuitant or successor annuitant
If this is a nonqualified contract, you may change the annuitant or successor
annuitant if the request is made before annuity payments begin and while the
existing annuitant is living. Once we receive a satisfactory written request and
we record the change, it will take effect as of the date of your request,
subject to any action taken or payment made by us before the receipt.
In the case of joint spousal ownership, one owner must be named as successor
annuitant.
If the annuitant and the owner are not the same person and the annuitant dies
before the contract is settled, the owner becomes the annuitant unless a
successor annuitant has been previously selected.
Assignment
If this is a nonqualified contract, you can assign this contract or any interest
in it. Your interest and the interest of any beneficiary are subject to the
interest of the assignee. An assignment is not a change of ownership and an
assignee is not an owner as these terms are used in this contract. Any amounts
payable to the assignee will be paid in a single sum.
A copy of any new assignment must be submitted to us at our corporate office.
Any assignment is subject to any action taken or payment made by us before the
assignment was received at our corporate office. We are not responsible for the
validity or effect, tax or otherwise, of any assignment.
139035A Page 6 (09/2003)
PAYMENTS TO BENEFICIARY
Death Benefit Before the Settlement Date
If you die before the settlement date while this contract is in force, and if
you are age 75 or younger on the Contract Date, we will pay the beneficiary the
greater of:
1. the contract value, less any purchase payment credits subject to reversal
as indicated in the Purchase Payment section of the contract, as of the
date we receive due proof of death; or
2. the total purchase payments minus any "adjusted partial surrenders."
An "adjusted partial surrender" is calculated for each partial surrender as the
product of (a) times (b) where:
(a) is the ratio of the amount of the partial surrender to the contract
value on the date of (but prior to) the partial surrender; and
(b) is the death benefit on the date of (but prior to) the partial
surrender.
If you are age 76 or older on the Contract Date, we will pay the beneficiary the
contract value, less any purchase payment credits subject to reversal as
indicated in the Purchase Payment section of the contract, as of the date we
receive due proof of death.
The death benefit will be payable in a lump sum on the valuation date we receive
due proof of death of the owner. Due proof of death includes all documents
needed to complete the beneficiary's claim. The beneficiary may elect to receive
payment anytime within 5 years after the date of death.
In lieu of a lump sum, payment may be made under an Annuity Payment Plan,
provided:
1. the beneficiary elects the plan within 60 days after we receive due proof
of death; and
2. payments begin no later than one year after the date of death; and
3. the plan provides payments over a period which does not exceed the life or
the life expectancy of the beneficiary.
In this event, the reference to "annuitant" in the Annuity Provisions shall
apply to the beneficiary.
We will determine the contract value on which we base amounts payable or applied
under this section at the next accumulation unit value calculated after we
receive due proof of death at our corporate office.
Pre-election of an Annuity Payment Plan
If this is a nonqualified contract, you may elect how the death benefit
described herein is to be paid under the contract in the event of death before
the settlement date. Any such election must be made on a form satisfactory to
us. We must receive the form in our corporate office prior to the date of death.
In this event the death benefit shall be payable as so elected by you, rather
than as requested by the beneficiary. If for any reason such election does not
satisfy Section 72 of the Code or related distribution requirements, the
election will be void and the beneficiary will then be permitted to elect
payment pursuant to the provisions of the contract.
Spouse Option to Continue Contract Upon Owner's Death
If the owner's death occurs prior to the settlement date, a spouse who is
designated as sole primary beneficiary, or as a joint tenant with right of
survivorship, may elect in writing to forego receipt of the death benefit and
instead continue this contract as owner, including any associated riders in
force, subject to rider continuation rules in effect. If the owner was also the
annuitant, then the spouse becomes the annuitant as well. The election by the
spouse must be made within 60 days after we receive due proof of death.
Death Benefits After Settlement
The death of the annuitant triggers a death benefit after the settlement date.
The amount payable, if any, will depend on the annuity payment plan then in
effect.
If the owner is the annuitant and dies after the settlement date, payments cease
for life-contingency only plans. Payments continue to beneficiaries for the
remainder of any guarantee period or for the lifetime of a surviving joint
annuitant, if any.
If the annuitant is other than the owner and the annuitant dies after the
settlement date, payments cease for life-contingency only plans. Payments
continue to the owner for the remainder of any guarantee period or for the
lifetime of a surviving joint annuitant, if any.
If the annuitant is other than the owner and the owner dies after the settlement
date, payments continue to the beneficiary according to the payment plan in
effect.
139035A Page 7 (09/2003)
PURCHASE PAYMENTS
Purchase Payments
Purchase payments are the payments you make for this contract and the benefits
it provides. Purchase payments must be paid or mailed to us at our corporate
office or to an authorized agent. If requested, we'll give you a receipt for
your purchase payments. Net purchase payments are that part of your purchase
payments applied to the contract value. A net purchase payment is equal to the
purchase payment less any applicable premium tax charge.
Amount and Intervals
Purchase payments may be paid in a single sum or in installments until the
earlier of: (1) the date this contract terminates by surrender or otherwise; or
(2) the date on which the annuity payments begin.
Subject to the Payment Limits Provision you may: (1) stop and/or restart
purchase payments; or (2) increase or decrease the amount of your purchase
payments; or (3) change the interval of your purchase payments.
Payment Limits Provision
Maximum Purchase Payments - The maximum purchase payments in the first or later
contract years may not exceed the amounts shown under Contract Data.
