------
------ GOLDEN FLEXIBLE PREMIUM
--------
-------- 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]
--------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$25,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
--------------------------------------------------------------------------------
Separate Account(s) Contract Number
[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456]
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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 you starting on
the Annuity Commencement Date as shown in the Schedule. If you die 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 IN DOLLAR AMOUNT, 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. PROVISIONS REGARDING THE
VARIABLE NATURE OF THIS CONTRACT ARE FOUND AT PAGE 11.
RIGHT TO EXAMINE THIS 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 Xxxxxxx-Xxxxxxx
0000 Xxxxxxxx Xxxxx
Xxxx Xxxxxxx, XX 00000
0-000-000-0000 President: /s/ Xxxxx Xxxxxx
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FLEXIBLE PREMIUM 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. Partial Withdrawal Option. Non-participating. Investment results
reflected in values.
CONTRACT CONTENTS
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THE SCHEDULE
Payment and Investment Information .................................... 3A
The General Account ................................................... 3B
Contract Facts ........................................................ 3C
Charges and Fees ...................................................... 3D
Income Plan Factors ................................................... 3E
IMPORTANT TERMS ............................................................ 4
INTRODUCTION TO THIS CONTRACT .............................................. 6
The Contract
The Owner
The Annuitant
The Beneficiary
Change of Owner or Beneficiary
PREMIUM PAYMENTS AND ALLOCATION CHANGES .................................... 8
Initial Premium Payment
Additional Premium Payments
Your Right to Change Allocation of
Accumulation Value
What Happens if a Variable Separate Account
Division is Not Available
Restricted Funds
Thresholds
Dollar Cap
Premium Threshold
Allocation Threshold
Thresholds - Effect on Withdrawals
Threshold Processing
HOW WE MEASURE THE CONTRACT'S
ACCUMULATION VALUE ...................................................... 11
The Variable Separate Accounts
The General Account
Valuation Period
Accumulation Value
Accumulation Value in each Division and
Fixed Allocation
Fixed Account
Measurement of Investment Experience
Charges Deducted from Accumulation Value on
each Contract Processing Date
YOUR CONTRACT BENEFITS ..................................................... 16
Cash Value Benefit
Partial Withdrawal Option
Proceeds Payable to the Beneficiary
BENEFIT OPTION PACKAGES .................................................... 18
Election of Benefit Option Packages
Description of Benefit Package I
Description of Benefit Package II
CHOOSING AN INCOME PLAN .................................................... 23
Annuity Benefits
Annuity Commencement Date Selection
Frequency Selection
The Income Plan
The Annuity Options
Payment When Named Person Dies
OTHER IMPORTANT INFORMATION ................................................ 26
Entire Contract
Sending Notice to Us
Reports to Owner
Assignment - Using this Contract as
Collateral Security
Changing this Contract
Contract Changes - Applicable Tax Law
Misstatement of Age or Sex
Non-Participating
Contestability
Payments We May Defer
Authority to Make Agreements
Required Note on Our Computations
Copies of 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-1108 2
THE SCHEDULE
PAYMENT AND INVESTMENT INFORMATION
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--------------------------------------------------------------------------------
Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
--------------------------------------------------------------------------------
Annuitant's Issue Age Annuitant's Sex Owner's Issue Age
[55] [MALE] [35]
--------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$25,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
--------------------------------------------------------------------------------
Contract Date Issue Date Residence Status
[JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE]
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Schedule Date Benefit Option Package
[JANUARY 1, 1996] [II]
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Separate Account(s) Contract Number
[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456]
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INITIAL INVESTMENT
Total Initial Premium Payment [$25,000]
Internal/Affiliate Exchange or
Replacement Premium: [$5,000]
Qualified Plan Type [403(b)]
Your initial Accumulation Value has been invested as follows:
Percentage of
Divisions Accumulation Value
--------- ------------------
[Liquid Asset Division] [100%]
--------- ------------------
Total 100%
===== ====
GA-IA-1108 3A1
THE SCHEDULE
PAYMENT AND INVESTMENT INFORMATION (continued)
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Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
--------------------------------------------------------------------------------
Annuitant's Issue Age Annuitant's Sex Owner's Issue Age
[55] [MALE] [35]
--------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$25,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
--------------------------------------------------------------------------------
Contract Date Issue Date Residence Status
[JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE]
--------------------------------------------------------------------------------
Schedule Date Benefit Option Package
[JANUARY 1, 1996] [II]
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Separate Account(s) Contract Number
[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456]
--------------------------------------------------------------------------------
ADDITIONAL PREMIUM PAYMENT INFORMATION
Except in the case of a Contract issued as an XXX, we will accept additional
Premium Payments until either you or the Annuitant reaches the Attained Age of
86. If this Contract is issued as an XXX, no contributions may be made 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 $50.00. Any additional
payment which would cause the Contract's Accumulation Value to exceed $1,000,000
requires our prior approval.
