EXHIBIT 4(c)
------GOLDEN
---------AMERICAN DEFERRED VARIABLE
-----------LIFE INSURANCE ANNUITY CONTRACT
-------COMPANY
Golden American is a stock company domiciled in Delaware.
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|-------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|-------------------------------------------------------------------------|
| Initial Premium Annuity Option |
|Annuity Commencement Date |
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]|
|-------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|-------------------------------------------------------------------------|
This is a legal Contract between its Owner and us. Please read it
carefully. In this contract you or your refers to the Owner shown
above. We, our or us refers to Golden American Life Insurance Company.
You may allocate this Contract's Accumulation Value among the Divisions
of the Variable Separate Account and the General Account shown in the
Schedule.
If this Contract is in force, we will make income payments to you
starting on the Annuity Commencement Date. If the Owner dies prior to
the Annuity Commencement Date, we will pay a death benefit to the
Beneficiary. The amount of such benefits is subject to the terms of
this Contract.
ALL PAYMENTS AND VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A
VARIABLE SEPARATE ACCOUNT, MAY INCREASE OR DECREASE, DEPENDING ON THE
CONTRACT'S INVESTMENT RESULTS.
RIGHT TO EXAMINE THIS CONTRACT: YOU MAY RETURN THIS CONTRACT TO US OR
THE AGENT THROUGH WHOM YOU PURCHASED IT WITHIN 10 DAYS AFTER YOU
RECEIVE IT. IF SO RETURNED, WE WILL TREAT THE CONTRACT AS THOUGH IT
WERE NEVER ISSUED. UPON RECEIPT WE WILL PROMPTLY REFUND THE
ACCUMULATION VALUE PLUS ANY CHARGES WE HAVE DEDUCTED AS OF THE DATE THE
RETURNED CONTRACT IS RECEIVED BY US.
Customer Service Center Secretary: /s/ Xxxxx X. Xxxxxxx
0000 Xxxxxxxx Xxxxx
Xxxx Xxxxxxx, XX 00000 President: /s/ Xxxxxxx Xxxxxxx
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DEFERRED VARIABLE ANNUITY CONTRACT - NO DIVIDENDS
Variable Cash Surrender Values while the Annuitant and Owner are
living and prior to the Annuity Commencement Date. Death benefit
subject to guaranteed minimum. Additional Premium Payment Option.
Partial Withdrawal Option. Non-participating. Investment results
reflected in values.
GA-IA-1059
CONTRACT CONTENTS
THE SCHEDULE YOUR CONTRACT BENEFITS...........14
Payment and Investment Information..... 3A Cash Value Benefit
The Variable Separate Accounts......... 3B Partial Withdrawal Option
The General Account.................... 3C Proceeds Payable to the
Beneficiary
Contract Facts......................... 3D
Charges and Fees....................... 3E
Income Plan Factors.................... 3F CHOOSING AN INCOME PLAN..........16
IMPORTANT TERMS ........................ 4
INTRODUCTION TO THIS CONTRACT........... 6 Annuity Benefits
Annuity Commencement Date Selection
The Contract Frequency Selection
The Owner The Income Plan
The Annuitant The Annuity Options
The Beneficiary Payment When Named Person
Dies
Change of Owner or Beneficiary
OTHER IMPORTANT INFORMATION......18
PREMIUM PAYMENTS AND ALLOCATION CHANGES. 8
Sending Notice to Us
Initial Premium Payment Reports to Owner
Additional Premium Payment Option Assignment - Using this Contract as
Your Right to Change Allocation of Collateral Security
Accumulation Value Changing this Contract
What Happens if a Variable Separate Account Contract Changes-Applicable Tax Law
Division is Not Available Misstatement of Age or Sex
Non-Participating
HOW WE MEASURE THE CONTRACT'S Payments We May Defer
ACCUMULATION VALUE..................... 9 Authority to Make Agreements
Required Note on Our Computations
The Variable Separate Accounts
The General Account
Valuation Period
Accumulation Value
Accumulation Value in each Division
Measurement of Investment Experience
Charges Deducted from Accumulation Value on
each Contract Processing Date
Copies of any additional Riders and Endorsements are at the back of
this Contract.
THE SCHEDULE
The Schedule gives specific facts about this Contract and its
coverage. Please refer to the Schedule while reading this Contract.
GA-IA-1059 2
THE SCHEDULE
PAYMENT AND INVESTMENT INFORMATION
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|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Annuitant's Issue Age Annuitant's Sex Owner's Issue Age |
| [55] [MALE] [35] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Contract Date Issue Date Residence Status |
| [JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
INITIAL INVESTMENT
Initial Premium Payment received: [$10,000]
Your initial Accumulation Value has been invested as follows:
Percentage of
Divisions Accumulation Value
--------- ------------------
[Multiple Allocation 10%
Fully Managed 10%
Capital Appreciation 10%
Rising Dividends 10%
All-Growth 10%
Real Estate 10%
Value Equity 10%
Hard Assets 5%
Emerging Markets 5%
Managed Global 5%
Limited Maturity 5%
Bond 5%
Liquid Asset 5%
Strategic Equity
-------------------- -------------------
Total 100%]
ADDITIONAL PREMIUM PAYMENT INFORMATION
[We will accept additional premium payments until either the
Annuitant or Owner reaches the Attained Age of 85. The minimum
additional payment which may be made is [$500.00].]
[In no event may you contribute to your XXX for the taxable year in
which you attain age 70 1/2 and thereafter (except for rollover
contributions). The minimum additional payment which may be added
is [$250.00].]
GA-IA-1059 3A1
THE SCHEDULE
PAYMENT AND INVESTMENT INFORMATION(continued)
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|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Annuitant's Issue Age Annuitant's Sex Owner's Issue Age |
| [55] [MALE] [35] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Contract Date Issue Date Residence Status |
| [JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
ACCUMULATION VALUE ALLOCATION RULES
The maximum number of Divisions in which you may be invested at any
one time is [sixteen]. You are allowed unlimited allocation changes
per Contract Year without charge. We reserve the right to impose a
charge for any allocation change in excess of [twelve] per Contract
Year. The Excess Allocation Charge is shown in the Schedule.
Allocations into and out of the Guaranteed Interest Divisions are
subject to restrictions (see General Account).
ALLOCATION CHANGES BY TELEPHONE
You may request allocation changes by telephone during our
telephone request business hours. You may call our Customer
Service Center at 1-800-366-0066 to make allocation changes by
using the personal identification number you will receive. You
may also mail any notice or request for allocation changes to our
Customer Service Center at the address shown on the cover page.
GA-IA-1059 3A2
THE SCHEDULE
THE VARIABLE SEPARATE ACCOUNTS
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|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND
Separate Account B (the "Account") is a unit investment trust
Separate Account, organized in and governed by the laws of the State
of Delaware, our state of domicile. The Account is divided into
Divisions. Each Division listed below invests in shares of the
mutual fund portfolio (the "Series") designated. Each portfolio is
a part of The GCG Trust managed by Directed Services, Inc.
SERIES SERIES
[Multiple Allocation Real Estate
Fully Managed Hard Assets
Value Equity Emerging Markets
Small Cap Limited Maturity Bond
Capital Appreciation Liquid Assets
Rising Dividend Strategic Equity
Capital Growth Managed Global
Developing World Global Fixed Income
Large Cap Value Total Return
Growth All-Cap
Mid-Cap Growth Investors
Research Equity Income]
GA-IA-1059 3B
THE SCHEDULE
THE GENERAL ACCOUNT
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|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
GENERAL ACCOUNT
[Guaranteed Interest Division
A Guaranteed Interest Division provides an annual minimum interest
rate of 3%. At our sole discretion, we may periodically declare
higher interest rates for specific Guarantee Periods. Such rates
will apply to periods following the date of declaration. Any
declaration will be by class and will be based on our future
expectations.
Limitations of Allocations
We reserve the right to restrict allocations into and out of the
General Account. Such limits may be dollar restrictions on
allocations into the General Account or we may restrict
reallocations into the General Account.
Guarantee Periods
Each allocation to a Guaranteed Interest Division will be
guaranteed an interest rate for the entire Initial Guarantee Period
elected. We currently offer Initial Guarantee Periods of one, two,
three, five, seven and ten years. The Initial Guarantee Period
starts on the day an allocation is made to a Guaranteed Interest
Division and ends on the last day of the calendar month following
one, two, three, five, seven or ten year(s) as appropriate, the
Maturity Date.
At the end of a Guarantee Period, you may transfer the Accumulation
Value in such Guarantee Period to the Variable Separate Account
Divisions or to a Guarantee Period we then offer. If we do not
receive notification by the Maturity Date, your Accumulation Value
in the maturing Guarantee Period will automatically be transferred
to a one-year Guarantee Period. Upon such automatic transfer you
will have thirty days to reallocate any of your Accumulation Value
to the Divisions.
Deduction for Charges
We do not deduct the Mortality and Expense Risk Charge and the
Asset-Based Administrative Charge with respect to the amount of the
Accumulation Value allocated to a Guaranteed Interest Division
while such Accumulation Value remains allocated to a Guaranteed
Interest Division.
Transfers from a Guaranteed Interest Division
On a Maturity Date, 100% of the Accumulation Value in the maturing
Guarantee Period may be transferred.
We currently require that an amount allocated to a Guarantee Period
not be transferred until the Maturity Date, except pursuant to our
published rules. We reserve the right not to allow amounts
previously transferred from a Guaranteed Interest Division to the
Variable Separate Account Divisions to be transferred back to the
Guaranteed Interest Division for a period of at least six months
from the date of transfer. We reserve the right to reduce the
amount otherwise available for transfer from a Guaranteed Interest
Division by any amounts previously withdrawn from that Guaranteed
Interest Division.]
