Exhibit 99.A9.A
Exhibit 24(b)(4)(a)
Specimen Flexible Payment Variable Accumulation Deferred
Annuity Contract
AUSA LIFE INSURANCE COMPANY, INC.
(A STOCK COMPANY)
Home Office: Purchase, New York
Administrative Office: Clearwater, Florida
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IN THIS CONTRACT AUSA Life Insurance Company, Inc. will be referred to as WE,
OUR or US. OFFICE refers to Our Administrative Office located in Clearwater,
Florida.
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WE agree to pay the benefits of this Contract in accordance with its provisions.
CONTRACT VALUES AND BENEFITS DURING THE ACCUMULATION PERIOD WILL INCREASE OR
DECREASE IN ACCORDANCE WITH THE CONTRACT VALUE PROVISIONS AND THE INVESTMENT
EXPERIENCE OF THE APPLICABLE SUBACCOUNTS IN THE SEPARATE ACCOUNT. CONTRACT
VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SUBACCOUNT OF THE SEPARATE
ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT.
THE SMALLEST annual rate of investment return which would have to be earned on
Separate Account assets so that the dollar amount of variable annuity payments
will not decrease is 5.65%.
THE CONSIDERATION for this Contract is the application and the payment of the
Initial Payment.
THE ANNUITANT, OWNER, AND BENEFICIARY are as shown in the application unless
changed in accordance with the provisions of this Contract.
THE PROVISIONS on the following pages are part of this Contract.
IN WITNESS WHEREOF, We have signed this Contract at Our Office in Clearwater,
Florida as of the Contract Date.
/s/ Xxxxx X. Xxxxxx /s/ Xxx X. Xxxxxxxxxxx
_____________________________________ _______________________________
Secretary President
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RIGHT TO EXAMINE CONTRACT - The Owner may cancel this Contract at any time
within thirty days after receipt by returning it to Us at P.O. Box 9054,
Clearwater, Florida 33758-9054. If the Contract is returned within this period,
We will pay to the Owner the sum of all purchase payments received for this
Contract.
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FLEXIBLE PAYMENT VARIABLE ACCUMULATION DEFERRED ANNUITY
Death Benefit Prior to Maturity
Monthly Annuity Commencing on Maturity Date
Non-Participating - No Dividends
CONTRACT GUIDE
ENDORSEMENTS.............................................................. 2
CONTRACT SCHEDULE......................................................... 3
DEFINITIONS............................................................... 5
SEPARATE ACCOUNT PROVISIONS............................................... 7
GENERAL PROVISIONS........................................................ 9
PURCHASE PAYMENT PROVISIONS............................................... 11
CONTRACT VALUE PROVISIONS................................................. 11
DEATH BENEFIT PROVISIONS.................................................. 13
ANNUITY PROVISIONS........................................................ 14
FIXED ACCOUNT ANNUITY PAYMENTS............................................ 16
VARIABLE ACCOUNT ANNUITY PAYMENTS......................................... 18
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ENDORSEMENTS
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AUSA LIFE INSURANCE COMPANY, INC.
CLEARWATER, FLORIDA
CONTRACT SCHEDULE
OWNER: XXXX XXX CONTRACT NUMBER: 01-12345678
ANNUITANT: XXXX XXX CONTRACT DATE: September 01, 2000
ANNUITY OPTION: D-10 YEAR CERTAIN MATURITY DATE: September 01, 2026
INITIAL PAYMENT: $29,000.00 REALLOCATION DATE: September 01, 2000
REALLOCATION ACCOUNT: Money Market
ANTICIPATED PURCHASE PAYMENT PATTERN *
NO PLANNED PAYMENT - ISSUED WITH THE INITIAL PAYMENT AS A SINGLE PAYMENT PLAN.
* THE ANTICIPATED PURCHASE PAYMENT PATTERN IS BASED UPON SELECTION MADE IN THE
APPLICATION. THE AMOUNT AND MODE MAY BE CHANGED IN ACCORDANCE WITH THE PURCHASE
PAYMENT PROVISIONS ON PAGE 10.
SEPARATE ACCOUNT PROVISIONS
SEPARATE ACCOUNT: AUSA SERIES ANNUITY ACCOUNT B
SEPARATE ACCOUNT CHARGE: 0.65% ANNUALLY
PURCHASE PAYMENT PROVISIONS
MAXIMUM ADDITIONAL PAYMENT: $1,000,000
MINIMUM ADDITIONAL PAYMENT: $100
CONTRACT VALUE PROVISIONS
MINIMUM ALLOCATION PERCENTAGE: 1%
ANNUAL CONTRACT CHARGE: $30**
MINIMUM BALANCE: $2,500
FIXED ACCOUNT MINIMUM GUARANTEED
EFFECTIVE ANNUAL INTEREST RATE: 3%
CURRENT INTEREST RATE: 4%
**CURRENTLY WAIVED IF THE ANNUITY VALUE IS GREATER THAN OR EQUAL TO $25,000 ON
THE CONTRACT ANNIVERSARY.
