EXHIBIT 4.(b)
ELECTION AND SUPPLEMENTARY AGREEMENT FOR A SETTLEMENT OPTION
SECURITY LIFE OF DENVER INSURANCE COMPANY
Customer Service Center:
Contract No.: Annuitant:
Supplementary Contract Effective Date: [Date] First Payout Amount: [$X,XXX.XX]
SECURITY LIFE, subject to the terms of the attached contract, hereby agrees to
pay the net proceeds due in the manner indicated below. If this contract is part
of a qualified pension, profit-sharing, or HR-10 plan we may require additional
forms, and the law may restrict the form of distribution.
Section I - Designation of Annuitants
Contingent Annuitants:
First Contingent Annuitant: [Name and Address]
Second Contingent Annuitant: [Name and Address]
Section II - How Payouts Will be Made
(Refer to the attached Contract for description of Annuity Options)
[Payouts for a Designated Period. Fixed Annuity Payout. Monthly installments
guaranteed for x years in an amount not less $xxx.xx]
[Payouts for a Designated Period. Variable Annuity Payout. Monthly installments
for x years in an amount which will vary in amount with the performance of the
Divisions to which the funds are invested. Initial payouts based upon a
benchmark total return of x%.]
[Life Income with Payouts for a Designated Period. Fixed Annuity Payout. Monthly
installments in an amount not less than $xxx.xx, payable throughout the
Annuitant's lifetime. If the Annuitant dies before the end of the Designated
Period of x years, payouts will be continued to the Contingent Annuitant until
the end of the Designated Period.]
[Life Income with Payouts for a Designated Period. Variable Annuity Payout.
Monthly installments payable throughout the Annuitant's lifetime in an amount
which will vary in amount with the performance of the Divisions to which the
funds are invested. If the Annuitant dies before the end of the Designated
Period of x years, payouts will be continued to the Contingent Annuitant until
the end of the Designated Period. Initial payouts based upon a benchmark total
return of x%.]
[Joint and Last Survivor, Fixed Annuity Payout. Monthly installments in an
amount not less than $xxx.xx payable while both Annuitants are living. Upon the
death of one Annuitant, the Survivor's Annuity Payout in an amount not less than
$xxx.xx will be paid throughout the lifetime of the Surviving Annuitant.]
[Joint and Last Survivor, Variable Annuity Payout. Monthly installments payable
while both Annuitants are living in an amount which will vary in amount with the
performance of the Divisions to which the funds are invested. The number of
Annuity Units applied to each installment will be level while both Annuitants
are living and upon the death of one annuitant will be reduced to 2/3rds of the
number of Annuity Units applied to each installment while both Annuitants were
living. This Survivor's Annuity Payout will be paid throughout the lifetime of
the Surviving Annuitant.]
This Supplementary Contract may not be assigned, nor payouts made to another
without our consent.
Supplementary Contract Effective Date:
Date: SECURITY LIFE OF DENVER INSURANCE COMPANY
By:
