EXHIBIT 4(c)
Form of Variable Annuity Contract
Form No. VVAPA U 1101
AUSA Life Insurance Company, Inc.
Variable Annuity Contract
AUSA Life Insurance Company, Inc.
(Xxxxxx referred to as the "Company")
Home Office: Purchase, New York 10577
FLEXIBLE PREMIUM VARIABLE ANNUITY
NON-PARTICIPATING
AUSA Life Insurance Company, Inc. (the "Company") has issued this Contract in
consideration of the application and the Initial Premium Payment.
This is a legal Contract between the Owner and the Company. AUSA Life Insurance
Company, Inc. agrees to provide the benefits and other rights described in this
Contract in accordance with this Contract. Please read it carefully.
This Contract permits the accumulation of funds on a tax-deferred basis and
provides a periodic Annuity Payment for the life of the Annuitant or for a
certain period of time. Payments start on the Income Date.
Benefits based on the performance of the Separate Account are variable and are
not guaranteed as to amount.
The smallest annual rate of investment return which would have to be earned on
the assets of the Separate Account so that the dollar amount of Variable Annuity
Payments will not decrease is 4.40%. A daily charge corresponding to an annual
charge of .20% per year is applied to the assets of the Separate Account by the
Company, plus a yearly administration charge of .10%. Contracts with Initial
Premium Payments of less than $25,000 will be charged an annual fee of $25 upon
issue and $25 each subsequent year if the Accumulated Value remains below
$25,000.
RIGHT TO CANCEL CONTRACT - FREE LOOK PERIOD
If for any reason the Contract Owner is not satisfied with the Contract, he or
she may return it to the Company within 30 days from the date of receipt along
with a written request to cancel. It may be returned by delivering or mailing it
to Vanguard Annuity and Insurance Services (administrator for the Company), P.O.
Box 1105, Valley Forge, PA 19482. If returned, the Contract shall be void from
the Contract Date and the Company will refund the Accumulated Value as of the
date the notice is received.
Signed for the Company at the Home Office.
Xxxxx X. Xxxxxx Xxx Xxxxxxxxxxx
Secretary President
VVAPA U 1101
2
TABLE OF CONTENTS
I. Contract Schedule Page................................................... 4
II. Definitions............................................................. 5
III. Premium Payments, Options, Benefits.................................... 6
Initial Premium Payments and Subsequent Premium Payments............ 6
Administrative/Maintenance Fee...................................... 7
Mortality and Expense Risk Fee...................................... 7
The Separate Account................................................ 7
Subaccounts......................................................... 8
Premium Allocation to the Subaccounts............................... 8
Accumulated Value .................................................. 8
Transfers .......................................................... 8
Automatic Asset Rebalancing......................................... 8
Automatic Exchange Service.......................................... 9
Transfer Limitations................................................ 9
Partial Withdrawals................................................. 9
Surrenders.......................................................... 9
IV. Annuity Payout Option Benefits.......................................... 9
Choosing an Option.................................................. 9
Selecting or Changing the Income Date............................... 10
Annuity Tables...................................................... 10
Annuity Payment Options............................................. 10
Adjusted Annuitant Age.............................................. 11
Fixed Annuity Payment Option........................................ 11
Determination of a Fixed Payment.................................... 11
Variable Annuity Payment Option..................................... 11
Determination of the First Variable Payment......................... 11
Determination of Subsequent Variable Payments....................... 11
V. Death Benefits and Options............................................... 12
The Death Benefit................................................... 12
Beneficiary......................................................... 12
Death prior to Income Date (in the Accumulation Phase).............. 12
Owner and Annuitant are the Same.................................... 12
Owner and Annuitant are Different and the Owner Dies................ 12
Owner and Xxxxxxxxx are Different and the Annuitant Dies............ 13
Death on or After the Income Date (in the Income Phase)............. 13
If the Owner dies................................................... 13
If the Annuitant dies............................................... 13
VI. General Contract Provisions............................................. 13
The Contract........................................................ 13
Ownership of the Contract............................................13
Beneficiary Change.................................................. 14
Deferment of Payment................................................ 14
Non-Participating................................................... 14
Assignments......................................................... 14
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Incontestability.................................................... 14
Quarterly Statements................................................ 14
Misstatement of Age or Gender....................................... 14
Contract Amendment.................................................. 14
VII. Annuity Tables......................................................... 14
Please address all correspondence to the address listed below. Vanguard Annuity
and Insurance Services is the administrator for AUSA Life Insurance Company,
Inc. Please include the Contract number on all correspondence in order to
facilitate the processing of the request.
Vanguard Annuity and Insurance Services
P.O. Box 1105
Valley Forge, PA 19482-1105
Or
AUSA Life Insurance Company, Inc.
0 Xxxxxxxxxxxxxx Xxxx
Xxxxxxxx, XX 00000
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I. CONTRACT SCHEDULE PAGE
CONTRACT NUMBER:
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Contract Owner: SSN/TIN:
---------------------------------- ---------------------
Joint Owner: SSN/TIN:
-------------------------------------- ---------------------
Owner's Designated Beneficiary: Relationship:
----------------- ------------------
Annuitant: Date of Birth: / / Sex:
------------------------------- ---- ----- ---- -----
Joint Annuitant: Date of Birth: / / Sex:
------------------------- ---- ----- ---- -----
Annuitant's Beneficiary: Relationship:
------------------------ ------------------
Annuitant's Secondary Beneficiary: Relationship:
------------- -------------------
Contract Date: / / Income Date: / /
---- ---- ---- ---- ---- ----
Initial Premium Payment $
-----------------------
The Vanguard Variable Insurance Fund consists of the following Portfolios, all
of which are available for investment through the Contract. The allocation of
the Initial Premium Payment chosen by the Owner is listed below:
Money Market Portfolio (64)....................................0%
Total Bond Market Index Portfolio (67).........................0%
High Yield Bond Portfolio (146)................................0%
Short Term Corporate Portfolio (144)...........................0%
Balanced Portfolio (69)........................................0%
Diversified Value Portfolio (145)..............................0%
Equity Income Portfolio (08)...................................0%
Equity Index Portfolio (68)....................................0%
Growth Portfolio (10)..........................................0%
Mid-Cap Index Portfolio (143)..................................0%
REIT Index Portfolio (147).....................................0%
Small Company Growth Portfolio (160)...........................0%
International Portfolio (86)...................................0%
Mortality and Expense Risk Fee: .20%
Annual Administrative Fee: .10%
Annual Fee (for Contracts with Accumulated Value less than $25,000): $25.00
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II. Definitions
Accumulation Phase - This is the phase during which Premium Payments (purchases)
are invested in the various Subaccounts selected by the Owner.
