FIRST FORTIS LIFE
INSURANCE COMPANY
Home Office-000 Xxxxxxx Xxxxxx
Xxxxx 000
Xxxxxxxx, Xxx Xxxx 00000
A Stock Company
We will pay the Annuitant the first of a series of annuity payments on the
Annuity Commencement Date. Subsequent payments will be paid on the same day
of each month according to the provisions of this contract.
This contract is issued in consideration of the attached application and the
payment of the purchase payment shown on the Contract Data Page.
Signed for First Fortis Life Insurance Company at the Home Office, Syracuse,
New York, on the contract date.
RIGHT TO RETURN CONTRACT
You may cancel this contract by delivering or mailing a written notice or
sending a telegram to the company and returning the contract before midnight
of the tenth day after the date you received it. Notice given by mail and
return of the contract by mail are effective on being postmarked, properly
addressed, and postage prepaid. The company must return the sum of (a) the
difference between the premiums paid including any contract fees or other
charges and the amounts allocated to any separate accounts including the
fixed account under the contract and (b) the cash value of the contract, or
if the contract does not have a cash value, the reserve for the contract, on
the date the returned contract is mailed or actually delivered to the company
or its agent. The company must return the payment within 10 days after it
receives notice of cancellation and the returned contract.
/s/ Xxxx X Xxxx /s/ Xxxxxx X Xxxxxxx
--------------- --------------------
SECRETARY PRESIDENT
Flexible Premium Deferred Combination Variable and Fixed
Annuity-Non-participating. No Dividends.
ALL PAYMENTS AND VALUES PROVIDED BY THE SEPARATE ACCOUNT ARE VARIABLE, MAY
INCREASE OR DECREASE, AND ARE NOT GUARANTEED AS TO AMOUNT. PAYMENTS AND
VALUES PROVIDED BY THE FIXED ACCOUNT ARE GUARANTEED AS FOUND IN THE CONTRACT.
THE VARIABLE PROVISIONS OF THIS CONTRACT ARE FOUND ON PAGES 5 AND 6. IF A
VARIABLE ANNUITY PAYOUT OPTION IS SELECTED, THE ANNUAL NET INVESTMENT RETURN
MUST BE AT LEAST 4% IN ORDER TO AVOID A DECREASE IN THE AMOUNT OF THE
VARIABLE ANNUITY PAYMENT. THE MAXIMUM ASSET CHARGE APPLICABLE TO THE SEPARATE
ACCOUNT ASSETS UNDER THIS CONTRACT IS 1.35% ANNUALLY.
READ YOUR CONTRACT CAREFULLY
This contract is a legal contract between the contract owner and First Fortis
Life Insurance Company.
TABLE OF CONTENTS
PAGE # PAGE #
Annuitant..................... 2 General Provisions................ 4,5
Assignment.................... 4 Purchase Payments................. 5
Beneficiary................... 4 Separate Account.................. 5,6
Death Benefit................. 8 Surrenders........................ 7
Definitions................... 2,3 Termination....................... 5
Fixed Account................. 5 Transfers......................... 6,7
Fixed Annuity Payments........ 9 Variable Annuity Payments......... 9
Any contract amendments or endorsements follow the Contract Data Page.
Additional benefits added by rider follow the Optional Annuity Forms Tables.
CONTRACT DATA PAGE
INITIAL ALLOCATION OF NET PURCHASE PAYMENTS
ANNUITANT:
BENEFICIARY AT ISSUE: TWO PRIMARY
CONTRACT NUMBER:
CONTRACT DATE:
OWNER: XXXXXXXX X XXXXXX
ANNUITY COMMENCEMENT DATE:
INITIAL PURCHASE PAYMENT:
The Annual Administrative Charge is $30.00. (Waived if Contract Value is Over
$25,000).
DEFINITIONS
WE, US, OUR
First Fortis Life Insurance Company.
YOU, YOUR
The owner of this contract, or after the annuity commencement date, the
annuitant.
ACCUMULATION UNIT
A unit of measurement used to calculate the value of your interest in the
separate account before the annuity commencement date.
ANNUITANT
The person or persons named in the application and on whose life the
first annuity payment is to be made. If more than one person is so named,
all provisions of the contract which are based on the death of the
"annuitant" will be based on the date of death of the last survivor of the
persons so named. By example, the death benefit will become due only upon
the death, prior to the annuity commencement date, of the last survivor
of the persons so named. Collectively, these persons are referred to in
the contract as "annuitant" or "annuitants." The contract owner is not
permitted to name more than one annuitant under a contract used in
connection with a retirement plan that receives favorable tax treatment
under the Internal Revenue Code.
ANNUITY UNIT
A unit of measurement to calculate variable annuity payments.
BENEFICIARY
The person entitled to receive benefits as per the terms of the contract
in case of the death of the annuitant or the contract owner.
CONTRACT YEAR
A period of 12 consecutive date months beginning on the issue date or any
anniversary thereafter.
FIVE YEAR ANNIVERSARY
The fifth anniversary of a contract date, and each subsequent fifth
anniversary of that date.
FIXED ANNUITY
An annuity under which we promise to pay the annuitant or other properly
designated payee one or more fixed payments.
FUND
Each fund is a separate investment portfolio of Fortis Series Fund, Inc.
a "series" type management investment company registered under the
Investment Company Act of 1940.
NET PURCHASE PAYMENT
The gross amount of the purchase payment less any applicable premium
taxes.
PURCHASE PAYMENT
An amount paid to the company under this contract as consideration for
the benefits described herein.
Page 2
SEPARATE ACCOUNT
A segregated investment account entitled Separate Account A, established
by us pursuant to applicable law.
SUBACCOUNT
The subaccounts of the Separate Account to which contract value may be
allocated and earn a return. Each subaccount invests all of its assets in
a different fund having the same investment policies and objectives as
that subaccount.
VALUATION DATE
All business days except, with respect to any subaccount, days on which
the related fund does not value its shares.