Minimum Purchase Payments - If you intend to make installment purchase payments
such payments, on an annualized basis, must be at least equal to $600.
Additional payments must be at least $50.
We reserve the right to cancel this contract if both of the following conditions
exist at the same time: (1) no purchase payments have been paid for a continuous
period of 36 months; and (2) the contract value is less than $2000. In this
event we will give you 30 days written notice of our intent to cancel this
contract. Upon such cancellation we will pay you the contract value in one sum.
This contract will then terminate.
Allocation of Purchase Payments
You instruct us on how you want your purchase payments allocated among the fixed
account and variable subaccounts. Your choice for each account may be made in
any whole percent from 0% to 100% as long as the total adds up to 100%. Your
allocation instructions as of the contract date are shown under Contract Data.
By written request, or by other method agreed to by us, you may change your
choice of accounts or percentages. The first net purchase payment will be
allocated as of the end of the valuation period during which we make an
affirmative decision to issue this contract. Net purchase payments after the
first will be allocated as of the end of the valuation period during which we
receive the payment at our corporate office.
We reserve the right to limit purchase payment allocations to the fixed account
during any time period that our credited rate of interest for new purchase
payments is equal to the fixed account minimum interest rate shown under
Contract Data.
Purchase Payment Credits
If shown under Contract Data, we add a percentage of all purchase payments
received in the first contract year as an additional credit to your contract.
Each credit is allocated to your contract value when the applicable purchase
payment is applied to your contract value. Such credits are allocated to your
contract value according to allocation instructions in effect for your purchase
payments.
Credits shall be reversed from the contract value for any purchase payment that
is not honored.
The unamortized portion of the credits applied within 12 months preceding the
date of death that results in a lump sum death benefit under this contract shall
be reversed from the contract value.
The amount returned to you under the Right to Examine Contract (Free-look)
provision shall not include any credits applied to your contract.
139035A Page 8 (09/2003)
CONTRACT VALUE
Contract Value
The contract value at any time is the sum of: (1) the Fixed Account Contract
Value; and (2) the Variable Account Contract Value.
If: (1) part or all of the contract value is surrendered; or (2) charges
described herein are made against the contract value; then a number of
accumulation units from the variable subaccounts and an amount from the fixed
account will be deducted to equal such amount. Such charges may be deducted from
any Special DCA account but only if insufficient amounts are available from your
fixed account and variable subaccounts. For surrenders, deductions will be made
from the fixed account or variable subaccounts that you specify. Otherwise, the
number of units from the variable subaccounts and the amount from the fixed
account, but not any Special DCA account, will be deducted in the same
proportion that your interest in each bears to the total contract value less any
Special DCA account.
Variable Account Contract Value
Your variable account contract value at any time will be the sum of the value of
the units in any variable subaccount resulting from: (1) purchase payments and
any purchase payment credits allocated to a subaccount; plus (2) any amounts
transferred to a subaccount from another subaccount or from the fixed account;
less (3) any amounts transferred from a subaccount to another subaccount or to
the fixed account; less (4) any amounts deducted from a subaccount for charges,
surrenders or transfers.
Fixed Account Contract Value
Your fixed account contract value at any time will be: (1) the sum of all
purchase payments and any purchase payment credits allocated to the fixed
account, plus interest credited; plus (2) any amounts transferred to the fixed
account from any variable subaccount, plus interest credited; less (3) any
amounts transferred from the fixed account to any variable subaccount; less (4)
any amounts deducted for charges or surrenders.
Interest to be Credited
We will credit interest to the fixed account contract value. Interest will begin
to accrue at our current crediting rate on the date the purchase payments which
are received in our corporate office become available to us for use. After the
first year, interest will accrue on the fixed account value at rates determined
by us and at our discretion. These rates will be based on various factors
including, but not limited to, the interest rate environment, returns earned on
investments backing these annuities, the rates currently in effect for new and
existing company annuities, product design, competition, and the company's
revenues and expenses. The Fixed Account Minimum Interest Rate is shown under
Contract Data.
Contract Administrative Charge
We charge a fee for establishing and maintaining our records for this contract.
The charge is shown under Contract Data and is deducted from the contract value
at the end of each contract year or, if earlier, when the contract is fully
surrendered.
Any deduction from the fixed account contract value will be limited to: (1) the
amount of interest credited in excess of the Fixed Account Minimum Interest Rate
shown under Contract Data; plus (2) any amounts allocated or transferred to the
fixed account in that year. In no instance will the charge from the fixed
account exceed $30 in any contract year.
The charge deducted will be prorated among the variable subaccounts and the
fixed account in the same proportion your interest in each bears to the total
contract value less any Special DCA fixed account. Such charges will only be
deducted from any Special DCA account if insufficient amounts are available from
your fixed account and variable subaccounts.
We reserve the right to adjust this charge after the first contract anniversary
but the charge will never exceed the amount shown under Contract Data. We waive
or reduce this charge if your contract value, or your total purchase payments,
less any purchase payments surrendered, equals or exceeds the amount shown under
Contract Data.
If you make a full surrender of this contract, we deduct the full contract
administrative charge at the time of the full surrender regardless of purchase
payments made or contract value.
The charge does not apply after settlement of this contract under an annuity
payment plan.
139035A Page 9 (09/2003)
CONTRACT VALUE (Continued)
Premium Tax Charges
We reserve the right to deduct an amount from the value of this contract at the
time that any applicable premium taxes assessed against the Company or otherwise
not previously deducted are payable.
