EXHIBIT (4)(a)
________ GOLDEN
_________ AMERICAN DEFERRED COMBINATION
____________ LIFE INSURANCE VARIABLE AND FIXED
_______ COMPANY ANNUITY CONTRACT
Golden American is a stock company domiciled in Delaware.
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| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
| |
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| Initial Premium Annuity Option Annuity Commencement |
| Date |
| [$25,000] [LIFE 10-YEAR [JANUARY 1, 2028] |
| CERTAIN] |
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| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B AND THE FIXED [123456] |
| ACCOUNT] |
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This is a legal Contract between its Owner and us. Please read it
carefully. In this Contract you or your refers to the Owner shown above.
We, our or us refers to Golden American Life Insurance Company. You may
allocate this Contract's Accumulation Value among the Variable Separate
Account, the General Account and the Fixed Account shown in the Schedule.
If this Contract is in force, we will make income payments to the Owner
starting on the Annuity Commencement Date as shown in the Schedule. If
the Owner dies prior to the Annuity Commencement Date, we will pay a
death benefit to the Beneficiary. The amount of such benefit is subject
to the terms of this Contract.
ALL PAYMENTS AND VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A
VARIABLE SEPARATE ACCOUNT DIVISION, MAY INCREASE OR DECREASE, DEPENDING
ON THE CONTRACT'S INVESTMENT RESULTS. ALL PAYMENTS AND VALUES BASED ON
THE FIXED ACCOUNT MAY BE SUBJECT TO A MARKET VALUE ADJUSTMENT, THE
OPERATION OF WHICH MAY CAUSE SUCH PAYMENTS AND VALUES TO INCREASE OR
DECREASE.
RIGHT TO EXAMINE CONTRACT: YOU MAY RETURN THIS CONTRACT TO US OR THE
AGENT THROUGH WHOM YOU PURCHASED IT WITHIN 10 DAYS AFTER YOU RECEIVE IT.
IF SO RETURNED, WE WILL TREAT THE CONTRACT AS THOUGH IT WERE NEVER
ISSUED. UPON RECEIPT WE WILL PROMPTLY REFUND THE ACCUMULATION VALUE,
ADJUSTED FOR ANY MARKET VALUE ADJUSTMENT, PLUS ANY CHARGES WE HAVE
DEDUCTED AS OF THE DATE THE RETURNED CONTRACT IS RECEIVED BY US.
Customer Service Center Secretary: /s/ Xxxxx X. Xxxxxxx
0000 Xxxxxxxx Xxxxx President: /s/ Xxx Xxxxxxx
West Chester, PA 19380-1478
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DEFERRED COMBINATION VARIABLE AND FIXED ANNUITY CONTRACT - NO DIVIDENDS
Variable Cash Surrender Values while the Annuitant and Owner are living
and prior to the Annuity Commencement Date. Death benefit subject to
guaranteed minimum. Additional Premium Payment Option. Partial
Withdrawal Option. Non-participating. Investment results reflected in
values.
GA-IA-1042-01/98
CONTRACT CONTENTS
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THE SCHEDULE....................... 3 YOUR CONTRACT BENEFITS........... 14
Payment And Investment Information 3a Cash Value Benefit
The Variable Separate Accounts.... 3b Partial Withdrawal Option
The General Account............... 3c Proceeds Payable to the
Contract Facts.................... 3d Beneficiary
Charges and Fees.................. 3e
Income Plan Factors............... 3F CHOOSING AN INCOME PLAN.......... 15
IMPORTANT TERMS ................... 4 Annuity Benefits
Annuity Commencement Date Selection
INTRODUCTION TO THIS CONTRACT...... 6 Frequency Selection
The Income Plan
The Contract The Annuity Options
The Owner Payment When Named Person Dies
The Annuitant
The Beneficiary OTHER IMPORTANT INFORMATION...... 17
Change of Owner or Beneficiary Sending Notice to Us
Reports to Owner
PREMIUM PAYMENTS AND ALLOCATION Assignment - Using This Contract
ADDITIONAL PREMIUM PAYMENT OPTION As Collateral Security
CHANGES.......................... 8 Changing This Contract
Contract Changes - Applicable
Initial Premium Payment Tax Law
Your Right to Change Allocation of Misstatement of Age or Sex
Accumulation Value Non-participating
What Happens if a Variable Separate Payments We May Defer
Account Division is Not Available Authority to Make Agreements
Required Note on Our Computations
HOW WE MEASURE THE CONTRACT'S
ACCUMULATION VALUE............... 9
The Variable Separate Accounts
The General Account
Valuation Period
Accumulation Value
Accumulation Value in Each Division
and Fixed Allocation
Fixed Allocation
Measurement of Investment Experience
Charges Deducted From Accumulation
Value on Each Contract Processing
Date
Copies of any application and any additional Riders and Endorsements are at
the back of this Contract.
THE SCHEDULE
The Schedule gives specific facts about this Contract and its coverage.
Please refer to the Schedule while reading this Contract.
GA-IA-1042-01/98 2
THE SCHEDULE
PAYMENT AND INVESTMENT INFORMATION
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| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
| |
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| Annuitant's Issue Age Annuitant's Sex Owner's Issue Age |
| [55] [MALE] [55] |
| |
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| Initial Premium Annuity Option Annuity Commencement |
| Date |
| [$25,000] [LIFE 10-YEAR [JANUARY 1, 2028] |
| CERTAIN] |
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| Contract Date Issue Date Residence Status |
| [JANUARY 1, 1998] [JANUARY 1, 1998] [DELAWARE] |
| |
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| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B AND THE FIXED [123456] |
| ACCOUNT] |
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INITIAL INVESTMENT
Initial Premium Payment received: [$25,000]
Your initial Accumulation Value has been invested as follows:
Percentage of
Divisions Accumulation Value
[Multiple Allocation 10%
Fully Managed 10%
Capital Appreciation 10%
Rising Dividends 10%
All-Growth 10%
Real Estate 10%
Hard Assets 5%
Total Return 5%
Limited Maturity 5%
Bond 5%
Liquid Asset 5%
Value Equity 5%
Strategic Equity 5%
Managed Global 5%]
Fixed Allocation - 1
Year
Total 100%
ADDITIONAL PREMIUM PAYMENT INFORMATION
[We will accept additional Premium Payments until either the Annuitant
or Owner reaches the Attained Age of 85. The minimum additional
payment which may be made is $1,000.00.]
[In no event may you contribute to your IRA for the taxable year in
which you attain age 70 1/2 and thereafter (except for rollover
contributions). The minimum additional payment which may be made is
[$1,000.00].]
GA-IA-1042-01/98 3A/1
THE SCHEDULE
PAYMENT AND INVESTMENT INFORMATION (continued)
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| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
| |
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| Annuitant's Issue Age Annuitant's Sex Owner's Issue Age |
| [55] [MALE] [55] |
| |
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| Initial Premium Annuity Option Annuity Commencement |
| Date |
| [$25,000] [LIFE 10-YEAR [JANUARY 1, 2028] |
| CERTAIN] |
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| Contract Date Issue Date Residence Status |
| [JANUARY 1, 1998] [JANUARY 1, 1998] [DELAWARE] |
| |
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| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B AND THE FIXED [123456] |
| ACCOUNT] |
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ACCUMULATION VALUE ALLOCATION RULES
The maximum number of Divisions in which you may be invested at any
one time is [sixteen]. You are allowed unlimited allocation changes
per Contract Year without charge. We reserve the right to impose a
charge for any allocation change in excess of [twelve] per Contract
Year. The Excess Allocation Charge is shown in the Schedule.
Allocations into and out of the Guaranteed Interest Divisions are
subject to restrictions (see General Account).
ALLOCATION CHANGES BY TELEPHONE
You may request allocation changes by telephone during our telephone
request business hours. You may call our Customer Service Center at
1-800-366-0066 to make allocation changes by using the personal
identification number you will receive. You may also mail any notice
or request for allocation changes to our Customer Service Center at
the address shown on the cover page.