Accumulation Unit - A unit of measure used to calculate the Accumulated Value of
the Contract during the Accumulation Phase. Premium Payments are used to
purchase Accumulation Units in the Subaccounts chosen by the Owner. The value of
the Accumulation Units increases or decreases in relation to the investment
experience of the underlying Portfolio(s).
Annuitant (or Joint Annuitant) - The person designated by the Owner, upon whose
life any Annuity Payments are determined and upon whose death a Death Benefit
becomes payable.
Annuity Payment Option - One of several ways in which the Accumulated Value of
this Contract can be paid out. The Owner can choose to receive regular payments
for the Annuitant's lifetime, or regular payments for a certain period of time.
Under a Fixed Annuity Payment Option, the dollar amount of each Annuity Payment
does not change over the time period selected. Under a Variable Annuity Payment
Option, the dollar amount of the Annuity Payment is dependent on the investment
experience of the Subaccounts chosen by the Owner.
Annuity Payment - One of a series of regular payments made under one of the
Annuity Payment Options.
Annuity Tables - The Tables included in this Contract provide (for each $1,000
of Accumulated Value) the guaranteed minimum amount of monthly Fixed Annuity
Payments or the first monthly Variable Annuity Payment on which all future
payments are based.
Annuity Unit - A unit of measure in the Income Phase that is used to calculate
Variable Annuity Payments. When a Variable Annuity Payment Option is chosen,
Accumulation Units are converted into Annuity Units, which determine the amount
of future payments based on the performance of the underlying Portfolio(s)
selected.
Assumed Interest Rate (AIR) - The annual rate used to calculate the first
payment under a Variable Annuity Option.
Automatic Asset Rebalancing - Prior to the Income Date, the Owner may designate
the Company to make automatic transfers in the invested Subaccounts in order to
maintain a desired allocation. Transfers can occur on a monthly, quarterly,
semi-annual or annual basis, as elected by the Owner.
Automatic Exchange Service - Prior to the Income Date, the Owner may elect to
automatically transfer a specified amount from one Subaccount to any other
Subaccounts. Transfers can occur on a monthly, quarterly, semi-annual, or annual
basis, as elected by the Owner.
Business Day - Each day the New York Stock Exchange is open for trading.
Company - AUSA Life Insurance Company, Inc.
Contract Anniversary - The annual date that coincides with the Contract Date.
Contract Date - The effective (or issue) date for this Contract.
Contract Owner (or Joint Owner) - The individual (or non-natural person)
designated on the Contract Schedule Page who exercises the rights of ownership
under this Contract.
Contract Year - A period of 12 months starting with the Contract Date or any
Contract Anniversary.
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Death Benefit - The Accumulated Value payable to the Annuitant's
Beneficiary(ies) upon the death of the Annuitant and the Joint Annuitant, if
applicable.
Free Look Period - The period during which this Contract can be cancelled by the
Owner.
Fund - The Vanguard Variable Insurance Fund, an open-end, diversified investment
company offered by The Vanguard Group, Inc., and in which the Separate Account
invests.
Guaranteed Interest Rate - The rate used in the Annuity Tables to determine the
minimum Fixed Annuity Payments guaranteed by the Contract.
Income Date - The date the Income Phase begins and Annuity Payments start.
Income Phase - The period during which the Owner (or his or her designated
Payee) receives regular Annuity Payments on a fixed or variable basis (or a
combination of both) for various periods of time, in accordance with the Annuity
Payment Option selected.
Initial Premium Payment - The first payment made to purchase this Contract.
Owner's Designated Beneficiary - The person (or non-natural person) designated
by the Owner to receive the Accumulated Value of the Contract upon the death of
the Owner.
Partial Withdrawal - Any amount equal to or greater than $250 that the Owner may
remove from the Accumulated Value at any time after the Free Look Period and
prior to the Income Date. The Accumulated Value of the Contract will be reduced
by the amount of any Partial Withdrawal.
Payee - The person (or non-natural person) designated by the Owner to whom any
benefits are to be paid.
Premium Payment - Any amount the Owner invests in this Contract.
Primary Annuitant's Beneficiary - The person (or non-natural person) designated
by the Owner to receive the Death Benefit upon the death of the Annuitant and
Joint Annuitant, if applicable.
Secondary Annuitant's Beneficiary - The person (or non-natural person)
designated by the Owner to receive the Death Benefit if the Primary Beneficiary
should die prior to the Annuitant and Joint Annuitant, if applicable.
Separate Account - The Separate Account consists of assets segregated by the
Company and invested in the Fund. The investment performance of the Separate
Account is independent of the performance of the general assets of the Company.
Subaccount - A portion of the Separate Account which invests in shares of one
Portfolio. The investment performance of each Subaccount is directly linked to
the investment performance of the corresponding Portfolio of the Fund.
Transfer - A Transfer is the exchange of assets from one Subaccount to another.
This results in the redemption of units from one Subaccount and the purchase of
units in another Subaccount. Transfer limitations may apply and are detailed in
the Transfers section of the Contract.
III. Premium Payments, Options, Benefits
Initial Premium Payments and Subsequent Premium Payments - The Initial Premium
Payment for this Contract must be a minimum of $5,000. Subsequent Premium
Payments may be made at any time during the Accumulation Phase (prior to the
Income Date) and must be at least $250. Premium in excess of
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$5,000,000 may require Company approval. The Company reserves the right to limit
the amount of any initial or subsequent Premium Payments.
Administrative/Maintenance Fee - An annual administrative fee is assessed daily
at a rate of .10% annually to offset the costs of maintaining the Contract and
the Separate Account. In addition, Contracts with Initial Premium Payments of
less than $25,000 will be charged an annual fee of $25 upon issue and $25 each
subsequent year if the Accumulated Value remains below $25,000.