If a tax is payable at the time of your purchase payment and we choose to not
deduct it at that time, we further reserve the right to deduct it at a later
date.
Transfers of Contract Values
While this contract is in force prior to the settlement date, transfer of
contract values may be made as outlined below:
1. You may transfer all or part of the values held in one or more variable
subaccounts to another one or more of the variable subaccounts. Subject to
item 2, you may also transfer values held in one or more of the variable
subaccounts to the fixed account (other than any Special DCA fixed
account).
2. On or within the 30 days after a contract anniversary you may transfer an
amount from the fixed account (other than any Special DCA fixed account) to
one or more of the variable subaccounts. This amount shall not exceed a)
the percentage of your fixed account contract value (as of the beginning of
the contract year) shown under Contract Data; or b) the amount transferred
out of the Fixed Account in the previous contract year excluding any
automated transfer amounts. Only one such transfer is allowed during this
period each year. If such a transfer is made, no transfers from a variable
subaccount to the fixed account may be made for six months after such a
transfer. We reserve the right to limit transfers to the fixed account
during any time period that our credited rate of interest for new purchase
payments is equal to the fixed account minimum interest rate shown under
Contract Data.
You may make a transfer by written request. There is no fee or charge for these
transfers. However, the minimum transfer amount is $250, or if less, the entire
value in the account from which the transfer is being made. The minimum
automated transfer is $50.
In order to prevent use of the transfer right to the disadvantage of other
contract owners, the right to transfer contract values among the subaccounts and
fixed account is limited. Transferring into a subaccount and then transferring
out of the same subaccount within a five business day period (or vice versa) is
potentially disruptive transfer activity, and, therefore, we prohibit this type
of transfer.
Dollar Cost Averaging (DCA)
You may authorize the automatic transfer of specified amounts from the regular
fixed account or any of the variable subaccounts to any other variable
subaccounts other than the source account.
The unit values credited and applied to your contract are determined on each
date of transfer. You may terminate the DCA program at any time.
Special DCA Program: You may elect to participate in any Special DCA Program we
may periodically offer by written request on a form approved by us. Under the
program you may allocate new purchase payments and any related purchase payment
credits to the Special DCA fixed account and authorize the automatic transfer of
amounts on a monthly basis from the Special DCA fixed account to any of the
variable subaccount(s). The minimum purchase payment into the Special DCA fixed
account is shown under Contract Data. All amounts allocated to the Special DCA
fixed account will be transferred out within the specified Special DCA fixed
account time period you elect from the time periods we make available.
We credit interest to each Special DCA fixed account at rates that generally are
higher than those we credit to the regular fixed account. We may change the
interest rate for any Special DCA account from time to time at our discretion.
You may terminate the Special DCA Program at any time. However, upon termination
or annuitization, any amounts remaining in the Special DCA fixed account will be
transferred to the regular fixed account.
139035A Page 10 (09/2003)
FIXED AND VARIABLE ACCOUNTS
The Fixed Account
The fixed account is our general account. It is made up of all of our assets
other than:
1. those in the variable subaccounts; and
2. those in any other segregated asset account.
The Variable Account
The variable account is a separate investment account of ours. It consists of
several subaccounts, which are named under Contract Data. We have allocated a
part of our assets for this contract to the variable accounts. Such assets
remain our property. However, they may not be charged with the liabilities from
any other business in which we may take part.
Investments of the Variable Account
Purchase payments applied to the variable subaccounts will be allocated as
specified by the owner. Each variable subaccount will buy, at net asset value,
shares of the fund shown for that subaccount under Contract Data or as later
added or changed.
We may change the funds from which the variable subaccounts buy shares if laws
or regulations change, the existing funds become unavailable or in our judgment,
the funds are no longer suitable for the subaccounts. We have the right to
substitute funds for those shown under Contract Data, including funds other than
those shown under Contract Data. We may also: add additional subaccounts
investing in other funds; combine subaccounts; transfer assets to and from the
subaccounts or the variable account; and eliminate or close any subaccounts.
When required, we would first seek approval of the Securities and Exchange
Commission and, the insurance regulator of the state where this contract is
delivered.
Valuation of Assets
Fund shares in the variable subaccounts will be valued at their net asset value.
Variable Account Accumulation Units
The number of accumulation units for each of the variable subaccounts is found
by adding the number of accumulation units resulting from:
1. purchase payments and any purchase payment credits allocated to the
subaccount; and
2. transfers to the subaccount;
and subtracting the number of accumulation units from:
1. transfers from the subaccount; and
2. surrenders (including surrender charges) from the subaccount; and
3. contract administrative charge or any rider charge deductions from the
subaccount.
The number of accumulation units added or subtracted for each of the above
transactions is found by dividing (1) by (2) where:
(1) is the amount allocated to or deducted from the subaccount; and
(2) is the accumulation unit value for the subaccount for the respective
valuation period during which we receive the purchase payment or transfer
value, or during which we deducted transfers, surrenders, surrender
charges, rider charges or contract administrative charges.
Variable Account Accumulation Unit Value
The value of an accumulation unit for each of the variable subaccounts was
arbitrarily set at $1 when the first fund shares were bought. The value for any
later valuation period is found as follows:
The accumulation unit value for each variable subaccount for the last prior
valuation period is multiplied by the net investment factor for the same
account for the next following valuation period. The result is the
accumulation unit value. The value of an accumulation unit may increase or
decrease from one valuation period to the next.