GA-IA-1042-01/98 3A/2
THE SCHEDULE
THE VARIABLE SEPARATE ACCOUNTS
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| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
| |
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| Initial Premium Annuity Option Annuity Commencement |
| Date |
| [$25,000] [LIFE 10-YEAR [JANUARY 1, 2028] |
| CERTAIN] |
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| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B AND THE FIXED [123456] |
| ACCOUNT] |
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DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND
Separate Account B (the "Account") is a unit investment trust Separate
Account, organized in and governed by the laws of the State of
Delaware, our state of domicile. The Account is divided into
Divisions. Each Division listed below invests in shares of the mutual
fund portfolio (the "Series") designated. Each portfolio is a part of
The GCG Trust managed by Directed Services, Inc.
SERIES SERIES
[Equity Income Real Estate
Fully Managed Hard Assets
Value Equity Limited Maturity Bond
Small Cap Liquid Asset
Capital Appreciation Strategic Equity
Rising Dividends Managed Global
All-Growth Research
Mid-Cap Growth Growth
Total Return Global Fixed Income
Growth & Income Growth Opportunities
Emerging Markets Developing World]
The Division listed below invests in shares of the mutual fund portfolio (the
"Portfolio") designated. The portfolio is a part of the Warburg Pincus Trust
managed by Warburg, Xxxxxx Counselors, Inc.
PORTFOLIO
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[International Equity]
The Division listed below invests in shares of the mutual fund portfolio (the
"Portfolio") designated. The portfolios are a part of the PIMCO Trust
managed by Pacific Investment Management Company.
PORTFOLIO
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High Yield
StocksPLUS Growth and Income
GA-IA-1042-01/98 3B
THE SCHEDULE
THE GENERAL ACCOUNT
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| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
| |
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| Initial Premium Annuity Option Annuity Commencement |
| Date |
| [$25,000] [LIFE 10-YEAR [JANUARY 1, 2028] |
| CERTAIN] |
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| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B AND THE FIXED [123456] |
| ACCOUNT] |
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GENERAL ACCOUNT
[Guaranteed Interest Division
A Guaranteed Interest Division provides an annual minimum interest
rate of 3%. At our sole discretion, we may periodically declare
higher interest rates for specific Guarantee Periods. Such rates will
apply to periods following the date of declaration. Any declaration
will be by class and will be based on our future expectations.
Limitations of Allocations
We reserve the right to restrict allocations into and out of the
General Account. Such limits may be dollar restrictions on
allocations into the General Account or we may restrict reallocations
into the General Account.
Transfers from a Guaranteed Interest Division
We currently require that an amount allocated to a Guarantee Period
not be transferred until the Maturity Date, except pursuant to our
published rules. We reserve the right not to allow amounts previously
transferred from a Guaranteed Interest Division to the Variable
Separate Account Divisions or to a Fixed Allocation to be transferred
back to a Guaranteed Interest Division for a period of at least six
months from the date of transfer.]
GA-IA-1042-01/98 3C
THE SCHEDULE
CONTRACT FACTS
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| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
| |
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| Initial Premium Annuity Option Annuity Commencement |
| Date |
| [$25,000] [LIFE 10-YEAR [JANUARY 1, 2028] |
| CERTAIN] |
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| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B AND THE FIXED [123456] |
| ACCOUNT] |
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Contract Processing Date
The Contract Processing Date for your Contract is [January 1] of each
year.
Specially Designated Divisions
When a distribution is made from an investment portfolio underlying a
Variable Separate Account Division in which reinvestment is not
available, we will allocate the amount of the distribution to the
[Liquid Asset Division] unless you specify otherwise.
PARTIAL WITHDRAWALS
The maximum amount that can be withdrawn each Contract Year without
being considered an Excess Partial Withdrawal is described below. We
will collect a Surrender Charge for Excess Partial Withdrawals and a
charge for any unrecovered Premium Tax. In no event may a Partial
Withdrawal exceed 90% of the Cash Surrender Value. After a Partial
Withdrawal, the remaining Accumulation Value must be at least $100 to
keep the Contract in force.
Maximum Partial Withdrawal not considered to be an Excess Partial
Withdrawal
The maximum amount that can be taken as a Partial Withdrawal each
Contract Year without being considered an Excess Partial Withdrawal is
the greater of the following:
(1) Earnings, less previous withdrawals not considered to be Excess
Partial Withdrawals, but not less than zero. Earnings are equal
to the Accumulation Value, less Premium Payments, plus prior
withdrawals.
(2) The Free Amount, equal to: a) 10% of Premium Payments not
previously withdrawn, which were received within seven years
prior to the date of withdrawal; less b) any withdrawals that
are made in the same Contract year, which are not considered to
be Excess Partial Withdrawals.
Withdrawals of Premium Payments are considered to be Excess Partial
Withdrawals.
Conventional Partial Withdrawals
Minimum Withdrawal Amount: [$100.00]
Any Conventional Partial Withdrawal from a Fixed Allocation is subject
to a Market Value Adjustment unless withdrawn from a Fixed Allocation
within 30 days prior to the Maturity Date.
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28
days from the Contract Issue Date and may be taken on a monthly,
quarterly or annual basis. You select the day withdrawals will be
made, but no later than the 28th day of the month. If you do not
elect a day, the Contract Date will be used.
Minimum Withdrawal Amount: [$100.00]
Maximum Withdrawal Amount:
Variable Separate Account 0.833% of Premium Payments
Divisions: monthly, 2.50% of Premium Payments
quarterly or 10% of Premium Payments
annual frequency.
Fixed Allocations and Interest earned on a Fixed Allocation
or Guaranteed
Guaranteed Interest Interest Division for the prior month,
Divisions: quarter or year (depending on the
frequency selected).
GA-IA-1042-01/98 3D/1
THE SCHEDULE
CONTRACT FACTS (continued)
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| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
| |
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| Initial Premium Annuity Option Annuity Commencement |
| Date |
| [$25,000] [LIFE 10-YEAR [JANUARY 1, 2028] |
| CERTAIN] |
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| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B AND THE FIXED [123456] |
| ACCOUNT] |
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Systematic Partial Withdrawals from Fixed Allocations are not subject
to a Market Value Adjustment. If the sum of Systematic Partial
Withdrawals in a Contract Year exceed the maximum withdrawal
not considered to be an Excess Partial Withdrawal, they may be subject
to a surrender charge.
[IRA Partial Withdrawals for Qualified Plans Only
IRA Partial Withdrawals may be taken on a monthly, quarterly or annual
basis. A minimum withdrawal of $100.00 is required. You select the
day the withdrawals will be made, but no later than the 28th day of
the month. If you do not elect a day, the Contract Date will be used.
Systematic Partial Withdrawals and Conventional Partial Withdrawals are
not allowed when IRA Partial Withdrawals are being taken. An IRA
Partial Withdrawal in excess of the maximum amount allowed under the
Systematic Partial Withdrawal option may be subject to a Market Value
Adjustment.]
DEATH BENEFITS
[IF DEATHBEN = "1": The Death Benefit is the greatest of (i) the
Accumulation Value, (ii) the Guaranteed Death Benefit, (iii) the Cash
Surrender Value, and (iv) the sum of premiums paid, less any Partial
Withdrawals.
IF DEATHBEN = "2": The Death Benefit is the greatest of (i) the
Accumulation Value, (ii) the Guaranteed Death Benefit, (iii) the Cash
Surrender Value, and (iv) the sum of premiums paid, less any Partial
Withdrawals.
IF DEATHBEN = "3": The Death Benefit is the greatest of (i) the Cash
Surrender Value, (ii) the Accumulation Value, (iii) the sum of the
premiums paid, less any Partial Withdrawals.]