GA-IA-1059 3C
THE SCHEDULE
CONTRACT FACTS
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|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
CONTRACT FACTS
Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each
year.
Specially Designated Divisions
When a distribution is made from an investment portfolio underlying
a Separate Account Division in which reinvestment is not available,
we will allocate the amount of the distribution to the [Liquid Asset
Division] unless you specify otherwise.
PARTIAL WITHDRAWALS
The maximum amount that can be withdrawn each Contract Year is
described below. In no event may a Partial Withdrawal exceed 90% of
the Cash Surrender Value. After a Partial Withdrawal, the remaining
Accumulation Value must be at least $100 to keep the Contract in
force.
Conventional Partial Withdrawals
Minimum Withdrawal Amount: $100.
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be taken on a monthly, quarterly or
annual basis. You select the day withdrawals will be made, but no
later than the 28th day of the month.
Minimum Withdrawal Amount: $100.
Maximum Withdrawal Amount:
Variable Separate Account Divisions: 1.25% monthly, 3.75%
quarterly or 15% annually of
Accumulation Value.
Guaranteed Interest Divisions: Interest earned on a Guaranteed
Interest Division for the prior month,
quarter or year (depending on the
frequency selected).
[XXX Partial Withdrawals for Qualified Plans Only
XXX Partial Withdrawals may be taken on a monthly, quarterly or
annual basis. A minimum withdrawal of $100.00 is required. You
select the day the withdrawals will be made, but no later than the
28th day of the month. If you do not elect a day, the Contract
Date will be used. Systematic Partial Withdrawals and Conventional
Partial Withdrawals are not allowed when XXX Partial Withdrawals
are being taken.]
GA-IA-1059 3D1
THE SCHEDULE
CONTRACT FACTS (continued)
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|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
DEATH BENEFITS
The Death Benefit is the greatest of (i) , (ii) ,and (iii), below,
where:
(i) the Accumulation Value;
(ii) the Guaranteed Death Benefit;
(iii) the Cash Surrender Value;
GUARANTEED DEATH BENEFIT
On the Contract Date, the Guaranteed Death Benefit is the initial
premium. On subsequent Valuation Dates, the guaranteed Death
Benefit is calculated as follows:
(1) Start with the Guaranteed Death Benefit from the prior
Valuation Date;
(2) Add any additional premiums paid during the current Valuation
Period to (1);
(3) Subtract any Prorata Partial Withdrawal Adjustments for any
Partial Withdrawal made during the current Valuation Period from (2).
PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS
For any partial withdrawal, the Death Benefit components will be
reduced by Prorata Partial Withdrawal Adjustments. The Prorata
Partial Withdrawal Adjustment to a death benefit component for a
partial withdrawal is equal to (1) divided by (2), multiplied by
(3), where: (1) is the Accumulation Value withdrawn, (2) is the
Accumulation Value immediately prior to withdrawal, and (3) is the
amount of the applicable death benefit component immediately prior
to the withdrawal.
CHANGE OF OWNER
A change of Owner will result in recalculation of the Death
Benefit and the Guaranteed Death Benefit. If the Owner's or the
oldest of multiple owners' attained age at the time of the change
is less than [86], the Guaranteed Death Benefit in effect prior to
the change will remain in effect and the Death Benefit provision
shall apply.
If any owner's or oldest multiple owners attained age is [86] or
greater at the time of the change, the Guaranteed Death Benefit will
be zero, and the Death Benefit will then be the cash surrender
value.
GA-IA-1059 3D2
THE SCHEDULE
CONTRACT FACTS (continued)
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|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
SPOUSAL CONTINUATION UPON DEATH OF OWNER
If at the Owner's death, the surviving spouse of the deceased Owner
is the beneficiary and such surviving spouse elects to continue the
contract as their own pursuant to Internal Revenue Code Section
72(s) or the equivalent provisions of U.S. Treasury Department rules
for qualified plans, the following will apply:
(a) If the Guaranteed Death Benefit as of the date we receive due
proof of death of the Owner, minus the Accumulation Value, also as
of that date, is greater than zero we will add such difference to
the Accumulation Value. Such addition will be allocated to the
divisions of the Separate Account in proportion to the Accumulation
Value in the Separate Account. If there is no Accumulation Value in
the Separate Account, the addition will be allocated to the Liquid
Assets division, or its successor.
(b) The Guaranteed Death Benefit will continue to apply, with all
age criteria using the surviving spouse's age as the determining age.
This addition to Accumulation Value is available only to the
spouse of the owner as of the date of death of the owner if such
spouse under the provisions of this contract elects to continue
the contract as their own.
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
[Distributions from a Contract funding a qualified plan must commence
no later than [April 1st] of the calendar year following the calendar
year in which the Owner attains age 70 1/2.]
The Annuity Commencement Date is required to be the same date as the
Contract Processing Date in the month following the Annuitant's 90th
birthday. In applying the Accumulation Value, we may first collect
any Premium Taxes due us.
GA-IA-1059 3D3
THE SCHEDULE
CONTRACT FACTS (continued)
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|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is
[$20].
Optional Benefit Riders - [None.]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full
years elapsed since the Contract Date.
GA-IA-1059 3D4
THE SCHEDULE
CHARGES AND FEES
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|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
DEDUCTIONS FROM PREMIUMS
[None.]
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
[None.]
Administrative Charge
[None]
Excess Allocation Charge
Currently none, however, we reserve the right to charge ]$25[ for a
change if you make more than [twelve] allocation changes per
Contract Year. Any charge will be deducted in proportion to the
amount being transferred from each Division.
[Premium Taxes
We deduct the amount of any premium or other state and local taxes
levied by any state or governmental entity when such taxes are
incurred.
We reserve the right to defer collection of Premium Taxes until
surrender or until application of Accumulation Value to an Annuity
Option. We reserve the right to change the amount we charge for
Premium Tax charges on future premium payments to conform with
changes in the law or if the Owner changes state of residence.]
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the
---------------------------------
assets in each separate account division on a daily basis at a rate
of [0.000961%] (equivalent to an annual rate of [0.35%]) for
mortality and expense risks. The charge is not deducted from the
general account accumulation values.
Asset Based Administrative Charge - We deduct [0.000411%] of the
---------------------------------
assets in each Variable Separate Account Division on a daily basis
(equivalent to an annual rate of [0.15%]) to compensate us for a
portion of our ongoing administrative expenses. This charge is not
deducted from the General Account values.
CHARGE DEDUCTION DIVISION
All charges against the Accumulation Value in this Contract will be
deducted from the [Liquid Asset Division].
GA-IA-1059 3E
THE SCHEDULE
INCOME PLAN FACTORS
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|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
Values for other payment periods, ages or joint life combinations
are available on request. Monthly payments are shown for each
$1,000 applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Period Monthly Fixed Period Monthly Fixed Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years 20 Years Refund
Certain Certain Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
GA-IA-1059 3F
IMPORTANT TERMS
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ACCUMULATION VALUE - The amount that a Contract provides for
investment at any time. Initially, this amount is equal to the
premium paid.
ANNUITANT - The person designated by the Owner to be the measuring
life in determining Annuity Payments.
ANNUITY COMMENCEMENT DATE - For each Contract, the date on which
Annuity Payments begin.
ANNUITY OPTIONS - Options the Owner selects that determine the form
and amount of annuity payments.
ANNUITY PAYMENT - The periodic payment an Owner receives. It may be
either a fixed or a variable amount based on the Annuity Option
chosen.
ATTAINED AGE - The Issue Age of the Annuitant or Owner plus the
number of full years elapsed since the Contract Date.
BENEFICIARY - The person designated to receive benefits in the case
of the death of the Owner.
BUSINESS DAY - Any day the New York Stock Exchange ("NYSE") is open
for trading, exclusive of federal holidays, or any day on which
the Securities and Exchange Commission ("SEC") requires that
mutual funds, unit investment trusts or other investment
portfolios be valued.
CASH SURRENDER VALUE - The amount the Owner receives upon surrender
of the Contract.
CHARGE DEDUCTION DIVISION - The Division from which all charges are
deducted if so designated or elected by the Owner.
CONTINGENT ANNUITANT - The person designated by the Owner who, upon
the Annuitant's death prior to the Annuity Commencement Date,
becomes the Annuitant.
CONTRACT ANNIVERSARY - The anniversary of the Contract Date.
CONTRACT DATE - The date we received the initial premium and upon
which we begin determining the Contract values. It may not be
the same as the Contract Issue Date. This date is used to
determine Contract months, processing dates, years, and
anniversaries.
CONTRACT ISSUE DATE - The date the Contract is issued at our
Customer Service Center.
CONTRACT PROCESSING DATES - The days when we deduct certain charges
from the Accumulation Value. If the Contract Processing Date is
not a Valuation Date, it will be on the next succeeding Valuation
date. The Contract Processing Date will be on the Contract
Anniversary of each year.
CONTRACT PROCESSING PERIOD - The period between successive Contract
Processing Dates unless it is the first Contract Processing
Period. In that case, it is the period from the Contract Date to
the first Contract Processing Date.
CONTRACT YEAR - The period between Contract Anniversaries.
GA-IA-1059 4
IMPORTANT TERMS (continued)
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EXPERIENCE FACTOR - The factor which reflects the investment
experience of the portfolio in which a Variable Separate Account
Division invests and also reflects the charges assessed against
the Division for a Valuation Period.
GUARANTEE PERIOD - The period of years a rate of interest is
guaranteed to be credited to a Guaranteed Interest Division.
GUARANTEED DEATH BENEFIT INTEREST RATE - The annual rate at which
the Guaranteed Death Benefit is calculated.
GUARANTEED INTEREST DIVISION - An investment option available in the
General Account, an account which contains all of our assets
other than those held in our Variable Separate Accounts.