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DEFINITIONS
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ACCOUNTS Allocation options including the Fixed Account and the
Subaccounts of the Separate Account.
ACCUMULATION The period between the Contract Date and the Maturity Date
PERIOD while the Contract is in force.
ACCUMULATION An accounting unit of measure used to calculate Subaccount
UNIT VALUE values for the Contract during the Accumulation Period.
ANNUITANT The person named on the application, or as subsequently
changed, to receive annuity payments. The Annuitant may be
changed as provided in the Death Benefit Provisions and
Annuity Provisions.
ANNUITY PROCEEDS The amount applied to purchase periodic annuity payments.
Such amount is the Annuity Value on the Maturity Date, less
any applicable Premium Tax.
ANNUITY UNIT An accounting unit of measure used to calculate annuity
VALUE payments from a Subaccount after the Maturity Date.
ANNUITY VALUE The value as described in the Annuity Value section of the
Contract Value Provisions.
CASH VALUE The value as described in the Cash Value section of the
Contract Value Provisions.
CONTINGENT The new Beneficiary upon the current Beneficiary's death.
BENEFICIARY
CONTRACT DATE The later of the date on which payments are first received
and the date the properly completed application is received
by Us at Our Office.
DEATH BENEFIT The value as described in the Death Benefit Proceeds section
PROCEEDS of the Death Benefit Provisions.
DEATH REPORT DAY The Valuation Date coincident with or next following the day
on which We have received both: 1) due proof of death; and
2) a Written Notice for an election of a) a single sum
payment or b) an alternative election as described under the
Death Benefit Provisions.
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FIXED ACCOUNT An allocation option other than the Separate Account.
MATURITY DATE The date on which the Accumulation Period ends and annuity
payments are to commence. The date may be changed as
provided in the Annuity Provisions
PREMIUM TAX Premium Tax levied by a state or other government
entity. The Premium Tax will be paid when due and charged
either against the purchase payment or the contract value.
REALLOCATION DATE The date on which any purchase payments are reallocated
from the Reallocation Account to the Accounts elected by the
Owner. The Reallocation Date is shown on the Contract
Schedule page.
SEC The United States Securities and Exchange Commission.
SEPARATE ACCOUNT A unit investment trust, consisting of Subaccounts.
Each Subaccount of the Separate Account buys shares of a
corresponding portfolio of a Series Fund.
SERIES FUND A designated mutual fund from which a Subaccount of the
Separate Account will buy shares.
SUBACCOUNT A Separate Account allocation option that is made available
under this Contract.
SURRENDER The termination of the Contract at the option of the Owner.
VALUATION DATE Each Monday through Friday except customary national
business holidays on which the New York Stock Exchange is
not open for business.
VALUATION PERIOD The period commencing at the end of one Valuation Date and
continuing to the end of the next succeeding Valuation Date.
WRITTEN NOTICE Written Notice means a notice by the Owner to Us requesting
or exercising a right of the Owner as provided in the
Contract provisions. In order for a notice to be considered
a Written Notice, it must: be in writing, signed by the
Owner; be in a form acceptable to Us; and contain the
information and documentation, as determined in Our sole
discretion, necessary for Us to take the action requested or
for the Owner to exercise the right specified. A Written
Notice will not be considered complete until all necessary
supporting documentation required or requested by Us has
been received by Us at Our Administrative Office.
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SEPARATE ACCOUNT PROVISIONS
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The variable benefits under this Contract are provided through the Separate
Account referenced on Page 3. This Separate Account is established under the
Laws and Regulations of New York. The assets of the Separate Account are Our
property. Assets equal to the liabilities of the Separate Account will not be
charged with liabilities arising out of any other business We may conduct. If
the assets of the Separate Account exceed the liabilities arising under the
contracts supported by the Separate Account, then the excess may be used to
cover the liabilities of Our general account. The assets of the Separate Account
shall be valued as often as any contract benefits vary, but at least monthly.
SUBACCOUNTS The Separate Account has various Subaccounts. Each
Subaccount invests exclusively in shares of one of the
portfolios of an underlying Series Fund. Assets invested
after the Maturity Date may be invested in different
Subaccounts than assets invested during the Accumulation
Period. We reserve the right to add or remove any Subaccount
of the Separate Account. Income and realized and unrealized
gains and losses from assets in each Subaccount are credited
to, or charged against, that Subaccount without regard to
income, gains, or losses in other Subaccounts. Any amount
charged against the contract value for federal or state
income taxes will be deducted from that Subaccount.
TRANSFERS AMONG During the Accumulation Period, the Owner may transfer
SUBACCOUNTS all or a portion of this Contract's value in its
Subaccounts to other Subaccounts or the Fixed Account.
We reserve the right to charge a $10 fee for each transfer
after the first twelve transfers during any one contract
year. This charge will be deducted from the funds
transferred. We must be notified in a manner satisfactory to
Us. The transfer ordinarily will take effect on the first
Valuation Date on or following the date notice is received
at Our Office.
After the Maturity Date, the Owner may transfer the value of
the variable annuity units from one Subaccount to another.