VALUATION PERIOD
The period beginning with the close of business on a valuation date and
ending at the close of business for the next valuation date.
VARIABLE ANNUITY
An annuity under which we promise to pay the annuitant or other properly
designated payee one or more payments which vary in amount in accordance
with the net investment experience of the applicable subaccounts you
select to measure the value of the contract.
WRITTEN, IN WRITING
A written request or notice, signed and dated, and received at our home
office. The form and content of the request or notice must be acceptable
to us.
Page 3
GENERAL PROVISIONS
THE CONTRACT
This contract, the application and any attached riders constitute the entire
contract. Any change or waiver of this contract or its provisions must be
made in writing and signed by our President, Secretary, and Registrar.
CONTROL
You may, during the lifetime of the Annuitant and without the consent of the
beneficiary, assign or surrender this contract, amend or modify it with our
written consent, and exercise, receive and enjoy every other right, benefit
and privilege contained in this contract except as otherwise provided herein.
INCONTESTABILITY
This contract will be incontestable from the contract date.
MISSTATEMENT OF AGE
If the age of the annuitant has been misstated, any amount payable will be
that which the purchase payments paid would have purchased at the correct
age. If we have made any overpayments because of incorrect information about
age, or any error or miscalculation, we will deduct the overpayment from the
next payment(s) due. We add underpayments to the next payment. The amount of
any adjustment will be paid or charged with interest at the rate of 4% per
year.
ASSIGNMENT OF OWNERSHIP RIGHTS
During the lifetime of the Annuitant and prior to the Annuity Commencement
Date You may change the ownership of this contract. An ownership change must
be made in writing and a copy must be sent to our home office. The change
will be effective on the date it was made as soon as we record it, although
we are not bound by a change until the date it is recorded. Owner and
beneficiary rights are subject to any assignment of record at our home office.
SETTLEMENT
All benefits under this contract are payable from our home office.
NON-PARTICIPATING
This contract is non-participating and does not share in our surplus earnings.
OWNERSHIP OF THE ASSETS
We will have exclusive and absolute ownership and control of our assets,
including all assets allocated to the separate account. That portion of the
assets of the separate account equal to the reserves and other contract
liabilities with respect to the separate account shall not be chargeable with
liabilities arising out of any other business we may conduct.
BENEFICIARY
Before the annuity commencement date and while the annuitant is living, you
may name or change a beneficiary, a successor beneficiary, or the successor
owner by giving us written notice of the change. We are not responsible for
the validity of any change. A change will take effect as of the date it is
signed but will not affect any payments we make or action we take before
receiving your notice. We need the consent of any irrevocably named person
before making a requested change.
Except as otherwise provided below, the beneficiary will be the beneficiary
designated by the contract owner. If there is no such designated beneficiary
in effect or if such designated beneficiary is no longer living, the contract
owner or his estate, will be the beneficiary. However, in the event of the
death of a contract owner prior to the annuity commencement date and if there
are surviving owners, the surviving owners will be the beneficiaries in equal
shares, notwithstanding that the beneficiaries designated by the contract
owners may be different.
REPORTS
At least once a year we will send you a report containing information
required by the Investment Company Act of 1940 and applicable state laws.
CHANGE OF INVESTMENT ADVISOR OR INVESTMENT POLICY
Unless otherwise required by law or regulation, the investment advisor or any
investment policy may not be changed without our consent. Any investment
policy will not be changed unless a statement of the change is filed with and
approved by the Superintendent of Insurance of the State of New York. If
required, approval of or change of any investment objective will be filed
with the Insurance Department of the state where this policy is delivered.
You will be notified of any material investment policy change which has been
approved. Notification of an investment policy change will be given in
advance if you have the right to comment on or vote on such change.
Any substitution of the underlying investments of any subaccount will comply
with all applicable requirements of the Investment Company Act of 1940 and
rules thereunder.
VALUES AND BENEFITS
The values and benefits payable under this contract are at least equal to the
minimum values and benefits required by the statutes of the state in which
this contract is delivered.
RIGHTS RESERVED BY US
Upon notice to You, the Contract may be modified by Us, but only if such
modification is necessary:
(1) To make the contract meet the requirements of the Investment Company Act of
1940.
(2) To operate the Separate Account in any form permitted by law.
(3) To transfer any assets in any subaccount to another subaccount, or to one or
more separate accounts, or to the fixed account.
(4) To add, combine or remove subaccounts in the separate account.
(5) To substitute for the fund shares held in any subaccount, the shares of
another fund of Fortis Series or the shares of another investment company
or any other investment permitted by law.
(6) To make any changes as required by the Internal Revenue Code or by any other
applicable law in order to continue treatment of the contract as an annuity.
Any changes described above are subject to the prior approval of the
Superintendent of Insurance of the State of New York. Also, when required, we
will obtain your approval of any changes.
PURCHASE PAYMENTS
The purchase payment shown on the contract data page is due on or before the
contract date. We will accept additional purchase payments of at least $50 at
any time after the contract date.
The total of all purchase payments for all annuity policies issued by us
having the same owner or annuitant may not exceed $1 million (with not more
than $500,000 allocated to the fixed account) without our prior approval. We
reserve the right to modify these maximums at any time.
ALLOCATION OF PURCHASE PAYMENTS
The initial allocation of purchase payments is shown on the contract data
page. The percentage allocation for future purchase payments between the
accounts may be changed at any time by written notice. Changes in allocations
of prior purchase payments are subject to the Transfer Provision. Changes in
the allocation will be effective on the date we receive your notice. The
allocation may be 100% to any account or may be divided among the accounts in
whole percentage points totalling 100%.
TERMINATION
This contract remains in force until surrendered for its full value.
If the contract value is less than $1,000, we may cancel this contract on any
contract anniversary which is a valuation date or the next valuation date if
the contract anniversary is not valuation date. We will notify you at least
90 days in advance of our intention to cancel this contract. Upon such
cancellation we will pay you your contract value.
