CONTRACT INFORMATION
First Insured [Xxxx Xxx] Certificate Number [NV-12345678]
Issue Age/Sex [65] [Male] Contract Date [January 1, 1999]
Rating Class [Standard] [Non-Tobacco]
Second Insured [Xxxx Xxx] Initial Death Benefit [$60,252.00]
Issue Age/Sex [65] [Female] Initial Payment [$30,000.00]
Rating Class [Standard] [Non-Tobacco] Initial Fixed Account [4.00%]
Additional Agreements
[
Last Survivor Death Benefit Agreement]
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON
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LAST SURVIVOR This is a Joint and Last Survivor Benefit Agreement for the
DEATH BENEFIT Certificate which summarizes changes in coverage under the
AGREEMENT Group Contact. The provisions summarized herein modify those
in Your Certificate of coverage. If this Agreement is
attached to Your Certificate, coverage is extended to two
Insureds. The Insured individuals are those shown on the
Contract Information page of the Certificate. The Death
Benefit under a Certificate is payable if the surviving
Insured dies while coverage under the Group Contract is in
force and before the Maturity Date. The surviving Insured is
the Insured who is living upon the death of the other
Insured under this Certificate. No Death Benefit is payable
upon the death of the first Insured to die.
DEFINITIONS
The Attained Age is an Insured's age on his or her last
birthday.
THE BENEFIT
In determining the Death Benefit, the applicable percentage
of the Account Value is based upon the Attained Age of the
younger Insured.
GUARANTEED DEATH BENEFIT
The Guaranteed Death Benefit will be in effect until the
date shown in the table below:
XXXXXXX INSURED'S EXPIRY DATE OF GUARANTEED
ISSUE AGE DEATH BENEFIT
0-39 25 Years from the Contract Date
40-59 15 Years from the Contract Date
60-85 10 Years from the Contract Date
MATURITY BENEFIT
The Maturity Date provision will be based upon the Attained
Age of the younger Insured.
REINSTATEMENT
You may reinstate the coverage under this Certificate
subject to the Reinstatement provision provided that: both
Insureds are alive; or one Insured is alive and the
termination of coverage without value occurred after the
death of the first Insured.
MISSTATEMENT OF AGE OR SEX, ASSIGNMENT
The Misstatement of Age or Sex and Assignment provisions
apply to either Insured.
OWNER
During the lifetime of both Insureds, the rights and
privileges stated in the Certificate may be exercised only
by You, the Owner.
BENEFICIARY
The Beneficiary is as named in the application on the
Contract Date of the Certificate, and may be changed from
time to time. The interest of any Beneficiary who dies
before the surviving Insured will terminate at the death of
that Beneficiary.
If no Beneficiary designation is in effect at the surviving
Insured's death, or if there is no designated Beneficiary
then living, You will be the Beneficiary. However, if the
surviving Insured was the Owner, the executors or
administrators of the Insured's estate will be the
Beneficiary.
CHANGE OF OWNERSHIP OR BENEFICIARY
You may change the Owner or any Beneficiary by Written
Request during the lifetime of either Insured. The change
will take effect as of the date the request is signed after
We acknowledge receipt in writing, whether or not the Owner
or an Insured are living at the time of acknowledgment. The
change will be subject to any assignment, and to any payment
made or action taken by Us before acknowledgment.
INCONTESTABILITY AFTER TWO YEARS
The Incontestability After Two Years provision applies to
both Insureds.
Before the end of the second year from the Contract Date of
a Certificate, We will send a notice to You requesting
notification of the death of any Insured. Failure to notify
Us of the death of either Insured will not avoid a contest
of the Group Contract.
SUICIDE WITHIN TWO YEARS
The Suicide Within Two Years provision applies to either
Insured.
COST OF INSURANCE RATE
The Cost of Insurance Rate is based on the Attained Age, sex
and rating classification of both Insureds. Pages 21 and
page 22 of this Certificate, which contain the Guaranteed
Monthly Maximum Cost of Insurance Rates, are hereby deleted
and replaced with the following:
The Guaranteed Monthly Maximum Cost of Insurance Rates are
based on the exact age and rating classification of each
Insured using the Xxxxxxx Method and the 1980 Commissioners
Standard Ordinary Mortality Table, age last birthday, on a
smoker/non-smoker basis.
A Table of the Guaranteed Monthly Maximum Cost of Insurance
Rates applicable to the Insureds named in Your application
has been printed on the Contract Information page of a
Certificate.
ACCELERATED DEATH BENEFIT
After the death of the first Insured, the Death Benefit may
be accelerated, subject to the conditions of the Accelerated
Death Benefit provision.
PAYMENT OF PROCEEDS
The Proceeds of this Certificate will be subject first to
the interest of an assignee, to whom payment will be made in
one sum. We will pay any remaining Proceeds to You before
the surviving Insured's death, and to the Beneficiary after
the surviving Insured's death.
Payment to the Beneficiary will be made only if We receive
proof, satisfactory to Us, of the death of both Insureds.
Unless otherwise provided, payment will be made in equal
shares to those Beneficiaries entitled to receive the
Proceeds.
TERMINATION OF AN INSURED'S COVERAGE
Coverage under this Agreement will terminate when one of the
following events occur:
- the surviving Insured dies;
- an Insured's coverage matures;
- the date an Insured's coverage ends without value; or
- the date an Insured's coverage is surrendered for its
Surrender Value.
2
THIS AGREEMENT AND THE CERTIFICATE
This Agreement is made a part of Your Certificate if We have
listed it on the Contract Information page of the
Certificate.
EFFECTIVE DATE
This Agreement takes effect on the Contract Date shown on
the Contract Information page for the Certificate.
/s/ Xxxxxx X. Xxxxx
PRESIDENT
3
TABLE OF GUARANTEED MONTHLY MAXIMUM COST OF INSURANCE RATES
PER $1,000 OF INSURANCE NET AMOUNT OF RISK
[MALE] [STANDARD] [NON-TOBACCO] ISSUE AGE [65]
[FEMALE] [STANDARD] [NON-TOBACCO] ISSUE AGE [65]
Attained Monthly Cost of
Age Insurance Rate
[0 -
1 -
2 -
3 -
4 -
5 -
6 -
7 -
8 -
9 -
10 -
11 -
12 -
13 -
14 -
15 -
16 -
17 -
18 -
19 -
20 -
21 -
22 -
23 -
24 -
25 -
26 -
27 -
28 -
29 -
30 -
31 -
32 -
33 -
34 -
35 -
36 -
37 -
38 -
39 -
40 -
41 -
42 -
43 -
44 -
45 -
46 -
47 -
48 -
49 -
50 -
51 -
52 -
53 -
54 -
55 -
56 -
57 -
58 -
59 -
60 -
61 -
62 -
63 -
64 -
65 0.0267
66 0.0884
67 0.1642
68 0.2559
69 0.3660
70 0.5020
71 0.6663
72 0.8666
73 1.1163
74 1.4171
75 1.7732
76 2.1831
77 2.6479
78 3.1709
79 3.7616
80 4.4380
81 5.2163
82 6.1130
83 7.1314
84 8.2628
85 9.4909
86 10.8022
87 12.1851
88 13.6300
89 15.1452
90 16.7381
91 18.4406
92 20.3084
93 22.4784
94 25.2634
95 29.2770
96 35.7275
97 46.8583
98 66.0868
99 81.9135]
For the purposes of this table, Attained Age is based upon the age of the
younger Insured.
4
[LIBERTY MUTUAL LOGO]
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LIBERTY LIFE ASSURANCE COMPANY OF BOSTON
A MEMBER OF THE LIBERTY MUTUAL GROUP
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Home Office: 000 Xxxxxxxx Xxxxxx, X.X. Box 140, Boston,
Massachusetts 02117-0140.
Service Center: 000 Xxxxxxx Xxx, Xxxxx, Xxx Xxxxxxxxx 00000-0000
READ THIS INSURANCE CONTRACT CAREFULLY
RIGHT TO RETURN
This is a legal contract between You and the Company. If You are not satisfied,
You may return it to Us or Your agent within [10] days of its receipt and any
payment will be refunded, less the amount of any partial withdrawals.