The minimum amount which may be transferred is the lesser of
$10 monthly income or the entire monthly income of the
variable annuity units in the Subaccount from which the
transfer is being made. If the monthly income of the
remaining units in a Subaccount is less than $10, We reserve
the right to include the value of those variable annuity
units as part of the transfer.
After the Maturity Date, no transfers may be made to or from
the Fixed Account. We reserve the right to limit transfers
to once per contract year.
ADDITION, DELETION We reserve the right to transfer assets of the
OR SUBSTITUTION Separate Account, which We determine to be associated with
OF INVESTMENTS the class of contracts to which this Contract belongs, to
another Separate Account, subject to prior approval by the
Superintendent of Insurance of New York State. If this type
of transfer is made, the term "Separate Account", as used in
this Contract, shall then mean the Separate Account to which
the assets were transferred. We also reserve the right to
add, delete, or substitute investments held by any
Subaccount, subject to prior approval by the Superintendent
of Insurance of New York State.
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We reserve the right, when permitted by law, to:
1. Deregister the Separate Account under the
Investment Company Act of 1940;
2. Manage the Separate Account under the direction of
a committee at any time;
3. Restrict or eliminate any voting privileges of
contractowners or other persons who have voting
privileges as to the Separate Account; and
4. Combine the Separate Account or any Subaccount(s)
with one or more other separate accounts or
subaccounts.
CHANGE OF We reserve the right to change the investment objective
INVESTMENT of any Subaccount. If required by law or regulation,
OBJECTIVES an investment objective of the Separate Account, or of a
Series Fund portfolio designated for a Subaccount,
will not be materially changed unless a statement of the
change is filed with and approved by the appropriate
insurance official of the state of Our domicile or deemed
approved in accordance with such law or regulation. If
required, approval of or change of any investment objective
will be filed with the Insurance Department of the state
where this Contract is delivered.
ACCUMULATION Some of the contract values fluctuate with the investment
UNIT VALUE results of the Subaccounts. In order to determine
how investment results affect the contract values, an
Accumulation Unit Value is determined for each Subaccount.
The Accumulation Unit Value may increase or decrease from
one Valuation Period to the next. Accumulation Unit Values
also will vary between Subaccounts.
The Accumulation Unit Value of any Subaccount at the end of
a Valuation Period is the result of:
1. The total value of the assets held in the
Subaccount, including the value of any dividends
or capital gains distribution declared and
reinvested by the portfolio during the Valuation
Period. This value is determined by multiplying
the number of shares of the designated Series Fund
portfolio owned by the Subaccount times the net
asset value per share; minus
2. The accrued charge for administration and
mortality and expense. The annual Separate Account
Charge is shown on Page 3. The daily amount of
this charge is equal to the net assets of the
Subaccount multiplied by the Separate Account
Charge; minus
3. The accrued amount of reserve for any taxes that
are determined by Us, subject to prior approval by
the Superintendent of Insurance of New York State,
to have resulted from the investment operations of
the Subaccount; and the result divided by
4. The number of outstanding units in the Subaccount
prior to the purchase or redemption of any units
on that date.
The use of the Accumulation Unit Value in determining
contract values is described in the Contract Value
Provisions.
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GENERAL PROVISIONS
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THE CONTRACT This Contract and the attached application constitute the
entire Contract. All statements in the application will be
deemed representations and not warranties. No statement can
be used to void this Contract or be used in defense of a
claim unless it is contained in the written application. No
Contract provision can be waived or changed except by
endorsement. Such endorsement must be signed by Our
President or Secretary. We reserve the right to amend the
Contract to meet the requirements of any applicable Federal
or state laws or regulations, subject to prior approval by
the Superintendent of Insurance of New York State.
OWNERSHIP This Contract belongs to the Owner. The Owner as shown on
Page 3, or as subsequently changed, may exercise all rights
under this Contract including the right to transfer
ownership. These rights may be subject to the consent of any
assignee or irrevocable beneficiary.
CHANGE OF We will not be bound by any requested change in the
OWNERSHIP ownership designation unless it is made by Written
UPON REQUEST Notice. The change will be effective on the date the Written
Notice is signed and recorded by Us. If We
request, this Contract must be returned to Our Office for
endorsement.
Changing the Owner cancels any prior Ownership designation,
but it does not change the beneficiary or the Annuitant.
CHANGE OF Should the Owner die during the Accumulation Period, We will
OWNERSHIP be bound by the following:
UPON DEATH
OF OWNER
1. If the Owner is the Annuitant, then the Death
Benefit Proceeds are payable as provided in the
Death Benefit Provisions.
2. If the Owner is not the Annuitant and dies before
the Annuitant:
(a) If no Beneficiary is named and alive,
the Owner's estate will become the new
Owner. The Cash Value must be
distributed within five years of the
former Owner's death; or
(b) If the Beneficiary is alive and is the
Owner's spouse, this Contract will
continue with the spouse as the new
Owner; or
(c) If the Beneficiary is alive and is not
the Owner's spouse, the Beneficiary will
become the new Owner. The Cash Value
must be distributed either:
(1) within five years of the former Owner's death; or
(2) over the lifetime of the new Owner, if a natural
person, with payments beginning within one year of
the former Owner's death; or
(3) over a period that does not exceed the life
expectancy (as defined by the Internal Revenue
Code and Regulations adopted under the Code) of
the new Owner, if a natural person, with payments
beginning within one year of the former Owner's
death.