FIXED ACCOUNT
Purchase Payments will be allocated to the fixed account in the percentage
you specified. Interest will be credited to the account at rates we
determine. We will not change interest rates with respect to any amount more
than once each calendar year. The interest credited will not be less than 4%
per year.
FIXED ACCOUNT VALUE
The fixed account value on any valuation date is:
(1) The sum of your net purchase payments allocated to the fixed account.
(2) PLUS any transfers from the separate account.
(3) PLUS interest credited as specified above.
(4) MINUS any surrenders, surrender charges, and annual administrative charges
to the fixed account.
(5) MINUS any transfers to the separate account.
SEPARATE ACCOUNT
SUBACCOUNTS
The separate account has several subaccounts, each investing in one of the
corresponding funds. Net purchase payments are initially allocated to the
subaccounts and the fixed account as shown on the contract data page.
Income, gains, and losses, whether or not realized, from assets allocated to
the subaccounts of the separate account are credited to or changed against
the subaccounts of the separate account without regard to Our other income,
gains, or losses.
We will use the net purchase payments to purchase fun shares applicable to
the subaccounts at their net asset value. We will be the owner of all fund
shares purchased with the net purchase payment.
Page 5
SUBACCOUNT ACCUMULATION UNITS
Purchase Payments received under this contract and allocated to the separate
account will be credited in the form of subaccount accumulation units. The
number of subaccount accumulation units is found by dividing the amount of
the net purchase payment allocated to the subaccount by the subaccount
accumulation unit value at the end of the valuation period in which the
purchase payment was received at the home office. The value of each
subaccount accumulation unit was arbitrarily set as of the date the
subaccount first purchased the fund shares. Subsequent values on any
valuation date are equal to the previous subaccount accumulation unit value
times the net investment factor for the valuation period ending on that
valuation date.
SEPARATE ACCOUNT VALUE
Your separate account value is the total of the values of your interest in
each subaccount, which for that subaccount is equal to:
(1) The number of subaccount accumulation units.
(2) TIMES the subaccount accumulation unit value.
Your separate account value will vary from valuation date to valuation date
reflecting the total value of your interest in the subaccounts.
CONTRACT VALUE
Your contract value is the total of the fixed account value and the separate
account value.
NET INVESTMENT FACTOR
The net investment factor is an index number which reflects charges to this
contract and the investment performance during a valuation period. If the net
investment factor is greater than one, the subaccount accumulation unit value
has increased. If it is less than one, then the subaccount accumulation unit
value has decreased.
The net investment factor for a subaccount is determined by dividing (1) by
(2), and then subtracting (3) from the result, where:
(1) is the net result of:
(a) the net asset value per share of the fund shares held in the
subaccount, determined at the end of the current valuation period.
(b) PLUS the per share amount of any dividend or capital gain
distributions made on the fund shares held in the subaccount during
the current valuation period.
(c) MINUS a per share charge for the increase PLUS a per share credit for
the decrease, in any income taxes reserved for which we determine to
have resulted from the investment operations of the subaccount or any
other taxes which are applicable to this contract.
(2) is the net asset value per share of the fund shares held in the subaccount,
determined at the beginning of the current valuation period.
(3) is a factor representing the mortality risk, expense risk, and
administrative expense charge. The annual charge is 1.35% (.8% for mortality
risk, .45% for expense risk and .10% for administrative expense charge).
ANNUAL ADMINISTRATIVE CHARGE
AND PREMIUM TAXES
We will deduct an annual administrative charge of $30 at the following times:
(1) On each contract anniversary.
(2) On the surrender of this contract for its full value if not surrendered on a
contract anniversary.
This charge will be waived if the contract value at the end of the contract
year (or upon total surrender) is $25,000 or more.
Premium taxes, if any, levied by any unit of government will be deducted from
the contract value.
These deductions will be made from the fixed account and separate account on
a pro rata basis. The amount deducted from the separate account value will be
deducted by an automatic surrender of subaccount accumulation units on a pro
rata basis.
TRANSFERS
We will make transfers at the end of the valuation period in which we receive
your request for the transfer subject to the restrictions shown below. There
are no charges for the transfer other than any that may be made by the funds.
FIXED ACCOUNT TRANSFERS
Before the annuity commencement date, you may transfer part or all of the
fixed account value from the fixed account to the separate account subject to
the following:
(1) You may only make a transfer once each contract year.
(2) No more than 50% of the fixed account value may be transferred unless the
balance after the transfer would be less than $1,000. If the value is less
than $1,000, you may transfer the entire balance to the separate account.
(3) You must transfer at least $500 or the total fixed account value, if less.
No transfers from the fixed account may be made after the annuity
commencement date.
SEPARATE ACCOUNT TRANSFERS
You may make transfers among the subaccounts of the separate account or to the
fixed account during the contract year.
SURRENDERS
TOTAL SURRENDER
At any time prior to the annuity commencement date and during the lifetime of
the annuitant, you may surrender this contract by sending us a written
request. The amount payable on surrender is:
(1) The contract value at the end of the valuation period in which we receive
your request.
(2) MINUS the annual administrative charge if the surrender does not occur on a
contract anniversary.
(3) MINUS any applicable surrender charge.
Upon payment of the above surrender amount, this contract is terminated and we
have no further obligation under this contract.
All collateral assignees must consent to any surrender. We may require that
this contract be returned to our home office prior to making payment.
PARTIAL SURRENDER
At any time prior to the annuity commencement date and during the lifetime of
the annuitant, you may surrender a portion of the fixed account value and/or
the separate account value by sending us a written request.
You must surrender an amount equal to at least $500 including any surrender
charge. The remaining contract value, if any, must be at least $1,000.
We will surrender subaccount accumulation units from the variable account,
and/or dollar amounts from the fixed account, so that the total amount
surrendered equals the sum of the following:
(1) The dollar amount of your partial surrender request.
(2) PLUS any surrender charges.
You must specify the accounts from which surrender is to be made. Surrenders
will be made effective the end of the valuation period in which we receive
your request.
