FIRST SECURITY BENEFIT LIFE INSURANCE AND ANNUITY
COMPANY OF NEW YORK
FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT
FSBL'S PROMISE
In consideration of the Purchase Payments, First Security Benefit Life Insurance
and Annuity Company of New York ("FSBL") will pay the benefits of this Contract
according to its terms.
LEGAL CONTRACT
PLEASE READ YOUR CONTRACT CAREFULLY. It is a legal Contract between you, the
Owner, and us, FSBL. The Contract's table of contents is on page 2.
FREE LOOK PERIOD-RIGHT TO CANCEL
IF FOR ANY REASON YOU ARE NOT SATISFIED WITH THE CONTRACT, YOU MAY RETURN THIS
CONTRACT WITHIN 10 DAYS AFTER YOU RECEIVE IT (60 DAYS FROM THE DATE OF RECEIPT
IF IT IS A REPLACEMENT CONTRACT). YOU MAY RETURN THE CONTRACT BY DELIVERING OR
MAILING IT TO FSBL. IF RETURNED, THIS CONTRACT WILL THEN BE DEEMED VOID FROM THE
BEGINNING. NO WITHDRAWAL CHARGE WILL BE IMPOSED, AND WE WILL REFUND: (1) ANY
PURCHASE PAYMENTS MADE AND ALLOCATED TO THE FIXED ACCOUNT; AND (2) SEPARATE
ACCOUNT CONTRACT VALUE AS OF THE DATE THE RETURNED CONTRACT IS DELIVERED TO
FSBL, INCREASED BY ANY FEES OR OTHER CHARGES PAID FROM SEPARATE ACCOUNT CONTRACT
VALUE.
Signed for First Security Benefit Life Insurance and Annuity Company of New York
on the Contract Date.
/s/ X. Xxxxxxx Xxxxxx /s/ Xxxx x. Xxxxxxx
--------------------- -------------------
[Secretary] [President]
A BRIEF DESCRIPTION OF THIS CONTRACT
This is a FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT.
- Purchase Payments may be made until the earlier of the Annuity Start Date
or termination of the Contract
- A death benefit may be paid prior to the Annuity Start Date according to
the Contract provisions
- Annuity Payments begin on the Annuity Start Date using the method
specified in the Contract
- This Contract is non-participating and does not participate in FSBL's
surplus
- The smallest annual net rate of return that would have to be earned on the
assets of the Separate Account so that the dollar amount of variable
Annuity Payments would not decrease is 3 -1/2%. The annual net rate of
return is based upon the rate of return of the underlying mutual fund
reduced by expenses of the Separate Account, including the maximum
mortality and expense risk charge of 1.45%, administrative charge of 0.15%
and any applicable rider charges.
BENEFITS AND VALUES PROVIDED BY THIS CONTRACT WHEN BASED UPON THE INVESTMENT
EXPERIENCE OF THE SEPARATE ACCOUNT ARE VARIABLE. THESE AMOUNTS MAY INCREASE OR
DECREASE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. (SEE "CONTRACT VALUE AND
EXPENSE PROVISIONS" AND "ANNUITY BENEFIT PROVISIONS" FOR DETAILS.)
[FSBL LOGO] FIRST SECURITY BENEFIT LIFE INSURANCE AND ANNUITY
COMPANY OF NEW YORK
[00 Xxxx Xxx Xxx Xxxx, Xxxxx Xxxxxx, XX 00000
0-000-000-0000]
IF A CREDIT ENHANCEMENT RIDER HAS BEEN PURCHASED, FSBL WILL RECAPTURE THE AMOUNT
OF ANY CREDIT ENHANCEMENT APPLIED DURING THE 12 MONTHS PRECEDING THE DATE OF THE
OWNER'S DEATH.
FSB236 (1-05)
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TABLE OF CONTENTS
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Page
CONTRACT DATA PAGE....................................................... 3
DEFINITIONS.............................................................. 4
GENERAL PROVISIONS....................................................... 7
The Contract....................................................... 7
Compliance......................................................... 8
Misstatement of Age or Sex......................................... 8
Evidence of Survival............................................... 8
Incontestability................................................... 8
Assignment......................................................... 8
Ownership of Assets................................................ 8
Transfers.......................................................... 8
Claims of Creditors................................................ 9
Basis of Values.................................................... 9
Participation...................................................... 9
Statements......................................................... 9
Delay of Payment................................................... 9
OWNERSHIP, ANNUITANT AND BENEFICIARY PROVISIONS.......................... 10
Ownership.......................................................... 10
Joint Ownership.................................................... 10
Annuitant.......................................................... 10
Primary and Contingent Beneficiaries............................... 10
Ownership and Beneficiary Changes.................................. 10
PURCHASE PAYMENT PROVISIONS.............................................. 11
Flexible Purchase Payments......................................... 11
Purchase Payment Limitations....................................... 11
Purchase Payment Allocation........................................ 11
Place of Payment................................................... 11
CONTRACT VALUE AND EXPENSE PROVISIONS.................................... 11
Contract Value..................................................... 11
Fixed Account Contract Value....................................... 11
Fixed Account Interest Crediting................................... 12
Separate Account Contract Value.................................... 12
Accumulation Unit Value............................................ 12
Net Investment Factor.............................................. 13
Determining Accumulation Units..................................... 13
Mortality and Expense Risk Charge.................................. 13
Rider Charge....................................................... 13
Method of Deducting Mortality and Expense Risk and Rider Charges... 14
Administration Charge.............................................. 15
Account Administration Charge...................................... 15
Premium Tax Expense................................................ 15
Withdrawal Charges................................................. 15
Free Withdrawals................................................... 16
Mutual Fund Expenses............................................... 16
WITHDRAWAL PROVISIONS.................................................... 16
Withdrawals........................................................ 16
Partial Withdrawals................................................ 17
Systematic Withdrawals............................................. 17
Withdrawal Value................................................... 17
DEATH BENEFIT PROVISIONS................................................. 18
Death Benefit...................................................... 18
Proof of Death..................................................... 18
Distribution Rules................................................. 18
ANNUITY BENEFIT PROVISIONS............................................... 19
Annuity Start Date................................................. 19
Change of Annuity Start Date....................................... 19
Annuity Options.................................................... 19
Annuity Start Amount............................................... 20
Fixed Annuity Payments............................................. 20
Variable Annuity Payments.......................................... 21
Annuity Tables..................................................... 21
Annuity Payments................................................... 21
Annuity Units...................................................... 21
Annuity Unit Value................................................. 22
Alternate Annuity Option Rates..................................... 22
ANNUITY TABLES........................................................... 23
AMENDMENTS OR RIDERS, if any
2
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CONTRACT DATA PAGE
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OWNER NAME: CONTRACT NUMBER:
[Xxxx Xxx] [123456789]
JOINT OWNER NAME: CONTRACT DATE:
[Xxxx Xxx] [July 1, 1999]
ANNUITANT NAME: ANNUITY START DATE:
[Xxxx Xxx] [October 5, 2030]
ANNUITANT DATE OF BIRTH: PLAN:
[October 5, 1960] [Non-Qualified]
ANNUITANT'S SEX: ASSIGNMENT:
[Female] This Contract may be assigned.
See assignment provision.
PRIMARY BENEFICIARY NAME: FIXED ACCOUNT:
[Xxxxx Xxx] The Fixed Account is available
under this Contract.
ANNUITY OPTION:
[Option 2]
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FIRST PURCHASE PAYMENT........................... [$10,000]
MINIMUM SUBSEQUENT PURCHASE PAYMENT.............. [$500 ($50 under an automatic
investment program)]
FREE WITHDRAWAL PERCENTAGE....................... 10%
FIXED ACCOUNT GUARANTEED RATE.................... 1.5%
FIXED ACCOUNT CURRENT RATE....................... [3%]
SEPARATE ACCOUNT................................. Variable Annuity Account B
ADMINISTRATION CHARGE............................ 0.15% Annually
ACCOUNT ADMINISTRATION CHARGE.................... $30 Annually*
WITHDRAWAL CHARGE
Age of Purchase Payment in Years............... 1 2 3 4 5 6 7 8
Withdrawal Charge.............................. 7% 7% 6% 5% 4% 3% 2% 0%
MORTALITY AND EXPENSE RISK CHARGE
CONTRACT VALUE
Less than $25,000............................ 0.85% Annually
At least $25,000 but less than $100,000...... 0.70% Annually
$100,000 or more............................. 0.60% Annually ("Base Charge")
AFTER ANNUITY START DATE....................... 1.25% Annually
RIDERS AND RIDER CHARGES -
Asset Allocation................................. No Charge
Dollar Cost Averaging............................ No Charge
[Any optional Rider(s) selected by the Applicant will print on this
Contract Data Page in addition to the automatic riders above.