Liberty Life Assurance Company of Boston, a stock Company has issued a Modified
Single Payment Variable Life Insurance contract to the Contractholder. We will
pay the benefits provided by the Group Contract, subject to its terms and
conditions, in consideration of Your application for coverage under the Group
Contract and the receipt of Your Initial Payment. The CONTRACT GUIDE on the
inside of the front cover shows where the major Contract provisions can be
found.
This contract is a Certificate which is evidence of Your coverage under the
Group Contract. It contains a summary of the Group Contract. If there is a
conflict between this Certificate and the Group Contract, the provisions of the
Group Contract will govern.
THE AMOUNT AND DURATION OF THE DEATH BENEFIT AND OTHER VALUES PROVIDED BY THIS
CONTRACT ARE BASED ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, THE
FIXED ACCOUNT EARNINGS AND CONTRACT CHARGES. SEPARATE ACCOUNT VALUES ARE
VARIABLE AND MAY INCREASE OR DECREASE. THESE VALUES ARE NOT GUARANTEED AS TO
FIXED DOLLAR AMOUNT. THE DEATH BENEFIT IS DESCRIBED ON PAGE 4.
Signed for the Company.
/s/ Xxxxxx X. Xxxx /s/ Xxxxxx X. Xxxxx
SECRETARY PRESIDENT
CERTIFICATE DESCRIPTION
This is a GROUP MODIFIED SINGLE PAYMENT VARIABLE LIFE INSURANCE CERTIFICATE.
The Death Benefit is payable if the Insured dies while this contract is in force
and before the Maturity Date.
A Maturity Benefit is payable if the Insured is living on the Maturity Date.
Death Benefit and Account Value may vary with investment and earnings experience
and contract charges.
This contract is not eligible for Dividends.
Page
CONTRACT ASSIGNMENT 7
GUIDE CONTRACT LOANS 12
CONTRACT VALUES 8
DEATH BENEFIT 4
DEFINITIONS 3
GENERAL CONTRACT PROVISIONS 6
GRACE PERIOD 6
INCONTESTABILITY AND SUICIDE 7
INTEREST AND CHARGES 23
MATURITY BENEFIT 5
OWNER AND BENEFICIARY 7
PAYMENT OF PROCEEDS 18
PAYMENT OF PROCEEDS OPTIONS 18
PAYMENTS 5
REINSTATEMENT 6
SEPARATE ACCOUNT PROVISIONS 11
TABLE OF GUARANTEED MONTHLY MAXIMUM
COST OF INSURANCE RATES 21, 22
TABLE OF WITHDRAWAL CHARGES 23
WITHDRAWAL 13
ANY ADDITIONAL AGREEMENTS, ENDORSEMENTS
AND A COPY OF THE APPLICATION APPEAR
AFTER PAGE 23
2
DEFINITIONS This is what We mean when We use the following words in Your
contract:
ACCUMULATION UNIT. An accounting unit of measurement which
We use to calculate the value of a sub-account.
ATTAINED AGE. The Insured's age on his or her last birthday.
CONTRACT DATE. The date when insurance coverage becomes
effective.
INDEBTEDNESS. Any unpaid contract loan and unpaid loan
interest.
LOAN ACCOUNT. An account established for amounts transferred
from the sub-accounts or the Fixed Account as security for
outstanding Indebtedness.
MONTHLY DATE. The same day in each month as the Contract
Date. The day of the month on which the Monthly Deduction is
taken from Your Account Value.
NET DEATH BENEFIT. The Death Benefit, less any Indebtedness.
PROCEEDS. All or part of the amount payable under any
provision of this contract.
WRITTEN REQUEST. A notice in writing, satisfactory to Us,
placed on file at Our Service Center.
VALUATION DAY. The day when a sub-account is valued. This
occurs every day We are open and the New York Stock Exchange
is open for trading.
VALUATION PERIOD. The time period between the close of
business on successive Valuation Days.
WE, OUR, US, THE COMPANY. Liberty Life Assurance Company of
Boston.
YOU, YOUR, OWNER. The Owner of this contract, who may be
someone other than the Insured.
3
DEATH THE BENEFIT
BENEFIT If the Insured dies while this contract is in force, We will
pay a Death Benefit to the Beneficiary. The Death Benefit
will be the greater of:
- the Initial Death Benefit shown on the Contract
Information page; or
- a percentage, shown below, of the Account Value.
The Initial Death Benefit is reduced proportionately for
partial withdrawals (see page 13). We will reduce the Death
Benefit by any Indebtedness. The Death Benefit will be
determined on the date We receive proof, satisfactory to Us,
of the Insured's death. The applicable percentage is based
upon the Insured's Attained Age.
Attained Age Account Value %
40 & less 250
41 243
42 236
43 229
44 222
45 215
46 209
47 203
48 197
49 191
50 185
51 178
52 171
53 164
54 157
55 150
56 146
57 142
58 138
59 134
60 130
61 128
62 126
63 124
64 122
65 120
66 119
67 118
68 117
69 116
70 115
71 113
72 111
73 109
74 107
75-90 105
91 104
92 103
93 102
94-99 101
100 100
GUARANTEED DEATH BENEFIT
This contract has a guaranteed Death Benefit equal to the
Initial Death Benefit. In the absence of Indebtedness, this
guaranteed Death Benefit will be in effect until the date
shown in the table below:
INSURED'S ISSUE AGE EXPIRY DATE OF GUARANTEED
DEATH BENEFIT
0-34 30 Years from the Contract Date
35-54 20 Years from the Contract Date
55-80 10 Years from the Contract Date
81-85 5 Years from the Contract Date
The guaranteed Death Benefit is reduced proportionately for
partial withdrawals (see page 13).
While the Guaranteed Death Benefit is in effect, on any
Monthly Date when the Surrender Value is not sufficient to
cover the Monthly Deduction and this contract has no
Indebtedness, We will waive that insufficiency and waive all
future Monthly Deductions until the earlier of the Surrender
Value being sufficient to cover the Monthly Deductions or
the Guaranteed Death Benefit expires.
4
If the Surrender Value is not sufficient to pay the Monthly
Deduction or Loan Interest after the Guaranteed Death
Benefit has expired or this contract has Indebtedness, this
contract will enter the Grace Period. To keep this contract
in force, an amount at least as large as (A) plus (B) plus
(C) must be remitted, where:
(A) is the amount by which the Monthly Deduction is
insufficient;
(B) is the next three Monthly Deductions; and
(C) is the net loan interest for the next 3 months (net
loan interest is contract loan interest charged less
interest credited on the loan balance).
This remittance will be considered a loan repayment, unless
otherwise specified in writing. If the amount necessary to
keep this contract in force exceeds the outstanding
Indebtedness, only the Indebtedness is due. Once the
Indebtedness has been repaid, all future Monthly Deductions
will be waived until the Surrender Value is sufficient to
cover the Monthly Deductions or the Guaranteed Death Benefit
expires.
INTEREST ON DEATH BENEFIT
We will pay interest on any Death Benefit payable in one
sum. The interest rate will never be less than 3 1/2% per
year from the date of death to the date of payment, or the
rate required by applicable state law, if greater.
MATURITY BENEFIT MATURITY BENEFIT
We will pay a Maturity Benefit to You if the Insured is
living and coverage under this contract is in force on the
Maturity Date, which is the contract anniversary on or
following the Insured's 100th birthday. The amount of the
Maturity Benefit is equal to the Surrender Value.
PAYMENTS INITIAL PAYMENT
The Initial Payment is shown on the Contract Information
page and is payable on or before delivery of this contract.
The payment is payable at Our Service Center or to an
authorized agent. A copy of Your application, signed by Us
or Our authorized agent, is Your receipt for Your Initial
Payment.
SUBSEQUENT PAYMENTS
We will accept additional payments if:
- the payment is required to keep this contract in force;
or
- the payment is at least $1,000 and the payment will not
result in the disqualification of coverage under the
Group Contract as life insurance under the Internal
Revenue Code as it now exists or may later be amended.