SURRENDER CHARGES
ORDER OF SURRENDER
For purposes of determining surrender charges, the contract value is
divided into the following categories:
(1) New Purchase Payments - purchase payments we received within five years of
the date of surrender or partial surrender.
(2) Old Purchase Payments - purchase payments not defined as new purchase
payments.
(3) Earnings.
Surrenders will be taken from the contract value available in the following
order:
(1) Old purchase payments.
(2) New purchase payments.
(3) Earnings.
SURRENDER WITHOUT CHARGE
Surrenders taken from the following amounts are not subject to a surrender
charge:
(1) Old purchase payments not already surrendered.
(2) 10% of all new purchase payments.
(3) Any earnings available after all purchase payments have been surrendered.
AMOUNT OF SURRENDER CHARGE
The surrender charge is found by multiplying the amount of the surrender
which is not eligible for a free surrender by .05. The surrender charge will
be deducted proportionately from the fixed account and/or the subaccounts
from which the surrender is taken.
GENERAL SURRENDER PROVISIONS
The amount surrendered, minus any charges, will normally be paid to you
within 7 days of:
(1) receipt of your written request; and
(2) receipt of your contract, if required.
Page 7
We have the right to defer payment of surrenders from the fixed account for
up to 6 months from the date we receive your request.
DEATH BENEFIT
DEATH BENEFIT BEFORE THE ANNUITY
COMMENCEMENT DATE
If the annuitant or contract owner dies prior to the annuity commencement
date (or upon the first death of an owner where there are multiple owners), a
death benefit will be paid to the beneficiary. Where a contract owner dies
before the annuity commencement date and there are one or more surviving
owners, the beneficiary of the death benefit will be the surviving owner or
owners, in equal shares, rather than the beneficiary designated by the
contract owners.
The death benefit will equal the greater of:
(1) the sum of all net purchase payments made, less all prior surrenders
(other than any automatic surrenders made to pay the annual administrative
charge) and previously-imposed surrender charges.
(2) the contract value as of the date used for valuing the death benefit, or
(3) the contract value (less the amount of any subsequent surrenders and
surrender charges) as of the contract's five year anniversary immediately
preceding the earlier of (a) the date of death of either the contract
owner or the annuitant, or (b) the date either first reaches his or her
75th birthday.
If a contract owner dies before the annuity commencement date, the death
benefit must be distributed to the beneficiary, either (1) within five years
after the date of death of the contract owner, or (2) over some period not
greater than the life or life expectancy of the beneficiary, with payments
beginning within one year after the date of death of the contract owner.
These mandatory distribution requirements will not apply when the beneficiary
designated by the contract owner is the spouse of the deceased contract
owner, if the spouse elects to continue the contract in the spouse's own name
as contract owner.
If the Owner of this contract is a corporation or other non-individual, then
for purposes of the mandatory distribution requirements described in this
section the Annuitant will be deemed to be the Owner.
We will pay a single sum to the beneficiary unless an annuity option is
chosen. The beneficiary will receive the death benefit as of the end of the
valuation period in which we receive:
(1) proof of the annuitant's or owner's death and
(2) A written request from the beneficiary for either a single sum payment or
payment under an annuity form.
DEATH BENEFIT ON OR AFTER
THE ANNUITY COMMENCEMENT DATE
If the annuitant dies on or after the annuity commencement date, the
beneficiary will receive the death benefit, if any, as provided by the
annuity form in effect.
In any event, to the extent required by the Internal Revenue Code, the
remaining interest payable to the beneficiary will be distributed at least as
rapidly as the method of distribution used at the date of death.
PROOF OF DEATH
We accept any of the following as proof of death:
(1) A copy of a certified death certificate.
(2) A copy of a certified decree of a court of competent jurisdiction as to
the finding of death.
(3) A written statement by a medical doctor who attended the deceased at the
time of death.
(4) Any other proof satisfactory to us.
PAYMENT OF BENEFITS
GENERAL
On the annuity commencement date, the contract value will be applied, as
specified by the contract owner, to provide payments to the annuitant under
one or more of the annuity options provided in the contract or under such
other settlement options as may be agreed to by the Company. If more than one
person is named as annuitant, due to the designation of multiple annuitants,
the contract owner may elect to name one of such persons to be the sole
annuitant as of the annuity commencement date.
APPLICATION OF CONTRACT VALUE
We apply the fixed account value to provide a fixed annuity, and the variable
account value to provide a variable annuity, unless you tell us in writing to
apply fixed and variable account values in different proportions. If the
contract value on the annuity commencement date is less than $2,000, we may
pay the contract value in a single sum and cancel this contract.
ANNUITY COMMENCEMENT DATE
The annuity commencement date is selected by you and stated in the
application. The date must be before the annuitant's 75th birthday unless we
agree to it. You may change the annuity commencement date at any time if we
receive written notice at least 30 days before both the current annuity
commencement date and the new annuity commencement date. The Annuity
Commencement Date cannot be later than the Annuitant's 85th birthday.
If the annuity commencement date does not occur on a valuation date that is
at least 2 years after the issue date, we reserve the right to change the
annuity commencement date to the first valuation date that is at least 2
years after the issue date.
FREQUENCY AND AMOUNT OF PAYMENTS
Annuity payments will be made monthly unless we agree to a different payment
schedule. We reserve the right to change the frequency of either a fixed
annuity payment or a variable annuity payment so that each payment will be at
least $50.
FIXED ANNUITY PAYMENTS
Fixed annuity payments start on the end of the valuation period that contains
the annuity commencement date. The amount of the first monthly payment for
the annuity form selected will be at least as favorable as the annuity tables
of this contract for each $1,000 of contract value applied as of the end of
such valuation period.
We may, as of the annuity commencement date offer for sale single premium
annuity contracts. If so, the annuity benefits available under this contract
will be at least as favorable as the benefit available by using the contract
value to purchase one of our single premium immediate annuities.
The dollar amount of any payments after the first payment are specified
during the entire period of annuity payments, according to the provisions of
the annuity form selected.