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-1108 3A2
THE SCHEDULE
THE GENERAL ACCOUNT
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--------------------------------------------------------------------------------
Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
--------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$25,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
--------------------------------------------------------------------------------
Separate Account(s) Contract Number
[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456]
--------------------------------------------------------------------------------
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-1108 3B
THE SCHEDULE
CONTRACT FACTS
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Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
--------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$25,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
--------------------------------------------------------------------------------
Separate Account(s) Contract Number
[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456]
--------------------------------------------------------------------------------
CONTRACT FACTS
Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each year.
Specially Designated Division
When a distribution is made from an investment portfolio underlying a 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.
Benefit Option Package
Benefit Option Package [II] was selected.
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 Taxes. In no event may a Partial Withdrawal be greater than 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.
Systematic Partial Withdrawals and Conventional Partial Withdrawals may not be
taken in the same Contract Year.
To determine the Surrender Charge on Excess Partial Withdrawals, the withdrawals
will occur in the following order:
(1) The Free Amount;
(2) Premium Payments made three or more years prior to the withdrawal;
(3) Premium Payments made less than three years prior to withdrawal; and
(4) Any Remaining Accumulation Value.
Free Amounts are not treated as withdrawals of Premium Payments for purposes of
calculating any Surrender Charge.
Conventional Partial Withdrawals
Minimum Withdrawal Amount: $100.
The maximum amount that can be taken as a Conventional Partial Withdrawal each
Contract Year without being considered an Excess Partial Withdrawal is the Free
Amount, equal to 10% of the Contract's Accumulation Value, determined as of the
date of withdrawal.
Any Conventional Partial Withdrawal is subject to a Market Value Adjustment
unless withdrawn from a Fixed Allocation within 30 days prior to the Maturity
Date.
GA-IA-1108 3C1
THE SCHEDULE
CONTRACT FACTS (continued)
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--------------------------------------------------------------------------------
Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
--------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$25,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
--------------------------------------------------------------------------------
Separate Account(s) Contract Number
[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456]
--------------------------------------------------------------------------------
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 same day of the month as the Contract
Date will be used.
Maximum Withdrawal Amounts:
Variable Separate Account Divisions: .833% of Accumulation Value monthly,
2.5% of Accumulation Value quarterly or
10% of Accumulation Value annually.
Fixed Allocations and Interest earned on a Fixed Allocation or
Guaranteed Interest Divisions Guaranteed Interest Division for the
prior month, quarter or year (depending
on the frequency selected).
The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal is
10% of Accumulation Value not previously withdrawn. Systematic Partial
Withdrawals from Fixed Allocations are not subject to a Market Value Adjustment.
A Systematic Partial Withdrawal in excess of the Free Amount may be subject to a
Surrender Charge.
XXX Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a Contract issued as an XXX on a monthly,
quarterly or annual basis. Such XXX Partial Withdrawals will not be subject to
Surrender Charges to the extent that they do not exceed the Minimum Required
Distribution based on the Accumulation Value of this Contract, as set forth in
the Internal Revenue Code. 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 same day of the month as the Contract
Date will be used. Systematic Partial Withdrawals and Conventional Partial
Withdrawals are not allowed when XXX Partial Withdrawals are being taken. An XXX
Partial Withdrawal in excess of the maximum amount allowed under the Systematic
Partial Withdrawal option may be subject to a Market Value Adjustment.
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 you
attain age 70 1/2. Otherwise, the Annuity Commencement Date may be no later than
the same date as the Contract Processing Date in the month following the later
of the Annuitant's 90th birthday or 10 years after the last Premium Payment. In
applying the Accumulation Value, we may first collect any Premium Taxes due us.
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.
Minimum Annuity Income Payment
The minimum initial monthly annuity income payment that we will make is $50. The
minimum total income payments in any one year is $250. We have the right to
increase these minimums based upon increases reflected in the Consumer Price
Index - Urban (CPI-U) since July 1, 1993.