Mortality and Expense Risk Fee - The Company charges a fee assessed daily at a
rate of .20% annually in compensation for bearing certain mortality and expense
risks under the Contract.
The Separate Account - The Separate Account is a unit investment trust
registered with the Securities and Exchange Commission (the "SEC") under the
Investment Company Act of 1940 (the "1940 Act"). Such registration does not
signify that the SEC supervises the management or the investment practices or
policies of the Separate Account.
The Separate Account operates under New York law. The Company owns the assets of
the Separate Account, and the obligations under the Contract are obligations of
the Company. These assets are held separately from the other assets of the
Company. The Company will maintain in each Separate Account assets with a value
at least equal to the amounts accumulated in accordance with the applicable
agreements with respect to such Separate Account and the reserves for annuities
in the course of payment that vary with the investment experience of such
Separate Account.
The Company will always keep assets in the Separate Account with a value at
least equal to the total Accumulated Value under the Contracts. Any realized or
unrealized income, net gains and losses from the assets of the Separate Account
are credited to or charged against it without regard to the Company's other
income, gains or losses.
Assets are invested in the Separate Account for this Contract, as well as assets
for other variable annuity policies. The Company's liability under any Contract
guarantees is limited to the Contract Owner's interest in the assets allocated
to the Separate Account. The investment performance of the Separate Account is
entirely independent of the investment performance of the Company's general
account assets or any other Separate Account the Company maintains.
The Company will determine the value of the assets in the Separate Account at
the end of each Business Day. In order to determine the value of an asset on a
day that is not a Business Day, the Company will use the value of that asset as
of the end of the next Business Day on which trading takes place.
The Company will determine the value of the reserves for assets in the Separate
Account at the end of each Business Day. In order to determine the value of
reserves for assets on a day that is not a Business Day, the Company will use
the value of that asset as of the end of the prior Business Day on which trading
took place.
The Separate Account is divided into Subaccounts. Each Subaccount invests
exclusively in shares of one of the portfolios. The Separate Account meets the
definition of a "separate account" under rule 0-1(e)(1) of the 1940 Act.
We reserve the right, subject to regulations governing the Separate Account, to
transfer assets of a Subaccount, in excess of the reserves and other Contract
liabilities with respect to that Subaccount, to another Subaccount or to our
General Account.
The Company further reserves 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;
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3) restrict or eliminate any voting rights of Contract Owners or other persons
who have voting rights as to the Separate Account;
4) combine the Separate Account with one or more other Separate Accounts;
5) create new Separate Accounts;
6) add new Subaccounts to or remove existing Subaccounts from the Separate
Account, or combine Subaccounts; and
7) add new underlying mutual funds, remove existing mutual funds, or substitute
a new fund for an existing fund.
Subaccounts - Each Subaccount will invest only in a single Portfolio. The
minimum investment required for each Subaccount selected is $1,000.
Premium Allocation to the Subaccounts - The Owner may specify what portion of
any Premium Payments will be allocated among which Subaccounts. All allocations
must be in whole number percentages and a minimum of $1,000.
The Company will immediately invest any Initial Premium Payments in the
Accumulation Phase by purchasing Accumulation Units in the chosen Subaccounts on
the Business Day the Company receives the Premium Payment. The Owner may change
the premium allocation percentages at any time. Any change will take effect on
the Business Day the notice is received.
Accumulated Value - The Accumulated Value on any Business Day is equal to the
Initial Premium Payment plus any additional Premium Payments received; less
- applicable administration and Mortality and Expense Fees;
- the annual maintenance fee (for accounts valued under $25,000 only);
- any Partial Withdrawals;
- premium taxes, if applicable;
plus any increase or decrease in the value of the Subaccount(s). The Value of
the Subaccount(s) are based on the value of the Separate Account assets which
are not guaranteed as to fixed dollar amounts and will increase or decrease in
value based on investment results.
Transfers - The Owner can choose to transfer assets from one Subaccount to
another during the Accumulation Phase and the Income Phase. A Transfer in the
Accumulation Phase will result in the redemption of Accumulation Units from one
Subaccount and the purchase of Accumulation Units in another Subaccount. During
the Income Phase, Annuity Units are transferred among the Subaccounts and are
recalculated in the Subaccounts in which the Transfer occurred. Transfers will
be processed with the Accumulation and/or Annuity Unit Value as of the Business
Date the request is received.
1) A Transfer request must be in writing. If a Transfer request is received
prior to the close of the New York Stock Exchange (generally 4:00 p.m.
Eastern time), it will be processed at the close of business that day. Any
Transfer requests received after the close of the New York Stock Exchange
will be processed at the close of the next Business Day.
2) The minimum amount the Owner may Transfer from a Portfolio is $250. During
the Income Phase, there is no minimum amount.
3) The $1,000 minimum Subaccount balance requirement must be satisfied at all
times during the Accumulation Phase.
Automatic Asset Rebalancing - During the Accumulation Phase, the Owner can
automatically rebalance the amounts invested in the Subaccounts in order to
maintain a desired allocation. This rebalancing occurs automatically on a date
selected by the Owner and can take place on a monthly, quarterly, semi-annual or
annual basis. Rebalancing can be started, stopped or changed at any time
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Automatic Exchange Service - During the Accumulation Phase, the Owner may elect
to automatically Transfer a specified amount from one Subaccount to any other
Subaccounts. The automatic Transfers can occur on a monthly, quarterly,
semi-annual, or annual basis. Transfers will continue for the specified period
of time, or until the elected Subaccount is depleted.
Transfer Limitations - The Fund's Transfer privilege is not intended to afford a
means to speculate on short-term movements in the market. Because excessive
Transfers can disrupt the management of the Fund and can increase transaction
costs, Transfers are limited as follows:
1) The Company may limit substantive redemptions from a Portfolio followed by
a purchase back into the same Portfolio (not including the Money Market
Portfolio) to two during any 12-month period. This covers transactions
accomplished by any combination of methods, including transactions
conducted by check, wire, or Transfer to or from another Vanguard Fund.
"Substantive" means a dollar amount that the portfolio manager determines,
in its sole discretion, could adversely affect the management of the Fund.