Available optional Riders are listed on the Application.]
3
MAXIMUM RIDER CHARGE ............................ [1.55% Annually]
BASIS OF ANNUITY TABLES.......................... 1983 (a) Mortality Table with
mortality improvement under
Projection Scale G
ASSUMED INTEREST RATE............................ 3.5% annually
SUBACCOUNTS:
Dreyfus IP Technology Growth SBL Large Cap Growth PIMCO VIT Low Duration
AIM V.I. Health Sciences SBL Social Awareness SBL Money Market
AIM V.I. Real Estate SBL Enhanced Index
Rydex VT Sector Rotation SBL Equity
AIM V.I. International Growth SBL Alpha Opportunity
Dreyfus VIF Intl Value SBL Main St. Growth & Income
SBL Global SBL Large Cap Value
SBL Small Cap Growth AIM V.I. Basic Value
Xxxxxxxxxxx Main St. Small Cap American Century VP Value
SBL Small Cap Value PIMCO VIT All Asset
SBL Mid Cap Growth SBL Equity Income
AIM V.I. Mid Cap Core Equity SBL Managed Asset Allocation
SBL Mid Cap Value SBL High Yield
SBL Select 25 PIMCO VIT Real Return
American Century VP Ultra SBL Diversified Income
METHOD FOR DEDUCTING ACCOUNT CHARGE:
*The Account Charge is deducted at each Contract Anniversary. A pro rata
Account Charge is deducted:
(1) upon a full Withdrawal of Contract Value;
(2) when a Contract has been in force for less than a full
Contract Year;
(3) upon the Annuity Start Date;
(4) upon payment of a death benefit.
The Account Charge will be waived if Contract Value is $50,000 or more
upon the date the Account Charge is to be deducted.
3A
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DEFINITIONS
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ACCOUNT
One of the Subaccounts or the Fixed Account.
ACCUMULATION UNIT
A unit of measure used to compute Separate Account Contract Value.
ADMINISTRATIVE OFFICE
The address of FSBL's Administrative Office is First Security Benefit Life
Insurance and Annuity Company of New York, [P.O. Box 750497, Topeka, Kansas
66675--0497.]
ANNUITANT
The person you name on whose life Annuity Payments may be determined. Please see
"Annuity Benefit Provisions" on page 19.
ANNUITY START AMOUNT
Contract Value as of the Annuity Start Date, less any Premium tax and, if
applicable, any pro rata Account Charge.
ANNUITY OPTION
A set of provisions that form the basis for making Annuity Payments. Please see
"Annuity Options" on page 19.
ANNUITY PAYMENTS
Payments made beginning on the Annuity Start Date according to the provisions of
the Annuity Option selected. Annuity Payments are made on the same day of each
month, on a monthly, quarterly, semiannual or annual basis.
ANNUITY START DATE
The date on which Annuity Payments begin as elected by the Owner.
ANNUITY UNIT
A unit of measure used to compute Variable Annuity Payments.
AUTOMATIC TRANSFERS
Transfers among the Subaccounts and the Fixed Account made automatically. FSBL
makes Automatic Transfers on a periodic basis at the written request of the
Owner. FSBL may discontinue, modify or suspend Automatic Transfers.
COMPANY
First Security Benefit Life Insurance and Annuity Company of New York, [00 Xxxx
Xxx Xxx Xxxx, Xxxxx Xxxxxx, Xxx Xxxx 00000.]
4
CONTRACT ANNIVERSARY
The same date in each subsequent year as your Contract Date.
CONTRACT DATE
The date the Contract begins. The Contract Date is shown on page 3.
CONTRACT VALUE
The total value of your Contract, which consists of amounts allocated to the
Subaccounts and the Fixed Account. FSBL determines Contract Value as of each
Valuation Date.
CONTRACT YEAR
Contract Years are measured from the Contract Date.
CURRENT INTEREST
FSBL will declare the rate of Current Interest applicable to any Guarantee
Period on or before the first day of such Guarantee Period. Current Interest
shall be declared at least monthly. Current Interest, once declared, is fixed
during the Guarantee Period.
DESIGNATED BENEFICIARY
Upon the death of the Owner or Joint Owner, the Designated Beneficiary will be
the first person on the following list who, if a natural person, is alive on the
date of death:
1. Owner;
2. Joint Owner;
3. Primary Beneficiary;
4. Contingent Beneficiary;
5. Annuitant; and
6. The Owner's estate if no one listed above is alive.
The Designated Beneficiary receives a death benefit upon the death of the Owner
prior to the Annuity Start Date. Please see "Ownership, Annuitant, and
Beneficiary Provisions" on page 10 and "Death Benefit Provisions" on page 18.
FIXED ACCOUNT
An account that is part of FSBL's General Account. FSBL guarantees that it will
credit interest on Contract Value allocated to the Fixed Account at an annual
rate at least equal to the Fixed Account Guaranteed Rate set forth on page 3.
GENERAL ACCOUNT
All assets of FSBL other than those allocated to the Separate Account or any
other separate account of FSBL.
GUARANTEE PERIOD
Current Interest, if declared, is fixed for one-year periods, referred to as
Guarantee Periods. The Guarantee Period that applies to any Fixed Account
Contract Value:
(1) starts on the date that such Contract Value is allocated to the
Fixed Account pursuant to:
(a) a Purchase Payment Received by FSBL; or
(b) a Transfer to the Fixed Account; and
5
(2) ends on the last day of the same month in the following year.
When any Guarantee Period expires, a new Guarantee Period shall start for such
Contract Value on the date that follows such expiration date. Such period shall
end on the immediately preceding date in the following year. For example,
Contract Value transferred to the Fixed Account on June 1 would have a Guarantee
Period starting on that date and ending on June 30 of the following year. A new
Guarantee Period for such Contract Value would start on July 1 of that year and
end on June 30 of the following year.
JOINT OWNER
The Joint Owner, if any, shares an undivided interest in the entire Contract
with the Owner. The Joint Owner, if any, is named on page 3. Please see "Joint
Ownership" provisions on page 10.
NONNATURAL PERSON
Any group or entity that is not a living person, such as a trust or corporation.
OWNER
The person(s) who has (have) all rights under this Contract. The Owner as of the
Contract Date is named on page 3. Please see "Ownership" provisions on page 10
and the definition of "Joint Owner," above.
PREMIUM TAX
Any Premium tax levied by a state or other governmental entity.
PURCHASE PAYMENT
Money Received by FSBL and applied to the Contract.
RECEIVED BY FSBL
Receipt by FSBL in good order at its Administrative Office, [P.O. Box 750497,
Topeka, Kansas 66675--0497.]
SEPARATE ACCOUNT
A separate account established and maintained by FSBL under New York law. The
Separate Account as set forth on page 3 is registered with the Securities and
Exchange Commission under the Investment Company Act of 1940 as a Unit
Investment Trust. It was established by FSBL to support variable annuity
contracts. FSBL owns the assets of the Separate Account and maintains them apart
from the assets of its General Account and its other separate accounts. The
assets held in the Separate Account equal to the reserves and other Contract
liabilities with respect to the Separate Account may not be charged with
liabilities arising from any other business FSBL may conduct. Income and
realized and unrealized gains and losses from assets in the Separate Account are
credited to, or charged against, the Separate Account without regard to the
income, gains or losses from FSBL's General Account or its other separate
accounts.
The Separate Account is divided into Subaccounts shown on page 3. Income and
realized and unrealized gains and losses from assets in each Subaccount are
credited to, or charged against, the Subaccounts without regard to income, gains
or losses in the other Subaccounts. FSBL has the right to transfer to its
General Account any assets of the Separate Account that are in excess of the
reserves and other Contract liabilities with respect to the Separate Account.
The value of the assets in the Separate Account is determined on each Valuation
Date as of the end of each Valuation Date.