Guaranteed Death Benefit
On the Contract Date, the Guaranteed Death Benefit is the initial
premium. On subsequent
Valuation Dates, the Guaranteed Death Benefit is calculated as
follows:
[IF DEATHBEN = "1": Option 1:
(1) Start with the Guaranteed Death Benefit from the prior
Valuation Date;
(2) Calculate interest on (1) for the current Valuation Period at
the Guaranteed Death Benefit Interest Rate;
(3) Add (1) and (2);
(4) Add any additional premiums paid during the current Valuation
Period to (3);
(5) Subtract Partial Withdrawals made during the current Valuation
Period from (4).
Each accumulated initial or additional Premium Payment, reduced by any
Partial Withdrawals (including any associated Market Value Adjustment
and Surrender Charge incurred) allocated to such premium, will
continue to grow at the Guaranteed Death Benefit Interest Rate. [IF
DEATHBEN = "1" AND % RATE = "7": In any event, the Guaranteed Death
Benefit will not exceed the Maximum Guaranteed Death Benefit.]
The Guaranteed Death Benefit is accumulated at a rate of [3, 4, 5 or
7%] compounded annually, except:
(1) Amounts in the Liquid Asset Division are accumulated at the net
rate of return for the Liquid Asset Division during the current
Valuation Period if less than [3, 4, 5, or 7%]; and
(2) Amounts in the Limited Maturity Bond Division are accumulated
at the net rate of return for the Limited Maturity Bond Division
during the current Valuation Period if less than [3, 4, 5, or 7%];
and
(3) Amounts in a Fixed Allocation or Guaranteed Interest Division
are accumulated at the interest rate being credited to such Fixed
Allocation or Guaranteed Interest Division during the current
Valuation Period if less than [3, 4, 5, or 7%].
GA-IA-1042-01/98 3D/2
THE SCHEDULE
CONTRACT FACTS (continued)
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| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
| |
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| Initial Premium Annuity Option Annuity Commencement |
| Date |
| [$25,000] [LIFE 10-YEAR [JANUARY 1, 2028] |
| CERTAIN] |
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| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B AND THE FIXED [123456] |
| ACCOUNT] |
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[IF DEATHBEN = "1" AND % RATE = "7"
Maximum Guaranteed Death Benefit
The Maximum Guaranteed Death Benefit is initially equal to two times
the initial or additional premium paid. Thereafter, the Maximum
Guaranteed Death Benefit as of the effective date of a Partial
Withdrawal is reduced first by the amount of any Partial Withdrawal
representing earnings and second in proportion to the reduction in
Accumulation Value for any Partial Withdrawal representing premium (in
each case, including any associated Market Value Adjustment and
Surrender Charge incurred). If withdrawals do not exceed 7% of
premium paid in a Contract Year, and did not exceed 7% of premiums
paid in any Contract Year, reductions in the Maximum Guaranteed Death
Benefit will be treated as withdrawals of earnings. Once withdrawals
exceed 7% in any Contract Year, withdrawals will be treated as
proportional in relation to the amount of Accumulation Value for any
Partial Withdrawals ( including any associated Market Value Adjustment
or Surrender Charge incurred.]
[IF DEATHBEN = "2": Option 2:
(1) Start with the Guaranteed Death Benefit from the prior
Valuation Date;
(2) Add to (1) any additional premium paid since the prior
Valuation Date and subtract from (1) any Partial Withdrawals
taken prior to the Valuation Date.
(3) On a Valuation Date that occurs on or prior to the Owner's
attained age 70, which is also a Contract Anniversary, we
set the Guaranteed Death Benefit equal to the greater of
(2) or the Accumulation Value as of such date.
On all other Valuation Dates, the Guaranteed Death Benefit is equal to (2).]
[IF DEATHBEN = "3": Option 3:
(1) Start with the Guaranteed Death Benefit from the prior
Valuation Date;
(2) Add any additional premiums paid during the current
Valuation Periods;
(3) Subtract any Partial Withdrawals made during the current
Valuation Period from (2).]
CHANGE OF OWNER
A change of Owner will result in recalculation of the death benefit
and Guaranteed Death Benefit. As of the date of change, we will use
the Accumulation Value of the Contract, for the purpose of such
recalculation only, as the initial premium to determine a new
Guaranteed Death Benefit for this Contract. The new Owner's age at
the time of the change will be used as the basis for this
calculation. The new Owner's death will determine when a death
benefit is payable.
[IF DEATHBEN = "1": If the new Owner's age is less than or equal to
70, the Guaranteed Death Benefit Option in effect prior to the
change of Owner will remain in effect. If the new Owner's age is
greater than 70, the Guaranteed Death Benefit will be zero and the
Death Benefit will be the greater of the Cash Surrender Value, the
Accumulation Value, and the sum of the premiums paid, less any Partial
Withdrawals.
IF DEATHBEN = "2": If the new Owner's age is less than or equal to
70, the Guaranteed Death Benefit Option in effect prior to the
change of Owner will remain in effect. If the new Owner's age is
greater than 70, the Guaranteed Death Benefit will be zero and the
Death Benefit will be the greater of the Cash Surrender Value, the
Accumulation Value and the sum of the premiums paid, less any Partial
Withdrawals.
IF DEATHBEN = "3": The Guaranteed Death Benefit Option after the
change of Owner will remain the same as before the change.]
GA-IA-1042-01/98 3D/3
THE SCHEDULE
CONTRACT FACTS (continued)
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| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
| |
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| Initial Premium Annuity Option Annuity Commencement |
| Date |
| [$25,000] [LIFE 10-YEAR [JANUARY 1, 2028] |
| CERTAIN] |
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| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B AND THE FIXED [123456] |
| ACCOUNT] |
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CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
[Distributions from a Contract funding a qualified plan must commence
no later than [April 1st] of the calendar year following the calendar
year in which the Owner attains age 70 1/2.]
The Annuity Commencement Date is required to be the same date as the
Contract Processing Date in the month following the Annuitant's [90th]
birthday. If, on the Annuity Commencement Date, a Surrender Charge
remains, your elected Annuity Option must include a period certain of
at least five years duration. In applying the Accumulation Value,
we may first collect any Premium Taxes due us.
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
Optional Benefit Riders - [None.]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full years
elapsed since the Contract Date.
FIXED ACCOUNT
Minimum Fixed Allocation
The minimum allocation to the Fixed Account in any one Fixed
Allocation is [$250.00].
Minimum Guaranteed Interest Rate - [3%.]
Guarantee Periods
We currently offer Guarantee Periods of [1,2,3,4,5,6,7,8,9 and 10]
year(s). We reserve the right to offer Guarantee Periods of durations
other than those available on the Contract Date. We also reserve the
right to cease offering a particular Guarantee Period or Periods.
We reserve the right to offer guarantee periods which require
systematic allocation to the General Account or to series of a
separate account elected by the Contractowner.
Index Rate
The Index Rate is the average of the Ask Yields for the U.S. Treasury
Strips as reported by a national quoting service for the applicable
maturity. The average is based on the period from the 22nd day of the
calendar month two months prior to the calendar month of Index Rate
determination to the 21st day of the calendar month immediately prior
to the month of determination. The applicable maturity date for these
U.S. Treasury Strips is on or next following the last day of the
Guarantee Period. If the Ask Yields are no longer available, the
Index Rate will be determined using a suitable replacement method.
We currently set the Index Rate once each calendar month. However, we
reserve the right to set the Index Rate more frequently than monthly,
but in no event will such Index Rate be based on a period less than 28
days.
GA-IA-1042-01/98 3D/4
THE SCHEDULE
CHARGES AND FEES
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| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
| |
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| Initial Premium Annuity Option Annuity Commencement |
| Date |
| [$25,000] [LIFE 10-YEAR [JANUARY 1, 2028] |
| CERTAIN] |
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| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B AND THE FIXED [123456] |
| ACCOUNT] |
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DEDUCTIONS FROM PREMIUMS
[None.]
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
[None.]
Administrative Charge
We charge [a maximum of $30 or 2% of Accumulation Value] to cover a
portion of our ongoing administrative expense for each Contract
Processing Period. The charge is incurred at the beginning of the
Contract Processing Period and deducted on the Contract Processing
Date at the end of the period.