GUARANTEED INTEREST RATE - The effective annual interest rate which
we will credit for a specified Guarantee Period.
GUARANTEED MINIMUM INTEREST RATE - The minimum interest rate which
can be declared by us for allocations to a Guaranteed Interest
Division.
INDEX OF INVESTMENT EXPERIENCE - The index that measures the
performance of a Variable Separate Account Division.
INITIAL PREMIUM - The payment amount required to put each Contract
in effect.
ISSUE AGE - The Annuitant's or Owner's age on the last birthday on
or before the Contract Date.
MATURITY DATE - The date on which a Guarantee Period matures.
OWNER - The person who owns a Contract and is entitled to exercise
all rights of the Contract. This person's death also initiates
payment of the death benefit.
RIDERS - Riders add provisions or change the terms of the Contract.
SPECIALLY DESIGNATED DIVISION - Distributions from a portfolio
underlying a Division in which reinvestment is not available will
be allocated to this Division unless you specify otherwise.
VALUATION DATE - The day at the end of a Valuation Period when each
Division is valued.
VALUATION PERIOD - Each business day together with any non-business
days before it.
VARIABLE SEPARATE ACCOUNT DIVISION - An investment option available
in the Variable Separate Account shown on the Schedule.
GA-IA-1059 5
INTRODUCTION TO THIS CONTRACT
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THE CONTRACT
This is a legal contract between you and us. We provide benefits as
stated in this Contract. In return, you supply us with the Initial
Premium Payment required to put this Contract in effect.
This Contract, together with any Riders or Endorsements, constitutes
the entire Contract. Riders and Endorsements add provisions or
change the terms of the basic Contract.
THE OWNER
You are the Owner of this Contract. You are also the Annuitant
unless another Annuitant has been named by you and is shown in the
Schedule. You have the rights and options described in this
Contract, including but not limited to the right to receive the
Annuity Benefits on the Annuity Commencement Date.
One or more people may own this Contract. If there are multiple
Owners named, the age of the oldest Owner will be used to determine
the applicable death benefit. In the case of a sole Owner who dies
prior to the Annuity Commencement Date, we will pay the Beneficiary
the death benefit then due. If the sole Owner is not an
individual, we will treat the Annuitant as Owner for the purpose of
determining when the Owner dies under the death benefit provision
(if there is no Contingent Annuitant), and the Annuitant's age will
determine the applicable death benefit payable to the Beneficiary.
The sole Owner's estate will be the Beneficiary if no Beneficiary
designation is in effect, or if the designated Beneficiary has
predeceased the Owner. In the case of a joint Owner of the Contract
dying prior to the Annuity Commencement Date, the surviving Owner(s)
will be deemed as the Beneficiary(ies).
THE ANNUITANT
The Annuitant is the measuring life of the Annuity Benefits provided
under this Contract. You may name a Contingent Annuitant. The
Annuitant may not be changed during the Annuitant's lifetime.
If the Annuitant dies before the Annuity Commencement Date, the
Contingent Annuitant becomes the Annuitant. You will be the
Contingent Annuitant unless you name someone else. The Annuitant
must be a natural person. If the Annuitant dies and no Contingent
Annuitant has been named, we will allow you sixty days to designate
someone other than yourself as an Annuitant. If all Owners are not
individuals and, through the operation of this provision, an Owner
becomes Annuitant, we will pay the death proceeds to the
Beneficiary. If there are joint Owners, we will treat the youngest
of the Owners as the Contingent Annuitant designated, unless you
elect otherwise.
THE BENEFICIARY
The Beneficiary is the person to whom we pay death proceeds if any
Owner dies prior to the Annuity Commencement Date. See Proceeds
Payable to the Beneficiary for more information. We pay death
proceeds to the primary Beneficiary (unless there are joint Owners
in which case the death benefit proceeds are payable to the
surviving Owner). If the primary Beneficiary dies before the Owner,
the death proceeds are paid to the Contingent Beneficiary, if any.
If there is no surviving Beneficiary, we pay the death proceeds to
the Owner's estate.
GA-IA-1059 6
INTRODUCTION TO THIS CONTRACT (continued)
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One or more persons may be named as primary Beneficiary or
contingent Beneficiary. In the case of more than one Beneficiary,
we will assume any death proceeds are to be paid in equal shares to
the surviving Beneficiaries. You can specify other than equal
shares.
You have the right to change Beneficiaries, unless you designate the
primary Beneficiary irrevocable. When an irrevocable Beneficiary
has been designated, you and the irrevocable Beneficiary may have to
act together to exercise the rights and options under this Contract.
CHANGE OF OWNER OR BENEFICIARY
During your lifetime and while this Contract is in effect you can
transfer ownership of this Contract or change the Beneficiary. To
make any of these changes, you must send us written notice of the
change in a form satisfactory to us. The change will take effect as
of the day the notice is signed. The change will not affect any
payment made or action taken by us before recording the change at
our Customer Service Center. A Change of Owner may affect the
amount of death benefit payable under this Contract. See Proceeds
Payable to Beneficiary.
GA-IA-1059 7
PREMIUM PAYMENTS AND ALLOCATION CHARGES
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INITIAL PREMIUM PAYMENT
The Initial Premium Payment is required to put this Contract in
effect. The amount of the Initial Premium Payment is shown in the
Schedule.
ADDITIONAL PREMIUM PAYMENT OPTION
You may make additional premium payments under this Contract after
the end of the Right to Examine period. Restrictions on additional
premium payments, such as the Attained Age of the Annuitant or Owner
and the timing and amount of each payment, are shown in the
Schedule. We reserve the right to defer acceptance of or to return
any additional premium payments.
As of the date we receive and accept your additional premium
payment:
(1) The Accumulation Value will increase by the amount of
the premium payment less any premium deductions as shown in
the Schedule.
(2) The increase in the Accumulation Value will be
allocated among the Divisions of the Variable Separate
Account and General Account in accordance with your
instructions. If you do not provide such instructions,
allocation will be among the Divisions of the Variable
Separate Account and General Account in proportion to the
amount of Accumulation Value in each Division.
Where to Make Payments
Remit the premium payments to our Customer Service Center at the
address shown on the cover page. On request we will give you a
receipt signed by our treasurer.
YOUR RIGHT TO CHANGE ALLOCATION OF ACCUMULATION VALUE
You may change the allocation of the Accumulation Value among the
Divisions after the end of the Right to Examine period. The number
of free allocation changes each year that we will allow is shown in
the Schedule. To make an allocation change, you must provide us
with satisfactory notice at our Customer Service Center. The change
will take effect when we receive the notice. Restrictions for
reallocation into and out of Divisions of the Variable Separate
Account and General Account are shown in the Schedule.
WHAT HAPPENS IF A VARIABLE SEPARATE ACCOUNT DIVISION IS NOT AVAILABLE
When a distribution is made from an investment portfolio supporting
a unit investment trust Separate Account Division in which
reinvestment is not available, we will allocate the distribution to
the Specially Designated Division shown in the Schedule unless you
specify otherwise.
Such a distribution may occur when an investment portfolio or
Division matures, when distribution from a portfolio or Division
cannot be reinvested in the portfolio or Division due to the
unavailability of securities, or for other reasons. When this
occurs because of maturity, we will send written notice to you
thirty days in advance of such date. To elect an allocation to
other than the Specially Designated Division shown in the Schedule,
you must provide satisfactory notice to us at least seven days prior
to the date the investment matures. Such allocations will not be
counted as an allocation change of the Accumulation Value for
purposes of the number of free allocations permitted.
GA-IA-1059 8
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE
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The variable Annuity Benefits under this Contract are provided
through investments which may be made in our Separate Accounts.
THE VARIABLE SEPARATE ACCOUNTS
These accounts, which are designated in the Schedule, are kept
separate from our General Account and any other Separate Accounts we
may have. They are used to support Variable Annuity Contracts and
may be used for other purposes permitted by applicable laws and
regulations. We own the assets in the Separate Accounts. Assets
equal to the reserves and other liabilities of the accounts will not
be charged with liabilities that arise from any other business we
conduct; but, we may transfer to our General Account assets which
exceed the reserves and other liabilities of the Variable Separate
Accounts. Income and realized and unrealized gains or losses from
assets in these Variable Separate Accounts are credited to or
charged against the account without regard to other income, gains or
losses in our other investment accounts.
The Variable Separate Account will invest in mutual funds, unit
investment trusts and other investment portfolios which we determine
to be suitable for this Contract's purposes. The Variable Separate
Account is treated as a unit investment trust under Federal
securities laws. It is registered with the Securities and Exchange
Commission ("SEC") under the Investment Company Act of 1940. The
Variable Separate Account is also governed by state law as
designated in the Schedule. The trusts may offer non-registered
series.
Variable Separate Account Divisions
A unit investment trust Separate Account includes Divisions, each
investing in a designated investment portfolio. The Divisions and
the investment portfolios designated may be managed by a separate
investment adviser. Such adviser may be registered under the
Investment Advisers Act of 1940.
Changes within the Variable Separate Accounts
We may, from time to time, make additional Variable Separate Account
Divisions available to you. These Divisions will invest in
investment portfolios we find suitable for this Contract. We also
have the right to eliminate Divisions from a Variable Separate
Account, to combine two or more Divisions or to substitute a new
portfolio for the portfolio in which a Division invests. A
substitution may become necessary if, in our judgment, a portfolio
or Division no longer suits the purpose of this Contract. This may
happen due to a change in laws or regulations, or a change in a
portfolio's investment objectives or restrictions, or because the
portfolio or Division is no longer available for investment, or for
some other reason. We may get prior approval from the insurance
department of our state of domicile before making such a
substitution. We will also get any required approval from the SEC
and any other required approvals before making such a substitution.