VARIABLE ANNUITY PAYMENTS
ANNUITY UNITS
We convert the subaccount accumulation units into subaccount annuity units at
the values determined at the end of the valuation period which contains the
annuity commencement date. The number of subaccount annuity units remains
constant, as long as an annuity remains in force and allocation among the
subaccounts has not changed.
Each subaccount annuity unit value was arbitrarily set at $10 when the
subaccount first converted subaccount accumulation units into annuity units.
Subsequent values on any valuation date are equal to the previous subaccount
annuity unit value times the net investment factor for that subaccount for
the valuation period ending on that valuation date, with an offset for the 4%
assumed interest rate used in the annuity tables of this contract.
Variable annuity payments start on the end of the valuation period that
contains the annuity commencement date. The amount of the first monthly
payment for the annuity form selected, is shown on the annuity tables of this
contract for each $1,000 of contract value applied as of the end of such
valuation period.
Payments after the first payment will vary in amount and are determined on
the first valuation date of each subsequent monthly period. If the monthly
payment under the annuity form selected is based on the variable annuity unit
value of single subaccount, the monthly payment is found by multiplying the
subaccount unit value on the payment date by the number of subaccount annuity
units.
If the monthly payment under the annuity form selected is based upon variable
annuity unit values of more than one subaccount, the above procedure is
repeated for each applicable subaccount. The sum of these payments is the
variable annuity payment.
We guarantee that the amount of each payment after the first payment will not
be affected by variations in expense or mortality experience.
OPTIONAL ANNUITY FORMS
You may select an annuity form or change a previous selection. The selection
or change must be in writing and received by us at least 30 days before the
annuity commencement date. If no annuity form selection is in effect on the
annuity commencement date, we automatically apply Option B, with payments
guaranteed for 10 years.
The following options are available for the fixed annuity payments and the
variable annuity payments:
OPTION A. LIFE ANNUITY - Payments are made as of the first valuation date of
each monthly period during the annuitant's life, starting with the annuity
commencement date. No payments will be made after the annuitant dies.
OPTION B. LIFE ANNUITY WITH PAYMENTS GUARANTEED FOR 10 YEARS OR 20 YEARS -
Payments are made as of the first valuation date of each monthly period
starting on the annuity commencement date. Payments will continue as long as
the annuitant lives. If the annuitant dies before all of the guaranteed
payments have been made, we will continue installments of the guaranteed
payments to the beneficiary.
OPTION C. JOINT AND FULL SURVIVOR ANNUITY - Payments are made as of the first
valuation date of each monthly period starting with the annuity commencement
date. Payments will continue as long as either the annuitant or the joint
annuitant is alive. Payments will stop when both the annuitant and the joint
annuitant have died.
Page 9
OPTION TABLES
Installments shown are for an initial monthly payment for each $1,000 of
contract value applied under an option. Age, as used in these tables, is age
as of nearest birthday on the annuity commencement date. Rates for monthly
payments for ages and periods certain not shown, if allowed by us, will be
computed on an actuarially equivalent basis.
ACTUARIAL BASIS
Installments shown in these tables are based on the 1983 Table a (20/80
Male/Female) and compound interest at the effective rate of 4% per year.
OPTIONS A AND B
-------------------------------------------------------------
10 YEAR PERIOD 20 YEAR PERIOD
AGE LIFE ONLY CERTAIN AND LIFE CERTAIN AND LIFE
-------------------------------------------------------------
50 4.56 4.54 4.45
51 4.63 4.60 4.50
52 4.69 4.66 4.55
53 4.76 4.73 4.60
54 4.84 4.80 4.66
55 4.92 4.87 4.72
56 5.00 4.95 4.78
57 5.09 5.03 4.84
58 5.18 5.12 4.90
59 5.29 5.21 4.96
60 5.39 5.30 5.03
61 5.51 5.41 5.09
62 5.63 5.51 5.16
63 5.76 5.63 5.23
64 5.90 5.75 5.29
65 6.05 5.87 5.36
66 6.21 6.01 5.42
67 6.38 6.15 5.49
68 6.57 6.29 5.55
69 6.76 6.45 5.60
70 6.98 6.61 5.66
71 7.21 6.78 5.71
72 7.46 6.95 5.75
73 7.73 7.13 5.79
74 8.02 7.31 5.83
75 8.33 7.50 5.86
-------------------------------------------------------------
OPTION C
-----------------------------------------
JOINT ANNUITANT AGE
50 55 60 65 70
------------------------------------------------------------
50 4.14 4.24 4.33 4.40 4.45
ANNUITANT 55 4.24 4.38 4.52 4.63 4.72
AGE 60 4.33 4.52 4.71 4.89 5.05
65 4.40 4.63 4.89 5.15 5.41
70 4.45 4.72 5.05 5.41 5.78
------------------------------------------------------------
10
Flexible Premium Deferred Combination Variable and Fixed
Annuity-Non participating. No Dividends.
FIRST FORTIS LIFE
INSURANCE COMPANY
000 Xxxxxxx Xxxxxx, Xxxxx 000, Xxxxxxxx, Xxx Xxxx 00000
0-000-000-0000
FIRST FORTIS LIFE INSURANCE COMPANY
SYSTEMATIC TRANSFER ENDORSEMENT
This Endorsement is a part of the contract to which it is attached.
This Endorsement adds a Systematic Transfer Option to the contract which
allows You to automatically transfer amounts from one selected subaccount
(from among those being allowed by Us under this option at such time) to one
or more Subaccounts on a periodic basis.
This option applies only if elected by You as described below. Your election
of this option will have no affect on benefits provided by the contract,
other than as specifically provided herein. The terms defined in the contract
and in any other endorsement attached to the contract will have the same
meaning when used in this Endorsement.