Excess Allocation Charge
Currently none, however, we reserve the right to charge [$25] for a
change if you make more than [twelve] allocation changes per Contract
Year. Any charge will be deducted in proportion to the amount being
transferred from each Division.
Surrender Charge
A Surrender Charge is imposed as a percentage of premium if the
Contract is surrendered or an Excess Partial Withdrawal is taken.
The percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed since a Premium
Payment was made. The Surrender charge expressed as a percentage of each
Premium Payment is as follows:
Complete Years Surrender
Elapsed Charges
Since Premium
Payment
[0 6%
1 6%
2 6%
3 5%
4 4%
5 3%
6 1%
7+ 0%]
For the purpose of calculating the Surrender Charge for an Excess
Partial Withdrawal: a) we treat premiums as being withdrawn on a
first-in, first-out basis; and b) amounts withdrawn which are not
considered an Excess Partial Withdrawal are not considered a
withdrawal of any Premium Payments.
GA-IA-1042-01/98 3E/1
THE SCHEDULE
CHARGES AND FEES
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| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
| |
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| Initial Premium Annuity Option Annuity Commencement |
| Date |
| [$25,000] [LIFE 10-YEAR [JANUARY 1, 2028] |
| CERTAIN] |
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| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B AND THE FIXED [123456] |
| ACCOUNT] |
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[Premium Taxes
We deduct the amount of any premium or other state and local taxes
levied by any state or governmental entity when such taxes are
incurred.
We reserve the right to defer collection of Premium Taxes until
surrender or until application of Accumulation Value to an Annuity
Option. We reserve the right to change the amount we charge for
Premium Tax charges on future Premium Payments to conform with changes
in the law or if the Owner changes state of residence.]
Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct up to a maximum of [IF
DEATHBEN = "1": [.002247%] IF DEATHBEN = "2": [.002615%] IF DEATHBEN =
"3": [.002063%]] of the assets in each Variable Separate Account Division
on a daily basis (equivalent to an annual rate up to a maximum rate of
[IF DEATHBEN = "1": [.90%] IF DEATHBEN = "2": [.95%] IF DEATHBEN = "3":
[.75%]) for mortality and expense risks. This charge is not deducted from
the Fixed Account or General Account values.
Asset Based Administrative Charge - We deduct up to a maximum of
[0.000411%] of the assets in each Variable Separate Account Division
on a daily basis (equivalent to an annual rate up to a maximum of
[0.15%]) to compensate us for a portion of our ongoing administrative
expenses. This charge is not deducted from the Fixed Account or
General Account values.
CHARGE DEDUCTION DIVISION
All charges against the Accumulation Value in this Contract will be
deducted from the Liquid Asset Division.
GA-IA-1042-01/98 3E/2
THE SCHEDULE
INCOME PLAN FACTORS
-------------------------------------------------------------------------
-------------------------------------------------------------------------
| Annuitant Owner |
| [XXXXXX X. XXX] [XXXX X. XXX] |
| |
-------------------------------------------------------------------------
| Initial Premium Annuity Option Annuity Commencement |
| Date |
| [$25,000] [LIFE 10-YEAR [JANUARY 1, 2028] |
| CERTAIN] |
-------------------------------------------------------------------------
| Separate Account(s) Contract Number |
| [SEPARATE ACCOUNT B AND THE FIXED [123456] |
| ACCOUNT] |
-------------------------------------------------------------------------
Values for other payment periods, ages or joint life combinations are
available on request. Monthly payments are shown for each $1,000
applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Fixed Fixed
Period Monthly Period Monthly Period Monthly
of Years Income of Years Income of Years Income
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years 20 Years Refund
Certain Certain Certain
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53
]
GA-IA-1042-01/98 3F
IMPORTANT TERMS
-------------------------------------------------------------------------
ACCUMULATION VALUE - The amount that a Contract provides for investment
at any time. Initially, this amount is equal to the premium paid.
ANNUITANT - The person designated by the Owner to be the measuring life
in determining Annuity Payments.
ANNUITY COMMENCEMENT DATE - For each Contract, the date on which Annuity
Payments begin.
ANNUITY OPTIONS - Options the Owner selects that determine the form and
amount of annuity payments.
ANNUITY PAYMENT - The periodic payment an Owner receives. It may be
either a fixed or a variable amount based on the Annuity Option
chosen.
ATTAINED AGE - The Issue Age of the Annuitant or Owner plus the number of
full years elapsed since the Contract Date.
BENEFICIARY - The person designated to receive benefits in the case of
the death of the Owner.
BUSINESS DAY - Any day the New York Stock Exchange ("NYSE") is open for
trading, exclusive of federal holidays, or any day on which the
Securities and Exchange Commission ("SEC") requires that mutual funds,
unit investment trusts or other investment portfolios be valued.
CASH SURRENDER VALUE - The amount the Owner receives upon surrender of
the Contract.
CONTRACT ANNIVERSARY - The anniversary of the Contract Date.
CONTRACT DATE - The date we received the initial premium and upon which
we begin determining the Contract values. It may not be the same as
the Contract Issue Date. This date is used to determine Contract
months, processing dates, years, and anniversaries.
CONTRACT ISSUE DATE - The date the Contract is issued at our Customer
Service Center.
CONTRACT PROCESSING DATES - The days when we deduct certain charges from
the Accumulation Value.
If the Contract Processing Date is not a Valuation Date, it will be on
the next succeeding Valuation date. The Contract Processing Date will
be on the Contract Anniversary of each year.
CONTRACT PROCESSING PERIOD - The period between successive Contract
Processing Dates unless it is
the first Contract Processing Period. In that case, it is the period
from the Contract Date to the
first Contract Processing Date.
CONTRACT YEAR - The period between Contract Anniversaries.
CHARGE DEDUCTION DIVISION - The Division from which all charges are
deducted if so designated or elected by the Owner.
CONTINGENT ANNUITANT - The person designated by the Owner who, upon the
Annuitant's death prior to the Annuity Commencement Date, becomes the
Annuitant.
GA-IA-1042-01/98 4
IMPORTANT TERMS (continued)
-------------------------------------------------------------------------
EXPERIENCE FACTOR - The factor which reflects the investment experience
of the portfolio in which a Variable Separate Account Division invests
and also reflects the charges assessed against the Division for a
Valuation Period.
FIXED ACCOUNT - This is the Separate Account established to support Fixed
Allocations.
FIXED ALLOCATION - An amount allocated to the Fixed Account that is
credited with a Guaranteed Interest Rate for a specified Guarantee
Period.
GUARANTEED DEATH BENEFIT INTEREST RATE - The annual rate at which the
Guaranteed Death Benefit is calculated.
GUARANTEE PERIOD - The period of years a rate of interest is guaranteed
to be credited to a Fixed Allocation or allocations to a Guaranteed
Interest Division.
GUARANTEED INTEREST DIVISION - An investment option available in the
General Account, an account which contains all of our assets other
than those held in our Separate Accounts.
GUARANTEED INTEREST RATE - The effective annual interest rate which we
will credit for a specified Guarantee Period.
GUARANTEED MINIMUM INTEREST RATE - The minimum interest rate which can be
declared by us for Fixed Allocations or allocations to a Guaranteed
Interest Division.
INDEX OF INVESTMENT EXPERIENCE - The index that measures the performance
of a Variable Separate Account Division.
INITIAL PREMIUM - The payment amount required to put each Contract in
effect.
ISSUE AGE - The Annuitant's or Owner's age on the last birthday on or
before the Contract Date.
MARKET VALUE ADJUSTMENT - A positive or negative adjustment to a Fixed
Allocation. It may apply if all or part of a Fixed Allocation is
withdrawn, transferred, or applied to an Annuity Option prior to the
end of the Guarantee Period.
MATURITY DATE - The date on which a Guarantee Period matures.
OWNER - The person who owns a Contract and is entitled to exercise all
rights of the Contract. This person's death also initiates payment of
the death benefit.