139035A Page 11 (09/2003)
FIXED AND VARIABLE ACCOUNTS (Continued)
Net Investment Factor
The net investment factor is an index applied to measure the investment
performance of a variable subaccount from one valuation period to the next. The
net investment factor may be greater or less than one; therefore, the value of
an accumulation or annuity unit may increase or decrease.
The net investment factor for any such subaccount for any one valuation period
is determined by: dividing (1) by (2) and subtracting (3) from the result. This
is done where:
(1) is the sum of:
a) the net asset value per share of the fund held in the variable
subaccount determined at the end of the current valuation period; plus
b) the per share amount of any dividend or capital gain distributions made
by the fund held in the variable subaccount, if the "ex-dividend" date
occurs during the current valuation period.
(2) is the net asset value per share of fund held in the variable subaccount,
determined at the end of the last prior valuation period.
(3) is a factor representing the mortality and expense risk charge.
Mortality and Expense Risk Charge
In calculating unit values we will deduct a mortality and expense risk charge
from the variable subaccounts which is equal, on an annual basis, to a
percentage of the daily net asset value. The percentage charge is shown under
Contract Data. This deduction is made to compensate us for assuming the
mortality and expense risks under contracts of this type. We estimate that
approximately 2/3 of this charge is for assumption of mortality risk and 1/3 is
for assumption of expense risk. The deduction will be: (1) made from each
variable subaccount; and (2) computed on a daily basis.
Annuity Unit Value
The value of an Annuity Unit for each variable subaccount was arbitrarily set at
$1 when the first funds were bought. The value for any later valuation period is
found as follows:
1. The annuity unit value for each variable subaccount for the last prior
valuation periods is multiplied by the net investment factor for the
subaccount for the valuation period for which the annuity unit value is
being calculated.
2. The result is multiplied by an interest factor, which on an annualized
basis is equal to .952381. This is done to neutralize the assumed
investment rate which is built into Table A under the Tables of Settlement
Rates section.
139035A Page 12 (09/2003)
SURRENDER PROVISIONS
Surrender
By written request and subject to the rules below you may:
1. surrender this contract for the total surrender value; or
2. partially surrender this contract for a part of the surrender value.
Rules for Surrender
All surrenders will have the following conditions:
1. You must apply by written request or other method agreed to by us: (a)
while this contract is in force; and (b) prior to the earlier of the
settlement date or the death of the owner.
2. Unless we agree otherwise, you must surrender an amount equal to at least
$250 or the entire contract value, if less.
3. The amount surrendered, less any charges, will normally be paid to you
within seven days of our receipt of your written surrender request and the
return of this contract, if required. For surrenders from the fixed
account, we have the right to defer payment to you for up to 6 months from
the date we receive the request. If we defer payment more than 10 days, we
will pay annual interest at a rate required by law on the amount deferred.
4. For partial surrenders, if you do not specify from which accounts the
surrender is to be made, the surrender will be made from the variable
subaccounts and fixed account, but not any Special DCA fixed account, in
the same proportion as your interest in each bears to the contract value
less any Special DCA fixed account.
5. If the owner dies following a surrender request and after the payment is
issued, payment will be made to the owner's estate.
6. If the owner dies following a surrender request and before the payment is
issued, payment will be made to the beneficiary as provided under the
Payments to Beneficiary section of the contract.
Upon surrender for the full surrender value this contract will terminate. We may
require that you return the contract to us before we pay the full surrender
value.
Surrender Value
The surrender value at any time will be:
1. the contract value;
2. minus the contract administrative charge;
3. minus any surrender charge.
Surrender Charge
If you surrender all or a part of your contract in the first three contract
years, you may be subject to a surrender charge as shown under Contract Data.
For full surrenders, the surrender charge applies to purchase payments you
have made that have not previously been subject to a surrender charge. The
surrender charge amount is determined by:
a) adding together all purchase payments you have made to the contract,
b) subtracting any purchase payments already surrendered,
c) subtracting any waiver of surrender charge as described in the "Waiver
of Surrender Charge" section, and
d) multiplying the result by the surrender charge percentage.
For partial surrenders, the surrender charge is prorated based on the
percentage of your contract value being surrendered. For example, if you
surrender half of your contract value, approximately half of the surrender
charge applicable for a full surrender would be charged. (However, any
waivers of surrender charge will not be prorated, so the surrender charge
in the above example would be reduced further to account for applicable
waivers.)
For partial surrenders within the first three contract years, we determine
the amount that represents purchase payments which could be subject to a
surrender charge by the following formula:
139035A Page 13 (09/2003)
SURRENDER PROVISIONS (Continued)
PS - FA X (PP - PE)
-------
CV - FA
PS = Amount of partial surrender
FA = Free amount (amounts that are subject to a waiver of surrender
charge)
CV = Contract value prior to the surrender
PP = Purchase payments not previously surrendered
PE = Amounts surrendered totaling up to 10% of the prior contract
anniversary value to the extent it is larger than amounts
surrendered that represent contract earnings (See item 1 under
Waiver of Surrender Charges.)
After calculating the amount of purchase payments that are subject to a
surrender charge, we multiply the result by the surrender charge
percentage.
For a partial surrender that is subject to a surrender charge, the amount
we actually surrender from your contract value will be the amount you
request plus any applicable surrender charge as of the date of surrender.
The surrender charge is applied to this total amount. We pay you the amount
you requested.
The surrender charge applies regardless of the contract value at time of
surrender. Therefore, the purchase payment amount applied to the surrender
charge percentage may be greater or less than the contract value.