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ASSIGNMENT This Contract may be assigned prior to the Maturity Date. We
will not be bound by any assignment unless made by Written
Notice. The assignment will be effective on the date the
Written Notice is received at Our Office and accepted by Us.
We assume no responsibility for the validity of any
assignment.
INCONTESTABILITY This Contract is incontestable from the Contract Date.
BENEFICIARY The Beneficiary, as named in the application or subsequently
changed, is entitled to receive the Death Benefit Proceeds
or the Cash Value, if any, as provided in 2(c) above as
provided in the Death Benefit Provisions of this Contract.
If no Beneficiary is alive, the benefits payable to the
Beneficiary will be paid to the Owner, if surviving,
otherwise to the Owner's estate.
CHANGE OF We will not be bound by any change in the
BENEFICIARY Beneficiary designation unless it is made by Written Notice.
The change will be effective on the date the Written Notice
was signed; however, no change will apply to any payment We
made before the Written Notice is received. If We request,
this Contract must be returned to Our Office for
endorsement.
AGE AND SEX If a date of birth or sex has been misstated, any
amount payable will be adjusted to conform to the correct
date of birth and sex. Any underpayment made by Us will be
paid with the next payment. Any overpayment made by Us will
be deducted from future payments. Any underpayment or
overpayment will include interest at 5% per year, from the
date of adjustment.
CONTRACT YEARS Contract years and anniversaries are measured from the
Contract Date.
REPORTS The report will also show any other information required by
the laws or regulations of the state in which the contract
is issued.
CONTRACT PAYMENT All payments from the Fixed Account will be paid in
one sum unless otherwise elected under the Annuity
Provisions of this Contract. We have the right to postpone
payments and transfers from the Fixed Account for up to six
months. We reserve the right, at Our option, to defer the
payment of any cash surrender value in accordance with the
deferral provisions of the Investment Company Act of 1940.
All payments and transfers from the Subaccounts will be
processed as provided in this Contract unless one of the
following situations exist:
1. The New York Stock Exchange is closed; or
2. The SEC requires that trading be restricted or
declares an emergency.
PROTECTION OF Unless the Owner directs by filing Written Notice, no
PROCEEDS Beneficiary may assign any payments under this
Contract before the same are due. To the extent permitted by
law, no payments under this Contract will be subject to the
claims of creditors of any Beneficiary.
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PURCHASE PAYMENT PROVISIONS
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PURCHASE PAYMENTS Payments after the first are payable at Our Office.
The amount of payment which may be paid during any contract
year may not exceed the Maximum Additional Payment shown on
Page 3 without Our consent. Payments will not be accepted in
an amount less than the Minimum Additional Payment shown on
Page 3 without Our consent. Our acceptance of any payment
shall not constitute a waiver of these limits with respect
to subsequent payments.
CONTRACT VALUE PROVISIONS
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NET PAYMENT The net payment will be the payment received less Premium
Tax, if any.
ALLOCATION OF NET Net payments will be allocated to the Accounts on the first
PAYMENTS Valuation Date on or following the date the payment is
received at Our Office. Any purchase payments received prior
to the Reallocation Date will be allocated to the
Reallocation Account. On the first Valuation Date on or
following the Reallocation Date, the values in the
Reallocation Account will be transferred in accordance with
the Owner's current purchase payment allocation
instructions.
Any allocation to an Account must not be less than the
Minimum Allocation Percentage shown on Page 3. No fractional
percentages are permitted. The allocation of future net
payments may be changed by the Owner. We reserve the right
to limit such change to once each year. The request for
change of allocations must be in a manner satisfactory to
Us. The allocation change will be effective the date the
request for change is recorded by Us.
SUBACCOUNT VALUE At the end of any Valuation Period, the Subaccount value is
equal to the number of units that the Contract has in the
Subaccount, multiplied by the Accumulation Unit Value of
that Subaccount.
The number of units that the Contract has in each Subaccount
is equal to:
1. The initial units purchased on the Contract Date;
plus
2. Units purchased at the time additional net
payments are allocated to the Subaccount; plus
3. Units purchased through transfers from another
Account; minus
4. Any units that are redeemed to pay for partial
withdrawals; minus
5. Any units that are redeemed as part of a transfer
to another Account; minus
6. Any units that are redeemed to pay the Annual
Contract Charge, Premium Tax and transfer fees, if
any.
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FIXED ACCOUNT At the end of any Valuation Period, the value is equal to:
1. The sum of all net payments allocated to the Fixed
Account; plus
2. Any amounts transferred from a Subaccount to the
Fixed Account; plus
3. Total interest credited to the Fixed Account;
minus
4. Any amounts withdrawn from the Fixed Account to
pay for partial withdrawals; minus
5. Any amounts transferred to a Subaccount from the
Fixed Account; minus
6. Any amounts charged to pay the Annual Contract
Charge, Premium Tax and transfer fees, if any.