GA-IA-1108 3C2
THE SCHEDULE
CONTRACT FACTS (continued)
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--------------------------------------------------------------------------------
Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
--------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$25,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
--------------------------------------------------------------------------------
Separate Account(s) Contract Number
[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456]
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OPTIONAL BENEFIT RIDERS
[None]
SPECIAL FUNDS
[None]
RESTRICTED FUND LIMITS
Maximum
Allocation % of Maximum
Accumulation Value Premium % Dollar Cap
------------------ --------- ----------
[30%] [99.999%] [$9,999,999]
GA-IA-1108 3C3
THE SCHEDULE
CONTRACT FACTS (continued)
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--------------------------------------------------------------------------------
Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
--------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$25,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
--------------------------------------------------------------------------------
Separate Account(s) Contract Number
[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456]
--------------------------------------------------------------------------------
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 [6 months and 1, 3, 5, 7 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.
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-1108 3C4
THE SCHEDULE
CHARGES AND FEES
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--------------------------------------------------------------------------------
Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
--------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$25,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
--------------------------------------------------------------------------------
Separate Account(s) Contract Number
[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456]
--------------------------------------------------------------------------------
DEDUCTIONS FROM PREMIUMS
None
DEDUCTIONS FROM ACCUMULATION VALUE
Initial Administrative Charge
None
Administrative Charge
We charge a maximum of $30 to cover a portion of our ongoing administrative
expenses 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.
At the time of deduction, this charge will be waived if:
(1) The Accumulation Value is at least $50,000; or
(2) The sum of premiums paid to date is at least $50,000
Excess Allocation Charge
[$25.] Any charge will be deducted in proportion to the amount being transferred
from each Division.
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. An Excess Partial
Withdrawal will result in the deduction of any Premium Tax then due us on such
amount. 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 you
change your state of residence.
GA-IA-1108 3D1
THE SCHEDULE
CHARGES AND FEES (continued)
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--------------------------------------------------------------------------------
Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
--------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$25,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
--------------------------------------------------------------------------------
Separate Account(s) Contract Number
[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456]
--------------------------------------------------------------------------------
Surrender Charge
A Surrender Charge is imposed as a percentage of premium not previously
withdrawn 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 Elapsed Surrender
Since Premium Payment Charges
--------------------- -------
[ 0 3%
1 2%
2 1%
3+ 0%]
However, for purposes of calculating the Surrender Charge on premium paid under
this Contract as a result of an exchange or replacement of a variable annuity
issued by us or one of our Affiliated Insurance Companies as a Qualified Plan,
the following apply:
(1) Surrender Charges will apply only to that portion of the premium paid
for this Contract equal to the lesser of (a) the premium paid under
the variable annuity being exchanged or replaced; or (b) the premium
applied to this Contract.
(2) Except as provided in (3) and (4) below, Surrender Charges will be
calculated using the date the premium was paid under the variable
annuity being exchanged or replaced, or the Effective Date of such
annuity, if earlier, as the date the premium was paid under this
Contract. Credit will be given for any Surrender Charge Period
satisfied under the variable annuity being exchanged or replaced.
(3) If the variable annuity being exchanged or replaced was subject to
Sales Charges (Front End Loads), no Surrender Charges will be assessed
under this Contract.
(4) If no Surrender Charges apply, or remain, on the premium paid under
the variable annuity being replaced or exchanged, no Surrender Charges
will be assessed under this Contract.
The Surrender Charge on any other Premium Payment will start at a duration of
zero as shown in the table of Surrender Charges.
GA-IA-1108 3D2
THE SCHEDULE
CHARGES AND FEES (continued)
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
--------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$25,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
--------------------------------------------------------------------------------
Separate Account(s) Contract Number
[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456]
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Deductions from the Divisions
MORTALITY AND EXPENSE RISK CHARGE - We deduct a charge from the assets in each
Variable Separate Account Division on a daily basis for mortality and expense
risks. The charge is not deducted from the Fixed Account or General Account
values. Prior to the Annuity Commencement Date, the Mortality and Expense Risk
Charge varies by Benefit Option Package selected by you, as follows:
--------------------------------------------------------------------------------
Benefit Option The Maximum Daily Equivalent to an Annual Maximum
Package Selected: Charge Is: Rate of:
--------------------------------------------------------------------------------
I [0.002063%] [.75%]
--------------------------------------------------------------------------------
II [0.002615%] [.95%]
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After the Annuity Commencement Date, the maximum daily Mortality and Expense
Risk Charge will be [0.004141%] (equivalent to an annual maximum rate of
[1.50%]), regardless of Benefit Option Package.