6
SUBACCOUNTS
The Separate Account is divided into Subaccounts which invest in shares of
mutual funds. Each Subaccount may invest its assets in a separate class or
series of a designated mutual fund or funds. The Subaccounts are shown on page
3. Subject to the regulatory requirements then in force, FSBL reserves the right
to:
1. change or add designated mutual funds or other investment vehicles;
2. add, remove or combine Subaccounts;
3. add, delete or make substitutions for securities that are held or
purchased by the Separate Account or any Subaccount;
4. operate the Separate Account as a management investment company;
5. combine the assets of the Separate Account with other separate
accounts of FSBL or an affiliate thereof;
6. restrict or eliminate any voting rights of the Owner with respect to
the Separate Account or other persons who have voting rights as to
the Separate Account; and
7. terminate and liquidate any Subaccount.
If any of these changes result in a material change to the Separate Account or a
Subaccount, FSBL will notify you of the change. FSBL will not change the
investment policy of any Subaccount in any material respect without complying
with the filing and other procedures of the insurance regulators of the state of
issue.
TRANSFER
A Transfer of Contract Value of one Subaccount or the Fixed Account for the
equivalent dollar amount of Contract Value of another Subaccount or the Fixed
Account.
VALUATION DATE
A Valuation Date is each day the New York Stock Exchange and FSBL's
Administrative Office are open for business.
VALUATION PERIOD
A Valuation Period is the interval of time from one Valuation Date to the next
Valuation Date.
WITHDRAWAL
A Withdrawal of Contract Value in the dollar amount specified by the Owner.
Withdrawals include Systematic Withdrawals. See "Withdrawal Provisions" on page
16.
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GENERAL PROVISIONS
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THE CONTRACT
The entire Contract between the Owner and FSBL consists of this Contract, and
any Amendments, Endorsements or Riders to the Contract. All statements made in
the Application will, as ruled by a court of competent jurisdiction, be deemed
representations and not warranties. Any change in the Contract can be made only
with the written consent of the President, a Vice President, or the Secretary of
FSBL.
The Purchase Payment(s) and the Application must be acceptable to FSBL under its
rules and practices. If they are not, FSBL's liability shall be limited to a
return of the Purchase Payment(s).
7
COMPLIANCE
FSBL reserves the right to make any change to the provisions of this Contract to
comply with or give the Owner the benefit of any federal or state statute, rule
or regulation. This includes, but is not limited to, requirements for annuity
contracts under the Internal Revenue Code or the laws of any state. FSBL will
provide the Owner with a copy of any such change and will also file such a
change with the insurance regulatory officials of the state in which the
Contract is delivered.
MISSTATEMENT OF AGE OR SEX
If the age or sex of the Annuitant has been misstated, payments shall be
adjusted, when allowed by law, to the amount which would have been provided for
the correct age or sex. Proof of the age of an Annuitant may be required at any
time, in a form suitable to FSBL. If payments have already commenced and the
misstatement has caused an underpayment, the amount of such underpayment, with
interest at the rate of 3%, will be paid with the next scheduled payment. If the
misstatement has caused an overpayment, the amount of such overpayment, with
interest at the rate of 3%, will be deducted from one or more future payments.
EVIDENCE OF SURVIVAL
Before FSBL makes a payment, it has the right to require proof of the life or
death of any person whose life or death determines whether, or to whom, or how
much FSBL must pay under this Contract.
INCONTESTABILITY
FSBL will not contest the validity of this Contract.
ASSIGNMENT
No Assignment under this Contract is binding unless Received by FSBL in writing.
FSBL assumes no responsibility for the validity, legality, or tax status of any
Assignment. The Assignment will be subject to any payment made or other action
taken by FSBL before the Assignment is Received by FSBL. Once filed, the rights
of the Owner are subject to the Assignment. Any claim is subject to proof of
interest of the assignee. If the Contract has been absolutely assigned, the
assignee becomes the Owner.
OWNERSHIP OF ASSETS
FSBL is the sole owner of the assets of the Fixed Account. FSBL has the sole
right to control, manage or administer such assets.
TRANSFERS
The Owner may Transfer Contract Value among the Fixed Account and Subaccounts
upon written request or under other methods allowed by FSBL, subject to the
following.
FSBL reserves the right to:
(1) limit the amount that may be subject to Transfer to $1,000,000 per
Transfer;
(2) limit the number of Transfers per Contract Year to six; and
(3) suspend Transfers if the Owner engages in a market timing strategy
or makes programmed transfers.
Transfers must be at least $500 or if less:
(1) the amount remaining in the Subaccount; or
(2) the amount of Fixed Account Contract Value, the Guarantee Period of
which expires in the calendar month in which the Transfer is
effected.
8
Contract Value may be transferred from the Fixed Account only:
(1) during the calendar month in which the applicable Guarantee Period
expires; or
(2) pursuant to an Automatic Transfer.
In the event of an Automatic Transfer, Transfers of Contract Value from the
Fixed Account shall be made:
(1) first from Fixed Account Contract Value for which the Guarantee
Period expires during the calendar month during which the Transfer
is effected;
(2) then in the order that starts with Fixed Account Contract Value that
has the longest amount of time remaining before its Guarantee Period
expires; and
(3) ends with that which has the least amount of time remaining before
its Guarantee Period expires.
FSBL will effect a Transfer to or from a Subaccount on the basis of Accumulation
Unit Value determined as of the end of the Valuation Period in which the
Transfer request is Received by FSBL. FSBL will effect a Transfer from the Fixed
Account on the basis of Fixed Account Contract Value as of the end of the
Valuation Period in which the Transfer request is Received by FSBL. Transfers
are effected as of the close of the Valuation Period in which all information
required to make the Transfer is Received by FSBL.
After the Annuity Start Date, you may Transfer Annuity Units only among the
Subaccounts.
CLAIMS OF CREDITORS
The Contract Value and other benefits under this Contract are exempt from the
claims of creditors to the extent allowed by law.
BASIS OF VALUES
A detailed statement showing how values are determined has been filed with the
state insurance departments. All values and reserves are at least equal to those
required by the laws of the state in which this Contract is delivered.
PARTICIPATION
This Contract is not participating and does not participate in FSBL's surplus.
STATEMENTS
At least once per year prior to the Annuity Start Date, FSBL will send you a
report that will show your Contract Value and any other information required by
law. After the Annuity Start Date, we will send you any information that may be
required.
DELAY OF PAYMENT
Generally, payments and Transfers will be made within seven days from receipt of
the payment and/or request in a form satisfactory to us. FSBL reserves the right
to suspend a Transfer or delay payment of a Withdrawal from Separate Account
Contract Value for any period:
1. when the New York Stock Exchange is closed; or
2. when trading on the New York Stock Exchange is restricted; or
3. when an emergency exists as a result of which:
(a) disposal of securities held in the Separate Account is not
reasonably practicable; or
(b) it is not reasonably practicable to fairly value the net
assets of the Separate Account; or
4. during any other period when the Securities and Exchange Commission,
by order, so permits to protect owners of securities.
9
Rules and regulations of the Securities and Exchange Commission will govern as
to whether the conditions set forth above exist. FSBL may delay payments or
Transfers from the Fixed Account (which would include payment of your Withdrawal
proceeds and Transfers from the Fixed Account, loans, fixed annuity payments and
lump sum death benefit payments unless state law requires otherwise) for up to
six months after the requested effective date of the transaction. Any amount
delayed will, as long as it is held under the Fixed Account, continue to earn
interest at the Current Rate then in effect until the applicable Guarantee
Period in effect has ended, and not less than the Guaranteed Rate on an annual
basis thereafter.
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OWNERSHIP, ANNUITANT AND BENEFICIARY PROVISIONS
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OWNERSHIP
During the Owner's lifetime, all rights and privileges under the Contract may be
exercised only by the Owner. If the purchaser names someone other than himself
or herself as Owner, the purchaser has no rights in the Contract. No Owner may
be older than age 85 on the Contract Date.
JOINT OWNERSHIP
If a Joint Owner is named in the application, then the Owner and Joint Owner
share an undivided interest in the entire Contract as joint tenants with rights
of survivorship. When an Owner and Joint Owner have been named, FSBL will honor
only requests for changes and the exercise of other Ownership rights made by
both the Owner and Joint Owner. When a Joint Owner is named, all references to
"Owner" throughout this Contract should be construed to mean both the Owner and
Joint Owner, except for the "Statements" provision on page 9 and the "Death
Benefit Provisions" on page 18.