Subject to any required regulatory approvals, we reserve the right
to transfer assets of the Variable Separate Account which we
determine to be associated with the class of contracts to which this
Contract belongs, to another Variable Separate Account or Division.
When permitted by law, we reserve the right to:
(1) deregister a Variable Separate Account under the
Investment Company Act of 1940;
(2) operate a Variable Separate Account as a management
company under the Investment Company Act of 1940, if it is
operating as a unit investment trust;
(3) operate a Variable Separate Account as a unit
investment trust under the Investment Company Act of 1940,
if it is operating as a managed Variable Separate Account;
(4) restrict or eliminate any voting rights of Owners, or
other persons who have voting rights to a Variable Separate
Account; and,
(5) combine a Variable Separate Account with other Variable
Separate Accounts.
GA-IA-1059 9
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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THE GENERAL ACCOUNT
The General Account contains all assets of the Company other than
those in the Separate Accounts we establish. The Guaranteed
Interest Divisions available for investment are shown in the
Schedule. We may, from time to time, offer other Divisions where
assets are held in our General Account.
VALUATION PERIOD
Each Division will be valued at the end of each Valuation Period on
a Valuation Date. A Valuation Period is each Business Day together
with any non-Business Days before it. A Business Day is any day the
New York Stock Exchange (NYSE) is open for trading, and the SEC
requires mutual funds, unit investment trusts, or other investment
portfolios to value their securities.
ACCUMULATION VALUE
The Accumulation Value of this Contract is the sum of the amounts in
each of the Divisions of the Variable Separate Account and General
Account. You select the Divisions of the Variable Separate Account
and General Account to which to allocate the Accumulation Value.
The maximum number of Divisions to which the Accumulation Value may
be allocated at any one time is shown in the Schedule.
ACCUMULATION VALUE IN EACH DIVISION
On the Contract Date
On the Contract Date, the Accumulation Value is allocated to each
Division as elected by you, subject to certain terms and conditions
imposed by us. We reserve the right to allocate premium to the
Specially Designated Division during any Right to Examine contract
period. After such time, allocation will be made proportionately in
accordance with the initial allocation(s) as elected by you.
On each Valuation Date
At the end of each subsequent Valuation Period, the amount of
Accumulation Value in each Division will be calculated as follows:
(1) We take the Accumulation Value in the Division or at
the end of the preceding Valuation Period.
(2) We multiply (1) by the Variable Separate Account
Division's Net Rate of Return for the current Valuation
Period or we calculate interest to be credited to a
Guaranteed Interest Division for the current Valuation
Period.
(3) We add (1) and (2).
(4) We add to (3) any additional premium payments (less any
premium deductions as shown in the Schedule) allocated to
the Division during the current Valuation Period.
(5) We add or subtract allocations to or from that Division
during the current Valuation Period.
(6) We subtract from (5) any Partial Withdrawals which are
allocated to the Division during the current Valuation
Period.
(7) We subtract from (6) the amounts allocated to that
Division for:
(a) any charges due for the Optional Benefit Riders as
shown in the Schedule;
(b) any deductions from Accumulation Value as shown in
the Schedule.
All amounts in (7) are allocated to each Division in the proportion
that (6) bears to the Accumulation Value unless the Charge Deduction
Division has been specified (see the Schedule).
GA-IA-1059 10
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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MEASUREMENT OF INVESTMENT EXPERIENCE
Index of Investment Experience
The Investment Experience of a Variable Separate Account Division is
determined on each Valuation Date. We use an Index to measure
changes in each Division's experience during a Valuation Period. We
set the Index at $10 when the first investments in a Division are
made. The Index for a current Valuation Period equals the Index for
the preceding Valuation Period multiplied by the Experience Factor
for the current Valuation Period.
How We Determine the Experience Factor
For Divisions of a unit investment trust Separate Account the
Experience Factor reflects the Investment Experience of the
portfolio in which the Division invests as well as the charges
assessed against the Division for a Valuation Period. The factor is
calculated as follows:
(1) We take the net asset value of the portfolio in which the
Division invests at the end of the current Valuation Period.
(2) We add to (1) the amount of any dividend or capital gains
distribution declared for the investment portfolio and
reinvested in such portfolio during the current Valuation
Period. We subtract from that amount a charge for our taxes,
if any.
(3) We divide (2) by the net asset value of the portfolio at
the end of the preceding Valuation Period.
(4) We subtract the daily Mortality and Expense Risk Charge
for each Division shown in the Schedule for each day in the
Valuation Period.
(5) We subtract the daily Asset Based Administrative Charge
shown in the Schedule for each day in the Valuation Period.
Calculations for Divisions investing in unit investment trusts are
on a per unit basis.
Net Rate of Return for a Variable Separate Account Division
The Net Rate of Return for a Variable Separate Account Division
during a Valuation Period is the Experience Factor for that
Valuation Period minus one.
Interest Credited to a Guaranteed Interest Division
Accumulation Value allocated to a Guaranteed Interest Division will
be credited with the Guaranteed Interest Rate for the Guarantee
Period in effect on the date the premium or reallocation is applied.
Once applied, such rate will be guaranteed until the Maturity Date
of that Guarantee Period. Interest will be credited daily at a rate
to yield the declared annual Guaranteed Interest Rate. No
Guaranteed Interest Rate will be less than the Minimum Interest Rate
shown in the Schedule
CHARGES DEDUCTED FROM ACCUMULATION VALUE ON EACH CONTRACT PROCESSING
DATE
Expense charges and fees are shown in the Schedule.
Charge Deduction Division Option
We will deduct all charges against the Accumulation Value of this
Contract from the Charge Deduction Division if you elected this
option on the application (see the Schedule). If you did not elect
this Option or if the charges are greater than the amount in the
Charge Deduction Division, the charges against the Accumulation
Value will be deducted as follows:
(1) If these charges are less than the Accumulation Value in
the Variable Separate Account Divisions, they will be deducted
proportionately from all Divisions.
(2) If these charges exceed the Accumulation Value in the
Variable Separate Account Divisions, any excess over such value
will be deducted proportionately from the Guaranteed Interest
Divisions.
Any charges taken from the General Account will be taken from the
Guaranteed Interest Division starting with the Guarantee Period
nearest its Maturity Date until such charges have been paid.
At any time while this Contract is in effect, you may change your
election of this Option. To do this you must send us a written
request to our Customer Service Center. Any change will take effect
within seven days of the date we receive your request.
GA-IA-1059 11
YOUR CONTRACT BENEFITS
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While this Contract is in effect, there are important rights and
benefits that are available to you. We discuss these rights and
benefits in this section.
CASH VALUE BENEFIT
Cash Surrender Value
The Cash Surrender Value, while the Annuitant is living and before
the Annuity Commencement Date, is determined as follows:
(1) We take the Contract's Accumulation Value;
(2) We deduct any charges shown in the Schedule that have
been incurred but not yet deducted, including;
(a) any administrative fee that has not yet been
deducted;
(b) the pro rata part of any charges for Optional
Benefit Riders; and
(c) any applicable premium or other tax.
Cancelling to Receive the Cash Surrender Value
At any time while the Annuitant is living and before the Annuity
Commencement Date, you may surrender this Contract to us. To do
this, you must return this Contract with a signed request for
cancellation to our Customer Service Center.
The Cash Surrender Value will vary daily. We will determine the
Cash Surrender Value as of the date we receive the Contract and your
signed request in our Customer Service Center. All benefits under
this Contract will then end.
We will usually pay the Cash Surrender Value within seven days; but,
we may delay payment as described in the Payments We May Defer
provision.
PARTIAL WITHDRAWAL OPTION
After the Contract Date, you may make Partial Withdrawals. The
minimum amount that may be withdrawn is shown in the Schedule. To
take a Partial Withdrawal, you must provide us satisfactory notice
at our Customer Service Center.
PROCEEDS PAYABLE TO THE BENEFICIARY
Prior to the Annuity Commencement Date
If the sole Owner dies prior to the Annuity Commencement Date, we
will pay the Beneficiary the death benefit. If there are joint
Owners and any Owner dies, we will pay the surviving Owners the
death benefit. We will pay the amount on receipt of due proof of
the Owner's death at our Customer Service Center. Such amount may
be received in a single lump sum or applied to any of the Annuity
Options (see Choosing an Income Plan). When the Owner (or all
Owners where there are joint Owners) is not an individual, the death
benefit will become payable on the death of the Annuitant prior to
the Annuity Commencement Date (unless a Contingent Annuitant
survived the Annuitant). Only one death benefit is payable under
this Contract. In all events, distributions under the Contract must
be made as required by applicable law.
GA-IA-1059 12
YOUR CONTRACT BENEFITS (continued)
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How to Claim Payments to Beneficiary
We must receive proof of the Owner's (or the Annuitant's) death
before we will make any payments to the Beneficiary. We will
calculate the death benefit as of the date we receive due proof of
death. The Beneficiary should contact our Customer Service Center
for instructions.
Guaranteed Death Benefits
The Guaranteed Death Benefit is as shown in the Schedule. A change
of Owner will affect the Guaranteed Death Benefit, as shown in the
Schedule.
GA-IA-1059 13
CHOOSING AN INCOME PLAN
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ANNUITY BENEFITS
If the Annuitant and Owner are living on the Annuity Commencement
Date, we will begin making payments to the Owner. We will make
these payment under the Annuity Option (or Options) as chosen in the
application or as subsequently selected. You may choose or change
an Annuity Option by making a written request at least 30 days prior
to the Annuity Commencement Date. Unless you have chosen otherwise,
Option 2 on a 10-year period certain basis will become effective.