ASSET BASED ADMINISTRATIVE CHARGE - We deduct a charge of not more than
[0.000411]% of the assets in each Variable Separate Account Division on a daily
basis (equivalent to an annual maximum rate 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
If elected by you, all charges against the Accumulation Value in this Contract
will be deducted from the [Liquid Asset Division].
GA-IA-1108 3D3
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 CERTAIN] [JANUARY 1, 2026]
--------------------------------------------------------------------------------
Separate Account(s) Contract Number
[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456]
--------------------------------------------------------------------------------
Values for other payment periods, ages or joint life combinations are available
on request. Monthly payments are shown for each $1,000 applied based on the
Annuity 2000 Mortality Table.
OPTION 1: INCOME FOR A FIXED PERIOD
--------------------------------------------------------------------------------
Rates for Fixed Annuity Payments with a 3% Guaranteed Interest Rate
--------------------------------------------------------------------------------
Years Income Years Income 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
--------------------------------------------------------------------------------
Rates for Variable Annuity Payments with a 3.5% Assumed Interest Rate (AIR)
--------------------------------------------------------------------------------
Years Income Years Income Years Income
5 18.17 14 7.51 23 5.25
6 15.39 15 7.12 24 5.11
7 13.41 16 6.78 25 4.98
8 11.93 17 6.48 26 4.86
9 10.78 18 6.22 27 4.75
10 9.86 19 5.98 28 4.64
11 9.11 20 5.77 29 4.55
12 8.49 21 5.58 30 4.46
13 7.96 22 5.41
--------------------------------------------------------------------------------
Rates for Variable Annuity Payments with a 5% Assumed Interest Rate (AIR)
--------------------------------------------------------------------------------
Years Income Years Income Years Income
5 18.82 14 8.23 23 6.04
6 16.05 15 7.85 24 5.91
7 14.08 16 7.52 25 5.78
8 12.61 17 7.23 26 5.67
9 11.46 18 6.97 27 5.56
10 10.55 19 6.74 28 5.47
11 9.81 20 6.54 29 5.38
12 9.19 21 6.36 30 5.30
13 8.67 22 6.19
GA-IA-1108 3E1
THE SCHEDULE
INCOME PLAN FACTORS (continued)
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
--------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$25,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
--------------------------------------------------------------------------------
Separate Account(s) Contract Number
[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT] [123456]
--------------------------------------------------------------------------------
OPTION 2: INCOME FOR LIFE (SINGLE ANNUITANT)
--------------------------------------------------------------------------------
Rates for Fixed Annuity Payments with a 3% Guaranteed Interest Rate
--------------------------------------------------------------------------------
Option 2(b) Option 2(b) Option 2(c)
Adjusted 10 Years Certain 20 Years Certain Refund Certain
Age Male/Female Male/Female Male/Female
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
--------------------------------------------------------------------------------
Rates for Variable Annuity Payments with a 3.5% Assumed Interest Rate (AIR)
--------------------------------------------------------------------------------
Option 2(b) Option 2(b)
Adjusted 10 Years Certain 20 Years Certain
Age Male/Female Male/Female
50 4.36/4.12 4.25/4.06
55 4.72/4.43 4.53/4.33
60 5.18/4.84 4.84/4.64
65 5.79/5.37 5.16/4.99
70 6.53/6.08 5.44/5.33
75 7.38/6.96 5.62/5.58
80 8.23/7.95 5.72/5.71
85 8.96/8.83 5.76/5.76
90 9.46/9.41 5.77/5.77
--------------------------------------------------------------------------------
Rates for Variable Annuity Payments with a 5% Assumed Interest Rate (AIR)
--------------------------------------------------------------------------------
Option 2(b) Option 2(b)
Adjusted 10 Years Certain 20 Years Certain
Age Male/Female Male/Female
50 5.28/5.04 5.15/4.98
55 5.62/5.33 5.41/5.22
60 6.06/5.72 5.69/5.50
65 6.65/6.23 5.98/5.82
70 7.36/6.91 6.23/6.13
75 8.17/7.77 6.40/6.36
80 9.00/8.72 6.49/6.48
85 9.69/9.56 6.53/6.53
90 10.17/10.12 6.54/6.54
GA-IA-1108 3E2
IMPORTANT TERMS
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ACCUMULATION VALUE - The amount that a Contract provides for investment at any
time. Initially, this amount is equal to the premium paid.