RIDERS - Riders add provisions or change the terms of the Contract.
SPECIALLY DESIGNATED DIVISION - Distributions from a portfolio underlying
a Division in which reinvestment is not available will be allocated to
this Division unless you specify otherwise.
VALUATION DATE - The day at the end of a Valuation Period when each
Division is valued.
VALUATION PERIOD - Each business day together with any non-business days
before it.
VARIABLE SEPARATE ACCOUNT DIVISION - An investment option available in
the Variable Separate Account shown in the Schedule.
GA-IA-1042-01/98 5
INTRODUCTION TO THIS CONTRACT
-------------------------------------------------------------------------
THE CONTRACT
This is a legal Contract between you and us. We provide benefits as
stated in this Contract. In
return, you supply us with the Initial Premium Payment required to put
this Contract in effect.
This Contract, together with any Riders or Endorsements, constitutes
the entire Contract. Riders and Endorsements add provisions or change
the terms of the basic Contract.
THE OWNER
You are the Owner of this Contract. You are also the Annuitant unless
another Annuitant has been named by you and is shown in the Schedule.
You have the rights and options described in this Contract, including
but not limited to the right to receive the Annuity Benefits on the
Annuity Commencement Date.
One or more people may own this Contract. If there are multiple
Owners named, the age of the oldest Owner will be used to determine
the applicable death benefit. In the case of a sole Owner who dies
prior to the Annuity Commencement Date, we will pay the Beneficiary
the death benefit then due. If the sole Owner is not an individual,
we will treat the Annuitant as Owner for the purpose of determining
when the Owner dies under the death benefit provision (if there is
no Contingent Annuitant), and the Annuitant's age will determine the
applicable death benefit payable to the Beneficiary. The sole Owner's
estate will be the Beneficiary if no Beneficiary designation is in effect,
or if the designated Beneficiary has predeceased the Owner. In the case
of a joint Owner of the Contract dying prior to the Annuity Commencement
Date, the surviving Owner(s) will be deemed as the Beneficiary(ies).
THE ANNUITANT
The Annuitant is the measuring life of the Annuity Benefits provided
under this Contract. You may name a Contingent Annuitant. The
Annuitant may not be changed during the Annuitant's lifetime.
If the Annuitant dies before the Annuity Commencement Date, the
Contingent Annuitant becomes the Annuitant. You will be the
Contingent Annuitant unless you name someone else. The Annuitant must
be a natural person. If the Annuitant dies and no Contingent
Annuitant has been named, we will allow you sixty days to designate
someone other than yourself as an Annuitant. If all Owners are not
individuals and, through the operation of this provision, an Owner
becomes Annuitant, we will pay the death proceeds to the Beneficiary.
If there are joint Owners, we will treat the youngest of the Owners as
the Contingent Annuitant designated, unless you elect otherwise.
THE BENEFICIARY
The Beneficiary is the person to whom we pay death proceeds if any
Owner dies prior to the Annuity Commencement Date. See Proceeds
Payable to the Beneficiary for more information. We pay death
proceeds to the primary Beneficiary (unless there are joint Owners in
which case the death benefit proceeds are payable to the surviving
Owner). If the primary Beneficiary dies before the Owner, the death
proceeds are paid to the Contingent Beneficiary, if any. If there is
no surviving Beneficiary, we pay the death proceeds to the Owner's
estate.
GA-IA-1042-01/98 6
INTRODUCTION TO THIS CONTRACT (continued)
-------------------------------------------------------------------------
One or more persons may be named as primary Beneficiary or contingent
Beneficiary. In the case of more than one Beneficiary, we will assume
any death proceeds are to be paid in equal shares to the surviving
Beneficiaries. You can specify other than equal shares.
You have the right to change Beneficiaries, unless you designate the
primary Beneficiary irrevocable. When an irrevocable Beneficiary has
been designated, you and the irrevocable Beneficiary may have to act
together to exercise the rights and options under this Contract.
CHANGE OF OWNER OR BENEFICIARY
During your lifetime and while this Contract is in effect you can
transfer ownership of this Contract or change the Beneficiary.
To make any of these changes, you must send us written notice of
the change in a form satisfactory to us. The change will take effect
as of the day the notice is signed. The change will not affect any
payment made or action taken by us before recording the change at our
Customer Service Center. A Change of Owner may affect the amount of
death benefit payable under this Contract. See Proceeds Payable to
Beneficiary.
GA-IA-1042-01/98 7
PREMIUM PAYMENTS AND ALLOCATION CHARGES
-------------------------------------------------------------------------
INITIAL PREMIUM PAYMENT
The Initial Premium Payment is required to put this Contract in
effect. The amount of the Initial Premium Payment is shown in the
Schedule.
ADDITIONAL PREMIUM PAYMENT OPTION
You may make additional Premium Payments under this Contract after the
end of the Right to Examine period. Restrictions on additional
Premium Payments, such as the Attained Age of the Annuitant or Owner
and the timing and amount of each payment, are shown in the Schedule.
We reserve the right to defer acceptance of or to return any
additional Premium Payments.
As of the date we receive and accept your additional Premium Payment:
(1) The Accumulation Value will increase by the amount of the
Premium Payment less any premium deductions as shown in the
Schedule.
(2) The increase in the Accumulation Value will be allocated among
the Divisions of the Variable Separate Account and General Account
and allocations to the Fixed Account in accordance with your
instructions. If you do not provide such instructions, allocation
will be among the Divisions of the Variable Separate Account and
General Account and allocations to the Fixed Account in proportion
to the amount of Accumulation Value in each Division or Fixed
Allocation.
Where to Make Payments
Remit the Premium Payments to our Customer Service Center at the address
shown on the cover page. On request we will give you a receipt signed
by our treasurer.
YOUR RIGHT TO CHANGE ALLOCATION OF ACCUMULATION VALUE
You may change the allocation of the Accumulation Value among the
Divisions and Fixed Allocations after the end of the Right to Examine
period. The number of free allocation changes each year that we will
allow is shown in the Schedule. To make an allocation change, you
must provide us with satisfactory notice at our Customer Service
Center. The change will take effect when we receive the notice.
Restrictions for reallocation into and out of Divisions of the
Variable Separate Account and General Account and allocations to the
Fixed Account are shown in the Schedule. An allocation from the Fixed
Account may be subject to a Market Value Adjustment. See the
Schedule.
WHAT HAPPENS IF A VARIABLE SEPARATE ACCOUNT DIVISION IS NOT AVAILABLE
When a distribution is made from an investment portfolio supporting a
unit investment trust Separate Account Division in which reinvestment
is not available, we will allocate the distribution to the Specially
Designated Division shown in the Schedule unless you specify
otherwise.
Such a distribution may occur when an investment portfolio or Division
matures, when distribution from a portfolio or Division cannot be
reinvested in the portfolio or Division due to the unavailability of
securities, or for other reasons. When this occurs because of
maturity, we will send written notice to you thirty days in advance of
such date. To elect an allocation to other than the Specially
Designated Division shown in the Schedule, you must provide
satisfactory notice to us at least seven days prior to the date the
investment matures. Such allocations will not be counted as an
allocation change of the Accumulation Value for purposes of the number
of free allocations permitted.
GA-IA-1042-01/98 8
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE
-------------------------------------------------------------------------
The variable Annuity Benefits under this Contract are provided through
investments which may be made in our Separate Accounts.
THE VARIABLE SEPARATE ACCOUNTS
These accounts, which are designated in the Schedule, are kept
separate from our General Account and any other Separate Accounts we
may have. They are used to support Variable Annuity Contracts and may
be used for other purposes permitted by applicable laws and
regulations. We own the assets in the Separate Accounts. Assets
equal to the reserves and other liabilities of the accounts will not
be charged with liabilities that arise from any other business we
conduct; but, we may transfer to our General Account assets which
exceed the reserves and other liabilities of the Variable Separate
Accounts. Xxxxxx and realized and unrealized gains or losses from
assets in these Variable Separate Accounts are credited to or charged
against the account without regard to other income, gains or losses in
our other investment accounts.