The amounts of the payments will be determined by applying the
Accumulation Value on the Annuity Commencement Date in accordance
with the Annuity Options section below (see Payments We Defer).
Before we pay any Annuity Benefits, we require the return of this
Contract. If this Contract has been lost, we require the applicable
lost Contract form.
ANNUITY COMMENCEMENT DATE SELECTION
You select the Annuity Commencement Date. You may select any date
following the fifth Contract Anniversary but before the required
date of Annuity Commencement as shown in the Schedule. If you do
not select a date, the Annuity Commencement Date will be in the
month following the required date of Annuity Commencement.
FREQUENCY SELECTION
You may choose the frequency of the Annuity Payments. They may be
monthly, quarterly, semi-annually or annually. If we do not receive
written notice from you, the payments will be made monthly.
THE INCOME PLAN
While this Contract is in effect and before the Annuity Commencement
Date, you may chose one or more Annuity Options for the payment of
death benefits proceeds. If, at the time of the Owner's death, no
Option has been chosen for paying the death benefit proceeds, the
Beneficiary may choose an Option within one year. You may also
elect an Annuity Option on surrender of the Contract for its Cash
Surrender Value. For each Option we will issue a separate written
agreement putting the Option into effect.
Our approval is needed for any Option where:
(1) the person named to receive payment is other than the
Owner or Beneficiary; or
(2) the person named is not a natural person, such as a
corporation; or
(3) any income payment would be less than the minimum
annuity income payment shown in the Schedule.
THE ANNUITY OPTIONS
There are four Options to choose from. They are:
Option 1. Income for a Fixed Period
Payment is made in equal installments for a fixed number of years.
We guarantee each monthly payment will be at least the Income for
Fixed Period amount shown in the Schedule. Values for annual,
semiannual or quarterly payments are available on request.
GA-IA-1059 14
CHOOSING AN INCOME PLAN (continued)
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Option 2. Income for Life
Payment is made to the person named in equal monthly installments
and guaranteed for at least a period certain. The period certain
can be 10 or 20 years. Other periods certain are available on
request. A refund certain may be chosen instead. Under this
arrangement, income is guaranteed until payments equal the amount
applied. If the person named lives beyond the Guarantee Period,
payments continue until his or her death.
We guarantee each payment will be at least the amount shown in the
Schedule. By age, we mean the named person's age on his or her last
birthday before the Option's effective date. Amounts for ages not
shown are available on request.
Option 3. Joint Life Income
This Option is available if there are two persons named to receive
payments. At least one of the persons named must be either the
Owner of Beneficiary of this Contract. Monthly payments are
guaranteed and are made as long as at least one of the named persons
is living. The monthly payment amounts are available upon request.
Such amounts are guaranteed and will be calculated on the same basis
as the Table for Income for Life, however, the amounts will be based
on two lives.
Option 4. Annuity Plan
An amount can be applied under any other settlement option we offer
for the Contract on the Option's effective date.
The minimum rates for Option 1 are based on 3% interest, compounded
annually. The minimum rates for Options 2 and 3 are based on 3%
interest, compounded annually, and the Annuity 2000 Mortality Table.
We may pay a higher rate at our discretion.
PAYMENT WHEN NAMED PERSON DIES
When the person named to receive payment dies, we will pay any
amounts still due as provided by the Option agreement. The amounts
still due are determined as follows:
(1) For Option 1 or for any remaining guaranteed payments
in Option 2, payments will be continued.
(2) For Option 3, no amounts are payable after both named
persons have died.
(3) For Option 4, the annuity agreement will state the
amount due, if any.
GA-IA-1059 15
OTHER IMPORTANT INFORMATION
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SENDING NOTICE TO US
Whenever written notice is required, send it to our Customer Service
Center. The address of our Customer Service Center is shown on the
cover page. Please include your Contract number in all
correspondence.
REPORTS TO OWNER
We will send you a report at least once during each Contract Year.
The report will show the Accumulation Value and the Cash Surrender
Value as of the end of the Contract Processing Period. The report
will also show the allocation of the Accumulation Value as of such
date and the amounts deducted from or added to the Accumulation
Value since the last report. The report will also include any
information that may be currently required by the insurance
supervisory official of the jurisdiction in which the Contract is
delivered.
We will also send you copies of any shareholder reports of the
portfolios in which the Divisions of the Variable Separate Account
invest, as well as any other reports, notices or documents required
by law to be furnished to Owners.
ASSIGNMENT - USING THIS CONTRACT AS COLLATERAL SECURITY
You can assign this Contract as collateral security for a loan or
other obligation. This does not change the ownership. Your rights
and any Beneficiary's right are subject to the terms of the
assignment. To make or release an assignment, we must receive
written notice satisfactory to us, at our Customer Service Center.
We are not responsible for the validity of any assignment.
CHANGING THIS CONTRACT
This Contract or any additional benefit riders may be changed to
another annuity plan according to our rules at the time of the
change.
CONTRACT CHANGES - APPLICABLE TAX LAW
We reserve the right to make changes in this Contract or its Riders
to the extent we deem it necessary to continue to qualify this
Contract as an annuity. Any such changes will apply uniformly to
all Contracts that are affected. You will be given advance written
notice of such changes.
MISSTATEMENT OF AGE OR SEX
If an age or sex has been misstated, the amounts payable or benefits
provided by this Contract will be those that the premium payment
made would have bought at the correct age or sex.
NON-PARTICIPATING
This Contract does not participate in the divisible surplus of
Golden American Life Insurance Company.
GA-IA-1059 16
OTHER IMPORTANT INFORMATION (continued)
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PAYMENTS WE MAY DEFER
We may not be able to determine the value of the assets of the Variable
Separate Account Divisions because:
(1) The NYSE is closed for trading;
(2) the SEC determines that a state of emergency exists;
(3) an order or pronouncement of the SEC permits a delay for
the protection of Owners; or
(4) the check used to pay the premium has not cleared through
the banking system. This may take up to 15 days.
During such times, as to amounts allocated to the Divisions of the
Variable Separate Account, we may delay;
(1) determination and payment of the Cash Surrender Value;
(2) determination and payment of any death benefit if death
occurs before the Annuity Commencement Date;
(3) allocation changes of the Accumulation Value; or,
(4) application of the Accumulation Value under an income plan.
As to the amounts allocated to a Guaranteed Interest Division in the
General Account, we may, at any time, defer payment of the Cash
Surrender Value for up to six months after we receive a request for it.
We will allow interest of at least 3.00% a year on any Cash Surrender
Value payment derived from the Guaranteed Interest Divisions that we
defer 30 days or more.
AUTHORITY TO MAKE AGREEMENTS
All agreements made by us must be signed by one of our officers. No
other person, including an insurance agent or broker, can:
(1) change any of this Contract's terms;
(2) extend the time for premium payments; or
(3) make any agreement binding on us.
REQUIRED NOTE ON OUR COMPUTATIONS
We have filed a detailed statement of our computations with the
insurance supervisory official in the jurisdiction where this Contract
is delivered. The values are not less than those required by the law of
that state or jurisdiction. Any benefit provided by an attached
Optional Benefit Rider will not increase these values unless otherwise
stated in that Rider.
GA-IA-1059 17
DEFERRED VARIABLE ANNUITY CONTRACT - NO DIVIDENDS
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Variable Cash Surrender Values while the Annuitant and Owner are
living and prior to the Annuity Commencement Date. Death benefit
subject to guaranteed minimum. Additional Premium Payment Option.
Partial Withdrawal Option. Non-participating. Investment results
reflected in values.
GA-IA-1059
THE SCHEDULE
CONTRACT FACTS
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
CONTRACT FACTS
Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each
year.
Specially Designated Divisions
When a distribution is made from an investment portfolio underlying
a Separate Account Division in which reinvestment is not available,
we will allocate the amount of the distribution to the [Liquid Asset
Division] unless you specify otherwise.
PARTIAL WITHDRAWALS
The maximum amount that can be withdrawn each Contract Year is
described below. In no event may a Partial Withdrawal exceed 90% of
the Cash Surrender Value. After a Partial Withdrawal, the remaining
Accumulation Value must be at least $100 to keep the Contract in
force.
Conventional Partial Withdrawals
Minimum Withdrawal Amount: $100.
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be taken on a monthly, quarterly or
annual basis. You select the day withdrawals will be made, but no
later than the 28th day of the month.
Minimum Withdrawal Amount: $100.
Maximum Withdrawal Amount:
Variable Separate Account Divisions: 1.25% monthly, 3.75%
quarterly or 15% annually of
Accumulation Value.
Guaranteed Interest Divisions: Interest earned on a Guaranteed
Interest Division for the prior month,
quarter or year (depending on the
frequency selected).
[XXX Partial Withdrawals for Qualified Plans Only
XXX Partial Withdrawals may be taken on a monthly, quarterly or
annual basis. A minimum withdrawal of $100.00 is required. You
select the day the withdrawals will be made, but no later than the
28th day of the month. If you do not elect a day, the Contract
Date will be used. Systematic Partial Withdrawals and Conventional
Partial Withdrawals are not allowed when XXX Partial Withdrawals
are being taken.]
GA-IA-1059 3D1
THE SCHEDULE
CONTRACT FACTS (continued)
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2053] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
[Alternate schedule page Ratchet Death Benefit]
DEATH BENEFIT
[The Death Benefit is the greatest of (i) , (ii) , (iii), and (iv)
below, where:
(i) the Accumulation Value ;
(ii) the Guaranteed Death Benefit;
(iii) the Cash Surrender Value;
(iv) the sum of premiums paid, reduced by Prorata Partial Withdrawal
Adjustment(s) for Accumulation Value withdrawn.