Interest on the Fixed Account will be compounded daily at a
minimum guaranteed effective annual interest rate as shown
on Page 3. We may declare from time to time higher current
interest rates. The interest rates We set will be credited
for increments of at least one year measured from each
purchase payment or transfer date.
On transfers from the Fixed Account to a Subaccount, unless
We otherwise consent:
1. Written Notice must be within 30 days after a
contract anniversary.
2. The transfer will ordinarily take place on the
first Valuation Date on or following the date We
receive such Written Notice.
3. The amount that may be transferred is the greater
of (a) 25% of the amount in the Fixed Account; or
(b) the amount transferred in the prior policy
year from the Fixed Account.
Unless We otherwise consent, transfers to the Fixed Account
or allocation of Net Premiums to the Fixed Account may be
restricted if the Fixed Account value following the transfer
or allocation would exceed $500,000.
We reserve the right to defer payment of any amounts from
the Fixed Account for no longer than six months after We
receive such Written Notice.
ANNUAL CONTRACT During the Accumulation Period, the Annual Contract Charge
CHARGE shown on Page 3 will be made once a year on each contract
anniversary from the Annuity Value.
ANNUITY VALUE At the end of any Valuation Period, the Annuity Value
is equal to the sum of the Subaccount value for each
Subaccount plus the Fixed Account Value.
PARTIAL WITHDRAWAL Prior to the Maturity Date, a partial withdrawal
may be made by the Owner without surrender of this Contract.
Unless We otherwise consent:
1. The request must be made by Written Notice.
2. The partial withdrawal may not reduce the Cash
Value to less than the Minimum Balance shown on
Page 3.
3. No amount from the Fixed Account may be withdrawn.
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The amount payable will be the partial withdrawal less any
applicable Premium Tax. The Subaccount(s) for the withdrawal
may be specified. If not specified, withdrawals will be
based on the current allocation election.
CASH VALUE This Contract may be surrendered by the Owner for its Cash
Value upon Written Notice at any time prior to the then
current Maturity Date. The Cash Value at any time equals the
Annuity Value on the Valuation Date coincident with or next
following the date We receive Written Notice of surrender
less any applicable Premium Tax. Payment will usually be
made within seven days of Written Notice subject to the
Contract Payment section of the General Provisions and the
Fixed Account section of these provisions.
BASIS OF A detailed statement of the method of computation of
COMPUTATION values has been filed with the insurance supervisory
official of the jurisdiction in which this Contract is
delivered. All values for this Contract are equal to or
greater than the values required by statutes in such
jurisdiction.
DEATH BENEFIT PROVISIONS
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DEATH OF ANNUITANT If the Annuitant dies during the Accumulation Period and the
ACCUMULATION Owner is a natural person other than the Annuitant, the
PERIOD Owner will automatically become the Annuitant and the
Contract will continue.
If the Annuitant dies during the Accumulation Period and the
Owner is either (1) the same individual as the Annuitant; or
(2) other than a natural person, then the Death Benefit
Proceeds as calculated below are payable to the Beneficiary.
DEATH BENEFIT The Death Benefit Proceeds during the Accumulation Period is
PROCEEDS the greater of:
1. The Annuity Value as of the Death Report Day; or
2. The excess of (a) the amount of purchase payments
paid less (b) any amounts withdrawn from the
Contract to pay for partial withdrawals.
ALTERNATIVE If the Beneficiary is entitled to receive the Death Benefit
ELECTION Proceeds, the Beneficiary may elect in lieu of a lump sum
payment, one of the following options that provide for
complete distribution and termination of this Contract at
the end of the distribution period:
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1. Within 5 years of the date of death of the
Annuitant; or
2. Over the lifetime of the Beneficiary; or
3. Over a period that does not exceed the life
expectancy (as defined by the Internal Revenue
Code and Regulations adopted under the Code) of
such Beneficiary.
Multiple beneficiaries may choose individually among any of
the three options.
For subparagraphs (1) and (3), the Annuity Value as of the
Death Report Day will be adjusted to equal the Death Benefit
Proceeds and this Contract will remain in force as a
deferred annuity until the end of the elected distribution
period. For subparagraph (2), the Maturity Date will be
changed to the Death Report Day and the Death Benefit
Proceeds will be used to purchase annuity payments under the
Annuity Provisions of this Contract.
For elections made under subparagraph (1), We will:
a. at the time of election, allow one partial
withdrawal and one transfer of all or a portion of
the Contract's value among Subaccounts or the
Fixed Account without a transfer charge.
Additional partial withdrawal and transfers are
not permitted;
b. not permit payment of the Death Benefit Proceeds
under the Annuity Provisions of this Contract upon
complete distribution.
The Beneficiary may not name a Beneficiary for payment of
the Death Benefit Proceeds. In the event the Beneficiary
dies prior to distribution of all Death Benefit Proceeds, We
will pay the remaining value of the Death Benefit Proceeds
to the Contingent Beneficiary, if named by the Owner. If no
Contingent Beneficiary is named, such payment will be made
to the Beneficiary's estate.