2) The Company may refuse a Transfer request at any time, for any reason.
Partial Withdrawals - At any time after the Free Look Period and prior to the
Income Date, the Owner may make Partial Withdrawals from the Accumulated Value
of the Contract. Partial Withdrawals are subject to the following:
1) The minimum Partial Withdrawal amount is $250.
2) Partial Withdrawals will be deducted from the allocated Subaccounts on an
equal (pro rata) basis unless otherwise directed by the Owner.
3) If the Partial Withdrawal reduces the Accumulated Value in a particular
Subaccount to less than $1,000, the remaining balance will be transferred
to the other Subaccounts under the Contract on an equal (pro rata) basis.
If a Partial Withdrawal reduces the Accumulated Value of the Contract to
less than $1,000, the Company reserves the right to liquidate the Contract.
The Owner will be notified if the balance falls below $1,000 and will be
given 60 days in which to make an additional Premium Payment to increase
the Accumulated Value to at least $1,000.
4) Partial Withdrawals are not permitted after the Income Date.
Surrenders - At any time prior to the Income Date, the Owner may fully surrender
this Contract. Full surrender requests must be received in writing and will be
processed as of the Business Day the notice is received. The Owner will receive
the Accumulated Value of the Contract. After the Income Date, no full surrenders
are permitted.
IV. Annuity Payout Option Benefits
Choosing an Option - Before the Income Date, the Owner may choose or change any
Annuity Payment Option. However, if an election to receive payments under one of
the Annuity Payment Options is not made before the Income Date, the Company will
begin Annuity Payments to the Owner (or to the Annuitant, if the Owner is a
non-natural person) on the Income Date. In that case, the Annuity Payments will
be made with an Annuity Payment Option that provides a life annuity with Annuity
Payments guaranteed for 10 years.
If on the Income Date the Accumulated Value of the Contract is less than $2,000,
the Company has the right to pay that amount in a lump sum.
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Selecting or Changing the Income Date - The Income Date may be advanced or
deferred by the Owner. To advance or defer the Income Date, a request must be
made in writing to the Company before the current Income Date and may only be
made during the Annuitant's lifetime. The Owner may also elect an Annuity
Payment Option at that time. The Income Date may not be earlier than the first
day of the calendar month coinciding with or next following the first Contract
Anniversary.
In no event may the Owner defer the Income Date later than the first day of the
month following the Annuitant's 90th birthday, or 10 years from the Contract
Date, whichever is later.
Annuity Tables - The Annuity Tables (see Section VII) show the guaranteed
minimum monthly payment amounts for each $1,000 of Accumulated Value for a Fixed
Annuity Payment, based on a Guaranteed Interest Rate of 3.25%. Fixed Annuity
Payments are guaranteed to be no less than the amount provided in the Tables.
The Annuity Tables also show the amount of monthly payment for each $1,000 of
Accumulated Value for calculation of the first payment of a Variable Annuity
Payment, based on the AIR of 4%.
For life contingent payment options, the Company uses the Annuity 2000 Mortality
Table projected for mortality improvement using Projection Scale G (50% of the
female scale G factors were used, while 100% of the male scale factors were
used). The rates were projected dynamically with an assumed commencement date of
2005.
The Company may at the time of election of an Annuity Payment Option, offer more
favorable rates in lieu of the guaranteed rates shown in the Annuity Tables.
Fixed Annuity Payments at the time of their commencement will not be less than
those which would be provided by the application of the Accumulated Value to
purchase any single consideration immediate annuity contract (as described in
Section 4223 (a)(1)(E) of New York Insurance Law) offered by the Company at the
time to the same class of Annuitant.
Annuity Payment Options - The Owner may elect an option with an Annuity Payment
on a fixed or variable basis, or a combination of both at any time prior to the
Income Date. The Company will require proof of the Annuitant's age before any
payments are made and may also require proof that the Annuitant is living. After
an Annuity Payment Option is selected and Annuity Payments begin, it may not be
changed. Once an Annuity Payment Option is selected, the entire Accumulated
Value of the Contract must be allocated to the Income Phase.
1) Life Only Annuity - Annuity Payments are made to the designated Payee for
the life of the Annuitant, ceasing with the last payment due prior to the
Annuitant's death. There are no payments to a Beneficiary.
2) Life Annuity with 120, 180, 240, or 360 Monthly Payments Certain - Annuity
Payments are made to the designated Payee for the life of the Annuitant
with 120, 180, 240, or 360 months guaranteed. If the Annuitant should die
within the guaranteed period, the payments would continue for the remainder
of that period to the Beneficiary. If the Annuitant dies after the
guaranteed period, there are no payments to the Beneficiary.
3) Joint and 100% Last Survivor Xxxxxxx - Xxxxxxx Payments are made for the
life of two Annuitants and thereafter for the life of the survivor, ceasing
with the last payment due prior to the survivor's death. There are no
payments to a Beneficiary. This option is also available as a 50% or 75%
Last Survivor Annuity.
4) Period Certain Annuity - Available with a Fixed Annuity Payment only, this
option provides Annuity Payments that are made to the Payee for a
designated period, which may be from 10 to 30 years. Annuity Payments are
guaranteed for the Period Certain elected. If the Annuitant should die
within the guaranteed period, the payments would continue for the remainder
of that period to the Beneficiary. If the Annuitant dies after the
guaranteed period, there are no payments to the Beneficiary.
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Other Annuity Payment Options may be available upon request.
Adjusted Annuitant Age - Annuity Payments under Options 1, 2, and 3 are based on
the Adjusted Age of the Annuitant. The Adjusted Age is the Annuitant's actual
age on the Annuitant's nearest birthday, at the Income Date, adjusted as
follows:
Income 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 2040 Determined by the Company
Fixed Annuity Payment Option - This option provides a fixed payment that does
not change over the time period selected. Once this option is selected, the
Accumulated Value of the Contract is transferred from the Separate Account to
the Company's General Account to fund all future payments. No further Transfers
are possible.
Determination of a Fixed Payment - The amount of the Fixed Annuity Payment will
depend on the Accumulated Value of the Contract and the Annuity Payment Option
selected. If a life income option is selected, the amount will also depend on
the age and gender of the Annuitant and the Joint Annuitant, if applicable.