Waiver of Surrender Charges
Surrender charges are waived for all of the following:
1. In each of the first three contract years, amounts surrendered totaling up
to 10% of the contract value as of the beginning of that contract year,(1)
or, if larger, amounts surrendered that represent contract earnings;(2) and
(1) Your initial purchase payment is considered the beginning of contract
year contract value during the first contract year.
(2) Contract earnings are defined as the contract value less purchase
payments not previously surrendered.
2. Death Benefit payments made in the event of the death of the owner; and
3. Contracts settled under an Annuity Payment Plan; and
4. For tax qualified contracts, amounts surrendered to meet applicable minimum
distribution requirements under the Code to the extent they exceed amounts
waived under item 1 of this provision; and Note: Amounts surrendered under
this waiver provision are limited to required minimum distributions for
this contract only and to one time per year unless we agree otherwise.
5. Exercise of the Waiver of Surrender Charges Upon Hospital or Nursing Home
Confinement described below; and
6. Exercise of the Waiver of Surrender Charges Upon Terminal Illness
Disability Diagnosis.
Waiver of Surrender Charges Upon Hospital or Nursing Home Confinement
If the owner is age 75 or younger on the contract date, surrender charges will
be waived providing the following requirements are met:
1. We receive satisfactory written proof as described below that you are or
your spouse is confined in a nursing home or hospital; and
2. such confinement has lasted for 60 straight days; and
3. such confinement began after the contract date of this contract; and
4. we receive your surrender request no later than 91 days after the release
from the hospital or nursing home.
To qualify, the letter of proof must:
(a) be signed by your licensed physician or the hospital or nursing home
administrator; and
(b) be on appropriate medical letterhead; and
(c) specify the confinement dates; and
(d) if hospital confinement, specify hospital name, address and that it is
operated pursuant to state and federal law; or
(e) if nursing home confinement, specify nursing home name, address and that it
meets the following definition of a nursing home.
139035A Page 14 (09/2003)
SURRENDER PROVISIONS (Continued)
To qualify, the nursing home must be a facility or distinctly separate part of a
hospital or other institution(3) which is licensed by the appropriate licensing
agency to engage primarily in providing nursing care and related services to
inpatients; and:
(a) provide 24 hour a day nursing service under a planned program of policies
and procedures which was developed with the advice of, and is periodically
reviewed and executed by, a professional group of at least one Doctor and
one Nurse; and
(b) have a Doctor available to furnish medical care in case of emergency; and
(c) have at least one Nurse who is employed there full time (or at least 24
hours per week if the facility has less than 10 beds); and (d) have a Nurse
on duty or on call at all times; and
(e) maintain clinical records for all patients; and
(f) have appropriate methods and procedures for handling and administering
drugs and biologicals.
(3) If an institution or facility has multiple licenses or purposes, a portion,
xxxx, wing or unit thereof will qualify as a Nursing Home only if it meets
all of the above criteria, is authorized by license to provide nursing care
to inpatients, and is engaged principally in providing such nursing care in
accordance with that license.
Waiver of Surrender Charges Upon Terminal Illness Disability Diagnosis
If the owner is age 75 or younger on the contract date, surrender charges will
be waived providing the following requirements are met:
1. We receive satisfactory written proof as described below that you are or
your spouse is is diagnosed as disabled with a medical condition that with
reasonable medical certainty will result in death within 12 months or less
from the date of the diagnosis; and
2. such diagnosis occurred after the contract date of this contract; and
3. a physician who is legally qualified and licensed to practice medicine in
his/her state of residence and is operating within the scope of that
license rendered such diagnosis.
You must provide us with a letter of proof when you request the surrender. Your
surrender request may be sent to us any time after the terminal illness
diagnosis and before the death. (At death, the contract value becomes payable to
the beneficiary.)
To qualify, the letter of proof must:
(a) be signed by your physician who is legally qualified and licensed to
practice medicine in his/her state of residence and is operating within the
scope of that license; and
(b) be on appropriate medical letterhead; and
(c) specify the terminal illness, the expected date of death and the date the
terminal illness was initially diagnosed.
Suspension or Delay in Payment of Surrender
We have the right to suspend or delay the date of any surrender payment from the
variable subaccounts for any period:
1. when the New York Stock Exchange is closed; or
2. when trading on the New York Stock Exchange is restricted; or
3. when an emergency exists as a result of which: (a) disposal of securities
held in the variable subaccounts is not reasonably practicable; or (b) it
is not reasonably practicable to fairly determine the value of the net
assets of the variable subaccounts; or
4. during any other period when the Securities and Exchange Commission, by
order, so permits for the protection of security holders; or
5. if and to the extent permitted or required under the Federal Investment
Company Act of 1940, as amended, and any other applicable federal or state
law.
Rules and regulations of the Securities and Exchange Commission will govern as
to whether the conditions set forth in 2 and 3 exist.
139035A Page 15 (09/2003)
ANNUITY PROVISIONS
Settlement
When settlement occurs, the contract value will be applied to make annuity
payments. The first payment will be made as of the settlement date. This date is
shown under Contract Data. Before payments begin we will require satisfactory
proof that the annuitant is alive. We may also require that you exchange this
contract for a supplemental contract, which provides for the annuity payments.
Change of Settlement Date
You may change the settlement date shown for this contract. Tell us the new date
by written request. The settlement date may not be earlier than 13 months from
the contract date. However the settlement date may not be later than the later
of: (1) the annuitant's 85th birthday; or (2) the tenth contract anniversary; or
(3) such other date as agreed upon by us. Also, if you select a new date, it
must be at least 30 days after we receive your written request at our corporate
office.