Subparagraphs (2) and (3) may be elected only if the
Beneficiary is a natural person and payments start within
one year of the date of death of the Annuitant.
In addition, if the Beneficiary is entitled to receive the
Death Benefit Proceeds and is the spouse of the deceased
Annuitant, then the Beneficiary may elect to become the new
Annuitant and Owner and keep the Contract in force in lieu
of receiving the Death Benefit Proceeds.
ANNUITY PROVISIONS
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COMMENCEMENT OF Monthly annuity payments will begin as of the Maturity Date
ANNUITY PAYMENTS shown on Page 3, unless another Maturity Date has been
elected as provided in these provisions.
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MATURITY DATE The Maturity Date shown on Page 3 may be changed to a
different Maturity Date, subject to all of the following:
1. Written Notice prior to the Maturity Date.
2. The new Maturity Date is at least 13 months after
the Contract Date.
3. The attained age of the Annuitant as of the new
Maturity Date is not greater than 90
On the Maturity Date the contract must annuitize. The
Systematic Payout Option cannot be used to continue the
contract In Force beyond the Maturity Date.
ANNUITY OPTION The Annuity Option shown on Page 3 may be changed to any
other option available upon Written Notice prior to the
Maturity Date. If a variable account annuity payment option
is chosen, the Owner must include in the Written Notice the
Subaccount allocation of the Annuity Proceeds as of the
Maturity Date.
CHANGE OF As of the Maturity Date and upon agreement with Us, the
ANNUITANT Owner may elect a different Annuitant or add a joint
annuitant who will be a joint payee under either Option C or
Option E.
PAYEE The Annuitant(s) on the Maturity Date will become the
payee(s) and receive the annuity payments.
AVAILABILITY If the payee is not a natural person, an Annuity Option is
only available with Our permission. No Annuity Option is
available if:
1. The payee is an assignee; or
2. The periodic payment is less than $20.
AGE Age, when required, means age nearest birthday on the
effective date of the option. We will furnish rates for ages
or combination of ages not shown upon request.
PROOF OF AGE Prior to making the first monthly annuity payment under this
AND SEX Contract, We reserve the right to require satisfactory
evidence of the birthdate and the sex of any payee. If
required by law to ignore differences in sex of any payee,
annuity payments will be determined using unisex rates.
PROOF OF SURVIVAL Prior to making any payment under this Contract, We reserve
the right to require satisfactory evidence that the payee
is:
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1. Alive on the due date of such payment; and
2. Legally qualified to receive such payment.
DEATH BENEFIT The death benefit after the Maturity Date and after the
AFTER THE commencement of annuity payments depends upon the annuity
MATURITY DATE option selected. If a payee dies on or after the
commencement of annuity payments, the remaining portion of
any interest in the Contract will be distributed at least as
rapidly as under the method of distribution being used as of
the date of the payee's death.
RESTRICTIONS After the Maturity Date, no additional purchase payments,
partial withdrawals, transfers, full surrenders, change of
Annuitants nor Annuity Options may be made under this
Contract.
FIXED ACCOUNT ANNUITY PAYMENTS
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Annuity payments at the time of annuitization will not be less than those that
would be provided by the application of "an amount" to purchase any single
consideration immediate annuity contract. "An amount" will be the greater of the
Cash Value or 95% of the Annuity Value.
INTEREST AND All Fixed Account annuity option payments are based on a
MORTALITY guaranteed interest rate of 3%. Mortality is based on the
"Annuity 2000" (male, female, and unisex if required by law)
mortality table projected for improvement using projection
scale G.
AMOUNT OF MONTHLY The amount of each monthly annuity payment will be
FIXED ACCOUNT determined by multiplying:
ANNUITY PAYMENT
1. The appropriate rate based on the guaranteed
interest rate and, for Options B and C, the
mortality table for Fixed Account annuity
payments; multiplied by
2. The Annuity Proceeds as of the Maturity Date.
FIXED ACCOUNT The following options are available for payment of Fixed
ANNUITY OPTIONS Account monthly annuity payments. The rates shown are
the guaranteed rates for each $1,000 of Annuity Proceeds at
adjusted ages. The adjusted age is the Annuitant's actual
age nearest birthday at the Maturity Date, adjusted as
follows:
Maturity Date Adjusted Age
Before 2010 Actual Age
2010 - 2019 Actual Age minus 1
2020 - 2026 Actual Age minus 2
2027 - 2033 Actual Age minus 3
2034 - 2040 Actual Age minus 4
After the year 2040 as determined by us.
Page 16
Any guaranteed rates not shown for the options above will be
available upon request. Higher current rates may be
available at the Maturity Date.
Option A - Fixed The Annuity Proceeds will be paid in equal installments.
Period. The installments will be paid over a fixed period determined
from the following table:
Fixed Period Rate
(in Months)
-----------
60 17.91
120 9.61
180 6.87
240 5.51
Option B - Life The Annuity Proceeds will be paid in equal installments
Income. determined from the following table. Such installments are
payable:
1. during the payee's lifetime only (Life Annuity);
or
2. during a 10 Year fixed period certain and for the
payee's remaining lifetime (Certain Period); or
3. until the sum of installments paid equals the
Annuity Proceeds applied and for the payee's
remaining lifetime (Installment Refund).