The amounts shown on the Annuity Tables (in Section VII) represent only the
guaranteed minimum for each Annuity Payment, based on an interest rate of 3.25%.
The minimum payment amount is $100. The number of payments per year may be
adjusted to maintain this minimum amount.
Variable Annuity Payment Option - This option provides a variable payment that
fluctuates with the investment performance of the Subaccounts chosen by the
Owner over the period selected.
Determination of the First Variable Payment - The Annuity Tables for this option
illustrate the minimum amount of a monthly Annuity Payment for each $1,000 of
Accumulated Value. The Tables are based on the AIR of 4%.
If the investment performance of the selected Subaccounts exceeds 4.40% (on an
annualized basis) in any period, the Annuity Payment amount will increase.
Conversely, in any period investment performance falls below 4.40%, the Annuity
Payment amount will decrease.
The first Variable Annuity Payment is based on the Accumulated Value of the
Contract on the Income Date. The minimum payment amount is $100. The number of
payments per year may be adjusted to maintain this minimum amount.
Determination of Subsequent Variable Payments - The amount of each subsequent
Annuity Payment is determined by means of Annuity Units. The number of Annuity
Units is determined by dividing the first Annuity Payment by the Annuity Unit
value for the selected Subaccount(s) on the Income Date.
The dollar amount for each subsequent payment is equal to the number of Annuity
Units multiplied by the current Annuity Unit Value for the Subaccount(s). The
Annuity Payment amount changes as the Annuity Unit Values change according to
the investment performance of the underlying Subaccounts. If a Transfer is made,
the Annuity Units are recalculated.
Once Annuity Payments begin, neither expenses actually incurred other than taxes
on the investment return, nor mortality actually experienced by the Company,
shall adversely affect the dollar amount of Variable Annuity Payments to any
Annuitant for whom such payments have commenced.
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V. Death Benefit and Options
The Death Benefit - The Death Benefit is the Accumulated Value of the Contract
and only becomes payable to the Primary Annuitant's Beneficiary (Beneficiary)
upon the death of the Annuitant and the Joint Annuitant, if applicable. The
Death Benefit will be calculated on the date the following are received by the
Company:
1) Proof of Death acceptable to the Company; and
2) all Company claim forms, fully completed by the Beneficiary(ies).
Proof of Death acceptable to the Company may be:
1) a certified copy of the death certificate;
2) a certified decree of a court of competent jurisdiction as to the finding
of death;
3) a written statement by a medical doctor who attended the deceased;
4) any other proof satisfactory to the Company.
Beneficiary - Unless the Owner has made other provisions, multiple Beneficiaries
will share equally in the Contract. If one of two or more Beneficiaries
predeceases the others, that share of the Contract will be paid equally to the
survivor(s).
If the Beneficiary dies at the same time as the Owner and/or the Annuitant, it
will be treated as the Beneficiary died first, and the Accumulated Value will
become payable to the estate of the deceased. If a Beneficiary dies within 15
days after the Owner and/or Xxxxxxxxx's death and before the Company receives
due proof of the death, it will be treated as the Beneficiary died first and the
Death Benefit will become payable to the estate of the deceased.
If a Secondary Annuitant's Beneficiary is named, he or she will become the
Primary Annuitant's Beneficiary if the Primary Annuitant's Beneficiary
predeceases the Annuitant.
The Accumulated Xxxxx becomes payable contingent upon the relationships between
the Owner, Annuitant, Beneficiary, and Owner's Designated Beneficiary. After the
Company receives Proof of Death of the Annuitant and/or Owner prior to the
Income Date along with the completed Company forms, the Accumulated Value will
be payable as outlined below:
Death prior to Income Date (in the Accumulation Phase)
1. Owner and Annuitant are the same
If the Beneficiary is the surviving spouse, he or she may receive the Death
Benefit; elect any available Annuity Payment Option; or continue the
Contract at the Accumulated Value as the new Owner and Annuitant and name a
new Beneficiary.
If the Beneficiary is not a spouse, he or she may receive the Death
Benefit; elect an Annuity Payment Option with a life option, or over a
Period Certain no longer than his or her life expectancy with payments
starting within one year of the date of death; or continue the Contract
at the Accumulated Value as the new Owner provided that the entire
Contract is distributed within five years of the date of death.
2. Owner and Annuitant are different and the Owner dies
When either the Owner or the Joint Owner (if applicable) of the Contract
dies during the Accumulation Phase, the Contract must be distributed within
five years of the date of death (pursuant to Internal Revenue Code Section
72(s)). There are two exceptions to this rule:
If the Owner's Designated Beneficiary or Joint Owner is the spouse of the
deceased Owner, he or she may elect to continue the Contract as the new
Owner at the Accumulated Value in lieu of receiving the
13
Accumulated Value in a lump sum payment. The new Owner may then continue
the Contract and name a new Beneficiary.
If the entire Accumulated Value of the Contract is to be distributed to the
Joint Owner or the Owner's Designated Beneficiary, he or she may elect to
have it paid under an Annuity Payment Option over his or her life or over a
Period Certain no longer than his or her life expectancy as long as the
payments start within one year of the date of death.
If there is no Joint Owner or Owner's Designated Beneficiary, the deceased
Owner's estate will become the new Owner and may elect to receive the
Accumulated Value of the Contract.
3. Owner and Annuitant are different and the Annuitant dies
The Beneficiary may receive the Death Benefit; elect an Annuity Payment
Option with a life option, or elect a Period Certain option no longer than
his or her life expectancy as long as payments start within one year of
the date of death, as long as the option is selected within 60 days of the
date of death.
If the Beneficiary is also the Owner of the Contract, and the spouse of the
deceased, he or she may continue the Contract as Owner and Annuitant and
name a new Beneficiary.
If the Owner of the Contract is a non-natural person, then the death of the
Annuitant will be treated as the death of the Owner.
Death on or after the Income Date (in the Income Phase)
Death options on or after the Income Date depend on the Annuity Payment Option
selected.
1. If the Owner dies
If any Owner dies before the entire interest in the Contract is
distributed, the remaining portion will be distributed at least as rapidly
as under the method of distribution then in effect. The Joint Owner or
Owner's Designated Beneficiary would have the option of changing the Payee.