If We accept an additional payment, evidence of insurability
satisfactory to Us will be required if an increase in the
Death Benefit occurs as a result of such payment.
PAYMENT ALLOCATION
The Initial Payment will be allocated to the Fixed Account
on the date We receive the payment.
The Account Value of the Fixed Account will then be
allocated to the sub-accounts, in whole percentages,
according to the payment allocation specified in the
application. We may delay such allocation until after the
expiration of the Right to Return period stated on the front
page of Your contract.
5
GRACE PERIOD
If this contract has Indebtedness and the Surrender Value is
insufficient to pay the Monthly Deduction and either a
contract has Indebtedness or the Guaranteed Death Benefit
has expired, a Grace Period of 61 days will be permitted for
a payment sufficient to continue this contract in force. We
will send a notice to You at Your last known address
requesting the amount due. If the required amount is not
received within 61 days, this contract will terminate
without value. If the Insured dies during a Grace Period,
the Death Benefit will be reduced by any Monthly Deductions
or Loan Interest due but not paid.
REINSTATEMENT
This contract may be reinstated within five years of the end
of the Grace Period and prior to the Maturity Date if We
receive:
- Your Written Request to reinstate this contract;
- evidence of insurability satisfactory to Us; and
- a payment equal to at least three Monthly Deductions
following the effective date of reinstatement.
If the Indebtedness is not repaid, such Indebtedness will
also be reinstated.
LIFE INSURANCE LIFE INSURANCE QUALIFICATION
QUALIFICATION Coverage under the Group Contract is intended to qualify for
treatment as life insurance under the Internal Revenue Code
as it now exists or may later be amended. We reserve the
right to amend the Group Contract and this contract to
comply with future changes in the Code and its Regulations.
Any amendments will be made by an agreement approved by the
proper regulatory authorities. We will promptly provide You
with a copy of any amendment.
We reserve the right to refuse premium payments and to
return those premium payments, in whole or in part, if
accepting them would disqualify coverage under the Group
Contract from favorable tax treatment under the Code. A
premium payment will not be refused if the payment will
prevent this contract from terminating.
GENERAL CONTRACT YOUR CONTRACT
PROVISIONS Your contract is issued in consideration of Your application
for coverage under the Group Contract and the Initial
Payment. This contract contains a summary of the terms of
the Group Contract. All statements made by the
Contractholder, or by an Owner, or an Insured are
representations and not warranties. No statement made by or
on behalf of an Insured will be used by Us to rescind the
coverage under the Group Contract, or defend a claim under
it, unless a copy of the instrument containing such
statement has been furnished to an Insured, if living,
otherwise to the Beneficiary of the coverage being
contested.
Any additional amendments to this contract, summarizing
changes to the Group Contract are shown on the Contract
Information page. These amendments are attached to and made
a part of this contract.
WAIVER
Only an officer of the Company can waive or change any
provision of the Group Contract or a contract issued under
the Group Contract, and only by means of a written
instrument.
No agent may change or waive any provision of the Group
Contract or a contract issued under the Group Contract.
We may modify the terms and conditions of the Group Contract
to conform to any new law
6
or regulation affecting the Group Contract or a contract
issued under the Group Contract. Any change to the Group
Contract or any contract agreed to between the
Contractholder and Us will not prejudice the rights of any
individual covered under the Group Contract on the effective
date of the change.
MISSTATEMENT OF AGE OR SEX
If the age or sex of the Insured has been misstated, any
Proceeds will be adjusted to that amount which the payments
paid would have purchased at the correct age and sex. Age
refers to the Insured's age last birthday on the Contract
Date.
ASSIGNMENT
Your contract may be assigned. We will not be on notice of
any assignment until a duplicate of the original assignment
is filed at Our Service Center. We assume no responsibility
for the validity or effect of any assignment, and may rely
solely on the assignee's statement of interest.
CONTRACT ANNIVERSARY
Contract years and anniversaries will be computed from the
Contract Date.
COMPLIANCE WITH LAW
If any provision of this contract is in conflict with any
applicable law, it is hereby amended to comply with the
minimum requirements of such law.
OWNER AND OWNER
BENEFICIARY The Owner is as named in the application on the Contract
Date, and may be changed from time to time. Unless otherwise
provided, the ownership rights of an individual who dies
before the Insured will belong to the surviving joint owner,
or if no joint owner, to the executors or administrators of
that individual's estate. The ownership rights of a
corporation, partnership or fiduciary will belong to its
successors or assigns.
During the Insured's lifetime, the rights and privileges
stated in this contract may be exercised only by the Owner.
BENEFICIARY
The Beneficiary is as named in the application on the
Contract Date, and may be changed from time to time. The
interest of any Beneficiary who dies before the Insured will
terminate at the death of that Beneficiary.
If no Beneficiary designation is in effect at the Insured's
death, or if there is no designated Beneficiary then living,
You will be the Beneficiary. However, if the Insured was the
Owner, the executors or administrators of the Insured's
estate will be the Beneficiary.
CHANGE OF OWNERSHIP OR BENEFICIARY
You may change the Owner or any Beneficiary by Written
Request during the Insured's lifetime. The change will take
effect as of the date the request is signed after We
acknowledge receipt in writing, whether or not You or the
Insured is living at the time of acknowledgment. The change
will be subject to any assignment, and to any payment made
or action taken by Us before acknowledgment.
INCONTESTABILITY INCONTESTABILITY AFTER TWO YEARS
AND SUICIDE In the absence of fraud, an Insured's coverage under this
contract will be incontestable after it has been in force
during the Insured's lifetime;
- with respect to the Initial Death Benefit, for two
years from the Contract Date; and
7
- with respect to each increase in the Initial Death
Benefit, for two years from the effective date of that
increase.
SUICIDE WITHIN TWO YEARS
If the Insured dies by suicide within two years from the
Contract Date, while sane or insane, the amount payable
under this contract will be limited to the greater of the
Account Value less Indebtedness or the minimum value
required by the state where this contract was issued for
delivery.
CONTRACT VALUES ACCOUNT VALUE
Your Account Value on the Contract Date is equal to the
Initial Payment less the Monthly Deduction for the first
contract month.
On each Monthly Date, Your Account Value equals:
- the sum of the value of Your Accumulation Units in the
sub-accounts; plus
- Your Account Value in the Fixed Account; plus
- the value of Your Loan Account, if any; minus
- the Monthly Deduction.
On each Valuation Day, other than a Monthly Date, Your
Account Value equals:
- the sum of the value of Your Accumulation Units in the
sub-accounts; plus
- Your Account Value in the Fixed Account; plus
- the value of Your Loan Account, if any.
CASH VALUE
A Withdrawal Charge will be subtracted from the Account
Value to determine the Cash Value. The Withdrawal Charges
are shown on the Interest and Charges page.
SURRENDER VALUE
Your Surrender Value is equal to Your Cash Value, minus the
Contract Fee, and minus any Indebtedness.
ACCOUNT VALUE IN FIXED ACCOUNT
The Account Value in the Fixed Account on the Contract Date
is equal to the Initial Payment less the Monthly Deduction
for the first contract month.
On each Monthly Date, the Account Value in the Fixed Account
is equal to:
- the Account Value in the Fixed Account on the preceding
Monthly Date with one month's interest; plus
- the Account Values transferred to the Fixed Account
since the preceding Monthly Date and interest from the
date the Account Value is transferred to the Monthly
Date; minus
- the Account Values transferred from the Fixed Account
since the preceding Monthly Date and interest from the
date the Account Value is transferred to the Monthly
Date; minus
- all withdrawals from the Fixed Account since the
preceding Monthly Date plus interest from the date of the
withdrawal to the Monthly Date; minus
- the portion of the Monthly Deduction allocated to the
Account Value in the Fixed Account, to cover the
contract month following the Monthly Date.
8
On any date other than a Monthly Date, the Account Value
will be calculated on a consistent basis.