AFFILIATED INSURANCE COMPANY - An insurance company which meets the definition
of an Affiliated Company under the Investment Company Act of 1940.
ANNUITANT - The person designated by you 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 you select that determine the form and amount of
Annuity Payments.
ANNUITY PAYMENT - The periodic payment you receive.
ATTAINED AGE - Your age, or that of the Annuitant, on the Contract Issue Date
plus the number of full years elapsed since the Contract Date.
BENEFICIARY - The person designated to receive benefits in the case of your
death.
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 you receive 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 you.
CONTINGENT ANNUITANT - The person designated by you who, upon the Annuitant's
death prior to the Annuity Commencement Date, becomes the Annuitant.
GA-IA-1108 4
IMPORTANT TERMS (continued)
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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.
FIXEDALLOCATION - An amount allocated to the Fixed Account that is credited with
a Guaranteed Interest Rate for a specified Guarantee Period.
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 Guaranteed Interest Divisions. The
Guaranteed Minimum Interest Rate is an effective annual rate of 3.0%
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 - Your age, or age of the Annuitant 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. "You" and "Your" refer to the Owner.
QUALIFIED PLAN - A Contract issued as a qualified funding vehicle under Internal
Revenue Code Sections 401(a), 401(k), 403(b), 408(b), or 457.
RIDERS - Riders add provisions or change the terms of the Contract.
SCHEDULE DATE - The date on which the Benefit Option Package takes effect. On
the Contract Issue Date, the Schedule Date is the same as the Contract
Date. Thereafter, if you elect to replace the then current Benefit Option
Package with another available Benefit Option Package, the Schedule Date
will be the effective date of the change.
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.
GA-IA-1108 5
INTRODUCTION TO THIS CONTRACT
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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 attached application, 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 to be the Beneficiary(ies) and any other Beneficiary(ies) on
record will be treated as the contingent 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-1108 6
INTRODUCTION TO THIS CONTRACT (continued)
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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.
When naming or changing the Beneficiary(ies), you may specify the form of
payments of the Death Benefits. We will honor the specified form of payment to
the extent permitted under section 72(s) of the Internal Revenue Code. If the
form of payment is not specified, the Beneficiary(ies) may determine the manner
of payment, to the extent allowed by the Code.
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. If there are joint Owners, both must agree to the change. 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 and Benefit Option
Packages.
GA-IA-1108 7
PREMIUM PAYMENTS AND ALLOCATION CHANGES
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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 PAYMENTS
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, 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, the
General Account and the Fixed Account after the end of the Right to Examine
period. Prior to the Annuity Commencement Date, allocation changes in excess of
twelve in any Contract Year are subject to the Excess Allocation Charge as
stated 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-1108 8
PREMIUM PAYMENTS AND ALLOCATION CHANGES (continued)
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RESTRICTED FUNDS
Restricted Funds are subject to limits as to amounts which may be invested or
transferred into such Divisions. The designation of a Division as a Restricted
Fund may be changed upon 30 days notice to the Owner with regard to future
transfers and Premium Payments into such Division. When a new Division is made
available it may be designated as a Restricted Fund. If so designated, the rules
regarding its restrictions will be sent to you. The total Contract limits which
apply to Restricted Funds available under this Contract, if any, are shown in
the Schedule.
THRESHOLDS
Each Restricted Fund has one or more thresholds at which point no further
amounts may be allocated to that Division. Compliance with a threshold is
verified whenever there is a transaction initiated which is subject to such
threshold (Premium Payments, transfers, withdrawals). A threshold is applied to
the total Accumulation Value of each Restricted Fund. Thresholds may be changed
by us for new premiums, transfers or withdrawals by Restricted Fund upon 30 day
notice.
DOLLAR CAP
The Dollar Cap is the dollar amount at which no further Accumulation Value may
be added to Restricted Funds.
PREMIUM THRESHOLD
The threshold for premium by Restricted Fund limits the amount of any premium
which may be allocated to that Division. Should a request for allocation to a
Restricted Fund exceed the limit in effect for that Division or for the
Contract, any excess over that amount shall be allocated prorata to any
non-Restricted Fund(s) in which the Contract is then invested. Should the
Contract not be invested in other non-Restricted Funds, the excess will be
invested in the Specially Designated Division unless we receive written
instructions to do otherwise. Premium allocations must also satisfy the
Allocation Threshold.