GUARANTEED DEATH BENEFIT
On the Contract Date, the Guaranteed Death Benefit is the initial
premium. On subsequent Valuation Dates, the Guaranteed Death
Benefit is calculated as follows:
(1) Start with the Guaranteed Death Benefit from the prior
Valuation Date;
(2) Add to (1) any additional premium paid since the prior
Valuation Date and subtract from (1) any Prorata Partial Withdrawal
Adjustments for any Partial Withdrawals taken since the prior
Valuation Date.
(3) On a Valuation Date that occurs on or prior to the owner's
attained age [80], which is also a Contract Anniversary, we set the
Guaranteed Death Benefit equal to the greater of (2) or the
Accumulation Value as of such date.
On all other Valuation Dates, the Guaranteed Death Benefit is equal
to (2).
PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS
For any partial withdrawal, the Death Benefit components will be
reduced by Prorata Partial Withdrawal Adjustments. The Prorata
Partial Withdrawal Adjustment to a death benefit component for a
partial withdrawal is equal to (1) divided by (2), multiplied by
(3), where: (1) is the Accumulation Value withdrawn, (2) is the
Accumulation Value immediately prior to withdrawal, and (3) is the
amount of the applicable death benefit component immediately prior
to the withdrawal.]
CHANGE OF OWNER
A change of Owner from a sole owner to a sole owner (where there
have never been multiple owners designated) will result in
recalculation of the Death Benefit and the Guaranteed Death
Benefit. If the new owner's attained age at the time of the
change is less than [80], the Guaranteed Death Benefit in effect
prior to the change will remain in effect and the Death Benefit
provision will apply. If the new owner's attained age at the time
of the change is [80] or greater, but not greater than [85]:
(a) the Guaranteed Death Benefit following the change will be zero; and
(b) the Death Benefit will then be the greatest of:
1) the cash surrender value;
2) the accumulation value prior to the date of death; and
3) the sum of the premiums paid, reduced by Prorata Partial
Withdrawal Adjustments for any Accumulation Value Withdrawn.
GA-IA-1059 3D2
THE SCHEDULE
CONTRACT FACTS (continued)
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2053] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
CHANGE OF OWNER (CONT)
If ownership changes result in multiple owners of a contract or if
there has ever been multiple owners, the Guaranteed Death Benefit
shall be set to zero. If the oldest owner is age [85] or younger
at the time of the change, the Death Benefit will then be the
greatest of: (b) 1, (b) 2 or (b) 3 above.
If any owner's or oldest multiple owners, attained age is [86] or
greater at the time of the change, the Guaranteed Death Benefit will
be zero, and the Death Benefit thereafter will be the cash surrender
value.
When a change of owner reduces the Guaranteed Death Benefit to zero,
there will be a reduction in the mortality and expense risk charge.
SPOUSAL CONTINUATION UPON DEATH OF OWNER
If at the Owner's death, the surviving spouse of the deceased Owner
is the beneficiary and such surviving spouse elects to continue the
contract as their own pursuant to Internal Revenue Code Section
72(s) or the equivalent provisions of U.S. Treasury Department rules
for qualified plans, the following will apply:
(a) If the Guaranteed Death Benefit as of the date we receive due
proof of death of the Owner, minus the Accumulation Value, also as
of that date, is greater than zero we will add such difference to
the Accumulation Value. Such addition will be allocated to the
divisions of the Separate Account in proportion to the Accumulation
Value in the Separate Account. If there is no Accumulation Value in
the Separate Account, the addition will be allocated to the Liquid
Assets division, or its successor.
(b) The Guaranteed Death Benefit will continue to apply, with all
age criteria using the surviving spouse's age as the determining age.
This addition to Accumulation Value is available only to the
spouse of the owner as of the date of death of the owner if such
spouse under the provisions of this contract elects to continue
the contract as their own.
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
[Distributions from a Contract funding a qualified plan must commence
no later than [April 1st] of the calendar year following the calendar
year in which the Owner attains age 70 1/2.]
The Annuity Commencement Date is required to be the same date as the
Contract Processing Date in the month following the Annuitant's[ 90]th
birthday. In applying the Accumulation Value, we may first collect
any Premium Taxes due us.
GA-IA-1059 3D3
THE SCHEDULE
CONTRACT FACTS (continued)
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is
[$20].
Optional Benefit Riders - [None.]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full
years elapsed since the Contract Date.
GA-IA-1059 3D4
THE SCHEDULE
CHARGES AND FEES
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
DEDUCTIONS FROM PREMIUMS
[None.]
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
[None.]
Administrative Charge
[None]
Excess Allocation Charge
Currently none, however, we reserve the right to charge [$25] for a
change if you make more than [twelve] allocation changes per
Contract Year. Any charge will be deducted in proportion to the
amount being transferred from each Division.
[Premium Taxes
We deduct the amount of any premium or other state and local taxes
levied by any state or governmental entity when such taxes are
incurred.
We reserve the right to defer collection of Premium Taxes until
surrender or until application of Accumulation Value to an Annuity
Option. We reserve the right to change the amount we charge for
Premium Tax charges on future premium payments to conform with
changes in the law or if the Owner changes state of residence.]
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the
assets in each separate account division on a daily basis at a rate
of [0.001373%] (equivalent to an annual rate of [0.50%]) for
mortality and expense risks. The charge is not deducted from the
general account accumulation values.
Asset Based Administrative Charge - We deduct [0.000411%] of the
assets in each Variable Separate Account Division on a daily basis
(equivalent to an annual rate of [0.15%]) to compensate us for a
portion of our ongoing administrative expenses. This charge is not
deducted from the General Account values.
CHARGE DEDUCTION DIVISION
All charges against the Accumulation Value in this Contract will be
deducted from the [Liquid Asset Division].
GA-IA-1059 3E
THE SCHEDULE
INCOME PLAN FACTORS
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
Values for other payment periods, ages or joint life combinations
are available on request. Monthly payments are shown for each
$1,000 applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Monthly Fixed Period Monthly Fixed Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years 20 Years Refund
Certain Certain Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
GA-IA-1059 3F
THE SCHEDULE
CONTRACT FACTS
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
CONTRACT FACTS
Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each
year.
Specially Designated Divisions
When a distribution is made from an investment portfolio underlying
a Separate Account Division in which reinvestment is not available,
we will allocate the amount of the distribution to the [Liquid Asset
Division] unless you specify otherwise.
PARTIAL WITHDRAWALS
The maximum amount that can be withdrawn each Contract Year is
described below. In no event may a Partial Withdrawal exceed 90% of
the Cash Surrender Value. After a Partial Withdrawal, the remaining
Accumulation Value must be at least $100 to keep the Contract in
force.
Conventional Partial Withdrawals
Minimum Withdrawal Amount: $100.
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be taken on a monthly, quarterly or
annual basis. You select the day withdrawals will be made, but no
later than the 28th day of the month.
Minimum Withdrawal Amount: $100.
Maximum Withdrawal Amount:
Variable Separate Account Divisions: 1.25% monthly, 3.75%
quarterly or 15% annually of
Accumulation Value.
Guaranteed Interest Divisions: Interest earned on a Guaranteed
Interest Division for the prior month,
quarter or year (depending on the
frequency selected).
[XXX Partial Withdrawals for Qualified Plans Only
XXX Partial Withdrawals may be taken on a monthly, quarterly or
annual basis. A minimum withdrawal of $100.00 is required. You
select the day the withdrawals will be made, but no later than the
28th day of the month. If you do not elect a day, the Contract
Date will be used. Systematic Partial Withdrawals and Conventional
Partial Withdrawals are not allowed when XXX Partial Withdrawals
are being taken.]
GA-IA-1059 3D1
THE SCHEDULE
CONTRACT FACTS (continued)
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2053] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
[Alternate schedule page 7% Enhanced Death Benefit]
[DEATH BENEFIT
The Death Benefit is the greatest of (i), (ii), (iii), and (iv)
below, where:
(i) the Accumulation Value;
(ii) the lesser of (a) and (b)
(a) the Guaranteed Death Benefit, and
(b) the Maximum Guaranteed Death Benefit;
(iii) the Cash Surrender Value;
(iv) the sum of premiums paid, reduced by Prorata Partial
Withdrawal Adjustment(s) for Accumulation Value withdrawn.
GUARANTEED DEATH BENEFIT
On the Contract Date, the Guaranteed Death Benefit is the initial
premium. On subsequent Valuation Dates, the guaranteed Death
Benefit is calculated as follows:
(1) Start with the Guaranteed Death Benefit on the prior
valuation date;
(2) Calculate interest on (1) for the current valuation period
at the Guaranteed Death Benefit Interest Rate;
(3) Add (1) and (2);
(4) Add to (3) any additional premiums paid during the current
valuation period;
(5) Subtract from (4) the amount of any Special Partial
Withdrawal Adjustments and Prorata Partial Withdrawal Adjustments
for any partial withdrawals made during the current valuation
period.
Transfer of Accumulation Value to or from Special Funds will
result in a corresponding reallocation of the Guaranteed Death
Benefit.
GUARANTEED DEATH BENEFIT INTEREST RATE
The Guaranteed Death Benefit Interest Rate is [7%] compounded
annually, except:
(a) For any portion of the Guaranteed Death Benefit attributable
to Accumulation Value allocated to Special Funds, the Guaranteed
Death Benefit Interest Rate is the lesser of: (1) [7%]
(compounded annually) and (2) the interest rate, positive or
negative, providing a yield on the Guaranteed Death Benefit for
Special Funds equal to the net return for the current valuation
period on the Accumulation Value allocated to Special Funds; and
(b) For any valuation period ending after the contract
anniversary on which the Owner attains age [80], or after the
Maximum Guaranteed Death Benefit has been reached, the Guaranteed
Death Benefit Interest Rate is [0%].