SUB-ACCOUNT VALUES
Amounts allocated to sub-accounts are applied to provide
Accumulation Units in each sub-account. An Accumulation Unit
is used to calculate the value of a sub-account. The number
of Accumulation Units credited to each sub-account is
determined by dividing the amount allocated to a sub-account
by the dollar value of one Accumulation Unit for such
sub-account. The number of Your Accumulation Units is not
affected by any subsequent change in the value of the units.
The Accumulation Unit values in each sub-account may
increase or decrease daily.
SUB-ACCOUNT ACCUMULATION UNIT VALUE
The Accumulation Unit value for each sub-account will vary
to reflect the investment experience of the applicable
sub-account and will be determined on each Valuation Day by
multiplying the Accumulation Unit value of the particular
sub-account on the preceding Valuation Day by a net
investment factor for that sub-account for the Valuation
Period then ended. The net investment factor for each
sub-account is equal to the net asset value per share of the
corresponding investment at the end of the Valuation Period
(plus the per share amount of any dividend or capital gain
distributions paid by that investment in the Valuation
Period then ended) divided by the net asset value per share
of the corresponding investment at the beginning of the
Valuation Period, less the Separate Account Expense Charge.
While We are not currently making a provision for current
taxes, any new taxes or increase in taxes attributable to
the operations of the Separate Account, We reserve the right
to deduct such a charge from the Accumulation Unit value.
SUB-ACCOUNT ACCUMULATION VALUE
Your accumulation value in any sub-account equals:
- the number of Your Accumulation Units in that sub-account
on the Valuation Day;
- multiplied by that sub-account's Accumulation Unit value
on the Valuation Day.
EMERGENCY PROCEDURE
With the exception of weekends or holidays, if a national
stock exchange is closed, or trading is restricted due to an
existing emergency as defined by the Securities and Exchange
Commission (SEC) so that We cannot value the sub-accounts,
or as otherwise ordered by the SEC, We may postpone all
procedures which require valuation of the sub-accounts until
valuation is possible. Any provision of this contract which
specifies a Valuation Day will be superseded by the
emergency procedure.
COST OF INSURANCE
The Cost of Insurance is determined on the Monthly Date and
is computed as follows:
- Divide the Death Benefit on the first day of the
contract month by 1 plus the Guaranteed Monthly
Equivalent Interest Rate shown on the Interest and
Charges page;
- Reduce the result by the Account Value on that day
before computing the Monthly Deduction for the Cost of
Insurance; and
- Multiply the difference by the Cost of Insurance Rate
for that month divided by 1000.
COST OF INSURANCE RATE
The Cost of Insurance Rate is the rate applied to the
insurance under this contract to determine the Cost of
Insurance. It is based on the Attained Age, sex and rating
9
classification of the Insured. The Cost of Insurance Rate
will not be greater than the guaranteed rates shown in the
Table of Guaranteed Monthly Maximum Cost of Insurance Rates
(see pages 21 and 22).
MONTHLY DEDUCTION
A Monthly Deduction is made for the Cost of Insurance,
Contract Fee, the Expense Charge on the Fixed Account and
the cost of any Additional Benefit Agreements. The Monthly
Deduction for a contract month will be calculated by adding:
- the Contract Fee, if due;
- the Expense Charge on the Fixed Account;
- the Cost of Insurance for the contract month; and
- the cost for the contract month of any Additional
Benefits.
The Expense Charge on the Fixed Account will be deducted
from Your Fixed Account balance. The remainder of the
Monthly Deduction for a contract month will be allocated
among the Fixed Account and the sub-accounts of the Separate
Account in proportion to the Account Value in each account.
When determining these proportions, the Account Values are
used net of any Indebtedness at the beginning of the month.
The Monthly Deduction for each date that falls on a contract
anniversary also includes the Contract Fee.
CONTRACT FEE
On each contract anniversary, the Contract Fee shown on the
Interest and Charges page will be deducted from the Fixed
Account and the sub-accounts in proportion to the Account
Value in each account. The Contract Fee is also deducted
upon full surrender of this contract.
FIXED ACCOUNT EXPENSE CHARGE
On each Monthly Date, an expense charge equal to the monthly
equivalent of the annual rate as shown on the Interest and
Charges page is deducted from the Fixed Account.
INTEREST RATES
The Guaranteed Interest Rate for the Fixed Account is shown
on the Interest and Charges page. Interest rates are
expressed as effective annual rates. The rate is compounded
daily and is used to calculate Account Values of the Fixed
Account. We may credit interest in excess of the Guaranteed
Interest Rate. Such excess interest will be at Our sole
discretion.
The Account Value allocated to the Fixed Account will be
guaranteed and the rate of interest will be guaranteed for
at least the balance of the contract year. We determine
interest rates in accordance with market conditions and
other factors. We may change the rate guaranteed on new
allocations at any time. This may cause the guaranteed
interest rate on Account Values at the beginning of a
contract year to differ from the guaranteed rate on values
transferred in at a later date. Once We guarantee an
interest rate for an amount in the Fixed Account, We will
not change it until the end of the current guarantee period.
Interest on Indebtedness will be credited on each contract
anniversary at the Guaranteed Interest Rate for the Fixed
Account, as shown on the Interest and Charges page.
BASIS OF VALUES
The method used in computing Account Values and reserves in
the Separate Account is in accordance with actuarial
procedures that recognize the variable nature of the
Separate Account. A detailed statement of the method of
computing values has been filed with the Insurance
Department of the state in which the Group Contract was
issued for delivery. All
10
contract values are equal to or in excess of the minimum
values required and all comply with the laws of that state.
SEPARATE ACCOUNT SEPARATE ACCOUNT
PROVISIONS The assets of the Separate Account will be used to provide
values and benefits under this contract and any similar
policies. The assets of the Separate Account are owned by Us
and cannot be charged with liabilities which may arise from
any other business the Company may conduct. The assets of
the Separate Account are not part of Our general account. We
may transfer to Our general account any assets of the
Separate Account which exceed the reserves and other
contract liabilities of the account. Unless otherwise
permitted by law, the investment policy of the Separate
Account will not be changed without the express or deemed
approval of the state where this contract was issued for
delivery.
INVESTMENT ALLOCATIONS
The Separate Account is divided into several sub-accounts.
We use amounts allocated to a sub-account to buy shares or
units of the investment option shown in the prospectus for
that sub-account. The Initial Payment is initially allocated
to the Fixed Account. Subsequently, the payment will be
allocated as You requested in the application. We may delay
such allocation until after the expiration of the Right to
Return period stated on the front page of Your contract.
SUBSTITUTION
We may substitute another underlying investment without Your
consent. Substitution would occur if We determine that the
use of such underlying investment is no longer possible or
if We determine it is no longer appropriate for the purposes
of this contract. No substitution will be made without
notice to You and without the prior approval of the SEC and
the state where this contract was issued for delivery, if
required. Should a substitution, addition or deletion occur,
You will be allowed to select from the then current
sub-accounts and substitution may be made with respect to
both existing payments and the investment of future
payments.
TRANSFERS
You may transfer Account Values among the sub-accounts or
from the sub-accounts into the Fixed Account, upon request.
The value transferred from any sub-account must be at least
$250 or the entire balance, if less. The Account Value
remaining in a sub-account after any transfer must be at
least $500. If the balance remaining in a sub-account as a
result of a transfer is less than $500, We may require You
to transfer the entire balance.
Transfers may be subject to a transfer charge. This charge
will not exceed $25. A transfer of all of the Account Value
from the Separate Account to the Fixed Account will not be
subject to a transfer charge.
Transfers from the Fixed Account to the sub-accounts must
occur within 60 days after each contract anniversary. The
largest amount that may be transferred out in each contract
year is the greater of the amount transferred in the prior
contract year or 20% of the balance in the Fixed Account. A
transfer of all of the Account Value from the Separate
Account to the Fixed Account will not be subject to a
transfer charge.
We may modify the transfer privilege at any time, upon
approval of the Insurance Department of the state in which
this contract was issued for delivery.
SEPARATE ACCOUNT EXPENSE CHARGE
On each Valuation Day, an expense charge equal to the daily
equivalent of the annual rate as shown on the Interest and
Charges page is deducted proportionately from the
sub-accounts.