ALLOCATION THRESHOLD
Allocations into a Restricted Fund are limited to that amount such that the
Accumulation Value in that Restricted Fund after such allocation does not exceed
the threshold for that Division and does not cause the Contract's total limit on
allocation to Restricted Funds to be exceeded. If the amount of an allocation
would cause either limit to be exceeded, the allocation will only be executed to
the extent the lower limit would allow.
Allocations from a Restricted Fund will be allowed even if the amount remaining
in the Restricted Fund after an allocation exceeds the Allocation Threshold. If
a program of allocations over time is authorized by us, verification of the
threshold will be performed at the initiation of such program. If such program
is modified at a later date, a testing of thresholds will be done at that time.
GA-IA-1108 9
PREMIUM PAYMENTS AND ALLOCATION CHANGES (continued)
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THRESHOLDS - EFFECT ON WITHDRAWALS
If a withdrawal is requested while any Accumulation Value is allocated to
Restricted Funds and the Allocation Threshold percentage is currently exceeded,
the percentage for funds invested in Restricted Funds for the total Contract,
after taking into account the withdrawal, may not be higher than prior to the
withdrawal. Should the calculated effect of a withdrawal result in the total
Contract threshold being exceeded, the excess portion of the withdrawal will be
processed prorata from all Variable Divisions. Systematic withdrawals, while the
Contract has investments in Restricted Funds, if not withdrawn prorata from all
Divisions, shall be monitored annually to assure threshold compliance. Should
the effect of such withdrawals cause a Restricted Fund to exceed its threshold,
the Divisions from which the withdrawals are processed may be adjusted to assure
that the percentage of Accumulation Value in the Restricted Funds does not
increase.
THRESHOLD PROCESSING
For the purpose of calculating any thresholds, the values for the Divisions will
be determined using the prior day's closing Index of Investment Experience.
GA-IA-1108 10
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE
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The variable Annuity Benefits under this Contract are provided through
investments which may be made in our Separate Account(s).
THE VARIABLE SEPARATE ACCOUNT(S)
The Separate Account (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 of which is
available for investment under this Contract.
The Account is kept separate from our General Account and any other Separate
Accounts we may have. It is 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 Account. Assets equal to the reserves and other
liabilities of the account 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
Account. Income and realized and unrealized gains or losses from assets in the
Variable Separate Account 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 described
above. 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 the 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 the 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 will obtain any required regulatory 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 the 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-1108 11
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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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 the Fixed Allocations of the Fixed Account to which to
allocate the Accumulation Value.
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 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-1108 12
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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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 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 expiry 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
expiry 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 are based solely on our
expectation as to our future earnings. 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 XXX Partial Withdrawals. The Market Value Adjustment is applied to each
Fixed Allocation separately.
The Market Value Adjustment during the Right to Examine period is determined by
multiplying the amount of the Accumulation Value withdrawn, transferred or
applied to an Income Plan by the following factor:
(((1+I)/(1+J))^(N/365))-1
The Market Value Adjustment following the Right to Examine period is determined
by multiplying the amount of the Accumulation Value withdrawn, transferred or
applied to an Income Plan by the following factor:
(((1+I)/(1+J+.0050))^(N/365))-1
Where I is the Index Rate for a Fixed Allocation on the first day of the
applicable Guarantee Period: J is the Index Rate for new Fixed Allocations with
Guarantee Periods equal to the number of years (fractional years rounded up to
the next full year) remaining in the Guarantee Period at the time of
calculation; and N is the remaining number of days in the Guarantee Period at
the time of calculation. (The Index Rate is described in the Schedule.)
GA-IA-1108 13
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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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
(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 (Net Return 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 described in the Schedule for each day in the Valuation
Period.
(5) We subtract the daily Asset Based Administrative Charge described 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 (Net Return Rate)
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.
GA-IA-1108 14
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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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.
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 the 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-1108 15
YOUR CONTRACT BENEFITS
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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 Charges;
(4) We deduct any charges shown in the Schedule that have been incurred
but not yet deducted, including:
(a) any administrative charge 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
On or before the Annuity Commencement Date if the Annuitant is living, 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. Partial Withdrawals
may be subject to a Surrender Charge (see the Schedule). The minimum amount that
may be withdrawn is shown in the Schedule. The maximum amount that may be
withdrawn without Surrender Charge is shown in the Schedule. 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 you die prior to the Annuity Commencement Date, we will pay the Beneficiary
the Death Benefit based on the Benefit Option Package elected and in effect on
the date of death. If there are joint Owners and any Owner dies, we will pay the
surviving Owner(s) 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.