Annuity Payment Plans
Subject to the terms of this contract, annuity payments may be made on a fixed
dollar basis, a variable basis, or a combination of both. You can schedule
receipt of annuity payments according to one of the Plans A through E below or
another plan agreed to by us.
Plan A - Life Income Non-Refund.
Monthly annuity payments will be paid during the lifetime of the annuitant.
No payments will be made after the annuitant dies.
Plan B - Life Income with Guaranteed Period.
Monthly annuity payments will be paid during the lifetime of the annuitant
with a guarantee that payments will be made for a period of at least five,
ten or fifteen years whether or not the annuitant is living. You must select
the guaranteed period.
Plan C - Life Income with Installment Refund.
Monthly annuity payments will be paid during the lifetime of the annuitant
with a guarantee that payments will be made for a certain number of months
whether or not the annuitant is living. The number of months is determined
by dividing the contract value applied under this plan by the amount of the
monthly payment.
Plan D - Joint and Survivor Life Income.
Monthly payments will be paid during the lifetime of the annuitant and a
joint annuitant. When either the annuitant or the joint annuitant dies, we
will continue to make monthly payments for the lifetime of the survivor. No
payments will be paid after the death of both the annuitant and joint
annuitant.
Plan E - Term Certain Installment.
Monthly annuity payments will be paid for a specified period of years. The
period of years may be no less than 10 nor more than 30.
By written request to us at least 30 days before the settlement date, you may
select the plan or change to another plan. If at least 30 days before the
settlement date we have not received at our corporate office your written
request to select a plan, we will make fixed dollar annuity payments according
to Plan B with payments guaranteed for ten years.
If the Plan selected has a payment amount that is the same as another Plan
having a longer guarantee period, then the Plan with the longer guarantee period
will be deemed to have been chosen.
If the amount applied to a Plan is less than $2,000 or would not provide an
initial monthly payment of at least $20, or if payments are to be made to other
than a natural person, we have the right to make a lump sum payment of the
contract value.
139035A Page 16 (09/2003)
ANNUITY PROVISIONS (Continued)
Allocation of Contract Values at Settlement
At the time of settlement under an Annuity Payment Plan you may reallocate your
contract value to the Fixed Account to provide fixed dollar payments and/or
among the variable subaccounts to provide variable annuity payments. Unless we
agree otherwise, you may use a maximum of five variable subaccounts at any one
time during settlement.
Xxxxx Xxxxxxx
A fixed annuity is an annuity with payments that are guaranteed by us as to
dollar amount. Fixed annuity payments after the first will never be less than
the amount of the first payment. At settlement, the fixed account contract value
will be applied to the applicable Settlement Table. This will be done in
accordance with the Payment Plan chosen. The amount payable for each $1,000 so
applied is shown in Table B under the Tables of Settlement Rates section.
Variable Annuity
A variable annuity is an annuity with payments which: (1) are not predetermined
or guaranteed as to dollar amount: and (2) vary in amount with the investment
experience of the variable subaccounts.
Determination of First Variable Annuity Payment
At settlement, the variable account contract value will be applied to the
applicable Settlement Table. This will be done: (1) on the valuation date on or
next preceding the 7th calendar day before the settlement date; and (2) in
accordance with the Payment Plan chosen. The amount payable for the first
payment for each $1,000 so applied is shown in Table A under the Tables of
Settlement Rates section.
Variable Annuity Payments After the First Payment
Variable annuity payments after the first vary in amount. The amount changes
with the investment performance of the variable subaccounts. The dollar amount
of variable annuity payments after the first is not fixed. It may change from
month to month. The dollar amount of such payments is determined as follows:
1. The dollar amount of the first annuity payment is divided by the value of
an annuity unit as of the valuation date on or next preceding the 7th
calendar day before the settlement date. This result establishes the fixed
number of annuity units for each monthly annuity payment after the first.
This number of annuity units remains fixed during the annuity payment
period.
2. The fixed number of annuity units is multiplied by the annuity unit value
as of the valuation date on or next preceding the 7th calendar day before
the date the payment is due. The result establishes the dollar amount of
the payment.
We guarantee that the dollar amount of each payment after the first will not be
affected by variation in expenses or mortality experience.
Exchange of Annuity Units
After annuity payments begin, annuity units of any variable subaccount may be
exchanged for units of any of the other variable subaccounts. This may be done
no more than once a year. Unless we agree otherwise you may use a maximum of
five variable subaccounts at any one time. Once annuity payments start, no
exchanges may be made to or from any fixed annuity.
139035A Page 17 (09/2003)
TABLES OF SETTLEMENT RATES
Table A below shows the amount of the first monthly variable annuity payment,
based on a 5% assumed investment return, for each $1,000 of value applied under
any payment plan. The amount of the first and all subsequent monthly fixed
dollar annuity payments for each $1,000 of value applied under any payment plan
will be based on our fixed dollar Table of Settlement Rates in effect at
settlement. Such rates are guaranteed to be not less than those shown in Table
B. The amount of such annuity payments under Plans A, B and C will depend upon
the sex and age of the annuitant at settlement. The amount of such annuity
payments under Plan D will depend upon the sex and the age of the annuitant and
the joint annuitant at settlement.