11
REPORTS ANNUAL REPORT
At least once each year, We will send You a report which
shows:
- the current Death Benefit;
- the current Account Value;
- the current Cash Value;
- the Payments paid;
- investment gain/loss;
- any Indebtedness;
- the Cost of Insurance;
- the Expense Charge;
- the current Surrender Value; and
- any other information required by the state in which
the Group Contract was issued for delivery.
ILLUSTRATION OF BENEFITS
During any contract year, We will provide You with one
illustration of hypothetical future Account Values and Death
Benefits at any time upon Written Request. We may charge a
reasonable fee for any subsequent illustrations during the
same contract year. However, the fee will not be greater
than $25.
CONTRACT LOANS LOANS
Your contract has a Loan Value which is equal to 90% of the
Cash Value (see page 8) as of the date of the loan. Loans
must be at least $250. You may borrow the Loan Value by
assigning this contract to Us as security for the loan. The
assignment form must be satisfactory to Us. Loans may be
made at any time while an Insured is covered under this
contract. We may defer the granting of a loan for up to 6
months.
You may decide the proportions in which to allocate the
contract loan among the sub-accounts of the Separate
Account. If You do not specify the allocation, then the
contract loan will be allocated among the sub-accounts of
the Separate Account and the Fixed Account in proportion to
the Account Value in each account. The Account Value equal
to the portion of the contract loan allocated to a
sub-account and the Fixed Account will be transferred from
that sub-account and the Fixed Account to the Loan Account
and the Account Value in that sub-account and the Fixed
Account will be reduced by the amount transferred. If loan
interest is not paid when due, an amount of Account Value
equal to the loan interest will also be transferred.
If on any contract anniversary, this contract's Indebtedness
exceeds the Account Value in the Loan Account, We will
transfer Account Value equal to the excess Indebtedness from
the Fixed Account and the sub-accounts of the Separate
Account to the Loan Account as security for the excess debt
in the same manner as the original loan. We will not delay a
policy loan if it is needed to pay premiums on policies with
Us.
PREFERRED LOAN
The amount available for a Preferred Loan is the earnings of
this contract since its inception.
Earnings equals (A) minus (B) minus (C) minus (D) plus (E);
where
(A) is the Account Value;
(B) is total payments made;
(C) is the preferred loan balance;
(D) is accrued loan interest; and
12
(E) is all prior partial withdrawals in excess of earnings.
LOAN INTEREST
Interest on contract loans equals the Guaranteed Interest
Rate For the Fixed Account, as shown on the Interest and
Charges page, plus 2%. Interest on Preferred Loans equals
the Guaranteed Interest Rate For the Fixed Account, as shown
on the Interest and Charges page. Interest will accrue daily
from the date of the loan, and is due on each contract
anniversary. Unpaid interest will be added to existing
Indebtedness, and will accrue interest at the same rate. If
the total Indebtedness on this contract equals or exceeds
the Cash Value, this contract will enter the Grace Period.
REPAYMENT
While this contract is in force during the Insured's
lifetime, any loan may be repaid in whole or in part. When a
loan repayment is made, the Account Value in the Loan
Account will be reduced by the loan repayment, and this
amount will be allocated proportionately among the Fixed
Account and sub-accounts of the Separate Account.
WITHDRAWAL WITHDRAWAL
You may withdraw from this contract its full Surrender Value
upon Written Request at any time during the lifetime of the
Insured and while an Insured is covered under the Group
Contract. Upon withdrawal of the full Surrender Value, this
contract will terminate.
You may also make a partial withdrawal under this contract.
Partial withdrawals must be at least $250. For any partial
withdrawal after the first in any contract year, We may
charge a transaction fee of the lesser of $25 or 2% of the
amount of the partial withdrawal. You may select the
sub-accounts from which to deduct the amount of the partial
withdrawal. If You do not indicate where the funds will be
deducted from, the amount of the partial withdrawal will be
deducted on a pro rata basis from the sub-accounts and the
Fixed Account. The Initial Death Benefit is reduced on the
date of the partial withdrawal in the same proportion that
the Account Value was reduced. If a partial withdrawal less
any applicable Withdrawal Charge, as described below,
reduces the Account Value to below Our current minimum, then
the withdrawal request will be treated as a request to
withdraw the full Surrender Value.
We may defer the payment of Your withdrawal from the Fixed
Account for up to 6 months.
WITHDRAWAL CHARGE
Unless waived by Us, a Withdrawal Charge will be deducted
from the Account Value in the event of a withdrawal.
For a full withdrawal, the Withdrawal Charge is calculated
by multiplying (B) by (C) and subtracting the product from
(A), where:
(A) is the Initial Payment multiplied by the applicable
percentage rate from the Table of Withdrawal Charges;
(B) is each previous withdrawal charge collected; and
(C) is the Withdrawal Charge percentage in effect at the
time of a full withdrawal divided by the Withdrawal
Charge percentage at the time each withdrawal was made.
For a partial withdrawal, the Withdrawal Charge is
calculated by multiplying the applicable percentage rate
from the Table of Withdrawal Charges by the amount of the
partial withdrawal. The total of the Withdrawal Charges in a
contract year may not be greater than the applicable
percentage rate from the Table of Withdrawal Charges
multiplied by the portion of the Initial Payment not
previously withdrawn as of the beginning of the contract
year.
13
WAIVER OF WITHDRAWAL CHARGE
We will waive the Withdrawal Charge on that portion of a
withdrawal not exceeding the greater of:
- 10% of the Account Value less any prior partial
withdrawals and Preferred Loans taken during the
contract year; or
- the earnings of the contract since its inception (see
page 12).
We will also waive the Withdrawal Charge in the event of a
Qualifying Medical Stay. To qualify for this waiver:
- the Insured must have a Qualifying Medical Stay which
begins after the first contract year and lasts at least
45 days during any continuous 60 day period; or
- the Insured's spouse must have a Qualifying Medical
Stay which begins after the first contract year and
lasts at least 45 days during any continuous 60 day
period; and
- You must mail Your Written Request for this waiver,
together with proof, satisfactory to Us, of the stay,
within 180 days of initial eligibility.
If the Insured's spouse had a Qualifying Medical Stay within
45 days prior to the Contract Date, a waiver of the
Withdrawal Charge will not be considered for the Insured's
spouse, until the later of:
- 6 months from the date of the last Qualifying Medical
Stay; or
- the first contract anniversary.
Qualifying Medical Stay means: 1) confinement in a
Qualifying Institution; and 2) treatment by a Qualifying
Medical Professional.
Qualifying Institution means a licensed hospital or licensed
skilled or intermediate care nursing facility at which: 1)
medical treatment is available on a daily basis; and 2)
daily medical records are kept on each patient. It does not
include: 1) a facility whose purpose is to provide
accommodations, board or personal care services to
individuals who do not need medical or nursing care; or 2) a
place mainly for rest.
A Qualifying Medical Professional is a legally qualified
practitioner of the healing arts who is: 1) acting within
the scope of his or her license; 2) not a resident of Your
household; and 3) not a member of Your immediate family
(children, grandchildren, parents, grandparents, siblings
and their spouses).
Treatment means the rendering of medical care or advice
related to a specific medical condition. Treatment includes
diagnosis and subsequent care. It does not include routine
monitoring unless medically necessary.
ACCELERATED THE RECEIPT OF AN ACCELERATED DEATH BENEFIT MAY BE TAXABLE.
DEATH BENEFIT YOU SHOULD CONSULT YOUR PERSONALTAX OR LEGAL ADVISOR BEFORE
PROVISIONS APPLYING FOR THIS BENEFIT.
THE DEATH BENEFIT, ACCOUNT VALUE AND LOAN VALUE WILL BE
REDUCED IF AN ACCELERATED DEATH BENEFIT IS PAID.
ACCELERATED DEATH BENEFIT
If, while this contract is in force, We receive proof,
satisfactory to Us, that the Insured
14
either:
(1) has a Terminal Condition; or
(2) is Chronically Ill;
We will pay a portion of the contract's Death Benefit to You
as an Accelerated Death Benefit.