ELECTION OF SYSTEMATIC TRANSFER OPTION - Upon written notice to Us before the
annuity commencement date, in the form and manner provided by Us, You may
elect to automatically transfer amounts from one selected Subaccount (from
among those allowed by us at such time), or from the fixed account if the
fixed account for the contract to which this Endorsement is attached is not
subject to a market value adjustment, to one or more Subaccounts on a
monthly, quarterly, semi-annual, or annual basis, subject to the provisions
of this Endorsement.
TRANSFER ALLOCATION - Your written request for this option must specify: (a)
the Subaccount(s), or the fixed account if applicable, from which the
transfers are to be made; (b) the dollar amount of each monthly transfer,
subject to the minimum and maximum transfer amount described below; and (c)
the Subaccount(s) to receive the transferred amounts.
MINIMUM CONTRACT VALUE - The contract value must be at least $5,000 at the
time of Your written election and of the first automatic transfer made under
this option. We reserve the right to increase this amount, if You have not
yet elected this option, by advanced written notice to You.
MINIMUM AND MAXIMUM TRANSFER AMOUNT - The minimum amount that can be
transferred from a selected Subaccount, or fixed account if applicable, is
$50, or $100 if the contract to which this Endorsement is attached has a
fixed account which is subject to a market value adjustment. If the transfer
is from the fixed account of a contract which does not provide for a market
value adjustment and the transfer is being made on a monthly basis, the
maximum amount of the monthly transfer is 1/36 of the premium payments which
have been allocated to the fixed account. These minimum amounts may be
increased by Us, or these maximum amounts may be decreased by Us, if You have
not yet elected this option, upon advance written notice to You, provided
that any such changes shall not violate limits otherwise imposed under the
terms of the contract to which this Endorsement is attached.
COMMENCEMENT OF SYSTEMATIC TRANSFER - Transfers under this option will
commence as follows. Where this option is elected at the time that the
contract is applied for, the first transfer will be made on the monthly,
quarterly, semi-annual, or annual (dependent upon the frequency elected by
You) anniversary date of the contract issue date. Subsequent transfers will
be made on the monthly, quarterly, semi-annual, or annual anniversary date
thereafter.
Where this option is elected after the contract is issued, the first transfer
will be made on the monthly, quarterly, semi-annual, or annual (dependent
upon the frequency elected by You) anniversary date of the date upon which We
receive the written notice of Your election of this option in good form.
If any systematic transfer date is not a Valuation Date, the systematic
transfer for that date will occur on the next following Valuation Date.
We reserve the right, upon advance written notice to You, to change the day
of the month on which transfers commence and/or are made under this option.
Transfers under this option will be in addition to any other transfer You may
make in accordance with the terms of the transfer provisions of the contract.
Contrary conditions outlined under the transfer provisions of the contract
will be waived only for transfers made under this option.
TERMINATION OF SYSTEMATIC TRANSFER OPTION - Systematic Transfers will
continue in effect unless terminated due to the occurrence of one of the
following events:
(a) the transfer amount has depleted the value of the selected Subaccount or
fixed account from which such transfers are made; or
(b) the contract is annuitized, surrendered or otherwise distributed as a
result of the death of You or the Annuitant; or
(c) You give us a written request to discontinue this option.
/s/ Xxxx X Xxxx /s/ Xxxxxx X Xxxxxxx
--------------- --------------------
SECRETARY PRESIDENT
FIRST FORTIS LIFE INSURANCE COMPANY
AUTOMATIC PORTFOLIO REBALANCING ENDORSEMENT
This Endorsement is a part of the contract to which it is attached.
This Endorsement adds an automatic portfolio rebalancing option to the
contract which allows You to automatically transfer amounts on a periodic
basis among the Subaccounts, and the fixed account if the fixed account for
the contract to which this Endorsement is attached is not subject to a market
value adjustment, to maintain the allocation which You have selected.
This option applies only if elected by You as described below. Your election
of this option will have no affect on benefits provided by the contract,
other than as specifically provided herein. The terms defined in the contract
and in any other endorsement attached to the contract will have the same
meaning when used in this Endorsement.
ELECTION OF AUTOMATIC PORTFOLIO REBALANCING OPTION - Upon written notice to
Us before the annuity commencement date, in the form and manner provided by
Us, You may elect to automatically transfer amounts among the Subaccounts,
and the fixed account if the fixed account for the contract to which this
Endorsement is attached is not subject to a market value adjustment, such
that the values in each account selected by You will, on the reallocation
date, be equal to that percentage of the total contract value which You have
selected. The automatic reallocations may be made on a quarterly,
semi-annual, or annual basis, as selected by You.
Your written request for this option must specify: (a) the frequency of the
reallocations, and (b) the accounts to which allocations are desired and the
percentage of Your total account value to be allocated to each account
selected.
MINIMUM CONTRACT VALUE - The contract value must be at least $10,000 at the
time of Your written election and of the first automatic rebalancing made
under this option. We reserve the right to increase this amount, if You have
not yet elected this option, by advanced written notice to You.
COMMENCEMENT OF AUTOMATIC REBALANCING - Automatic rebalancing under this
option will commence as follows. If You have selected quarterly rebalancing,
the rebalancing will occur on March 31, June 30, September 30 and December
31. If You have selected semi-annual rebalancing, the rebalancing will occur
on June 30 and December 31. If You have selected annual rebalancing, the
rebalancing will occur on December 31. If this option is elected at the time
that the contract is applied for, the first rebalancing will occur on the
first rebalancing date after the contract issue date. If You elect this
option after the contract is issued, the first rebalancing will occur on the
first rebalancing date after We receive the written notice of Your election
of this option in good form. If any rebalancing date is not a Valuation Date,
the automatic rebalancing for that date will occur on the next following
Valuation Date.
We reserve the right, upon advance written notice to You, to change the day
of the month on which automatic rebalancing commences and/or subsequently
occurs under this option.
Transfers under this option will be in addition to any other transfer You may
make in accordance with the terms of the transfer provisions of the contract.
Contrary conditions outlined under the transfer provisions of the contract
will be waived only for transfers made under this option.