ANNUITANT
The Annuitant is named on page 3. The Owner may change the Annuitant prior to
the Annuity Start Date. The request for this change must be made in writing and
Received by FSBL at least 30 days prior to the Annuity Start Date. No Annuitant
may be named who is more than 85 years old on the Contract Date. When the
Annuitant dies prior to the Annuity Start Date, the Owner must name a new
Annuitant within 30 days or, if sooner, by the Annuity Start Date, except where
the Owner is a Nonnatural Person. If a new Annuitant is not named, the Owner
becomes the Annuitant.
PRIMARY AND CONTINGENT BENEFICIARIES
The Primary Beneficiary is named on page 3. The Owner may change any Beneficiary
as described in "Ownership and Beneficiary Changes" below. If the Primary
Beneficiary dies prior to the Owner, the Contingent Beneficiary becomes the
Primary Beneficiary. Unless the Owner directs otherwise, when there are two or
more Primary Beneficiaries, they will receive equal shares.
OWNERSHIP AND BENEFICIARY CHANGES
Subject to the terms of any existing Assignment, you may name a new Owner, a new
Primary Beneficiary or a new Contingent Beneficiary; provided that you may not
change or remove an irrevocable Beneficiary without obtaining his or her written
consent in a form acceptable to us. Any new choice of Owner, Primary Beneficiary
or Contingent Beneficiary will revoke any prior choice. Any change must be made
in writing and recorded at the Administrative Office. The change will become
effective as of the date the written request is signed, whether or not the Owner
is living at the time the change is recorded. A new choice of Primary
Beneficiary or Contingent Beneficiary will not apply to any payment made or
action taken by FSBL prior to the time it was received. FSBL may require the
Contract be returned so these changes may be made.
10
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PURCHASE PAYMENT PROVISIONS
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FLEXIBLE PURCHASE PAYMENTS
This Contract will not be in force until we receive at our Administrative Office
the initial Purchase Payment. You may make additional Purchase Payments at any
time before the Annuity Start Date, while the Owner is living, and this Contract
is in force. Purchase Payments are payable in U.S. dollars and checks should be
made payable to FSBL.
PURCHASE PAYMENT LIMITATIONS
Purchase Payments exceeding $1,000,000 will not be accepted without prior
approval by FSBL. The Minimum Subsequent Purchase Payment amount is shown on
page 3.
PURCHASE PAYMENT ALLOCATION
Purchase Payments will be allocated among the Fixed Account and the Subaccounts.
The allocations may be a whole dollar amount or a whole percentage and no less
than $25 per Purchase Payment may be allocated to any Account. Purchase Payments
will be allocated according to the Owner's instructions in the Application or
more recent instructions, if any. The Owner may change the allocations by
written notice to FSBL.
PLACE OF PAYMENT
All Purchase Payments under this Contract are to be paid to FSBL at its
Administrative Office. Purchase Payments after the initial Purchase Payment are
applied as of the end of the Valuation Period during which they are Received by
FSBL.
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CONTRACT VALUE AND EXPENSE PROVISIONS
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CONTRACT VALUE
Your Contract Value on any Valuation Date is the sum of:
(1) your Separate Account Contract Value on that date; and
(2) your Fixed Account Contract Value on that date.
FSBL reserves the right to pay to the Owner the Contract Value as a lump sum if
it is below $2,000 and no Purchase Payments have been received during the
preceding three-year period.
FIXED ACCOUNT CONTRACT VALUE
On any Valuation Date, the Fixed Account Contract Value is equal to the amount
of the initial Purchase Payment allocated under the Contract to the Fixed
Account,
PLUS:
1. any other Purchase Payments allocated under the Contract to the
Fixed Account;
2. any Transfers from the Separate Account to the Fixed Account; and
3. any Current Interest credited to the Fixed Account.
LESS:
1. any Withdrawals, including Withdrawal Charges, deducted from the
Fixed Account;
2. any Transfers from the Fixed Account to the Separate Account;
3. any amount applied as Annuity Start Amount under Annuity Options 1
through 6 and
4. any Premium tax and Account Charge.
11
FIXED ACCOUNT INTEREST CREDITING
FSBL shall credit Current Interest on Fixed Account Contract Value on a daily
basis. Current Interest will be credited from the Valuation Date on which a
Purchase Payment is applied to the date of Withdrawal, Transfer, or application
as Annuity Start Amount.
FSBL shall credit interest on Fixed Account Contract Value at an annual rate at
least equal to the Fixed Account Guaranteed Rate shown on page 3. Also, FSBL may
in its sole judgment credit Current Interest at a rate in excess of the
Guaranteed Rate. The rate of Current Interest, if declared shall be fixed during
the Guarantee Period. Fixed Account Contract Value shall earn Current Interest
during each Guarantee Period at the rate, if any, declared by FSBL on the first
day of the Guarantee Period.
FSBL may credit Current Interest on Contract Value that was allocated or
transferred to the Fixed Account during one period at a different rate than
amounts allocated or transferred to the Fixed Account in another period. FSBL
will deduct any charges for Riders from Current Interest. Therefore, at any
time, portions of Fixed Account Contract Value may be earning Current Interest
at different rates based upon the period during which such portions were
allocated or transferred to the Fixed Account and the Riders selected by the
Owner.
SEPARATE ACCOUNT CONTRACT VALUE
On any Valuation Date, the Separate Account Contract Value is the sum of the
then current value of the Accumulation Units allocated to each Subaccount for
this Contract. For example, if 100 Accumulation Units were allocated to each of
the Money Market and Equity Subaccounts as of June 1, Separate Account Contract
Value as of that date would be determined as follows:
Number of Accumulation Unit
Subaccount Accumulation Units Value as of June 1 Subaccount Value
---------- ------------------ ------------------ ----------------
Money Market 100 $10 $1,000
Equity 100 $12 $1,200
------
Separate Account Contract Value as of June 1................... $2,200
ACCUMULATION UNIT VALUE
The initial Accumulation Unit Value for each Subaccount was set by FSBL. The
Accumulation Unit Value for any subsequent Valuation Date is equal to (1) times
(2) where:
1. is the Accumulation Unit Value determined on the immediately
preceding Valuation Date; and
2. is the Net Investment Factor as of the Valuation Date with respect
to which Accumulation Unit Value is being determined.
The Accumulation Unit Value for any subsequent Valuation Date which is a
Subaccount Payable Date is further adjusted by deducting any Subaccount
Adjustment declared as of the preceding Subaccount Record Date. See "Method of
Deducting Mortality and Expense Risk and Rider Charges," below.
12
NET INVESTMENT FACTOR
The Net Investment Factor for any Subaccount as of the end of any Valuation
Period is determined by dividing (1) by (2) and subtracting (3) from the result,
where:
1. is equal to:
a. the net asset value per share of the mutual fund held in the
Subaccount, found as of the end of the current Valuation
Period; plus
b. the per share amount of any dividend or capital gain
distributions paid by the Subaccount's underlying mutual fund
that is not included in the net asset value per share; plus or
minus
c. a per share charge or credit for any taxes reserved for, which
FSBL deems to have resulted from the operation of the Separate
Account or the Subaccounts; operations of FSBL with respect to
the Contract; or the payment of premiums or acquisition costs
under the Contract.
2. is the net asset value per share of the Subaccount's underlying
mutual fund as of the end of the prior Valuation Period.
3. is a daily factor which is deducted from the Separate Account
representing the Base Charge for mortality and expense risk and the
Administration Charge.
The Accumulation Unit Value may increase or decrease from one Valuation Period
to the next.
DETERMINING ACCUMULATION UNITS
The number of Accumulation Units allocated to a Subaccount under this Contract
is found by dividing:
(1) the amount allocated to, or deducted from, the Subaccount; by
(2) the Accumulation Unit Value for the Subaccount as of the end of the
Valuation Period during which the amount is allocated or deducted
under the Contract.