The Variable Separate Account will invest in mutual funds, unit
investment trusts and other investment portfolios which we determine
to be suitable for this Contract's purposes. The Variable Separate
Account is treated as a unit investment trust under Federal securities
laws. It is registered with the Securities and Exchange Commission
("SEC") under the Investment Company Act of 1940. The Variable
Separate Account is also governed by state law as designated in the
Schedule. The trusts may offer non-registered series.
Variable Separate Account Divisions
A unit investment trust Separate Account includes Divisions, each
investing in a designated investment portfolio. The Divisions and the
investment portfolios designated may be managed by a separate
investment adviser. Such adviser may be registered under the
Investment Advisers Act of 1940.
Changes within the Variable Separate Accounts
We may, from time to time, make additional Variable Separate Account
Divisions available to you. These Divisions will invest in investment
portfolios we find suitable for this Contract. We also have the right
to eliminate Divisions from a Variable Separate Account, to combine
two or more Divisions or to substitute a new portfolio for the
portfolio in which a Division invests. A substitution may become
necessary if, in our judgment, a portfolio or Division no longer suits
the purpose of this Contract. This may happen due to a change in laws
or regulations, or a change in a portfolio's investment objectives or
restrictions, or because the portfolio or Division is no longer
available for investment, or for some other reason. We may get prior
approval from the insurance department of our state of domicile before
making such a substitution. We will also get any required approval
from the SEC and any other required approvals before making such a
substitution.
Subject to any required regulatory approvals, we reserve the right to
transfer assets of the Variable Separate Account which we determine to
be associated with the class of contracts to which this Contract
belongs, to another Variable Separate Account or Division.
When permitted by law, we reserve the right to:
(1) deregister a Variable Separate Account under the Investment
Company Act of 1940;
(2) operate a Variable Separate Account as a management company
under the Investment Company Act of 1940, if it is operating as
a unit investment trust;
(3) operate a Variable Separate Account as a unit investment
trust under the Investment Company Act of 1940, if it is
operating as a managed Variable Separate Account;
(4) restrict or eliminate any voting rights of Owners, or other
persons who have voting rights to a Variable Separate Account;
and,
(5) combine a Variable Separate Account with other Variable
Separate Accounts.
GA-IA-1042-01/98 9
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
-------------------------------------------------------------------------
THE GENERAL ACCOUNT
The General Account contains all assets of the Company other than
those in the Separate Accounts we establish. The Guaranteed Interest
Divisions available for investment are shown in the Schedule. We may,
from time to time, offer other Divisions where assets are held in our
General Account.
VALUATION PERIOD
Each Division and Fixed Allocation will be valued at the end of each
Valuation Period on a Valuation Date. A Valuation Period is each
Business Day together with any non-Business Days before it. A
Business Day is any day the New York Stock Exchange (NYSE) is open for
trading, and the SEC requires mutual funds, unit investment trusts, or
other investment portfolios to value their securities.
ACCUMULATION VALUE
The Accumulation Value of this Contract is the sum of the amounts in
each of the Divisions of the Variable Separate Account and General
Account and allocations to the Fixed Account. You select the
Divisions of the Variable Separate Account and General Account and
allocations to the Fixed Account to which to allocate the Accumulation
Value. The maximum number of Divisions and Fixed Allocations to which
the Accumulation Value may be allocated at any one time is shown in
the Schedule.
ACCUMULATION VALUE IN EACH DIVISION AND FIXED ALLOCATION
On the Contract Date
On the Contract Date, the Accumulation Value is allocated to each
Division and Fixed Allocation as elected by you, subject to certain
terms and conditions imposed by us. We reserve the right to allocate
premium to the Specially Designated Division during any Right to
Examine Contract period. After such time, allocation will be made
proportionately in accordance with the initial allocation(s) as
elected by you.
On each Valuation Date
At the end of each subsequent Valuation Period, the amount of
Accumulation Value in each Division and Fixed Allocation will be
calculated as follows:
(1) We take the Accumulation Value in the Division or Fixed
Allocation at the end of the preceding Valuation Period.
(2) We multiply (1) by the Variable Separate Account Division's
Net Rate of Return for the current Valuation Period or we
calculate the interest to be credited to a Fixed Allocation
or to a Guaranteed Interest Division for the current Valuation
Period.
(3) We add (1) and (2).
(4) We add to (3) any additional Premium Payments (less any
premium deductions as shown in the Schedule) allocated to the
Division or Fixed Allocation during the current Valuation
Period.
(5) We add or subtract allocations to or from that Division or
Fixed Allocation during the
current Valuation Period.
(6) We subtract from (5) any Partial Withdrawals which are
allocated to the Division or Fixed Allocation during the
current Valuation Period.
(7) We subtract from (6) the amounts allocated to that
Division or Fixed Allocation for:
(a) any charges due for the Optional Benefit Riders as
shown in the Schedule;
(b) any deductions from Accumulation Value as shown in the
Schedule.
All amounts in (7) are allocated to each Division or Fixed Allocation
in the proportion that (6) bears to the Accumulation Value unless the
Charge Deduction Division has been specified (see the Schedule).
GA-IA-1042-01/98 10
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
-------------------------------------------------------------------------
FIXED ACCOUNT
The Fixed Account is a Separate Account under state insurance law and
is not required to be registered with the Securities and Exchange
Commission under the Investment Company Act of 1940. The Fixed
Account includes various Fixed Allocations which we credit with fixed
rates of interest for the Guarantee Period or Periods you select. We
reset the interest rates for new Fixed Allocations periodically based
on our sole discretion.
Guarantee Periods
Each Fixed Allocation is guaranteed an interest rate or rates for a
period, a Guarantee Period. The Guaranteed Interest Rates for a Fixed
Allocation are effective for the entire period. The Maturity Date of
a Guarantee Period will be on the last day of the calendar month in
which the Guarantee Period ends. Withdrawals and transfers made
during a Guarantee Period may be subject to a Market Value Adjustment
unless made within thirty days prior to the Maturity Date.
Upon the attainment of the Maturity Date of a Guarantee Period, we
will transfer the Accumulation Value of the expiring Fixed Allocation
to a Fixed Allocation with a Guarantee Period equal in length to the
expiring Guarantee Period, unless you select another period prior to a
Maturity Date. We will notify you at least thirty days prior to a
Maturity Date of your options for renewal. If the period remaining
from the Maturity Date of the previous Guarantee Period to the Annuity
Commencement Date is less than the period you have elected or the
period expiring, the next shortest period then available that will not
extend beyond the Annuity Commencement Date will be offered to you.
If a period is not available, the Accumulation Value will be
transferred to the Specially Designated Division.
We will declare Guaranteed Interest Rates for the then available Fixed
Allocation Guarantee Periods. These interest rates will be based on
our future expectations. Declared Guaranteed Interest Rates are
subject to change at any time prior to application to specific Fixed
Allocations, although in no event will the rates be less than the
Minimum Guaranteed Interest Rate (see the Schedule).
Market Value Adjustments
A Market Value Adjustment will be applied to a Fixed Allocation upon
withdrawal, transfer or application to an Income Plan if made more
than thirty days prior to such Fixed Allocation's Maturity Date,
except on Systematic Partial Withdrawals and IRA Partial Withdrawals.
The Market Value Adjustment is applied to each Fixed Allocation
separately.
The Market Value Adjustment is determined by multiplying the amount of
the Accumulation Value withdrawn, transferred or applied to an Income
Plan by the following factor:
( 1+I ) N/365
(---------) -1
(1+J+.0050)
Where I is the Index Rate for a Fixed Allocation as of the first day
of the applicable Guarantee Period; J is the Index Rate for new Fixed
Allocation as of the time of calculation for a new Guarantee Period,
equal to the applicable Guarantee Period, reduced for the number of
complete years elapsed since the first day of the applicable Guarantee
Period; and N is the remaining number of days in the applicable
Guarantee Period at the time of calculation. (The Index Rate is
described in the Schedule.)