The balance of the Death Benefit is payable upon the
Insured's Death. Only one Accelerated Death Benefit payment
is payable under this contract.
DEFINITION OF TERMINAL CONDITION
Terminal Condition means a medical condition which is
expected to result in the Insured's death within 24 months
from the date of the medical certification submitted to Us
in connection with the application for the Accelerated Death
Benefit and from which there is no reasonable prospect of
recovery. Such Terminal Condition must be certified by a
physician who meets the definition of a physician under
Section 101(g) of the Internal Revenue Code.
DEFINITION OF CHRONICALLY ILL
Chronically Ill means any Insured who has been certified by
a licensed health care practitioner within the last 12
months as:
(1) being unable to perform, without substantial assistance
from another individual, at least two activities of
daily living for a period of at least 90 days due to a
loss of functional capacity; or
(2) requiring substantial supervision to protect such
individual from threats to health and safety due to
severe cognitive impairment.
Such licensed health care practitioner must meet the
definition of a licensed health care practitioner under
Section 7702B(c) of the Internal Revenue Code.
ACTIVITIES OF DAILY LIVING
The activities of daily living prescribed in item (1) above
are:
- eating
- toileting
- transferring
- bathing
- dressing
- continence
AMOUNT OF ACCELERATED DEATH BENEFIT
We first calculate the Benefit Base, which equals the Death
Benefit as defined in the DEATH BENEFIT section of this
contract (before subtracting any Indebtedness).
We then calculate the Maximum Available Accelerated Death
Benefit by multiplying the Benefit Base by 90%.
You may elect all or a portion of this Maximum Available
Accelerated Death Benefit. However, the amount elected may
not be less than $10,000, nor greater than $250,000.
Additionally, the Initial Death Benefit for this contract
remaining in force must be no less than $10,000.
You will receive less than the amount You elect because We:
(1) discount the amount You receive because it is an early
payment;
(2) deduct a processing fee, not to exceed $100; and
(3) repay and reduce any Indebtedness by the percentage of
Death Benefit accelerated.
15
In discounting the amount You elect, We will assume that the
Death Benefit would have been paid 24 months after the date
the Accelerated Death Benefit is paid. The discount rate
will equal the greater of:
(1) the current yield on 90 day treasury bills; or
(2) the current maximum statutory adjustable contract loan
interest rate based on the greater of:
(a) Moody's Corporate Bond Yield Averages-Monthly
Average Corporates-published by Xxxxx'x Investors
Services, Inc., or any successor thereto for the
calendar month ending two months before the date of
application for an accelerated payment; and (b) the
contract's Guaranteed Annual Interest Rate for the
Fixed Account rate plus 1%.
No Withdrawal Charge will apply when You receive an
Accelerated Death Benefit.
TERMINAL CONDITION OPTION
This option provides that the Accelerated Death Benefit will
be paid to You in equal monthly installments for 12 months.
For each $1,000 of Accelerated Death Benefit, each payment
will be at least $84.65. This assumes an annual interest
rate of 3.5%.
If the Insured dies before all the payments have been made,
We will pay the Beneficiary in one sum. The one sum payment
will be the present value of the payments that remain. We
will compute the value based on the interest rate We used to
determine those payments.
If You do not want monthly payments, We will pay You the
Accelerated Death Benefit in one sum, upon Written Request.
Such payment will be calculated described in the Amount of
Accelerated Death Benefit provision.
CHRONICALLY ILL PAYMENT OPTION
This option provides level monthly payments for the number
of years shown in the table that follows. For each $1,000 of
Accelerated Death Benefit, each payment will be at least the
minimum amount shown in the table. The table uses an annual
interest rate of 3.5%; We may use a higher rate.
ATTAINED PAYMENT MINIMUM MONTHLY
AGE OF PERIOD IN PAYMENT FOR EACH
INSURED YEARS $1,000 OF DISCOUNTED BENEFIT
64 and under 10 $ 9.83
65-67 8 $11.90
68-70 7 $13.38
71-73 6 $15.35
74-77 5 $18.12
78-81 4 $22.27
82-86 3 $29.19
87 and over 2 $43.05
If the Insured dies before all the payments have been made,
We will pay the beneficiary in one sum. The one sum We pay
will be the present value of the payments that remain. We
will compute the value based on the interest rate We used to
determine those payments.
If We agree, You may choose a longer payment period than
that shown in the table; if You do, monthly payments will be
reduced so that the present value of the payments is the
same. We will use an interest rate of at least 3.5%.
We reserve the right to set a maximum monthly benefit that
We will pay under this option.
16
If We do so, it will be at least $5,000.
If You do not want monthly payments, We will pay You the
Accelerated Death Benefit in one sum, upon Written Request.
Such payment will be calculated as described in the Amount
of Accelerated Death Benefit provision with the exception of
the period over which the payment will be discounted. The
lump sum payment will be discounted over a period not less
than the Payment Period in Years section of this provision.
If the Insured dies before the end of the discount period,
We will recalculate the Accelerated Benefit based upon the
number of years between the end of the discount period and
the date of death. The Beneficiary will be paid the
difference between this recalculated amount and the amount
that was received, minus the processing fee.
EFFECT ON THIS CONTRACT
When We pay the Accelerated Death Benefit, We will calculate
a percentage which equals:
(1) the amount You elect to receive (before any
reductions); divided by
(2) the Benefit Base.
We will reduce by that percentage:
(1) the Initial Death Benefit;
(2) the Account Value; and
(3) any Indebtedness.
Any future Monthly Deductions, Cost of Insurance charges, or
Withdrawal Charges will be based on the reduced amount of
insurance.
Once We approve Your claim, We will send You a new Contract
Information page with these changes. The subsequent payment
of a Death Benefit or Maturity Benefit of this contract will
constitute full settlement of the obligations of the Group
Contract and of this contract.
CONDITIONS
Your right to receive the Accelerated Death Benefit is
subject to the following conditions:
(1) We must receive evidence, satisfactory to Us, of the
Insured's eligibility for this Benefit. Evidence
satisfactory to Us, may include, but is not limited to:
- the records of the Insured's attending physician,
including a prognosis of the Insured;
- all pertinent facts concerning the Insured's health;
and
- a medical examination of the Insured conducted by a
physician chosen by Us and at Our expense. If there
is a difference of opinion as to the prognosis of
the Insured, the opinion of a licensed physician,
acceptable to both Us and the Insured, will control.
(2) You must choose the option in writing in a form that
meets Our needs.
(3) If You have assigned all or a portion of this contract,
You must also give Us a signed consent form from the
assignee.
(4) All beneficiaries must consent in writing to the
payment of the Accelerated Death Benefit on the date
the Benefit is requested.
(5) You must send Us this contract.
EXCEPTIONS
This Benefit will not be paid if:
(1) the Insured is required by a governmental agency to
claim this Benefit in order to apply for, receive, or
continue a government benefit or entitlement;
(2) the Insured is required by law to use this Benefit to
meet the claims of creditors, whether in bankruptcy or
otherwise;
17
(3) all or part of this contract's Death Benefit must be
paid to the Insured's children or spouse or former
spouse as part of a divorce decree, separate
maintenance or property settlement contract; or
(4) the Insured is married and lives in a community
property state, unless the Insured's spouse has given
Us signed written consent.
TERMINATION TERMINATION OF AN INSURED'S COVERAGE
An Insured's coverage under the Group Contract will
terminate when one of the following events occur:
- an Insured dies;
- an Insured's coverage matures;
- the date an Insured's coverage ends without value; or
- the date an Insured's coverage is surrendered for its
Surrender Value.
CONTINUATION OF INSUREDS' COVERAGE AFTER DISCONTINUANCE
If the Group Contract is discontinued, any insurance then in
effect will remain in force under this contract, provided it
is not cancelled or surrendered by the Owner.