Table A - Dollar Amount of First Monthly Variable Annuity Payment Per $1,000 Applied
------------ -------- ----------------- --- ----------- ----------------- --- ------------- --------------- ------------------
Plan A Plan B Plan C Plan D
------------ -------- ----------------- --- ----------- ----------------- --- ------------- --------------- ------------------
Age Life Income Life Income Joint & Survivor
at Beginning Life Income Five Years with Ten Years Fifteen Years Installment Non-Refund
Annuit- In Non-Refund Certain Certain Certain Refund Male & Female
ization Year Male Female Male Female Male Female Male Female Male Female Same Age
------------ -------- -------- -------- -------- ------ -------- -------- -------- -------- ------- ------- ------------------
Age 65 2005 6.51 5.87 6.46 5.85 6.31 5.78 6.07 5.67 6.14 5.68 5.35
2010 6.42 5.80 6.37 5.78 6.23 5.72 6.01 5.62 6.07 5.63 5.31
2015 6.33 5.73 6.29 5.71 6.16 5.66 5.96 5.57 6.01 5.57 5.26
2020 6.25 5.67 6.21 5.65 6.09 5.61 5.91 5.53 5.95 5.52 5.22
2025 6.17 5.61 6.13 5.60 6.02 5.55 5.85 5.48 5.89 5.48 5.18
2030 6.09 5.56 6.06 5.54 5.96 5.51 5.80 5.44 5.83 5.43 5.15
------------ -------- -------- -------- -------- ------ -------- -------- -------- -------- ------- ------- ------------------
Age 70 2005 7.43 6.56 7.32 6.52 6.99 6.38 6.55 6.16 6.81 6.24 5.86
2010 7.30 6.47 7.20 6.42 6.90 6.30 6.49 6.10 6.71 6.16 5.80
2015 7.18 6.37 7.08 6.34 6.81 6.22 6.44 6.04 6.63 6.09 5.73
2020 7.06 6.28 6.97 6.25 6.73 6.15 6.38 5.98 6.55 6.03 5.67
2025 6.95 6.20 6.87 6.17 6.65 6.08 6.32 5.93 6.47 5.97 5.62
2030 6.85 6.13 6.78 6.10 6.57 6.02 6.27 5.88 6.39 5.91 5.57
------------ -------- -------- -------- -------- ------ -------- -------- -------- -------- ------- ------- ------------------
Age 75 2005 8.71 7.61 8.45 7.49 7.81 7.17 7.03 6.71 7.67 7.01 6.61
2010 8.53 7.46 8.29 7.36 7.70 7.07 6.98 6.65 7.55 6.91 6.51
2015 8.35 7.33 8.14 7.24 7.60 6.98 6.92 6.59 7.44 6.81 6.42
2020 8.19 7.20 7.99 7.12 7.50 6.88 6.87 6.53 7.33 6.72 6.33
2025 8.03 7.08 7.86 7.01 7.40 6.80 6.82 6.47 7.23 6.64 6.25
2030 7.89 6.97 7.73 6.91 7.31 6.71 6.76 6.41 7.13 6.56 6.18
------------ -------- -------- -------- -------- ------ -------- -------- -------- -------- ------- ------- ------------------
Age 85 2005 13.09 11.51 11.76 10.74 9.48 9.11 7.69 7.61 10.34 9.54 9.35
2010 12.72 11.18 11.53 10.50 9.40 9.01 7.67 7.58 10.15 9.36 9.13
2015 12.38 10.88 11.30 10.28 9.32 8.92 7.66 7.56 9.96 9.19 8.93
2020 12.05 10.60 11.09 10.06 9.24 8.82 7.64 7.54 9.79 9.03 8.75
2025 11.75 10.34 10.88 9.86 9.16 8.73 7.63 7.51 9.63 8.88 8.58
2030 11.47 10.10 10.68 9.68 9.08 8.63 7.61 7.49 9.48 8.74 8.43
------------ -------- -------- -------- -------- ------ -------- -------- -------- -------- ------- ------- ------------------
Table A above is based on the "1983 Individual Annuitant Mortality Table A" with
100% Projection Scale G and a 5% assumed investment return. Settlement rates for
any year, age, or any combination of year, age and sex not shown above, will be
calculated on the same basis as those rates shown in the Table above. Such rates
will be furnished by us upon request. Amounts shown in the Table below are based
on a 5% assumed investment return.
Plan E - Dollar Amount of First Monthly Variable Annuity Payment Per $1,000 Applied
--------------------- ------------------ ------------------- ------------------ ------------------- ------------------
Years Payable Monthly Payment Years Payable Monthly Payment Years Payable Monthly Payment
--------------------- ------------------ ------------------- ------------------ ------------------- ------------------
10 10.51 17 7.20 24 5.88
11 9.77 18 6.94 25 5.76
12 9.16 19 6.71 26 5.65
13 8.64 20 6.51 27 5.54
14 8.20 21 6.33 28 5.45
15 7.82 22 6.17 29 5.36
16 7.49 23 6.02 30 5.28
--------------------- ------------------ ------------------- ------------------ ------------------- ------------------
139035A Page 18 (09/2003)
Fixed Dollar annuity payments will not be less than those shown in Table B. In
addition, the amount of payments under any annuity payment plan will not be less
than that which would be provided if a single premium immediate annuity contract
then offered by us to annuitants in the same class and were to be purchased with
the greater of: (1) surrender value of the contract; or (2) 95% of the contract
value of this contract.