The number of Accumulation Units allocated to a Subaccount under the Contract
will not change as a result of investment experience. Events that change the
number of Accumulation Units are:
1. Purchase Payments that are applied to the Subaccount;
2. Contract Value that is Transferred into or out of the Subaccount;
3. Withdrawals and applicable Withdrawal Charges that are deducted from
the Subaccount;
4. Annuity Start Amount applied from the Subaccount to one of Annuity
Options 1 through 6;
5. Premium tax and Account Charges that are deducted from the
Subaccount; and
6. Reinvestment of Subaccount Adjustments that are paid by the
Subaccount.
MORTALITY AND EXPENSE RISK CHARGE
FSBL will deduct a Mortality and Expense Risk Charge as shown on the Contract
Data page against your Contract Value held in the Subaccounts. This charge is
guaranteed not to increase.
RIDER CHARGE
FSBL will deduct a charge for Riders as shown on the Contract Data page against
your Contract Value held in the Subaccounts. This charge will be deducted from
Current Interest with respect to your Contract Value held in the Fixed Account.
The amount of the charge for Riders is based upon the Riders selected by the
Owner on the application or as otherwise permitted by FSBL. The charge for any
Rider is guaranteed not to increase after it has been issued. You may not select
Riders with a total charge that exceeds the Maximum Rider Charge set forth on
the Contract Data page.
13
METHOD OF DEDUCTING MORTALITY AND EXPENSE RISK AND RIDER CHARGES
The Base Charge for mortality and expense risk as shown on the Contract Data
page will be computed and deducted from each Subaccount on each Valuation Date.
The Base Charge is factored into the Accumulation Unit Values on each Valuation
Date.
Any charge for mortality and expense risk or Riders above the Base Charge
("Excess Charge") will be deducted from monthly Subaccount Adjustments paid by,
and reinvested in, the respective Subaccounts. Subaccount Adjustments are
declared by FSBL and paid monthly by the Subaccounts for the purpose of
deducting any applicable Excess Charge.
The amount of the Excess Charge is determined by adding:
(1) the total charge for all Riders selected by the Owner; and
(2) the applicable mortality and expense risk charge; and subtracting
(3) the Base Charge.
The applicable mortality and expense risk charge, which is based upon the amount
of Contract Value as of the date the charge is deducted, is shown on the
Contract Data page. The Excess Charge is a percentage on an annual basis of
Contract Value allocated to each Subaccount as of the Subaccount Payable Date.
FSBL will declare a Subaccount Adjustment for each Subaccount on one Valuation
Date of each calendar month ("Subaccount Record Date"). FSBL will pay the
Subaccount Adjustment on a subsequent Valuation Date ("Subaccount Payable Date")
within five Valuation Dates of the Subaccount Record Date. Such Subaccount
Adjustment will be declared as a dollar amount per Accumulation Unit.
For each Subaccount, any Owner as of the Subaccount Record Date will receive on
the Subaccount Payable Date a net Subaccount Adjustment equal to:
(1) the amount of Subaccount Adjustment per Accumulation Unit; times
(2) the number of Accumulation Units allocated to the Subaccount as of
the Subaccount Record Date; less
(3) the amount of the Excess Charge for that Subaccount; provided that
FSBL will not deduct any Excess Charge from the first Subaccount
Adjustment following the Contract Date.
The net Subaccount Adjustment will be reinvested on the Subaccount Payable Date
at the Accumulation Unit Value determined as of the close of the Subaccount
Payable Date in Accumulation Units of the Subaccount. The net Subaccount
Adjustment shall never be less than zero.
FSBL reserves the right to compute and deduct the Excess Charge from each
Subaccount on each Valuation Date in lieu of the method discussed above, in
which event the charge would be factored into the Accumulation Unit Values on
each Valuation Date.
EXAMPLE
Assuming Contract Value of $50,000 allocated to the Equity Subaccount and no
Riders, the Excess Charge would be computed as follows:
Mortality and Expense Risk Charge; plus 0.70%
Rider Charges; less + N/A
Base Charge -0.60%
------
Excess Charge on Annual Basis 0.10%
14
Further assuming 5,000 Accumulation Units with an Accumulation Unit Value of $10
per unit on December 30 and a gross Subaccount Adjustment of $0.25 per unit
declared on December 31 (Subaccount Record Date), the net Subaccount Adjustment
amount would be as follows:
Gross Subaccount Adjustment Accumulation Unit Value
Per Unit; less $ 0.25 as of Valuation Date
Excess Charge Per Unit -$ 0.00085 before Subaccount
--------- Record Date $10.00
Net Subaccount Adjustment
Per Unit; times $ 0.24915 X
Number of Accumulation Units 5,000 Accumulation Unit Value
--------- as of Subaccount
Net Subaccount Payable Date $ 9.75
Adjustment Amount $1,245.75
The net Subaccount Adjustment amount would be reinvested on the Subaccount
Payable Date in Accumulation Units of the Equity Subaccount, as follows:
$0.24915 (net Subaccount Adjustment per unit) divided by $9.75 (Accumulation
Unit value as of the Subaccount Payable Date) times 5,000 Units equals 127.769
Accumulation Units. On the Subaccount Payable Date, 127.769 Accumulation Units
are added to Contract Value for a total of 5,127.769 Accumulation Units after
the Subaccount Adjustment reinvestment. Contract Value on the Subaccount Payable
Date is equal to 5,127.769 Accumulation Units times $9.75 (Accumulation Unit
Value as of the Subaccount Payable Date) for a Contract Value of $49,995.75
after the Subaccount Adjustment reinvestment.
FSBL will deduct the Mortality and Expense Risk Charge applicable to Annuity
Options 1 through 6 after the Annuity Start Date as shown on the Contract Data
page. This charge is factored into the Annuity Unit Values on each Valuation
Date.
ADMINISTRATION CHARGE
FSBL will deduct the Administration Charge shown on page 3 against your Contract
Value held in the Subaccounts. This charge will be computed and deducted from
each Subaccount on each Valuation Date. This charge is factored into the
Accumulation Unit and Annuity Unit Values on each Valuation Date. This charge is
guaranteed not to increase.
ACCOUNT ADMINISTRATION CHARGE
FSBL will deduct the Account Administration Charge ("Account Charge") from
Contract Value as shown on page 3. FSBL will allocate the Account Charge to the
Accounts in the same proportion that Contract Value is allocated among the
Accounts. The Account Charge and other charges may be waived or reduced
uniformly on all Contracts issued under certain plans or arrangements which are
expected to result in administrative cost savings. This charge is guaranteed not
to increase.
PREMIUM TAX EXPENSE
FSBL reserves the right to deduct Premium tax when due or any time thereafter.
FSBL will allocate the Premium tax to the Accounts in the same proportion that
Contract Value is allocated among the Accounts.
WITHDRAWAL CHARGES
Purchase Payments are subject to a Withdrawal Charge, which is shown on page 3.
The Withdrawal Charge may apply to amounts you withdraw under your Contract,
depending on the length of time each Purchase Payment has been allocated to your
Contract and the amount you withdraw. FSBL does not apply the Withdrawal Charge
on:
- Death benefit proceeds; or
- Annuity Payments.
The amount of the Withdrawal Charge depends on how long your Purchase Payments
are held under the Contract. Each Purchase Payment you make is considered to
have a certain "age," depending on the length of time since that Purchase
Payment was effective. A Purchase Payment is "age one" in the year beginning on
the
15
date the purchase payment is Received by FSBL and increases in age each year
thereafter. When you withdraw an amount, the "age" of any Purchase Payment you
withdraw determines the level(s) of Withdrawal Charge as shown on page 3. For
the purpose of calculating Withdrawal Charge, FSBL assumes that withdrawal
amounts will be applied to Purchase Payments first in the order Purchase
Payments were received. The Withdrawal Charge will be deducted proportionately
from each Account selected for Withdrawal. This charge is guaranteed not to
increase.
FREE WITHDRAWALS
During a Contract Year, you may make Free Withdrawals, which are Withdrawals
that are not subject to the Withdrawal Charge. The amount of Free Withdrawals
available in any Contract Year is determined as follows. In the first Contract
Year, the amount is equal to:
(1) cumulative purchase payments; times
(2) the Free Withdrawal percentage shown on page 3; less
(3) any Free Withdrawals made during the Contract Year.