DELAY OF PAYMENT
We will pay Surrender Values, withdrawals and contract loans
allocated to the Separate Account within seven days after We
receive Your Written Request. We will pay death Proceeds
allocated to the Separate Account within seven days, only
after We receive Your Written Request and receive proof,
satisfactory to Us, of the Insured's death. Payment may be
delayed if:
- the New York Stock Exchange is closed on other than
customary weekend and holiday closings or trading on
the New York Stock Exchange is restricted as determined
by the SEC; or
- an emergency exists, as determined by the SEC, as a
result of which disposal of securities is not
reasonably practicable to determine the value of the
sub-accounts; or
- the SEC, by order, permits postponement for the
protection of contract owners.
PAYMENT OF PAYMENT
PROCEEDS The Proceeds of this contract will be subject first to the
interest of an assignee, to whom payment will be made in on
sum. We will pay any remaining Proceeds to You before the
Insured's death, and to the Beneficiary after the Insured'se
death.
Payment to the Beneficiary will be made only if We receive
proof, satisfactory to Us, of the Insured's death. Unless
otherwise provided, payment will be made in equal shares to
those Beneficiaries entitled to receive the Proceeds.
PAYMENT OF PAYMENT OF PROCEEDS OPTIONS
PROCEEDS The Proceeds may be applied under one of the following
OPTIONS Options. An Option must be selected by Written Request. You
may select an Option during the Insured's lifetime. If You
have not selected an Option before the Insured's death, the
Beneficiary may choose one. We will not permit surrenders or
partial withdrawals after payments under a proceeds option
involving life contingencies commence.
THE OPTIONS
1. INTEREST. We will pay interest monthly on Proceeds left
on deposit with Us. We will declare the interest rate each
year. It will never be less than 3 1/2% a year.
2. FIXED AMOUNT. We will pay equal monthly installments,
first payment immediately, until the Proceeds and the
interest have been exhausted. Interest will be credited on
unpaid
18
balances at the rate which We will declare each year. It
will never be less than 3 1/2%, compounded annually.
3. FIXED PERIOD. We will pay equal monthly installments,
first payment immediately, for not more than 25 years. The
minimum amount of each installment may be determined from
the OPTION 3 TABLE on page 20. This Table is based on a
guaranteed interest rate of 3 1/2%, compounded annually.
4. LIFE INCOME. We will pay equal monthly installments,
first payment immediately, for the lifetime of the payee
with or without a guaranteed period. The minimum amount of
each installment may be determined from the OPTION 4 TABLE
on page 20. This table is based on the 1983a Individual
Annuity Mortality Table, adjusted to include 10 years of
mortality improvement under Projection Scale G. Installment
payments for ages not listed in the table will be provided
upon request. This Table is based on a guaranteed interest
rate of 3 1/2%, compounded annually. The guaranteed period
selected may be: (1) 10 years; (2) 15 years; or (3) 20
years.
5. OTHER PAYMENT. We will pay the Proceeds in any other
manner that may be mutually agreed upon.
AVAILABILITY
No Option may be selected unless the amount to be applied is
more than $2,000 and will provide an installment payment of
at least $20. Unless We consent, these Options will not be
available if the payee is an assignee, administrator,
executor, trustee, association, partnership or corporation.
ADDITIONAL INTEREST
At Our discretion, additional interest may be declared
annually on all Payment Options. This interest will lengthen
the period under Option 2, and increase the installment
amounts under Options 3 and 4.
19
OPTION 3 TABLE
MINIMUM MONTHLY INSTALLMENT PAYMENT PER $1,000 APPLIED
-------------------------------------------------------------------------------------------------------------------------
Number Monthly Number Monthly Number Monthly Number Monthly Number Monthly
of Years Payment of Years Payment of Years Payment of Years Payment of Years Payment
-------------------------------------------------------------------------------------------------------------------------
1 $ 84.65 6 $ 15.35 11 $ 9.09 16 $ 6.76 21 $ 5.56
-------------------------------------------------------------------------------------------------------------------------
2 43.05 7 13.38 12 8.46 17 6.47 22 5.39
-------------------------------------------------------------------------------------------------------------------------
3 29.19 8 11.90 13 7.94 18 6.20 23 5.24
-------------------------------------------------------------------------------------------------------------------------
4 22.27 9 10.75 14 7.49 19 5.97 24 5.09
-------------------------------------------------------------------------------------------------------------------------
5 18.12 10 9.83 15 7.10 20 5.75 25 4.96
-------------------------------------------------------------------------------------------------------------------------
OPTION 4 TABLE
MINIMUM MONTHLY INSTALLMENT PAYMENT PER $1,000 APPLIED
----------------------------------------------------------------------------------------------------------------------------------
MALE FEMALE
----------------------------------------------------------------------------------------------------------------------------------
No Guaranteed Guaranteed Guaranteed No Guaranteed Guaranteed Guaranteed
Guaranteed Period Period Period Guaranteed Period Period Period
Age Period 10 Years 15 Years 20 Years Age Period 10 Years 15 Years 20 Years
----------------------------------------------------------------------------------------------------------------------------------
50 $ 4.45 $ 4.41 $ 4.36 $ 4.29 50 $ 4.11 $ 4.09 $ 4.07 $ 4.04
51 4.52 4.47 4.42 4.34 51 4.16 4.15 4.12 4.09
52 4.59 4.55 4.48 4.40 52 4.22 4.20 4.18 4.14
53 4.67 4.62 4.55 4.45 53 4.29 4.27 4.24 4.19
54 4.76 4.70 4.62 4.51 54 4.36 4.33 4.30 4.24
55 4.85 4.78 4.70 4.57 55 4.43 4.40 4.36 4.30
56 4.94 4.87 4.77 4.63 56 4.50 4.47 4.42 4.36
57 5.04 4.96 4.85 4.70 57 4.58 4.54 4.49 4.42
58 5.15 5.06 4.93 4.76 58 4.67 4.62 4.57 4.48
59 5.26 5.16 5.02 5.82 59 4.76 4.71 4.64 4.55
60 5.39 5.26 5.11 4.89 60 4.85 4.80 4.72 4.61
61 5.52 5.38 5.20 4.95 61 4.95 4.89 4.81 4.68
62 5.66 5.50 5.29 5.01 62 5.06 4.99 4.89 4.75
63 5.80 5.62 5.39 5.08 63 5.18 5.10 4.98 4.82
64 5.96 5.75 5.49 5.14 64 5.30 5.21 5.08 4.89
65 6.14 5.89 5.58 5.20 65 5.43 5.32 5.18 4.96