2. If the Annuitant Dies
If the Annuitant dies on or after the Income Date, and before the end of
any guaranteed period, the remaining portion of the Contract will be
distributed at least as rapidly as under the method of distribution then
in effect to the Beneficiary. If the Annuitant dies after the end of any
guaranteed period, there are no payments to the Beneficiary.
VI - General Contract Provisions
The Contract - This Contract, the application, and any endorsements or riders
attached to the Contract constitute the entire Contract. No insertion in or
other alteration of any written application can be made by any person other than
the Owner without his or her written consent, except that insertions may be made
by the Company for administrative purposes only in such manner as to clearly
indicate that the insertions are not to be ascribed to the Owner. All statements
in the application are representations and not warranties. Nothing is
incorporated by reference, unless a copy is endorsed upon or attached to the
Contract.
No change in this Contract nor any waiver of rights or requirements is valid
unless approved by an executive officer of the Company and evidenced by
endorsement hereon, or by amendment hereto signed by such an officer.
Ownership of Contract - The Owner is the person who has the legal authority to
exercise the rights within this Contract. A Joint Owner, if named, will be
treated as having equal, undivided interests in the Contract. Joint Owners may
not exercise ownership rights in the Contract independently of each other. The
Company reserves the right to require a written request signed by both Owners
for certain transactions. Any request is subject to any action taken by the
Company prior to receipt of the notice.
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Beneficiary Change - The Beneficiary(ies) may be changed by the Owner by written
notice only. The Beneficiary(ies) may be made irrevocable by a written notice
filed with and acknowledged by the Company. An irrevocable Beneficiary may only
be changed with written consent of such Beneficiary. Beneficiary changes will
take effect on the date the notice is signed, subject to receipt by the Company.
Deferment of Payment - If a lump sum or cash withdrawal is to be paid from the
Separate Account, payment will be made within seven days from the date the
election becomes effective. The Company may defer cases where the New York Stock
Exchange is closed or the SEC has restricted trading, or when the SEC allows the
Company to defer payments in order to protect its Contract Owners.
Non-Participating - This Contract does not pay dividends. It will not share in
any Company profits or surplus earnings.
Assignments - The Company is not responsible for the validity of any assignment.
No assignment will be recognized until the Company receives written notice from
the Owner. The interest of any Beneficiary which the assignor has the right to
change shall be subordinate to the interest of an assignee.
Any amount paid to the assignee shall be paid in one lump sum, notwithstanding
any settlement agreement in effect at the time assignment was executed. The
Company shall not be liable as to any payment or other settlement made by it
before receipt of written notice.
Incontestability - This Contract is incontestable from the Contract Date, except
in cases where the Annuitant's age or gender has been misstated.
Quarterly Statements - The Owner will receive a statement at least once per
calendar quarter. The statements will show the Accumulated Value of the
Subaccount(s), as well as any subsequent Premium Payments, Partial Withdrawals,
charges or Transfers made during that quarter. The statement may also contain
information as required by law or regulation. Contracts in the Income Phase will
receive a confirmation of each Annuity Payment.
Misstatement of Age or Gender - If the Annuitant's age or gender has been
misstated, Annuity Income Payments will be adjusted to the amount which would
have been provided for the correct age or gender. If Annuity Payments have
already commenced and the misstatement has caused an underpayment, the full
amount due plus interest, will be paid with the next scheduled payment. If the
misstatement has caused an overpayment, the amount due plus interest, will be
deducted from one or more future payments until the amount is paid in full. Such
underpayment or overpayment shall bear interest at 5% per year, from the date of
the wrong payment to the date of the adjustment.
Contract Amendment - The Company may amend this Contract at any time by
notifying the Owner in writing. These changes may be made without the approval
of the Annuitant or Beneficiary, as long as the change does not result in a
claim or benefit being reduced or denied to the Annuitant or Beneficiary as of
the date of the change. Such amendment shall be subject to applicable notice and
approval requirements of The New York State Insurance Department.
VII - Annuity Tables
Table 1 - This table provides the guaranteed minimum monthly payment amounts for
each $1,000 of Accumulated Value for Fixed Annuity Payments, based on a
guaranteed interest rate of 3.25%. The options shown here are Life Only Annuity,
Life Annuity with 120 Monthly Payments Certain, and Life Annuity with 240
Monthly Payments Certain. Other ages and options such as 60, 180, or 360 months
are also available.