The amount of Free Withdrawals in subsequent Contract Years is equal to:
(1) Contract Value as of the first day of the current Contract Year;
times
(2) the Free Withdrawal percentage shown on page 3; less
(3) any Free Withdrawals made during the Contract Year.
Unused Free Withdrawal amounts are not carried from one Contract Year to the
next. Free Withdrawals do not reduce Purchase Payments for purposes of
calculating the Withdrawal Charge on future Withdrawals.
MUTUAL FUND EXPENSES
Each Subaccount invests in shares of a mutual fund. The net asset value per
share of each underlying fund reflects the deduction of any investment advisory
and administration fees and other expenses of the fund. These fees and expenses
are not deducted from the assets of a Subaccount, but are paid by the underlying
funds. The Owner indirectly bears a pro rata share of such fees and expenses. An
underlying fund's fees and expenses are not specified or fixed under the terms
of this Contract.
--------------------------------------------------------------------------------
WITHDRAWAL PROVISIONS
--------------------------------------------------------------------------------
WITHDRAWALS
A full or partial Withdrawal of Separate Account Contract Value is allowed at
any time prior to the Annuity Start Date while the Owner is living. Withdrawals
will be effected as of the end of the Valuation Period in which the Withdrawal
request is Received by FSBL, and payment will be made within the time frame
required by applicable law. (Please see "Delay of Payment," page 9 for a
discussion of the circumstances under which payments may be delayed.)
Withdrawals normally will be effective as of the close of the Valuation Period
during which we receive your proper request. Any Withdrawal will reduce Contract
Value by the amount of the Withdrawal, any Withdrawal Charges attributable to
the Withdrawal, any Premium tax and, in the case of a full Withdrawal, any pro
rata Account Charge.
Upon the Owner's request for a full Withdrawal, FSBL will pay the Withdrawal
Value in a lump sum, and the Contract will terminate. If you make a full
withdrawal, we require return of your Contract or a signed Lost Contract
Affidavit with your proper request.
All Withdrawals must meet the following conditions.
1. The request for Withdrawal must be Received by FSBL in writing or
under other methods allowed by FSBL, if any;
2. The Owner must apply prior to the Annuity Start Date while this
Contract is in force; and
3. The amount withdrawn must be at least $500, except upon a full
Withdrawal.
16
PARTIAL WITHDRAWALS
A partial Withdrawal request must state the allocations for deducting the
Withdrawal from each Account. If no allocation is specified, FSBL will deduct
the Withdrawal from the Accounts in the same proportion that Contract Value is
allocated among the Accounts. If a partial Withdrawal causes your Contract Value
to be less than $2,000 immediately after the Withdrawal and no Purchase Payments
have been made in the prior three years, we may terminate your Contract and send
you the Withdrawal proceeds.
SYSTEMATIC WITHDRAWALS
Systematic Withdrawals are automatic periodic Withdrawals from Contract Value in
substantially equal amounts prior to the Annuity Start Date. To start Systematic
Withdrawals, you must make the request in writing, stating the type of payment,
its frequency and allocations for such Withdrawals. If no allocation is
specified, FSBL will deduct Systematic Withdrawals from the Accounts in the same
proportion that Contract Value is allocated among the Accounts. Any Systematic
Withdrawal will reduce Contract Value by the amount of the Systematic
Withdrawal, any Withdrawal Charges attributable to the Systematic Withdrawal,
and any Premium tax.
The type of payment may be:
(1) in a fixed amount;
(2) in Level Payments calculated by FSBL;
(3) for a specified period;
(4) a specified percentage;
(5) earnings only; or
(6) based upon the life expectancy of the Owner or the Owner and a
beneficiary.
The payment frequency may be:
(1) monthly;
(2) quarterly;
(3) semiannually; or
(4) annually.
The minimum Systematic Withdrawal amount is $100 per payment. You may stop or
change Systematic Withdrawals upon proper written request Received by FSBL at
least 30 days in advance of the requested date of termination or change. FSBL
reserves the right to stop, modify or suspend Systematic Withdrawals at any
time.
WITHDRAWAL VALUE
The Withdrawal Value is the amount available for Withdrawal. The Withdrawal
Value as of the close of any Valuation Date is the Contract Value less:
(1) any Withdrawal Charges;
(2) any pro rata Account Charge; and
(3) any Premium tax due or paid by FSBL.
17
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DEATH BENEFIT PROVISIONS
--------------------------------------------------------------------------------
DEATH BENEFIT
A Death Benefit will be paid upon the death of the Owner prior to the Annuity
Start Date while this Contract is in force. The Death Benefit will be paid to
the Designated Beneficiary when due Proof of Death and instructions regarding
payment are Received by FSBL.
If the age of each Owner was 80 or younger on the Contract Date, the Death
Benefit is equal to the greater of:
(1) the sum of all Purchase Payments made by the Owner, less any Premium
tax due or paid by FSBL with respect to your Contract, less any pro
rata Account Charge, and less the sum of all partial Withdrawals and
Withdrawal Charges deducted from your Contract Value; or
(2) your Contract Value as of the date due Proof of Death and
instructions regarding payment are Received by FSBL, less any
Premium tax due or paid by FSBL with respect to your Contract, less
any pro rata Account Charge.
Notwithstanding the foregoing, if any Owner was age 81 or older on the Contract
Date, or if due proof of death and instructions regarding payment are not
Received by FSBL within six months of the date of the Owner's death, the Death
Benefit will be as described under (2) above without reference to (1) above.
If a lump sum payment is requested, the payment will be made in accordance with
any laws and regulations that govern the payment of Death Benefits.
PROOF OF DEATH
Any of the following will serve as Proof of Death of the Owner:
1. certified copy of the death certificate;
2. certified decree of a court of competent jurisdiction as to the
finding of death;
3. written statement by a medical doctor who attended the deceased
Owner; or
4. any proof accepted by FSBL.
DISTRIBUTION RULES
In the event of an Owner's death prior to the Annuity Start Date, the entire
Death Benefit shall be paid within 5 years after the death of the Owner, except
as provided below. In the event that the Beneficiary elects an Annuity Option,
the length of time for payment of the benefit may be longer than 5 years if:
1. The Designated Beneficiary is a natural person;
2. The Death Benefit is paid out under one of Annuity Options 1 through
6;
3. Payments are made over a period that does not exceed the life or
life expectancy of the Beneficiary; and
4. Payments begin within one year of the death of the Owner.
If the deceased Owner's spouse is the sole Designated Beneficiary, the spouse
shall become the sole Owner of the Contract. He or she may elect to:
(1) keep the Contract in force until the sooner of the spouse's death or
the Annuity Start Date; or
(2) receive the Death Benefit.
If any Owner dies on or after the Annuity Start Date, Annuity Payments shall
continue to be paid at least as rapidly as under the method of payment being
used as of the date of the Owner's death.
If the Owner is a Nonnatural Person, the distribution rules set forth above
apply in the event of the death of, or change in, the Annuitant.
18
The foregoing distribution rules do not apply to a Contract, which is:
(1) provided under a plan described in Code section 401(a) or 403(b);
(2) an individual retirement annuity or provided under an individual
retirement account or annuity; or
(3) otherwise exempt from the Code section 72(s) distribution rules.
--------------------------------------------------------------------------------
ANNUITY BENEFIT PROVISIONS
--------------------------------------------------------------------------------
ANNUITY START DATE
The Annuity Start Date is the date as of which the first Annuity Payment is
computed under one of the Annuity Options. The Annuity Start Date shall not be
earlier than the 12-month anniversary of the Contract Date. The Owner may elect
the Annuity Start Date at the time of application. If no Annuity Start Date is
selected, FSBL will use the later of:
(1) the oldest Annuitant's seventieth birthday; or
(2) the tenth Contract Anniversary.
The Annuity Start Date must be prior to the later of the oldest Annuitant's 90th
birthday or the tenth Contract Anniversary.
CHANGE OF ANNUITY START DATE
The Owner may change the Annuity Start Date. A request for the change must be
made in writing. The written request must be received by FSBL at least 30 days
prior to the new Annuity Start Date as well as 30 days prior to the previous
Annuity Start Date.
ANNUITY OPTIONS
The Contract provides for Annuity Payments to be made under one of Annuity
Options 1 through 6. Your Annuity Option is shown on page 3. Options 1 through 4
and 6 generally provide for payments to be made during the life of the Annuitant
or Joint Annuitants. Under Option 5, Annuity Payments are made to the Annuitant
and in the event of the Annuitant's death, to the Designated Beneficiary.