66 6.32 6.03 5.68 5.26 66 5.57 5.45 5.28 5.03
67 6.51 6.18 5.78 5.31 67 5.72 5.58 5.38 5.10
68 6.72 6.33 5.88 5.37 68 5.89 5.72 5.49 5.17
69 6.94 6.49 5.98 5.42 69 6.06 5.86 5.60 5.23
70 7.18 6.65 6.08 5.46 70 6.25 6.01 5.71 5.30
71 7.44 6.82 6.18 5.50 71 6.45 6.18 5.82 5.36
72 7.71 6.99 6.27 5.54 72 6.67 6.34 5.93 5.41
73 7.99 7.16 6.36 5.58 73 6.91 6.52 6.04 5.46
74 8.30 7.33 6.44 5.61 74 7.17 6.70 6.15 5.51
75 8.63 7.51 6.52 5.63 75 7.45 6.89 6.26 5.55
76 8.99 7.68 6.60 5.66 76 7.75 7.08 6.36 5.59
77 9.37 7.86 6.67 5.68 77 8.08 7.28 6.45 5.62
78 9.77 8.03 6.73 5.69 78 8.43 7.48 6.54 5.65
79 10.21 8.19 6.79 5.71 79 8.81 7.68 6.62 5.67
80 10.67 8.36 6.84 5.72 80 9.22 7.88 6.70 5.69
----------------------------------------------------------------------------------------------------------------------------------
20
TABLE OF GUARANTEED MONTHLY MAXIMUM COST OF INSURANCE RATES
PER $1,000 OF INSURANCE NET AMOUNT AT RISK
NON-TOBACCO
Attained Monthly Cost of Insurance Rate
Age
Male Female
0 0.2193 0.1567
1 0.0859 0.0701
2 0.0826 0.0667
3 0.0809 0.0651
4 0.0776 0.0642
5 0.0734 0.6254
6 0.0692 0.0609
7 0.0651 0.0592
8 0.0626 0.0584
9 0.0617 0.0576
10 0.0626 0.0567
11 0.0676 0.0584
12 0.0767 0.0609
13 0.0892 0.0642
14 0.1034 0.0684
15 0.1134 0.0717
16 0.1234 0.0751
17 0.1309 0.0776
18 0.1359 0.0801
19 0.1392 0.0826
20 0.1401 0.0842
21 0.1384 0.0859
22 0.1359 0.0867
23 0.1326 0.0884
24 0.1292 0.0901
25 0.1251 0.0917
26 0.1226 0.0942
27 0.1209 0.0959
28 0.1201 0.0984
29 0.1201 0.1017
30 0.1209 0.1042
31 0.1234 0.1076
32 0.1267 0.1109
33 0.1317 0.1151
34 0.1376 0.1201
35 0.1442 0.1259
36 0.1517 0.1342
37 0.1617 0.1442
38 0.1726 0.1551
39 0.1843 0.1667
40 0.1984 0.1809
41 0.2134 0.1959
42 0.2293 0.2109
43 0.2468 0.2259
44 0.2660 0.2409
45 0.2876 0.2576
46 0.3110 0.2751
47 0.3360 0.2943
48 0.3635 0.3143
49 0.3935 0.3368
50 0.4277 0.3618
51 0.4669 0.3894
52 0.5120 0.4211
53 0.5637 0.4561
54 0.6213 0.4920
55 0.6855 0.5303
56 0.7556 0.5687
57 0.8299 0.6063
58 0.9125 0.6438
59 1.0052 0.6864
60 1.1088 0.7364
61 1.2240 0.7982
62 1.3569 0.8750
63 1.5073 0.9693
64 1.6745 1.0754
65 1.8577 1.1898
66 2.0559 1.3084
67 2.2685 1.4296
68 2.4996 1.5550
69 2.7560 1.6946
70 3.0703 1.8585
71 3.4033 2.0584
72 3.7600 2.3037
73 4.1934 2.5976
74 4.6701 2.9361
75 5.1801 3.3143
76 5.7192 3.7239
77 6.2835 4.1631
78 6.8762 4.6390
79 7.5161 5.1666
80 8.2238 5.7673
81 9.0181 6.4590
82 9.9157 7.2573
83 10.9129 8.1594
84 11.9904 9.1556
85 13.1242 10.2354
86 14.3000 11.3917
87 15.5000 12.6232
88 16.7191 13.9315
89 17.9749 15.3273
90 19.2858 16.8225
91 20.6825 18.4527
92 22.2180 20.2807
93 24.0437 22.4383
94 26.5035 25.2231
95 30.2074 29.2496
96 36.3581 35.7221
97 47.2118 46.8683
98 66.2071 66.0943
99 82.5000 81.6667
Class A Guaranteed Monthly Maximum Insurance Rates are equal to 250% of the
Guaranteed Maximum Insurance Rates for the Standard Class.
21
TABLE OF GUARANTEED MONTHLY MAXIMUM COST OF INSURANCE RATES
PER $1,000 OF INSURANCE NET AMOUNT AT RISK
TOBACCO
Attained Monthly Cost of Insurance Rate
Age
Male Female
0 0.2193 0.1567
1 0.0859 0.0701
2 0.0826 0.0667
3 0.0809 0.0651
4 0.0776 0.0642
5 0.0734 0.0626
6 0.0692 0.0609
7 0.0651 0.0592
8 0.0626 0.0584
9 0.0617 0.0576
10 0.0626 0.0567
11 0.0676 0.0584
12 0.0767 0.0609
13 0.0892 0.0642
14 0.1034 0.0684
15 0.1467 0.0801
16 0.1634 0.0842
17 0.1751 0.0884
18 0.1843 0.0926
19 0.1901 0.0951
20 0.1934 0.0976
21 0.1934 0.0992
22 0.1901 0.1017
23 0.1868 0.1042
24 0.1817 0.1067
25 0.1759 0.1092
26 0.1726 0.1134
27 0.1709 0.1167
28 0.1709 0.1209
29 0.1734 0.1259
30 0.1776 0.1317
31 0.1834 0.1367
32 0.1909 0.1426
33 0.2009 0.1501
34 0.2126 0.1584
35 0.2268 0.1676
36 0.2434 0.1817
37 0.2643 0.1984
38 0.2876 0.2176
39 0.3143 0.2384
40 0.3452 0.2635
41 0.3785 0.2901
42 0.4152 0.3168
43 0.4553 0.3435
44 0.4995 0.3702
45 0.5462 0.3985
46 0.5946 0.4277
47 0.6471 0.4578
48 0.7039 0.4903
49 0.7656 0.5262
50 0.8341 0.5645
51 0.9117 0.6054
52 0.9994 0.6521
53 1.0988 0.7039
54 1.2073 0.7565
55 1.3235 0.8107
56 1.4463 0.8641
57 1.5759 0.9142
58 1.7121 0.9635
59 1.8585 1.0161
60 2.0216 1.0787
61 2.2057 1.1572
62 2.4134 1.2583
63 2.6454 1.3811
64 2.8993 1.5182
65 3.1684 1.6628
66 3.4502 1.8100
67 3.7423 1.9522
68 4.0489 2.0961
69 4.3817 2.2526
70 4.7492 2.4376
71 5.1624 2.6722
72 5.6299 2.9596
73 6.1485 3.3017
74 6.7174 3.6920
75 7.3258 4.1186
76 7.9486 4.5725
77 8.5746 5.0471
78 9.2082 5.5490
79 9.8715 6.0962
80 10.5868 6.7098
81 11.3746 7.4070
82 12.2491 8.2009
83 13.1961 9.1191
84 14.1843 10.1164
85 15.1804 11.1778
86 16.1604 12.2952
87 17.1682 13.4579
88 18.2203 14.6722
89 19.2685 15.9376
90 20.3284 17.3441
91 21.4331 18.8626
92 22.7172 20.5523
93 24.3689 22.5437
94 26.6300 25.2231
95 30.2074 29.2496
96 36.3581 35.7221
97 47.2118 46.8683
98 66.2071 66.0943
99 82.5000 81.6667
Class A Guaranteed Monthly Maximum Insurance Rates are equal to 250% of the
Guaranteed Maximum Insurance Rates for the Standard Class.
22
INTEREST AND CHARGES
INTEREST RATES
Guaranteed Annual Interest Rate For the Fixed Account [3.50%]
Guaranteed Monthly Equivalent Interest Rate [0.28709%]
CONTRACT CHARGES
Contract Fee [$30.00] per year
Cost of Insurance as defined on page 9.
Fixed Account Expense Charge [0.48%] per year
Separate Account Expense Charge [1.65%] per year
Withdrawal Charge on Withdrawal as defined on page 13.
TABLE OF WITHDRAWAL CHARGES
This table applies to the Initial Payment in the event of a
Withdrawal in the first [7] contract years.
Contract Year Percentage
[1 9.75%
2 9.50%
3 9.25%
4 7.50%
5 7.25%
6 5.00%
7 4.75%
8 and thereafter 0.00%]
MORTALITY TABLE
1980 Commissioners Standard Ordinary Age Last Birthday Smoker or Non-smoker
This contract may end before the Maturity Date if the payments are not
sufficient to continue this contract to that date. If current values change,
this will also affect the benefits.
23
[LIBERTY MUTUAL LOGO]
--------------------------------------------------------------------------------
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON
A MEMBER OF THE LIBERTY MUTUAL GROUP
--------------------------------------------------------------------------------
CERTIFICATE DESCRIPTION
This is a GROUP MODIFIED SINGLE PAYMENT VARIABLE LIFE INSURANCE CERTIFICATE.
The Death Benefit is payable if the Insured dies while this contract is in force
and before the Maturity Date.
A Maturity Benefit is payable if the Insured is living on the Maturity Date.
Death Benefit and Account Value may vary with investment and earnings experience
and contract charges.
This contract is not eligible for Dividends.