GA-IA-1059 3D2
THE SCHEDULE
CONTRACT FACTS (continued)
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2053] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
SPECIAL FUNDS
The Special Funds are [the Liquid Assets Division, the Limited
Maturity Bond Division, the Fixed Allocations, and the Guaranteed
Interest Division]. The Company reserves the right to classify
newly available divisions as Special Funds from the date of their
availability to the Owner. The Company may reclassify an existing
division as a Special Fund or remove such designation. Such
reclassification shall be made with 30 days notice to contract
owners, and will apply to amounts transferred or otherwise added to
such division after the date of change.
MAXIMUM GUARANTEED DEATH BENEFIT
The Maximum Guaranteed Death Benefit is equal to [three] times
premium paid, reduced by the amount of any Special and Prorata
Partial Withdrawal Adjustments. Any addition due to spousal
continuation will not affect the Maximum Guaranteed Death Benefit or
the Guaranteed Death Benefit.
SPECIAL AND PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS
For any partial withdrawal, the Death Benefit components will be
reduced by Prorata or Special Partial Withdrawal Adjustments. A
Prorata Partial Withdrawal Adjustment will be made unless a Special
Partial Withdrawal Adjustment applies to that component for the
withdrawal. Special Partial Withdrawal Adjustments are made when
partial withdrawals in a contract year do not exceed [7%] of the sum
of cumulative premiums, but only if partial withdrawals in each
prior contract year did not exceed [7%] of the sum of cumulative
premiums paid prior to that year. The Special Partial Withdrawal
Adjustment is equal to the amount of Accumulation Value withdrawn.
Special Partial Withdrawal Adjustments are applicable only in the
calculation of the Maximum Guaranteed Death Benefit and the
Guaranteed Death Benefit, and in all other cases withdrawals are
treated as Prorata Partial Withdrawal Adjustment.
The Prorata Partial Withdrawal Adjustment to a death benefit
component is equal to (1) divided by (2), multiplied by (3),
where: (1) is the Accumulation Value withdrawn, (2) is the
Accumulation Value immediately prior to withdrawal, and (3) is the
amount of the applicable death benefit component immediately prior
to the withdrawal.
CHANGE OF OWNER
A change of Owner from a sole owner to a sole owner (where there
have never been multiple owners designated) will result in
recalculation of the Death Benefit and the Guaranteed Death
Benefit. If the new owner's attained age at the time of the
change is less than [80], the Guaranteed Death Benefit in effect
prior to the change will remain in effect and the Death Benefit
provision will apply. If the new owner's attained age at the time
of the change is [80] or greater, but not greater than [85]:
(a) the Guaranteed Death Benefit following the change will be zero;
and
(b) the Death Benefit will then be the greatest of:
1) the cash surrender value;
2) the accumulation value prior to death; and
3) the sum of the premiums paid, reduced by Prorata Partial
Withdrawal Adjustments for any Accumulation Value Withdrawn.
GA-IA-1059 3D3
THE SCHEDULE
CONTRACT FACTS (continued)
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2053] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
CHANGE OF OWNER (CONT)
If ownership changes result in multiple owners of a contract or if
there has ever been multiple owners, the Guaranteed Death Benefit
shall be set to zero. If the oldest owner is age [85] or younger
at the time of the change, the Death Benefit will then be the
greatest of: (b) 1, (b) 2 or (b) 3 above.
If any owner's or oldest multiple owners, attained age is [86] or
greater at the time of the change, the Guaranteed Death Benefit will
be zero, and the Death Benefit thereafter will be the cash surrender
value.
When a change of owner reduces the Guaranteed Death Benefit to zero,
there will be a reduction in the mortality and expense risk charge.
SPOUSAL CONTINUATION UPON DEATH OF OWNER
If at the Owner's death, the surviving spouse of the deceased Owner
is the beneficiary and such surviving spouse elects to continue the
contract as their own pursuant to Internal Revenue Code Section
72(s) or the equivalent provisions of U.S. Treasury Department rules
for qualified plans, the following will apply:
(a) If the Guaranteed Death Benefit as of the date we receive due
proof of death of the Owner, minus the Accumulation Value, also as
of that date, is greater than zero we will add such difference to
the Accumulation Value. Such addition will be allocated to the
divisions of the Separate Account in proportion to the Accumulation
Value in the Separate Account. If there is no Accumulation Value in
the Separate Account, the addition will be allocated to the Liquid
Assets division, or its successor.
(b) The Guaranteed Death Benefit will continue to apply, with all
age criteria using the surviving spouse's age as the determining age.
This addition to Accumulation Value is available only to the
spouse of the owner as of the date of death of the owner if such
spouse under the provisions of this contract elects to continue
the contract as their own.
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
[Distributions from a Contract funding a qualified plan must commence
no later than [April 1st] of the calendar year following the calendar
year in which the Owner attains age 70 1/2.]
The Annuity Commencement Date is required to be the same date as the
Contract Processing Date in the month following the Annuitant's[ 90]th
birthday. In applying the Accumulation Value, we may first collect
any Premium Taxes due us.
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
Optional Benefit Riders - [None.]
GA-IA-1059 3D4
THE SCHEDULE
CHARGES AND FEES
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2053] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
DEDUCTIONS FROM PREMIUMS
[None.]
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
[None.]
Administrative Charge
[None]
Excess Allocation Charge
Currently none, however, we reserve the right to charge [$25] for a
change if you make more than [twelve] allocation changes per
Contract Year. Any charge will be deducted in proportion to the
amount being transferred from each Division.
[Premium Taxes
We deduct the amount of any premium or other state and local taxes
levied by any state or governmental entity when such taxes are
incurred.
We reserve the right to defer collection of Premium Taxes until
surrender or until application of Accumulation Value to an Annuity
Option. We reserve the right to change the amount we charge for
Premium Tax charges on future premium payments to conform with
changes in the law or if the Owner changes state of residence.]
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the
assets in each separate account division on a daily basis at a rate
of [0.001925%] (equivalent to an annual rate of [0.70%]) for
mortality and expense risks. The charge is not deducted from the
general account accumulation values.
Asset Based Administrative Charge - We deduct [0.000411%] of the
assets in each Variable Separate Account Division on a daily basis
(equivalent to an annual rate of [0.15%]) to compensate us for a
portion of our ongoing administrative expenses. This charge is not
deducted from the General Account values.
CHARGE DEDUCTION DIVISION
All charges against the Accumulation Value in this Contract will be
deducted from the [Liquid Asset Division].
GA-IA-1059 3E
THE SCHEDULE
INCOME PLAN FACTORS
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
Values for other payment periods, ages or joint life combinations
are available on request. Monthly payments are shown for each
$1,000 applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Period Monthly Fixed Period Monthly Fixed Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years 20 Years Refund
Certain Certain Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
GA-IA-1059 3F
THE SCHEDULE
CONTRACT FACTS
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
CONTRACT FACTS
Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each
year.
Specially Designated Divisions
When a distribution is made from an investment portfolio underlying
a Separate Account Division in which reinvestment is not available,
we will allocate the amount of the distribution to the [Liquid Asset
Division] unless you specify otherwise.
PARTIAL WITHDRAWALS
The maximum amount that can be withdrawn each Contract Year is
described below. In no event may a Partial Withdrawal exceed 90% of
the Cash Surrender Value. After a Partial Withdrawal, the remaining
Accumulation Value must be at least $100 to keep the Contract in
force.
Conventional Partial Withdrawals
Minimum Withdrawal Amount: $100.
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be taken on a monthly, quarterly or
annual basis. You select the day withdrawals will be made, but no
later than the 28th day of the month.
Minimum Withdrawal Amount: $100.
Maximum Withdrawal Amount:
Variable Separate Account Divisions: 1.25% monthly, 3.75%
quarterly or 15% annually of
Accumulation Value.
Guaranteed Interest Divisions: Interest earned on a Guaranteed
Interest Division for the prior month,
quarter or year (depending on the
frequency selected).
[XXX Partial Withdrawals for Qualified Plans Only
XXX Partial Withdrawals may be taken on a monthly, quarterly or
annual basis. A minimum withdrawal of $100.00 is required. You
select the day the withdrawals will be made, but no later than the
28th day of the month. If you do not elect a day, the Contract
Date will be used. Systematic Partial Withdrawals and Conventional
Partial Withdrawals are not allowed when XXX Partial Withdrawals
are being taken.]
GA-IA-1059 3D1
THE SCHEDULE
CONTRACT FACTS (continued)
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2053] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
[Alternative schedule pages option 4 death benefit]
DEATH BENEFIT
The Death Benefit is the greatest of (i) , (ii) , (iii), (iv) and
(v) below, where:
(i) the Accumulation Value;
(ii) the lesser of (a) and (b):
(a) the Guaranteed Death Benefit, and
(b) the Maximum Guaranteed Death Benefit;
(iii) the Cash Surrender Value;
(iv) the sum of premiums paid, reduced by Prorata Partial
Withdrawal Adjustment(s) for Accumulation Value withdrawn, and
(v) the Alternate Death Benefit.
GUARANTEED DEATH BENEFIT
On the Contract Date, the Guaranteed Death Benefit is the initial
premium. On subsequent Valuation Dates, the guaranteed Death
Benefit is calculated as follows:
(1) Start with the Guaranteed Death Benefit on the prior
valuation date;
(2) Calculate interest on (1) for the current valuation period
at the Guaranteed Death Benefit Interest Rate;
(3) Add (1) and (2);
(4) Add to (3) any additional premiums paid during the current
valuation period;
(5) Subtract from (4) the amount of any Special Partial
Withdrawal Adjustments and Prorata Partial Withdrawal Adjustments
for any partial withdrawals made during the current valuation
period.
Transfer of Accumulation Value to or from Special Funds will
result in a corresponding reallocation of Guaranteed Death
Benefit.