Option B: Life Income
Monthly Income Payments
Guaranteed for Life Guaranteed for 10 Years Guaranteed Return of
Policy Proceeds
-------------------------------------------------------------------------------------------------------
Age* Male Female Unisex Male Female Unisex Male Female Unisex
50 $ 3.82 3.70 3.74 3.80 3.69 3.72 3.70 3.62 3.65
55 4.18 4.01 4.06 4.13 3.99 4.03 3.99 3.89 3.92
60 4.64 4.42 4.49 4.57 4.38 4.44 4.36 4.23 4.27
65 5.30 4.98 5.08 5.14 4.89 4.97 4.83 4.67 4.72
70 6.21 5.78 5.90 5.86 5.58 5.66 5.43 5.26 5.31
*Adjusted Age as defined in Fixed Account Annuity Options Provision
Option C - Joint Survivor The Annuity Proceeds will be paid in equal
and Life Income installments during the joint lifetime of two payees and
continuing upon the death of the first payee for the
remaining lifetime of the survivor.
Page 17
Option C: Joint and Survivor Life Income
Monthly Payments for Each $1,000 of Amount Retained
Age of Other Payee (Female)
Age of One 15 Years Less 12 Years Less 9 Years Less 6 Years Less 3 Years Less Same as
Payee* (Male) Than Male Than Male Than Male Than Male Than Male Male Payee's
Payee's Payee's Payee's Payee's Payee's
------- ------- ------- ------- -------
50 $3.06 $3.12 $3.19 $3.25 $3.31 $3.38
55 3.20 3.27 3.35 3.44 3.52 3.61
60 3.37 3.47 3.57 3.68 3.79 3.91
65 3.59 3.72 3.86 4.01 4.16 4.32
70 3.88 4.06 4.25 4.45 4.67 4.89
*Adjusted Age as defined in Fixed Account Annuity Options Provision
UNISEX MONTHLY PAYMENTS FOR EACH $1,000 OF AMOUNT RETAINED
Age of Other Payee*
Age of First 15 Years Less 12 Years Less 9 Years Less 6 Years Less 3 Years Less Same as
Payee* Than First Than First Than First Than First Than First First Payee's
Payee's Payee's Payee's Payee's Payee's
------- ------- ------- ------- -------
50 $3.07 $3.13 $ 3.19 $3.25 3.31 3.37
55 3.20 3.28 3.36 3.44 3.52 3.60
60 3.38 3.48 3.58 3.68 3.79 3.89
65 3.61 3.73 3.87 4.01 4.16 4.30
70 3.90 4.07 4.26 4.46 4.66 4.86
*Adjusted Age as defined in Fixed Account Annuity Options Provision
VARIABLE ACCOUNT ANNUITY PAYMENTS
================================================================================
Annuity payments at the time of annuitization will not be less than those that
would be provided by the application of "an amount" to purchase any single
consideration immediate annuity contract. "An amount" will be the greater of the
Cash Value or 95% of the Annuity Value.
ANNUITY UNIT The Annuity Proceeds will be used to purchase variable
VALUE annuity units in the chosen Subaccount(s). The Annuity Unit
Value in any Subaccount will increase or decrease reflecting
the investment experience of that Subaccount.
The Annuity Unit Value of any Subaccount at the end of a
Valuation Period is equal to (a) multiplied by (b)
multiplied by (c), where:
(a) is the Annuity Unit Value for that Subaccount at
the end of the immediately preceding Valuation
Period;
(b) is the net investment factor for the Subaccount
for the Valuation Period; and
(c) is the Assumed Investment Return adjustment factor
for the Valuation Period.
Page 18
The Assumed Investment Return adjustment factor for the
Valuation Period is the product of discount factors of
.99986634 per day to recognize the 5.0% effective annual
Assumed Investment Return.
The net investment factor used to calculate the value of the
Annuity Unit Value in each Subaccount for the Valuation
Period is determined by dividing (d) by (e) and subtracting
(f) from the result, where:
(d) is the net result of:
(1) the net asset value of a Series Fund
share held in that Subaccount determined
as of the end of the current Valuation
Period; plus
(2) the per share amount of any dividend or
capital gain distributions made by the
Series Fund for shares held in that
Subaccount if the ex-dividend date
occurs during the Valuation Period; plus
or minus
(3) a per share charge or credit for any
taxes reserved for, which We determine
to have resulted from the investment
operations of the Subaccount.
(e) is the net asset value of a Series Fund share held
in the Subaccount determined as of the end of the
immediately preceding Valuation Period.
(f) is a factor representing the mortality and expense
risk fee, and administrative charge. This factor
is equal, on an annual basis, to 0.65% of the
daily net asset value of a Series Fund share held
in the Separate Account for that Subaccount.