Market Value Adjustments will be applied as follows:
(1) The Market Value Adjustment will be applied to the amount
withdrawn before deduction of any applicable Surrender Charge.
(2) For a Partial Withdrawal, partial transfer or in the case
where a portion of an allocation is applied to an Income Plan,
the Market Value Adjustment will be calculated on the total
amount that must be withdrawn, transferred or applied to an
Income Plan in order to provide the amount requested.
GA-IA-1042-01/98 11
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
-------------------------------------------------------------------------
(3) If the Market Value Adjustment is negative, it will be
assessed first against any remaining Accumulation Value in the
particular Fixed Allocation. Any remaining Market Value
Adjustment will be applied against the amount withdrawn,
transferred or applied to an Income Plan.
(4) If the Market Value Adjustment is positive, it will be
credited to any remaining Accumulation Value in the particular
Fixed Allocation. If a cash surrender, full transfer or full
application to an Income Plan has been requested, the Market
Value Adjustment is added to the amount withdrawn, transferred or
applied to an Income Plan.
MEASUREMENT OF INVESTMENT EXPERIENCE
Index of Investment Experience
The Investment Experience of a Variable Separate Account Division is
determined on each Valuation Date. We use an Index to measure changes
in each Division's experience during a Valuation Period. We set the
Index at $10 when the first investments in a Division are made. The
Index for a current Valuation Period equals the Index for the
preceding Valuation Period multiplied by the Experience Factor for the
current Valuation Period.
How We Determine the Experience Factor
For Divisions of a unit investment trust Separate Account the
Experience Factor reflects the Investment Experience of the portfolio
in which the Division invests as well as the charges assessed against
the Division for a Valuation Period. The factor is calculated as
follows:
(1) We take the net asset value of the portfolio in which the
Division invests at the end of the current Valuation Period.
(2) We add to (1) the amount of any dividend or capital gains
distribution declared for the investment portfolio and reinvested
in such portfolio during the current Valuation Period. We
subtract from that amount a charge for our taxes, if any.
(3) We divide (2) by the net asset value of the portfolio at the
end of the preceding Valuation Period.
(4) We subtract the daily Mortality and Expense Risk Charge for
each Division shown in the Schedule for each day in the Valuation
Period.
(5) We subtract the daily Asset Based Administrative Charge
shown in the Schedule for each day in the Valuation Period.
Calculations for Divisions investing in unit investment trusts are on
a per unit basis.
Net Rate of Return for a Variable Separate Account Division
The Net Rate of Return for a Variable Separate Account Division during
a Valuation Period is the Experience Factor for that Valuation Period
minus one.
Interest Credited to a Guaranteed Interest Division
Accumulation Value allocated to a Guaranteed Interest Division will be
credited with the Guaranteed Interest Rate for the Guarantee Period in
effect on the date the premium or reallocation is applied. Once
applied, such rate will be guaranteed until the Maturity Date of that
Guarantee Period. Interest will be credited daily at a rate to yield
the declared annual Guaranteed Interest Rate. No Guaranteed Interest
Rate will be less than the Minimum Interest Rate shown in the
Schedule.
Interest Credited to a Fixed Allocation
A Fixed Allocation will be credited with the Guaranteed Interest Rate
for the Guarantee Period in effect on the date the premium or
reallocation is applied. Once applied, such rate will be guaranteed
until that Fixed Allocation's Maturity Date. Interest will be
credited daily at a rate to yield the declared annual Guaranteed
Interest Rate.
We periodically declare Guaranteed Interest Rates for then available
Guarantee Periods. No Guaranteed Interest Rate will be less than the
Minimum Interest Rate shown in the Schedule.
GA-IA-1042-01/98 12
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
-------------------------------------------------------------------------
CHARGES DEDUCTED FROM ACCUMULATION VALUE ON EACH CONTRACT PROCESSING DATE
Expense charges and fees are shown in the Schedule.
Charge Deduction Division Option
We will deduct all charges against the Accumulation Value of this
Contract from the Charge Deduction Division if you elected this option
on the application (see the Schedule). If you did not elect this
Option or if the charges are greater than the amount in the Charge
Deduction Division, the charges against the Accumulation Value will
be deducted as follows:
(1) If these charges are less than the Accumulation Value in the
Variable Separate Account Divisions, they will be deducted
proportionately from all Divisions.
(2) If these charges exceed the Accumulation Value in the
Variable Separate Account Divisions, any excess over such value
will be deducted proportionately from any Fixed Allocations and
Guaranteed Interest Divisions.
Any charges taken from the Fixed Account or the General Account will
be taken from the Fixed Allocations or Guaranteed Interest Divisions
starting with the Guarantee Period nearest its Maturity Date until
such charges have been paid.
At any time while this Contract is in effect, you may change your
election of this Option. To do this you must send us a written request
to our Customer Service Center. Any change will take effect within seven
days of the date we receive your request.
GA-IA-1042-01/98 13
YOUR CONTRACT BENEFITS
-------------------------------------------------------------------------
While this Contract is in effect, there are important rights and
benefits that are available to you. We discuss these rights and
benefits in this section.
CASH VALUE BENEFIT
Cash Surrender Value
The Cash Surrender Value, while the Annuitant is living and before the
Annuity Commencement Date, is determined as follows:
(1) We take the Contract's Accumulation Value;
(2) We adjust for any applicable Market Value Adjustment;
(3) We deduct any Surrender Charge;
(4) We deduct any charges shown in the Schedule that have been
incurred but not yet deducted, including;
(a) any administrative fee that has not yet been deducted;
(b) the pro rata part of any charges for Optional Benefit
Riders; and
(c) any applicable premium or other tax.
Cancelling to Receive the Cash Surrender Value
At any time while the Annuitant is living and before the Annuity
Commencement Date, you may surrender this Contract to us. To do this,
you must return this Contract with a signed request for cancellation
to our Customer Service Center.
The Cash Surrender Value will vary daily. We will determine the Cash
Surrender Value as of the date we receive the Contract and your signed
request in our Customer Service Center. All benefits under this
Contract will then end.
We will usually pay the Cash Surrender Value within seven days; but,
we may delay payment as described in the Payments We May Defer
provision.
PARTIAL WITHDRAWAL OPTION
After the Contract Date, you may make Partial Withdrawals. The
minimum amount that may be withdrawn is shown in the Schedule. For
purposes of calculating any Surrender Charge, any Partial Withdrawal
you take will not be considered premium, unless it is an Excess
Partial Withdrawal. To take a Partial Withdrawal, you must provide us
satisfactory notice at our Customer Service Center.
PROCEEDS PAYABLE TO THE BENEFICIARY
Prior to the Annuity Commencement Date
If the sole Owner dies prior to the Annuity Commencement Date, we will
pay the Beneficiary the death benefit. If there are joint Owners and
any Owner dies, we will pay the surviving Owners the death benefit.
We will pay the amount on receipt of due proof of the Owner's death at
our Customer Service Center. Such amount may be received in a single
lump sum or applied to any of the Annuity Options (see Choosing an
Income Plan). When the Owner (or all Owners where there are joint
Owners) is not an individual, the death benefit will become payable on
the death of the Annuitant prior to the Annuity Commencement Date
(unless a Contingent Annuitant survived the Annuitant). Only one
death benefit is payable under this Contract. In all events,
distributions under the Contract must be made as required by
applicable law.
How to Claim Payments to Beneficiary
We must receive proof of the Owner's (or the Annuitant's) death before
we will make any payments to the Beneficiary. We will calculate the
death benefit as of the date we receive due proof of death. The
Beneficiary should contact our Customer Service Center for
instructions.