Table B- Dollar Amounts of Each Monthly Fixed Dollar Annuity Payment Per $1,000 Applied
------------ -------- ----------------- --- ----------- ----------------- --- ------------- --------------- ------------------
Plan A Plan B Plan C Plan D
------------ -------- ----------------- --- ----------- ----------------- --- ------------- --------------- ------------------
Age Life Income Life Income Joint & Survivor
at Beginning Life Income Five Years with Ten Years Fifteen Years Installment Non-Refund
Annuit- In Non-Refund Certain Certain Certain Refund Male & Female
ization Year Male Female Male Female Male Female Male Female Male Female Same Age
----------- --------- -------- -------- -------- ------ -------- -------- -------- ------- ------- -------- ------------------
Age 65 2005 4.75 4.14 4.72 4.13 4.62 4.09 4.43 4.01 4.19 3.83 3.68
2010 4.66 4.07 4.63 4.06 4.54 4.03 4.37 3.96 4.13 3.78 3.63
2015 4.57 4.01 4.55 4.00 4.46 3.97 4.31 3.90 4.08 3.74 3.59
2020 4.49 3.95 4.47 3.94 4.39 3.91 4.25 3.85 4.02 3.70 3.54
2025 4.41 3.89 4.39 3.88 4.33 3.86 4.20 3.81 3.97 3.66 3.50
2030 4.34 3.84 4.32 3.83 4.26 3.81 4.15 3.76 3.93 3.62 3.47
----------- --------- -------- -------- -------- ------ -------- -------- -------- ------- ------- -------- ------------------
Age 70 2005 5.66 4.85 5.59 4.82 5.35 4.73 4.98 4.55 4.76 4.34 4.23
2010 5.54 4.76 5.47 4.73 5.26 4.65 4.92 4.49 4.69 4.28 4.16
2015 5.42 4.67 5.36 4.64 5.16 4.57 4.85 4.42 4.62 4.22 4.10
2020 5.31 4.58 5.25 4.56 5.08 4.50 4.79 4.37 4.55 4.17 4.04
2025 5.20 4.50 5.15 4.49 4.99 4.43 4.73 4.31 4.49 4.12 3.98
2030 5.10 4.43 5.05 4.41 4.91 4.36 4.67 4.25 4.43 4.07 3.93
----------- --------- -------- -------- -------- ------ -------- -------- -------- ------- ------- -------- ------------------
Age 75 2005 6.92 5.89 6.74 5.81 6.23 5.57 5.53 5.17 5.50 5.01 5.01
2010 6.74 5.75 6.58 5.68 6.11 5.47 5.47 5.10 5.41 4.93 4.91
2015 6.58 5.62 6.43 5.56 6.01 5.37 5.41 5.04 5.32 4.86 4.82
2020 6.42 5.50 6.29 5.45 5.90 5.27 5.35 4.97 5.24 4.79 4.73
2025 6.27 5.39 6.15 5.34 5.80 5.18 5.29 4.91 5.16 4.72 4.65
2030 6.13 5.28 6.02 5.24 5.71 5.10 5.23 4.85 5.08 4.66 4.58
----------- --------- -------- -------- -------- ------ -------- -------- -------- ------- ------- -------- ------------------
Age 85 2005 11.23 9.72 10.15 9.11 8.06 7.67 6.27 6.18 7.75 7.14 7.76
2010 10.88 9.41 9.91 8.88 7.97 7.56 6.26 6.16 7.61 7.01 7.56
2015 10.55 9.13 9.69 8.66 7.89 7.46 6.24 6.13 7.47 6.88 7.37
2020 10.24 8.86 9.47 8.45 7.80 7.36 6.23 6.11 7.34 6.77 7.19
2025 9.96 8.62 9.26 8.25 7.72 7.26 6.21 6.08 7.22 6.66 7.03
2030 9.69 8.39 9.06 8.06 7.64 7.16 6.19 6.05 7.11 6.56 6.88
----------- --------- -------- -------- -------- ------ -------- -------- -------- ------- ------- -------- ------------------
Table B above is based on the "1983 Individual Annuitant Mortality Table A" at
2.00% with 100% Projection Scale G. Settlement rates for any year, age, or any
combination of year, age and sex not shown above, will be calculated on the same
basis as those rates shown in the Table above. Such rates will be furnished by
us upon request. Amounts shown in the Table below are based on a 2% annual
effective interest rate.
Plan E - Dollar Amount of Each Monthly Fixed Dollar Annuity Payment Per $1,000 Applied
--------------------- ------------------ ------------------- ------------------ ------------------- ------------------
Years Payable Monthly Payment Years Payable Monthly Payment Years Payable Monthly Payment
--------------------- ------------------ ------------------- ------------------ ------------------- ------------------
10 9.18 17 5.77 24 4.36
11 8.42 18 5.50 25 4.22
12 7.80 19 5.26 26 4.10
13 7.26 20 5.04 27 3.98
14 6.81 21 4.85 28 3.87
15 6.42 22 4.67 29 3.77
16 6.07 23 4.51 30 3.68
--------------------- ------------------ ------------------- ------------------ ------------------- ------------------
139035A Page 19 (09/2003)
DEFERRED ANNUITY CONTRACT
- Flexible purchase payments.
- Optional fixed dollar or variable accumulation values and annuity payments.
- Annuity payments to begin on the settlement date.
- This contract is nonparticipating. Dividends are not payable.
IDS Life Insurance Company
Of New York
00 Xxxxxxx Xxx. Ext.
P.O. Box 5144
Albany, New York 12205