DETERMINATION OF The amount of the first variable payment is determined by
THE FIRST multiplying the Annuity Proceeds times the appropriate
VARIABLE PAYMENT rate from the variable option selected. The tables are based
on the "Annuity 2000" (male, female, and unisex if required
by law) mortality table projected for improvement using
projection scale G. Neither expenses actually incurred,
other than taxes on the investment return, nor mortality
actually experienced, shall adversely affect the dollar
amount of variable annuity payments after such payments have
commenced.
The amount of the first payment depends upon the adjusted
age of the Annuitant. The adjusted age is the Annuitant's
actual age nearest birthday at the Maturity Date, adjusted
as follows:
Maturity Date Adjusted Age
Before 2010 Actual Age
----------- ----------
2010 - 2019 Actual Age minus 1
2020 - 2026 Actual Age minus 2
2027 - 2033 Actual Age minus 3
2034 - 2040 Actual Age minus 4
After the year 2040 as determined by us.
Page 19
DETERMINATION The amount of variable annuity payments after the first will
OF SUBSEQUENT increase or decrease according to the Annuity Unit Value
VARIABLE PAYMENTS which reflects the investment experience of the selected
Subaccount(s). Each variable annuity payment after the first
will be equal to the number of variable annuity units in
each selected Subaccount multiplied by the Annuity
Unit Value of that Subaccount on the date the payment is
processed. The number of variable annuity units in any
selected Subaccount is determined by dividing the first
variable annuity payment allocated to that Subaccount by
the variable Annuity Unit Value of that Subaccount on the
date the first annuity payment is processed.
VARIABLE ACCOUNT The following options are available for payment of Variable
ANNUITY OPTIONS Account monthly annuity payments. The rates shown are the
guaranteed rates for each $1,000 of Annuity Proceeds at
adjusted ages. These rates are used to determine the first
variable payment under each option. Any guaranteed rates not
shown for the options below will be available upon request.
Option D - Variable The Annuity Proceeds will be paid in installments determined
Life Income. from the following table. Such installments are payable:
1. during the payee's lifetime only (Variable Life
Annuity); or
2. during a 10 year fixed period certain and for the
payee's remaining lifetime (Variable Certain
Period).
Variable Life Annuity Variable Certain Period
--------------------- -----------------------
Payee's Age* Male Female Unisex Male Female Unisex
------------ ---- ------ ------ ---- ------ ------
50 5.07 4.93 4.98 5.04 4.92 4.95
55 5.40 5.22 5.27 5.34 5.18 5.23
60 5.85 5.61 5.68 5.75 5.55 5.61
65 6.50 6.16 6.26 6.29 6.03 6.11
70 7.41 6.94 7.08 6.98 6.69 6.77
*Adjusted Age as defined in Variable Account Annuity Options Provision
Page 20
Option E - The Annuity Proceeds will be paid in installments during the
Variable Joint joint lifetime of two payees and continuing upon the death
and Survivor Life of the first payee for the remaining lifetime of the
Income survivor.
Option E: Monthly Installment For Joint and Full Survivor
Monthly Payments for Each $1,000 of Amount Retained
AGE OF OTHER PAYEE (FEMALE)*
Age of First 15 Years Less 12 Years Less 9 Years Less 6 Years Less 3 YEARS LESS Same as
Payee*(Male) Than Male Than Male Than Male Than Male Than Male Male Payee's
Payee's Payee's Payee's Payee's Payee's
------- ------- ------- ------- -------
50 $4.37 $4.42 $4.46 $4.51 $4.56 $4.62
55 4.48 4.54 4.60 4.67 4.74 4.81
60 4.62 4.70 4.79 4.88 4.98 5.08
65 4.81 4.92 5.04 5.17 5.31 5.46
70 5.07 5.23 5.40 5.59 5.79 6.00
*Adjusted Age as defined in Variable Account Annuity Options Provision
UNISEX MONTHLY PAYMENTS FOR EACH $1,000 OF AMOUNT RETAINED
Age of Other Payee*
Age of First 15 Years Less 12 Years Less 9 Years Less 6 Years Less 3 Years Less Same as
Payee* Than First Than First Than First Than First Than First First Payee's
Payee's Payee's Payee's Payee's Payee's
------- ------- ------- ------- -------
50 $4.38 $4.42 $4.47 $4.51 $4.56 $4.61
55 4.48 4.54 4.60 4.67 4.73 4.80
60 4.63 4.70 4.79 4.88 4.97 5.07
65 4.82 4.93 5.05 5.17 5.30 5.44
70 5.09 5.24 5.41 5.59 5.78 5.97
*Adjusted Age as defined in Variable Account Annuity Options Provision
Page 21
AUSA LIFE INSURANCE COMPANY, INC.
Home Office: 0 Xxxxxxxxxxxxxx Xxxx
Xxxxxxxx, Xxx Xxxx 00000
Administrative Office:
P.O. Box 9054
Clearwater, Florida 33758-9054
FLEXIBLE PAYMENT VARIABLE ACCUMULATION DEFERRED ANNUITY
Death Benefit prior to Maturity.
Monthly Annuity commencing on Maturity Date.
Non-participating - No Dividends