GA-IA-1042-01/98 14
CHOOSING AN INCOME PLAN
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ANNUITY BENEFITS
If the Annuitant and Owner are living on the Annuity Commencement
Date, we will begin making payments to the Owner. We will make these
payments under the Annuity Option (or Options) as chosen in the
application or as subsequently selected. You may choose or change an
Annuity Option by making a written request at least 30 days prior to the
Annuity Commencement Date. Unless you have chosen otherwise, Option 2
on a 10-year period certain basis will become effective. The amounts
of the payments will be determined by applying the Accumulation Value on
the Annuity Commencement Date in accordance with the Annuity Options
section below (see Payments We Defer). Before we pay any Annuity
Benefits, we require the return of this Contract. If this Contract
has been lost, we require the applicable lost Contract form.
ANNUITY COMMENCEMENT DATE SELECTION
You select the Annuity Commencement Date. You may select any date
following the fifth Contract Anniversary but before the required date
of Xxxxxxx Commencement as shown in the Schedule. If you do not
select a date, the Annuity Commencement Date will be in the month
following the required date of Annuity Commencement.
FREQUENCY SELECTION
You may choose the frequency of the Annuity Payments. They may be
monthly, quarterly, semi-annually or annually. If we do not receive
written notice from you, the payments will be made monthly.
THE INCOME PLAN
While this Contract is in effect and before the Annuity Commencement
Date, you may chose one or more Annuity Options for the payment of
death benefits proceeds. If, at the time of the Owner's death, no
Option has been chosen for paying the death benefit proceeds, the
Beneficiary may choose an Option within one year. You may also elect
an Annuity Option on surrender of the Contract for its Cash Surrender
Value. For each Option we will issue a separate written agreement
putting the Option into effect.
Our approval is needed for any Option where:
(1) the person named to receive payment is other than the Owner
or Beneficiary; or
(2) the person named is not a natural person, such as a
corporation; or
(3) any income payment would be less than the minimum annuity
income payment shown in the Schedule.
THE ANNUITY OPTIONS
There are four Options to choose from. They are:
Option 1. Income for a Fixed Period
Payment is made in equal installments for a fixed number of years. We
guarantee each monthly payment will be at least the Income for Fixed
Period amount shown in the Schedule. Values for annual, semiannual or
quarterly payments are available on request.
GA-IA-1042-01/98 15
CHOOSING AN INCOME PLAN (continued)
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Option 2. Income for Life
Payment is made to the person named in equal monthly installments and
guaranteed for at least a period certain. The period certain can be
10 or 20 years. Other periods certain are available on request. A
refund certain may be chosen instead. Under this arrangement, income
is guaranteed until payments equal the amount applied. If the person
named lives beyond the guaranteed period, payments continue until his
or her death.
We guarantee each payment will be at least the amount shown in the
Schedule. By age, we mean the named person's age on his or her last
birthday before the Option's effective date. Amounts for ages not
shown are available on request.
Option 3. Joint Life Income
This Option is available if there are two persons named to receive
payments. At least one of the persons named must be either the Owner
of Beneficiary of this Contract. Monthly payments are guaranteed and
are made as long as at least one of the named persons is living. The
monthly payment amounts are available upon request. Such amounts are
guaranteed and will be calculated on the same basis as the Table for
Income for Life, however, the amounts will be based on two lives.
Option 4. Annuity Plan
An amount can be applied under any other settlement option we choose
to offer for the Contract form on the Option's effective date.
The minimum rates for Option 1 are based on 3% interest, compounded
annually. The minimum rates for Options 2 and 3 are based on 3%
interest, compounded annually, and the Annuity 2000 Mortality Table.
We may pay a higher rate at our discretion.
PAYMENT WHEN NAMED PERSON DIES
When the person named to receive payment dies, we will pay any amounts
still due as provided by the Option agreement. The amounts still due
are determined as follows:
(1) For Option 1 or for any remaining guaranteed payments in
Option 2, payments will be continued.
(2) For Option 3, no amounts are payable after both named
persons have died.
(3) For Option 4, the annuity agreement will state the amount
due, if any.
GA-IA-1042-01/98 16
OTHER IMPORTANT INFORMATION
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SENDING NOTICE TO US
Whenever written notice is required, send it to our Customer Service
Center. The address of our Customer Service Center is shown on the
cover page. Please include your Contract number in all correspondence.
REPORTS TO OWNER
We will send you a report at least once during each Contract Year.
The report will show the Accumulation Value and the Cash Surrender
Value as of the end of the Contract Processing Period. The report
will also show the allocation of the Accumulation Value as of such
date and the amounts deducted from or added to the Accumulation Value
since the last report. The report will also include any information
that may be currently required by the insurance supervisory official
of the jurisdiction in which the Contract is delivered.
We will also send you copies of any shareholder reports of the
portfolios in which the Divisions of the Variable Separate Account
invest, as well as any other reports, notices or documents required by
law to be furnished to Owners.
ASSIGNMENT - USING THIS CONTRACT AS COLLATERAL SECURITY
You can assign this Contract as collateral security for a loan or
other obligation. This does not
change the ownership. Your rights and any Beneficiary's right are
subject to the terms of the assignment. To make or release an
assignment, we must receive written notice satisfactory to us, at our
Customer Service Center. We are not responsible for the validity of
any assignment.
CHANGING THIS CONTRACT
This Contract or any additional benefit riders may be changed to
another annuity plan according to our rules at the time of the change.
CONTRACT CHANGES - APPLICABLE TAX LAW
We reserve the right to make changes in this Contract or its Riders to
the extent we deem it necessary to continue to qualify this Contract
as an annuity. Any such changes will apply uniformly to all Contracts
that are affected. You will be given advance written notice of such
changes.
MISSTATEMENT OF AGE OR SEX
If an age or sex has been misstated, the amounts payable or benefits
provided by this Contract will be those that the Premium Payment made
would have bought at the correct age or sex.
NON-PARTICIPATING
This Contract does not participate in the divisible surplus of Golden
American Life Insurance Company.
GA-IA-1042-01/98 17
OTHER IMPORTANT INFORMATION (continued)
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PAYMENTS WE MAY DEFER
We may not be able to determine the value of the assets of the
Variable Separate Account Divisions because:
(1) the NYSE is closed for trading;
(2) the SEC determines that a state of emergency exists;
(3) an order or pronouncement of the SEC permits a delay for the
protection of Owners; or
(4) the check used to pay the premium has not cleared through
the banking system. This may take up to 15 days.
During such times, as to amounts allocated to the Divisions of the
Variable Separate Account, we may delay;
(1) determination and payment of the Cash Surrender Value;
(2) determination and payment of any death benefit if death
occurs before the Annuity Commencement Date;
(3) allocation changes of the Accumulation Value; or,
(4) application of the Accumulation Value under an income plan.
As to the amounts allocated to a Guaranteed Interest Division of the
General Account and as to amounts allocated to Fixed Allocations of
the Fixed Account, we may, at any time, defer payment of the Cash
Surrender Value for up to six months after we receive a request for
it. We will allow interest of at least 3.00% a year on any Cash
Surrender Value payment derived from the Fixed Allocations or the
Guaranteed Interest Divisions that we defer 30 days or more.
AUTHORITY TO MAKE AGREEMENTS
All agreements made by us must be signed by one of our officers. No
other person, including an insurance agent or broker, can:
(1) change any of this Contract's terms;
(2) extend the time for Premium Payments; or
(3) make any agreement binding on us.
REQUIRED NOTE ON OUR COMPUTATIONS
We have filed a detailed statement of our computations with the
insurance supervisory official in the jurisdiction where this Contract
is delivered. The values are not less than those required by the law
of that state or jurisdiction. Any benefit provided by an attached
Optional Benefit Rider will not increase these values unless otherwise
stated in that Rider.
GA-IA-1042-01/98 18
DEFERRED COMBINATION VARIABLE AND FIXED ANNUITY CONTRACT - NO DIVIDENDS
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Variable Cash Surrender Values while the Annuitant and Owner are living
and prior to the Annuity Commencement Date. Death benefit subject to
guaranteed minimum. Additional Premium Payment Option. Partial
Withdrawal Option. Non-participating. Investment results reflected in
values.