GUARANTEED DEATH BENEFIT INTEREST RATE
The Guaranteed Death Benefit Interest Rate is [7%] compounded
annually, except:
(a) For any portion of the Guaranteed Death Benefit attributable
to Accumulation Value allocated to Special Funds, the Guaranteed
Death Benefit Interest Rate is the lesser of: (1) [7%]
(compounded annually) and (2) the interest rate, positive or
negative, providing a yield on the Guaranteed Death Benefit for
Special Funds equal to the net return for the current valuation
period on the Accumulation Value allocated to Special Funds; and
(b) For any valuation period ending after the contract
anniversary on which the Owner attains age [80], or after the
Maximum Guaranteed Death Benefit has been reached, the Guaranteed
Death Benefit Interest Rate is [0%].
GA-IA-1059 3D2
THE SCHEDULE
CONTRACT FACTS (continued)
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2053] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
SPECIAL FUNDS
Special Funds are [the Liquid Assets Division, the Limited Maturity
Bond Division, the Fixed Allocations, and the Guaranteed Interest
Division]. The Company reserves the right to classify newly
available divisions as Special Funds from the date of their
availability to the Owner. The Company may reclassify an existing
division as a Special Fund or remove such designation. Such
reclassification shall be made with 30 days notice to contract
owners, and will apply to amounts transferred or otherwise added to
such division after the date of change.
MAXIMUM GUARANTEED DEATH BENEFIT
The Maximum Guaranteed Death Benefit is equal to [three] times
premium paid reduced by the amount of any Special and Prorata
Partial Withdrawal Adjustments. Any addition due to spousal
continuation will not affect the Maximum Guaranteed Death Benefit or
the Guaranteed Death Benefit.
SPECIAL AND PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS
For any partial withdrawal, the Death Benefit components will be
reduced by Prorata or Special Partial Withdrawal Adjustments. A
Prorata Partial Withdrawal Adjustment will be made unless a Special
Partial Withdrawal Adjustment applies to that component for the
withdrawal. Special Partial Withdrawal Adjustments are made when
partial withdrawals in a contract year do not exceed [7%] of the sum
of cumulative premiums but only if partial withdrawals in each prior
contract year did not exceed [7%] of the sum of cumulative premiums
paid. The Special Partial Withdrawal Adjustment is equal to the
amount of Accumulation Value withdrawn. Special Partial Withdrawal
Adjustments are applicable only in the calculation of the Maximum
Guaranteed Death Benefit and the Guaranteed Death Benefit, in all
other cases including the Alternate Guaranteed Death Benefit,
withdrawals are treated as Prorata Partial Withdrawal Adjustment.
The Prorata Partial Withdrawal Adjustment to a death benefit
component for a partial withdrawal is equal to (1) divided by (2),
multiplied by (3), where: (1) is the Accumulation Value withdrawn,
(2) is the Accumulation Value immediately prior to withdrawal, and
(3) is the amount of the applicable death benefit component
immediately prior to the withdrawal.
ALTERNATE GUARANTEED DEATH BENEFIT
On the Contract Date, the Alternate Guaranteed Death Benefit is the
initial premium. On subsequent Valuation Dates, the Alternate
Guaranteed Death Benefit is calculated as follows:
(1) Start with the Alternate Guaranteed Death Benefit from the
prior Valuation Date;
(2) Add to (1) any additional premium paid since the prior
Valuation Date and subtract from (1) any Prorata Partial Withdrawal
Adjustments for any Partial Withdrawals taken since the prior
Valuation Date.
(3) On a Valuation Date that occurs on or prior to the owner's
attained age [80], which is also a Contract Anniversary, we set the
Guaranteed Death Benefit equal to the greater of (2) or the
Accumulation Value as of such date.
On all other Valuation Dates, the Alternate Guaranteed Death Benefit
is equal to (2).
GA-IA-1059 3D3
THE SCHEDULE
CONTRACT FACTS (continued)
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2053] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
CHANGE OF OWNER
A change of Owner from a sole owner to a sole owner (where there
have never been multiple owners designated) will result in
recalculation of the Death Benefit, the Guaranteed Death Benefit
the Alternate Death Benefit, and the Maximum Guaranteed Death
Benefit. If the new owner's attained age at the time of the
change is less than [80], the Guaranteed Death Benefit, the
Alternate Death Benefit, and the Maximum Guaranteed Death Benefit
in effect prior to the change will remain in effect and the Death
Benefit provision shall apply. If the new owner's attained age at
the time of the change is [80] or greater, but not greater than
[85]:
(a) the Guaranteed Death Benefit, the Alternative Death Benefit,
and the Maximum Guaranteed Death Benefit following the change will
be zero; and
(b) the Death Benefit will then be the greatest of:
1) the cash surrender value;
2) the accumulation value prior to the date of death; and
3) the sum of the premiums paid, reduced by Prorata Partial
Withdrawal Adjustments for any Accumulation Value withdrawn.
If ownership change results in multiple owners of a contract or if
there has ever been multiple owners, the Guaranteed Death Benefit,
the Alternate Death Benefit and the Maximum Guaranteed Death
Benefit shall be set to zero. If the oldest owner is age [85] or
younger at the time of the change, the Death Benefit will then be
the greatest of: (b) 1, (b) 2 or (b) 3 above.
If any owner's or oldest multiple owner's attained age is [86] or
greater at the time of the change, the Guaranteed Death Benefit, the
Alternate Death Benefit and the Maximum Guaranteed Death Benefit
will be zero, and the Death Benefit will then be the cash surrender
value.
When a change of owner reduces the Guaranteed Death Benefit, the
Alternate Death Benefit and the Maximum Guaranteed Death Benefit to
zero, there will be a reduction in the mortality and expense risk
charge.
SPOUSAL CONTINUATION UPON DEATH OF OWNER
If at the Owner's death, the surviving spouse of the deceased Owner
is the beneficiary and such surviving spouse elects to continue the
contract as their own pursuant to Internal Revenue Code Section
72(s) or the equivalent provisions of U.S. Treasury Department rules
for qualified plans, the following will apply:
(a)If the greater of: A) the lesser of 1) the Guaranteed Death
Benefit and 2) the Maximum Guaranteed Death Benefit, or B) the
Alternate Death Benefit as of the date we receive due proof of death
of the Owner, minus the Accumulation Value, also as of that date, is
greater than zero we will add such difference to the Accumulation
Value. Such addition will be allocated to the divisions of the
Separate Account in proportion to the Accumulation Value in the
Separate Account. If there is no Accumulation Value in the Separate
Account, the addition will be allocated to the Liquid Assets
division, or its successor.
(b)The Guaranteed Death Benefit, the Alternate Death Benefit and
the Maximum Guaranteed Death Benefit will continue to apply, with
all age criteria using the surviving spouse's age as the determining
age. The Guaranteed Death Benefit shall be reallocated to the
Special and other funds in proportion to the Accumulation Value.
GA-IA-1059 3D4
THE SCHEDULE
CONTRACT FACTS (continued)
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2053] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
SPOUSAL CONTINUATION (CONT)
This addition to Accumulation Value is available only to the spouse
of the owner as of the date of death of the owner if such spouse
under the provisions of this contract elects to continue the
contract as their own.
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
[Distributions from a Contract funding a qualified plan must commence
no later than [April 1st] of the calendar year following the calendar
year in which the Owner attains age 70 1/2.]
The Annuity Commencement Date is required to be the same date as the
Contract Processing Date in the month following the Annuitant's[ 90]th
birthday. In applying the Accumulation Value, we may first collect
any Premium Taxes due us.
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
Optional Benefit Riders - [None.]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full
years elapsed since the Contract Date.
GA-IA-1059 3D5
THE SCHEDULE
CHARGES AND FEES
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2053] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
DEDUCTIONS FROM PREMIUMS
[None.]
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
[None.]
Administrative Charge
[None]
Excess Allocation Charge
Currently none, however, we reserve the right to charge [$25] for a
change if you make more than [twelve] allocation changes per
Contract Year. Any charge will be deducted in proportion to the
amount being transferred from each Division.
[Premium Taxes
We deduct the amount of any premium or other state and local taxes
levied by any state or governmental entity when such taxes are
incurred.
We reserve the right to defer collection of Premium Taxes until
surrender or until application of Accumulation Value to an Annuity
Option. We reserve the right to change the amount we charge for
Premium Tax charges on future premium payments to conform with
changes in the law or if the Owner changes state of residence.]
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the
---------------------------------
assets in each separate account division on a daily basis at a rate
of [0.002192%] (equivalent to an annual rate of [0.80%]) for
mortality and expense risks. The charge is not deducted from the
general account accumulation values.
Asset Based Administrative Charge - We deduct [0.000411%] of the
---------------------------------
assets in each Variable Separate Account Division on a daily basis
(equivalent to an annual rate of [0.15%]) to compensate us for a
portion of our ongoing administrative expenses. This charge is not
deducted from the General Account values.
CHARGE DEDUCTION DIVISION
All charges against the Accumulation Value in this Contract will be
deducted from the [Liquid Asset Division].
GA-IA-1059 3E
THE SCHEDULE
INCOME PLAN FACTORS
--------------------------------------------------------------------------
|--------------------------------------------------------------------------|
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
|--------------------------------------------------------------------------|
| Initial Premium Annuity Option Annuity Commencement Date|
| [$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026] |
|--------------------------------------------------------------------------|
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B] [123456] |
|--------------------------------------------------------------------------|
Values for other payment periods, ages or joint life combinations are
available on request. Monthly payments are shown for each $1,000
applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Period Monthly Fixed Period Monthly Fixed Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years 20 Years Refund
Certain Certain Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
GA-IA-1059 3F