TERMINATION OF AUTOMATIC PORTFOLIO REBALANCING OPTION - The automatic
portfolio balancing will continue in effect unless terminated due to the
occurrence of one of the following events:
(1) the contract is annuitized, surrendered or otherwise distributed as a
result of the death of You or the Annuitant; or
(2) You give us a written request to discontinue this option.
/s/ Xxxx X Xxxx /s/ Xxxxxx X Xxxxxxx
--------------- --------------------
SECRETARY PRESIDENT
FIRST FORTIS LIFE INSURANCE COMPANY
SYSTEMATIC WITHDRAWAL OPTION ENDORSEMENT
This Endorsement is a part of the contract to which it is attached.
This Endorsement adds a Systematic Withdrawal Option to the contract which
allows You to automatically withdraw amounts from one or more Subaccounts, or
the fixed account if the fixed account for the contract to which this
Endorsement is attached is not subject to a market value adjustment, on a
periodic basis.
This option applies only if elected by You as described below. Your election
of this option will have no affect on other rights and benefits provided by
the contract except as set forth herein. The terms defined in the contract
and in any other endorsement attached to the contract will have the same
meaning when used in this Endorsement.
ELECTION OF SYSTEMATIC WITHDRAWAL OPTION - Upon written notice to Us before
the annuity commencement date, in the form and manner provided by Us, You may
elect to automatically withdraw amounts from one or more Subaccounts, or from
the fixed account if the fixed account for the contract to which this
Endorsement is attached is not subject to a market value adjustment, on a
monthly, quarterly, semi-annual, or annual basis, subject to any withdrawal
limitations imposed under any applicable Federal or State law, rules or
regulations and further subject to the provisions of this Endorsement.
FUND ALLOCATION - All systematic withdrawals will be taken from the
Subaccounts, or the fixed account if applicable, selected by You based on the
percentage allocations specified by You.
MINIMUM CONTRACT VALUE - There is no required minimum contract value at the
time of Your written election. However, We reserve the right to impose or
increase the minimum amount, if You have not yet elected this option, by
advanced written notice to You.
SYSTEMATIC WITHDRAWAL AMOUNT - The minimum amount of each systematic
withdrawal may not be less than $50, or $100 if the contract to which this
Endorsement is attached has a fixed account which is subject to a market
value adjustment. The minimum amounts may be increased by Us, if You have not
yet elected this option, upon advance written notice to You, provided that
any such changes shall not violate limits otherwise imposed under the terms
of the contract to which this Endorsement is attached.
COMMENCEMENT OF SYSTEMATIC WITHDRAWALS - Systematic withdrawals will commence
as follows. Where this option is elected at the time that the contract is
applied for, the first withdrawal will be made on the monthly, quarterly,
semi-annual, or annual (dependent upon the frequency elected by You)
anniversary date of the contract issue date. Subsequent withdrawals will be
made on the monthly, quarterly, semi-annual, or annual anniversary date
thereafter.
Where this option is elected after the contract is issued, the first
withdrawal will be made on the monthly, quarterly, semi-annual, or annual
(dependent upon the frequency elected by You) anniversary date of the date
upon which We receive the written notice of Your election of this option in
good form.
If any systematic withdrawal date is not a Valuation Date, the systematic
withdrawal for that date will occur on the next following Valuation Date.
We reserve the right, upon advance written notice to You, to change the day
of the month on which withdrawals commence and/or are made under this option.
Systematic withdrawals will be subject to any withdrawal or surrender charges
imposed by the contract.
TERMINATION OF SYSTEMATIC WITHDRAWALS - The Systematic Withdrawal Option will
continue in effect unless terminated due to the occurrence of one of the
following events:
(1) the withdrawal amount has depleted the value of the selected Subaccount
or fixed account from which such withdrawals are made; or
(2) the contract is annuitized, surrendered or otherwise distributed as a
result of the death of You or the Annuitant; or
(3) You give us a written request to discontinue this option.
/s/ Xxxx X Xxxx /s/ Xxxxxx X Xxxxxxx
--------------- --------------------
SECRETARY PRESIDENT
FIRST FORTIS LIFE INSURANCE COMPANY
000 XXXXXXX XXXXXX
XXXXX 000
XXXXXXXX, XX 00000
XXXX
INDIVIDUAL RETIREMENT ANNUITY ENDORSEMENT
This Endorsement is made a part of the attached contract.
As annuitant, you are the owner of the contract. The contract is established
for the exclusive benefit of you and your beneficiaries.
The contract is endorsed to qualify as a Xxxx Individual Retirement Annuity
(Xxxx XXX) under the Taxpayer Relief Act of 1997 and any of its amendments.
The following provisions supersede any contrary provisions of the contract.
ASSIGNMENT AND OWNERSHIP RIGHTS
This contract is nontransferable and may not be assigned, sold, transferred,
discounted, or pledged as collateral or as security, except as may be
provided in the Internal Revenue Code of 1986, as amended (the Code).
PURCHASE PAYMENTS
Except in the case of a qualified rollover described in Section 408A(e) of
the Code, or as otherwise provided by law, you may not make purchase payments
in excess of $2,000 for any taxable year. All purchase payments shall be in
cash.
Lower annual purchase payment limits may apply based on your applicable
adjusted gross income and on your other IRA contributions for the year. It is
your responsibility to monitor and follow any lower annual limits and to
notify us when a qualified rollover occurs. The annual limits and the
qualified rollover rules are described in accompanying disclosure.
Purchase payments up to $2,000 for a year, or which you tell us are qualified
rollovers, will be invested subject to contract terms. Purchase payments in
excess of actual limits will not enjoy the tax advantages of a Xxxx XXX and
must be withdrawn to avoid tax penalties.
Any refund of purchase payments (other than those distributed to you as
excess contributions) will be applied to the purchase of additional benefits
under this contract.
SURRENDERS
You may be subject to tax penalties under the Code and under state law if you
request a partial or complete surrender before you reach age 59 1/2. You may
not be subject to the tax penalties if: (1) you become disabled as defined by
the Code; (2) the entire interest in this contract is received and invested
in a similar plan which is entitled to similar tax treatment under the Code;
or (3) the distribution qualifies for another exemption from the penalty tax
pursuant to Code provisions.