Options 1 through 6 are available as either a Fixed or Variable Annuity or a
combination Fixed and Variable Annuity. The Annuity Options are shown below.
Prior to the Annuity Start Date, the Owner may change the Annuity Option
selected. The Owner must request the change in writing. This request must be
Received by FSBL at least 30 days prior to the Annuity Start Date.
OPTION 1 LIFE INCOME OPTION: This option provides Annuity Payments for the
life of the Annuitant. Upon the Annuitant's death, no further
Annuity Payments will be made.
OPTION 2 LIFE INCOME WITH PERIOD CERTAIN OPTION: This option provides
Annuity Payments for the life of the Annuitant. A fixed period of 5,
10, 15 or 20 years may be chosen. Annuity Payments will be made to
the end of this period even if the Annuitant dies prior to the end
of the period. If the Annuitant dies before receiving all of the
Annuity Payments during the fixed period, the remaining Annuity
Payments will be made to the Designated Beneficiary. Upon the
Annuitant's death after the period certain, no further Annuity
Payments will be made.
19
OPTION 3 LIFE INCOME WITH INSTALLMENT OR UNIT REFUND OPTION: This option
provides Annuity Payments for the life of the Annuitant, with a
period certain determined by dividing the Annuity Start Amount by
the amount of the first Annuity Payment. A fixed number of Annuity
Payments will be made even if the Annuitant dies. If the Annuitant
dies before receiving the fixed number of Annuity Payments, any
remaining Annuity Payments will be made to the Designated
Beneficiary. If the Annuitant dies after receiving the fixed number
of Annuity Payments, no further Annuity Payments will be made.
OPTION 4 JOINT AND LAST SURVIVOR OPTION: This option provides Annuity
Payments for the lives of the Annuitant and Joint Annuitant. Annuity
Payments will be made as long as either is living. Upon the death of
one Annuitant, Annuity Payments continue to the surviving Joint
Annuitant at the same or a reduced level of 75%, 66 2/3% or 50% of
Annuity Payments, as elected by the Owner. With respect to Fixed
Annuity Payments, the amount of the Annuity Payment, and with
respect to Variable Annuity Payments, the number of Annuity Units
used to determine the Annuity Payment, is reduced as of the first
Annuity Payment following the Annuitant's death. In the event of the
death of one Annuitant, the surviving Joint Annuitant has the right
to exercise all rights under the Contract. Upon the death of the
last Annuitant, no further Annuity Payments will be made.
OPTION 5 PERIOD CERTAIN OPTION: This option provides Annuity Payments for a
fixed period of 10, 15 or 20 years. Annuity Payments will be made
until the end of this period. If the Annuitant dies prior to the end
of the period, the remaining Annuity Payments will be made to the
Designated Beneficiary.
OPTION 6 JOINT AND CONTINGENT SURVIVOR OPTION: This option provides Annuity
Payments for the life of the primary Annuitant. Annuity Payments
will be made to the primary Annuitant as long as he or she is
living. Upon the death of the primary Annuitant, Annuity Payments
will be made to the contingent Annuitant as long as he or she is
living. If the contingent Annuitant is not living upon the death of
the primary Annuitant, no further payments will be made.
ANNUITY START AMOUNT
Annuity Start Amount is Contract Value as of the Annuity Start Date, less any
Premium tax and, if applicable, any pro rata Account Charge. Annuity Start
Amount allocated to the Fixed Account is applied to purchase a Fixed Annuity and
that allocated to the Subaccounts is applied to purchase a Variable Annuity. For
Annuity Options 1 through 6, the Annuity Start Amount is divided by $1,000, and
the result is multiplied by the applicable amount in the Annuity Tables to
determine the minimum guaranteed monthly Annuity Payment with respect to a Fixed
Annuity or the first monthly Annuity Payment with respect to a Variable Annuity.
FIXED ANNUITY PAYMENTS
With respect to Fixed Annuity Payments, the amount set forth in the Annuity
Tables as adjusted for the rate of interest credited by FSBL, is the amount of
each monthly Annuity Payment for Annuity Options 1 through 6. Neither expense
actually incurred (other than tax on investment return), nor mortality actually
experienced, shall adversely affect the dollar amount of Annuity Payments
already commenced.
20
VARIABLE ANNUITY PAYMENTS
With respect to Variable Annuity Payments, the amount set forth in the Annuity
Tables, as adjusted for the Assumed Interest Rate, is the amount of the FIRST
monthly Annuity Payment for Annuity Options 1 through 6. The amount of each
Annuity Payment after the first for these options is computed by means of
Annuity Units. Variable Annuity Payments will fluctuate with the performance of
the Subaccount(s). Neither expense actually incurred (other than tax on
investment return), nor mortality actually experienced, shall adversely affect
the dollar amount of Annuity Payments already commenced.
ANNUITY TABLES
The amounts set forth in the Annuity Tables for Annuity Options 1 through 4 and
6 depend on the sex and age of the Annuitant or the Joint Annuitants on the
Annuity Start Date. The Annuity Tables are modified to reflect:
(1) the Assumed Interest Rate for Variable Annuity Payments; or
(2) the rate of interest in effect on the Annuity Start Date for Fixed
Annuity Payments.
The rate of interest for Fixed Annuity Payments is guaranteed not to be less
than 1.5%. The basis of the Annuity Tables for Options 1 through 4 and 6 is the
1983(a) Mortality Table projected for mortality improvement for 45 years using
Projection Scale G and an interest rate factor equal to 1.5%. The Annuity Tables
contain the amount of monthly Annuity Payment per $1,000 of Annuity Start
Amount. The Annuity Tables state values for the exact ages shown.
The values will be interpolated based on the exact age(s) of the Annuitant or
Joint Annuitants on the Annuity Start Date. The Assumed Interest Rate is set
forth on page 3. The Annuity Table for Option 5 is determined without reference
to the age or sex of the Annuitant and is based upon an interest rate factor
equal to 1.5%. The Annuity Tables are used in accordance with generally accepted
actuarial principles.
ANNUITY PAYMENTS
If no Purchase Payments have been received by FSBL during the three-years
preceding the Annuity Start Date, you may not select an Annuity Option that
requires FSBL to make Annuity Payments of less than $20.00. If FSBL refuses to
commence Annuity Payments of less than $20.00, FSBL will permit surrender of the
contract, with no withdrawal charges. If no Annuity Option is chosen prior to
the Annuity Start Date, FSBL will use Option 1 with a ten-year period certain.
Each Annuity Option allows for making Annuity Payments annually, semiannually,
quarterly or monthly. Annuity Payments due on a date other than a Valuation
Date, are paid as of the end of the next following Valuation Date.
ANNUITY UNITS
On the Annuity Start Date, the amount of the first Variable Annuity Payment is
divided by the Annuity Unit Value as of that date to determine the number of
Annuity Units to be used in calculating subsequent Annuity Payments. If the
Annuity Start Amount was allocated to more than one Subaccount, the first
Variable Annuity Payment will be allocated to each Subaccount in the percentage
corresponding to the allocation of Annuity Start Amount. The number of Annuity
Units for each Subaccount is then found by dividing the amount of the first
Variable Annuity Payment allocated to that Subaccount by the Annuity Unit Value
for the Subaccount on the Annuity Start Date. The number of Annuity Units for
the Subaccount then remains constant, unless a Transfer of Annuity Units is
made. After the first Variable Annuity Payment, the dollar amount of each
subsequent Annuity Payment is equal to the sum of the payment amount determined
for each Subaccount. The payment amount for each Subaccount is equal to the
number of Annuity Units allocated to that Subaccount multiplied by the Annuity
Unit Value as of the date of the Annuity Payment.