15
Table Monthly Installment Monthly Installment Monthly Installment
1 for Life Only for Life with for Life with
No Period Certain 10 Years Period Certain 20 Years Period Certain
Adjusted Male Female Unisex Male Female Unisex Male Female Unisex
Age
50 $3.97 $3.85 $3.89 $3.95 $3.83 $3.87 $3.87 $3.79 $3.82
51 $4.04 $3.90 $3.94 $4.01 $3.89 $3.92 $3.93 $3.84 $3.86
52 $4.10 $3.96 $4.00 $4.07 $3.94 $3.98 $3.98 $3.89 $3.91
53 $4.17 $4.02 $4.07 $4.14 $4.00 $4.04 $4.03 $3.94 $3.97
54 $4.25 $4.09 $4.13 $4.21 $4.07 $4.11 $4.09 $3.99 $4.02
55 $4.32 $4.16 $4.21 $4.28 $4.13 $4.18 $4.15 $4.05 $4.08
56 $4.41 $4.23 $4.28 $4.36 $4.20 $4.25 $4.21 $4.11 $4.14
57 $4.49 $4.30 $4.36 $4.44 $4.27 $4.32 $4.27 $4.17 $4.20
58 $4.59 $4.39 $4.45 $4.52 $4.35 $4.40 $4.33 $4.23 $4.26
59 $4.68 $4.47 $4.54 $4.62 $4.43 $4.49 $4.40 $4.29 $4.33
60 $4.79 $4.57 $4.63 $4.71 $4.52 $4.58 $4.46 $4.36 $4.39
61 $4.90 $4.66 $4.74 $4.81 $4.61 $4.67 $4.53 $4.43 $4.46
62 $5.03 $4.77 $4.84 $4.92 $4.71 $4.77 $4.60 $4.50 $4.53
63 $5.16 $4.88 $4.96 $5.04 $4.81 $4.88 $4.67 $4.57 $4.60
64 $5.29 $5.00 $5.09 $5.15 $4.92 $4.99 $4.74 $4.64 $4.67
65 $5.44 $5.13 $5.22 $5.28 $5.03 $5.11 $4.81 $4.72 $4.75
66 $5.60 $5.26 $5.36 $5.41 $5.15 $5.23 $4.88 $4.79 $4.82
67 $5.77 $5.41 $5.52 $5.55 $5.28 $5.36 $4.94 $4.87 $4.89
68 $5.95 $5.57 $5.68 $5.69 $5.42 $5.50 $5.01 $4.94 $4.96
69 $6.15 $5.74 $5.86 $5.84 $5.56 $5.65 $5.07 $5.01 $5.03
70 $6.35 $5.92 $6.05 $5.99 $5.71 $5.80 $5.13 $5.08 $5.10
71 $6.57 $6.12 $6.25 $6.15 $5.87 $5.96 $5.19 $5.14 $5.16
72 $6.81 $6.33 $6.47 $6.32 $6.04 $6.12 $5.25 $5.21 $5.22
73 $7.06 $6.56 $6.71 $6.49 $6.21 $6.30 $5.30 $5.27 $5.27
74 $7.33 $6.81 $6.96 $6.66 $6.40 $6.48 $5.34 $5.32 $5.33
75 $7.61 $7.08 $7.24 $6.84 $6.58 $6.66 $5.39 $5.37 $5.37
76 $7.92 $7.38 $7.54 $7.01 $6.78 $6.85 $5.43 $5.41 $5.42
77 $8.25 $7.69 $7.86 $7.20 $6.98 $7.04 $5.46 $5.45 $5.45
78 $8.60 $8.03 $8.20 $7.38 $7.18 $7.24 $5.49 $5.48 $5.49
79 $8.98 $8.41 $8.58 $7.56 $7.38 $7.44 $5.52 $5.51 $5.51
80 $9.38 $8.81 $8.98 $7.74 $7.59 $7.63 $5.54 $5.54 $5.54
81 $9.82 $9.25 $9.42 $7.92 $7.79 $7.83 $5.56 $5.56 $5.56
82 $10.28 $9.72 $9.89 $8.09 $7.98 $8.01 $5.58 $5.58 $5.58
83 $10.78 $10.24 $10.40 $8.26 $8.17 $8.20 $5.59 $5.59 $5.59
84 $11.31 $10.80 $10.95 $8.41 $8.35 $8.37 $5.60 $5.60 $5.60
85 $11.87 $11.40 $11.54 $8.56 $8.52 $8.53 $5.61 $5.61 $5.61
86 $12.48 $12.05 $12.17 $8.70 $8.67 $8.68 $5.62 $5.62 $5.62
87 $13.13 $12.74 $12.86 $8.84 $8.82 $8.82 $5.62 $5.62 $5.62
88 $13.82 $13.48 $13.58 $8.96 $8.95 $8.95 $5.63 $5.63 $5.63
89 $14.55 $14.27 $14.35 $9.07 $9.06 $9.06 $5.63 $5.63 $5.63
90 $15.32 $15.10 $15.16 $9.17 $9.17 $9.17 $5.63 $5.63 $5.63
91 $16.14 $15.96 $16.01 $9.26 $9.26 $9.26 $5.63 $5.63 $5.63
92 $17.00 $16.86 $16.90 $9.35 $9.34 $9.34 $5.63 $5.63 $5.63
93 $17.91 $17.79 $17.83 $9.42 $9.42 $9.42 $5.63 $5.63 $5.63
94 $18.89 $18.77 $18.80 $9.49 $9.48 $9.48 $5.63 $5.63 $5.63
95 $19.93 $19.79 $19.83 $9.54 $9.54 $9.54 $5.63 $5.63 $5.63
Table 2 - This table provides the guaranteed minimum monthly payment amounts for
each $1,000 of Accumulated Value for Fixed Annuity Payments based on a
guaranteed interest rate of 3.25%. The option shown here is Joint and 100% Last
Survivor Annuity. This option is also available as a 50% or 75% Last Survivor
Annuity. Other ages are available upon request.
16
Table Monthly Installment for Joint and 100% Last Survivor
2 Adjusted Age of Female
Adjusted 15 Years 12 Years 9 Years 6 Years 3 Years Same Age 3 Years
Age of Less Than Less Than Less Than Less Than Less Than As More Than
Male Male Male Male Male Male Male Male
50 $3.22 $3.28 $3.34 $3.40 $3.46 $3.52 $3.58
55 $3.35 $3.42 $3.50 $3.58 $3.67 $3.75 $3.83
60 $3.52 $3.61 $3.72 $3.82 $3.94 $4.05 $4.16
65 $3.74 $3.86 $4.00 $4.15 $4.30 $4.46 $4.61
70 $4.03 $4.20 $4.39 $4.59 $4.80 $5.03 $5.25
Table 3 - This table provides the first monthly payment amounts for each $1,000
of Accumulated Value for the calculation of a Variable Annuity Payment, based on
the AIR of 4%. The options shown here are Life Only Annuity, Life Annuity with
120 Months Period Certain, and Life Annuity with 240 Months Period Certain.
Other ages and options such as 60, 180, or 360 months are available upon
request.