You may owe federal ordinary income taxes on the taxable part of any
distribution unless you have satisfied the five year holding period
requirement specified under the Code and are 59 1/2 or older or disabled
within the meaning of pertinent Code provisions or qualify for another
exemption from federal income tax pursuant to Code provisions. Your
beneficiary, after your death, may owe federal ordinary income taxes on any
distribution to him or her unless any five year holding period specified
under the Code is satisfied.
Under the Code, an individual is considered to be disabled if he or she is
unable to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be expected to
result in death or to be of long continued and indefinite duration. An
individual must furnish proof of such disability in such form and manner as
the IRS may require.
Actual federal tax rules may differ from the above because new federal tax
laws, regulations, and rulings may cause rule changes. State and local taxes
may also apply to distributions. See your tax adviser before taking
distributions.
DEATH BENEFIT-MINIMUM DISTRIBUTION
The distribution of your contract value at your death shall be made in
accordance with the minimum distribution requirements of Section 408(b)(3) of
the Code as modified by Section 408A(c)(5) of the Code. If you die before
your entire interest is distributed, the entire remaining interest will be
distributed as follows:
If you die before you commence an annuity form of payment, unless you made
the election previously, your designated beneficiary must elect to have
the entire remaining interest distributed as follows: Option 1--by
December 31st of the year containing the fifth anniversary of your death;
or Option 2--in equal or substantially equal payments over the life
or life expectancy of your designated beneficiary starting by December
31st of the year following the year of your death. If, however, the
designated beneficiary is your surviving spouse, distribution is not
required at your death, but shall be required at the death of your spouse
as if he or she had been the contract owner.
If no election is made, the automatic option shall be Option 1 above for
a beneficiary who was not your spouse on the date of your death and shall
be no distribution at all for a beneficiary who was your spouse on the
date of your death. Option 2 is not an annuity form of payment unless such
a form of payment is specifically elected. Unless an annuity form of
payment is elected, payments cease when your contract value is exhausted.
If an annuity form of payment is elected, payments continue during the
term and in the amount specified for that form of payment.
If there is more than one beneficiary or there is a nonperson beneficiary,
the proposed income tax regulations regarding such beneficiary, to the
extent effective, limit the payment options available to beneficiaries
hereunder.
LIFE EXPECTANCY FOR MINIMUM DISTRIBUTION AT DEATH
For an annuity form of payment, life expectancy shall be calculated at the
time the payments begin and shall not be recalculated except as agreed upon
by you and the Company subject to IRS rules.
For any other method of minimum distribution, the following rules apply:
Unless otherwise elected prior to the date minimum distribution must
commence, the life expectancy of a beneficiary who was your spouse on the
date of your death shall be recalculated annually for purposes of any minimum
distribution. An election not to recalculate shall be irrevocable and shall
apply to all subsequent years. The life expectancy of a beneficiary who was
not your spouse on the date of your death shall not be recalculated.
To the extent required by the Code, life expectancy is computed by use of the
expected return multiples in Tables V and VI of Section 1.72-9 of the Income
Tax Regulations.
MULTIPLE XXXX IRAS -- MINIMUM DISTRIBUTION AT DEATH
If permitted to do so under Sections 408(a)(6) and 408(b)(3) and related
provisions of the Code, a designated beneficiary of two or more Xxxx IRA's of
the same deceased person may satisfy the minimum distribution requirements
under this contract by receiving a distribution from any one or more of those
Xxxx IRAs that is equal to the amount required to satisfy the minimum
distribution requirements for all of those Xxxx IRAs. To the extent permitted
by IRS rules, the designated beneficiary of two or more Xxxx IRAs of the same
person may use the "alternating method" described in Notice 88-38, 1988-1
C.B 524, to satisfy the minimum distribution requirements described above.
However, if an annuity form of payment was previously begun, payments must
continue during the term and in the amount specified for that form of payment.
REPORTS
We will send you such information annually as may be required under the Code
and regulations and public revenue rulings thereunder.
RIGHTS RESERVED BY US
You agree to authorize us to amend the contract so that it conforms to
changes in the Code, regulations, and public revenue rulings governing a Xxxx
XXX. We will send you a copy of any required amendment.
NONFORFEITURE
Your entire interest in the contract is nonforfeitable. You do, however,
remain subject to all contract charges, including surrender charges, if
applicable.
RESPONSIBILITY
You are responsible for compliance with the Code requirements relating to a
Xxxx XXX. We are not liable for any tax or tax penalties on amounts paid out
or applied to this contract.
Valid contributions under any Xxxx XXX are based on compensation including
wages, salaries, professional fees, tips, bonuses, taxable alimony, and self
employment income. It does not include interest, dividends, rent, retirement
benefits, income from the sale of property, or certain other forms of income.
Rollovers or direct transfers from other Xxxx IRAs and from traditional IRAs
maintained by you also may be possible. Contact your own tax adviser to
determine if your program is valid.
This endorsement is effective as of the date it is added to the contract. It
supersedes any IRA endorsement previously added to the contract.
/s/ Xxxx X Xxxx /s/ Xxxxxx X Xxxxxxx
--------------- --------------------
SECRETARY PRESIDENT
FIRST FORTIS LIFE INSURANCE COMPANY
ANNUITY COMMENCEMENT DATE ENDORSEMENT
The last sentence of the first paragraph under the subsection entitled Annuity
Commencement Date under the section of the Contract entitled PAYMENT OF
BENEFITS is hereby deleted and replaced by the following:
The Annuity Commencement Date cannot be later than the Annuitant's 90th
birthday.
Signed for the Company at the Home Office in Syracuse, New York, to take
effect on the Contract Date.
/s/ Xxxx X Xxxx /s/ Xxxxxx X Xxxxxxx
--------------- --------------------
Secretary President