21
An example of an initial Variable Annuity Payment calculation for a male, age 60
is as follows:
Annuity Start Amount = $100,000 $100,000
-------- = 100
$1,000
Amount determined by reference in 1999 to Annuity
Table for a male, age 60 under Option 1 $4.00
First Variable Annuity Payment 100 x $4.00 = $400
Annuity Number of
Annuity First Unit Value Annuity Units
Start Amount Variable Annuity on Annuity Used to Determine
Subaccount Allocation Payment Allocation Start Date Subsequent Payments
---------- ------------ ------------------ ---------- -------------------
Equity 50% $200.00 / $1.51 = 132.4503
Global 50% $200.00 / $1.02 = 196.0784
An example of a subsequent Variable Annuity Payment calculation using the
assumptions above is as follows:
Annuity Unit
Value on Date of New Annuity
Subaccount Annuity Units Subsequent Payment Payment Amount
---------- ------------- ------------------ --------------
Equity 132.4503 x $1.60 = $211.92
Global 196.0784 x $1.10 = $215.69
-------
$427.61
ANNUITY UNIT VALUE
The Annuity Unit Value for each Subaccount was first set by FSBL. The Annuity
Unit Value for any subsequent Valuation Date is equal to (a) times (b) times
(c), where:
(a) is the Annuity Unit Value on the immediately preceding Valuation
Date:
(b) is the Net Investment Factor for the day;
(c) is a factor used to adjust for the Assumed Interest Rate set forth
on page 3 which is used to determine Variable Annuity Payment
amounts.
ALTERNATE ANNUITY OPTION RATES
Currently, FSBL does not sell single premium immediate annuities ("SPIAs").
However, in the future, FSBL may sell SPIAs. If so, any more favorable rates
available under FSBL's SPIAs will be given to the Annuitant.
22
ANNUITY TABLES
TABLE A
--------------------------------------------------------------------------------
ANNUITY OPTIONS ONE, TWO, AND THREE
MINIMUM MONTHLY INSTALLMENTS PER $1,000 OF AMOUNT APPLIED
Option One Option Three
Age Life Income Option Two Unit
Of Annuitant Only Life Income with Period Certain Refund
5 10 15 20
---------------------------------------------------------------------------------
MALE
55 3.33 3.32 3.31 3.28 3.22 3.10
56 3.41 3.40 3.38 3.35 3.28 3.16
57 3.49 3.48 3.46 3.42 3.35 3.22
58 3.57 3.56 3.54 3.49 3.41 3.28
59 3.66 3.65 3.62 3.57 3.48 3.34
60 3.76 3.75 3.71 3.65 3.54 3.41
61 3.86 3.85 3.81 3.74 3.61 3.48
62 3.96 3.95 3.91 3.82 3.68 3.56
63 4.08 4.06 4.01 3.91 3.75 3.63
64 4.20 4.18 4.12 4.01 3.83 3.72
65 4.33 4.31 4.24 4.10 3.90 3.80
66 4.47 4.44 4.36 4.20 3.97 3.89
67 4.61 4.59 4.49 4.31 4.04 3.98
68 4.77 4.74 4.62 4.41 4.11 4.08
69 4.94 4.90 4.76 4.52 4.18 4.19
70 5.12 5.07 4.91 4.62 4.25 4.29
71 5.30 5.25 5.06 4.73 4.31 4.41
72 5.50 5.43 5.21 4.84 4.37 4.53
73 5.71 5.63 5.37 4.95 4.43 4.65
74 5.94 5.84 5.54 5.05 4.48 4.77
75 6.18 6.06 5.71 5.16 4.53 4.91
FEMALE
55 3.00 3.00 3.00 2.98 2.96 2.88
56 3.07 3.06 3.06 3.04 3.02 2.93
57 3.13 3.13 3.12 3.10 3.07 2.98
58 3.20 3.20 3.19 3.17 3.13 3.04
59 3.27 3.27 3.26 3.23 3.20 3.10
60 3.35 3.34 3.33 3.31 3.26 3.16
61 3.43 3.42 3.41 3.38 3.33 3.22
62 3.51 3.51 3.49 3.46 3.40 3.29
63 3.60 3.60 3.58 3.54 3.47 3.36
64 3.70 3.69 3.67 3.62 3.54 3.43
65 3.80 3.79 3.77 3.71 3.61 3.50
66 3.91 3.90 3.87 3.80 3.69 3.58
67 4.02 4.01 3.98 3.90 3.77 3.67
68 4.15 4.13 4.09 4.00 3.85 3.75
69 4.28 4.26 4.21 4.11 3.93 3.85
70 4.42 4.40 4.34 4.21 4.01 3.94
71 4.57 4.55 4.48 4.33 4.08 4.05
72 4.74 4.71 4.62 4.44 4.16 4.16
73 4.91 4.88 4.77 4.56 4.24 4.27
74 5.10 5.07 4.93 4.68 4.31 4.39
75 5.31 5.26 5.10 4.80 4.38 4.52
VALUES NOT SHOWN WILL BE PROVIDED UPON REQUEST. ANNUAL, SEMIANNUAL, OR QUARTERLY
INSTALLMENTS CAN BE DETERMINED BY MULTIPLYING THE MONTHLY INSTALLMENTS BY
11.9185007, 5.9814315, AND 2.9962817.
23
ANNUITY TABLES (CONTINUED)
TABLE B
--------------------------------------------------------------------------------
ANNUITY OPTIONS FOUR AND SIX (100% SURVIVOR OPTION)
MINIMUM MONTHLY INSTALLMENT PER $1,000 OF AMOUNT APPLIED
AGE OF FEMALE ANNUITANT AGE OF MALE ANNUITANT
55 60 62 65 70 75
--------------------------------------------------------------------------------
55 2.76 2.84 2.87 2.90 2.94 2.97
60 2.90 3.03 3.08 3.14 3.22 3.27
62 2.96 3.11 3.17 3.24 3.34 3.41
65 3.03 3.22 3.29 3.40 3.54 3.64
70 3.13 3.39 3.49 3.65 3.88 4.08
75 3.21 3.52 3.66 3.87 4.23 4.56
VALUES NOT SHOWN WILL BE PROVIDED UPON REQUEST. ANNUAL, SEMIANNUAL, OR QUARTERLY
INSTALLMENTS CAN BE DETERMINED BY MULTIPLYING THE MONTHLY INSTALLMENTS BY
11.9185007, 5.9814315, AND 2.9962817, RESPECTIVELY.
TABLE C
--------------------------------------------------------------------------------
ANNUITY OPTION FIVE
MINIMUM MONTHLY INSTALLMENT PER $1,000 OF
AMOUNT APPLIED FOR FIXED ANNUITY PAYMENTS
PERIOD CERTAIN
5 YEARS 7 YEARS 10 YEARS 15 YEARS 20 YEARS
--------------------------------------------------------------------------------
FIXED ANNUITY PAYMENT 17.28 12.53 8.96 6.20 4.81
VALUES NOT SHOWN WILL BE PROVIDED UPON REQUEST. ANNUAL, SEMIANNUAL, OR QUARTERLY
INSTALLMENTS CAN BE DETERMINED BY MULTIPLYING THE MONTHLY INSTALLMENTS BY
11.9185007, 5.9814315, 2.9962817, RESPECTIVELY.
24
A BRIEF DESCRIPTION OF THIS CONTRACT
This is a FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT.
* Purchase Payments may be made until the earlier of the Annuity Start Date
or termination of the Contract
* A death benefit may be paid prior to the Annuity Start Date according to
the Contract provisions
* Annuity Payments begin on the Annuity Start Date using the method
specified in the Contract
* This Contract is non-participating and does not participate in FSBL's
surplus
BENEFITS AND VALUES PROVIDED BY THIS CONTRACT WHEN BASED UPON THE INVESTMENT
EXPERIENCE OF THE SEPARATE ACCOUNT ARE VARIABLE. THESE AMOUNTS MAY INCREASE OR
DECREASE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. (SEE "CONTRACT VALUE AND
EXPENSE PROVISIONS" AND "ANNUITY BENEFIT PROVISIONS" FOR DETAILS.)
IF A CREDIT ENHANCEMENT RIDER HAS BEEN PURCHASED, FSBL WILL RECAPTURE THE AMOUNT
OF ANY CREDIT ENHANCEMENT APPLIED DURING THE 12 MONTHS PRECEDING THE DATE OF THE
OWNER'S DEATH.
[FSBL LOGO] FIRST SECURITY BENEFIT LIFE INSURANCE AND ANNUITY
COMPANY OF NEW YORK
[00 Xxxx Xxx Xxx Xxxx, Xxxxx Xxxxxx, XX 00000
0-000-000-0000]
FSB236 (1-05)