Table Monthly Installment Monthly Installment Monthly Installment
3 for Life Only for Life with for Life with
No Period Certain 10 Years Period Certain 20 Years Period Certain
Adjusted Male Female Unisex Male Female Unisex Male Female Unisex
Age
50 $4.43 $4.30 $4.34 $4.41 $4.29 $4.32 $4.32 $4.24 $4.26
51 $4.50 $4.36 $4.40 $4.46 $4.34 $4.38 $4.37 $4.28 $4.31
52 $4.56 $4.41 $4.46 $4.52 $4.39 $4.43 $4.42 $4.33 $4.36
53 $4.63 $4.47 $4.52 $4.59 $4.45 $4.49 $4.47 $4.38 $4.41
54 $4.70 $4.53 $4.58 $4.65 $4.51 $4.55 $4.53 $4.43 $4.46
55 $4.78 $4.60 $4.65 $4.73 $4.57 $4.62 $4.58 $4.48 $4.51
56 $4.86 $4.67 $4.73 $4.80 $4.64 $4.69 $4.64 $4.54 $4.57
57 $4.94 $4.75 $4.81 $4.88 $4.71 $4.76 $4.70 $4.60 $4.63
58 $5.04 $4.83 $4.89 $4.97 $4.79 $4.84 $4.76 $4.66 $4.69
59 $5.13 $4.91 $4.98 $5.06 $4.87 $4.92 $4.82 $4.72 $4.75
60 $5.24 $5.00 $5.07 $5.15 $4.95 $5.01 $4.89 $4.78 $4.81
61 $5.35 $5.10 $5.18 $5.25 $5.04 $5.10 $4.95 $4.85 $4.88
62 $5.47 $5.20 $5.28 $5.36 $5.13 $5.20 $5.02 $4.92 $4.95
63 $5.60 $5.32 $5.40 $5.47 $5.23 $5.30 $5.08 $4.98 $5.01
64 $5.74 $5.43 $5.52 $5.58 $5.34 $5.41 $5.15 $5.05 $5.08
65 $5.89 $5.56 $5.66 $5.71 $5.45 $5.53 $5.21 $5.12 $5.15
66 $6.05 $5.70 $5.80 $5.84 $5.57 $5.65 $5.28 $5.19 $5.22
67 $6.22 $5.84 $5.95 $5.97 $5.70 $5.78 $5.34 $5.27 $5.29
68 $6.40 $6.00 $6.12 $6.11 $5.83 $5.92 $5.41 $5.34 $5.36
69 $6.60 $6.17 $6.29 $6.26 $5.97 $6.06 $5.47 $5.40 $5.42
70 $6.80 $6.35 $6.48 $6.41 $6.12 $6.21 $5.52 $5.47 $5.49
71 $7.02 $6.55 $6.69 $6.57 $6.28 $6.37 $5.58 $5.53 $5.55
72 $7.26 $6.76 $6.91 $6.73 $6.45 $6.53 $5.63 $5.59 $5.61
73 $7.51 $6.99 $7.15 $6.89 $6.62 $6.70 $5.68 $5.65 $5.66
74 $7.78 $7.25 $7.40 $7.06 $6.80 $6.88 $5.73 $5.70 $5.71
75 $8.07 $7.52 $7.68 $7.24 $6.98 $7.06 $5.77 $5.75 $5.75
76 $8.38 $7.81 $7.98 $7.41 $7.17 $7.25 $5.80 $5.79 $5.79
77 $8.71 $8.13 $8.30 $7.59 $7.37 $7.44 $5.84 $5.83 $5.83
78 $9.06 $8.47 $8.65 $7.77 $7.57 $7.63 $5.87 $5.86 $5.86
79 $9.44 $8.85 $9.02 $7.95 $7.77 $7.82 $5.89 $5.89 $5.89
80 $9.85 $9.25 $9.43 $8.12 $7.97 $8.01 $5.91 $5.91 $5.91
81 $10.28 $9.70 $9.87 $8.29 $8.16 $8.20 $5.93 $5.93 $5.93
82 $10.75 $10.17 $10.34 $8.46 $8.35 $8.39 $5.95 $5.95 $5.95
83 $11.25 $10.69 $10.86 $8.62 $8.54 $8.57 $5.96 $5.96 $5.96
84 $11.78 $11.25 $11.41 $8.78 $8.71 $8.73 $5.97 $5.97 $5.97
85 $12.35 $11.86 $12.00 $8.92 $8.88 $8.89 $5.98 $5.98 $5.98
86 $12.96 $12.51 $12.64 $9.06 $9.03 $9.04 $5.99 $5.99 $5.99
87 $13.61 $13.21 $13.33 $9.19 $9.17 $9.18 $5.99 $5.99 $5.99
17
88 $14.30 $13.96 $14.06 $9.31 $9.30 $9.30 $6.00 $6.00 $6.00
89 $15.04 $14.75 $14.84 $9.42 $9.41 $9.41 $6.00 $6.00 $6.00
90 $15.81 $15.58 $15.65 $9.52 $9.51 $9.51 $6.00 $6.00 $6.00
91 $16.63 $16.45 $16.50 $9.61 $9.60 $9.60 $6.00 $6.00 $6.00
92 $17.50 $17.35 $17.40 $9.69 $9.69 $9.69 $6.00 $6.00 $6.00
93 $18.41 $18.29 $18.33 $9.76 $9.76 $9.76 $6.00 $6.00 $6.00
94 $19.39 $19.26 $19.30 $9.82 $9.82 $9.82 $6.00 $6.00 $6.00
95 $20.43 $20.28 $20.33 $9.88 $9.88 $9.88 $6.00 $6.00 $6.00
Table 4 - This table provides the first monthly payment amounts for each $1,000
of Accumulated Value for the calculation of a Variable Annuity Payment, based on
the AIR of 4%. The option shown here is Joint and 100% Last Survivor Annuity.
This option is also available as a 50% or 75% Last Survivor Annuity. Other ages
are available upon request.
Table Monthly Installment for Joint and 100% Last Survivor
4 Adjusted Age of Female
Adjusted 15 Years 12 Years 9 Years 6 Years 3 Years Same Age 3 Years
Age of Less Than Less Than Less Than Less Than Less Than As More Than
Male Male Male Male Male Male Male Male
50 $3.70 $3.75 $3.81 $3.86 $3.92 $3.98 $4.04
55 $3.82 $3.89 $3.96 $4.04 $4.11 $4.19 $4.27
60 $3.98 $4.07 $4.16 $4.27 $4.37 $4.48 $4.59
65 $4.19 $4.31 $4.44 $4.58 $4.73 $4.88 $5.03
70 $4.46 $4.63 $4.81 $5.01 $5.22 $5.44 $5.66
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AUSA Life Insurance Company, Inc.
Home Office: 0 Xxxxxxxxxxxxxx Xxxx, Xxxxxxxx, XX 00000
FLEXIBLE PREMIUM VARIABLE ANNUITY
NON-PARTICIPATING
19