GA-IA-1108 16
YOUR CONTRACT BENEFITS (continued)
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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-1108 17
BENEFIT OPTION PACKAGES
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This Contract offers two Benefit Option Packages. The Option Package you elect
is shown in the Schedule.
ELECTION OF BENEFIT OPTION PACKAGES
On any Contract Anniversary prior to and including the date you reach Attained
Age 80, you may elect to replace the Benefit Option Package in effect with
another Benefit Option Package provided you are the sole Owner and you and the
Annuitant meet the eligibility criteria stated below. Such election must be
received by us in writing at our Customer Service Center on or during the sixty
day period immediately preceding the Contract Anniversary.
The effective date of the newly elected Benefit Option Package will be the
Contract Anniversary at the end of the sixty day election period. We will issue
another Schedule reflecting the new Benefit Option Package Chosen. This new
Schedule will reflect the new Schedule Date and the revised Charges, if any, for
the Benefit Option Package elected.
SPECIAL FUNDS
The allocation of Accumulation Value to the Fixed Account, the Guaranteed
Interest Divisions and Divisions of the Separate Account may be subject to
specific limitations or rules when calculating the Death Benefits provided in
each of the Benefit Option Packages described below. Collectively, such
allocations are called Special Funds. Special Funds, if any, are shown in the
Schedule.
We may add newly available Divisions as Special Funds. We may also reclassify an
existing Division as a Special Fund or remove such designation upon 30 days
notice to you. Such reclassifications will apply to amounts transferred or
otherwise allocated to such Division after the date of the change. We may reduce
any applicable Mortality and Expense Risk Charge for that portion of the
Contract allocated to a Special Fund.
DESCRIPTION OF BENEFIT OPTION PACKAGE I
Benefit Option Package I is not available if, at the time of election, the
Contract's Accumulation Value is less than $5,000 ($1,500 for Qualified Plans).
Death Benefit
The Death Benefit is the greatest of (i), (ii) and (iii) below, where:
(i) is the Accumulation Value;
(ii) is the Guaranteed Death Benefit;
(iii) is the Cash Surrender Value.
Guaranteed Death Benefit
The Guaranteed Death Benefit for the Contract is equal to the sum of I and II
below.
I. The Guaranteed Death Benefit Base for non-Special Funds
II. The Accumulation Value allocated to Special Funds
On the Contract Date, the Guaranteed Death Benefit Base for non-Special Funds is
the initial premium allocated to non-Special Funds. On subsequent Valuation
Dates, the Guaranteed Death Benefit Base for non-Special Funds is calculated as
follows:
(1) Start with the Guaranteed Death Benefit Base for non-Special Funds
from the prior Valuation Date.
GA-IA-1108 18
BENEFIT OPTION PACKAGES (continued)
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(2) Add any additional premiums paid and allocated to non-Special Funds
during the current Valuation Period to (1).
(3) Adjust (2) for any transfers to or from Special Funds during the
current Valuation Period.
(4) Subtract from (3) any Prorata Partial Withdrawal Adjustments for any
Partial Withdrawal made from non-Special Funds during the current
Valuation Period.
The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds.
Transfers from Special Funds to non-Special Funds will reduce the Guaranteed
Death Benefit Base for Special Funds on a prorata basis. The resulting increase
in the Guaranteed Death Benefit Base for non-Special Funds will equal the lesser
of the reduction in the Guaranteed Death Benefit Base for Special Funds and the
net Accumulation Value transferred.
Transfers from non-Special Funds to Special Funds will reduce the Guaranteed
Death Benefit Base for non-Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for Special Funds will equal the
reduction in Guaranteed Death Benefit Base for non-Special Funds.
Prorata Partial Withdrawal Adjustments
For any partial withdrawal, the Death Benefit components will be reduced by
Prorata Partial Withdrawal Adjustments. The Prorata Partial Withdrawal
Adjustment to a Death Benefit component for a partial withdrawal is equal to (1)
divided by (2) multiplied by (3), where: (1) is the Accumulation Value
withdrawn; (2) is the Accumulation Value immediately prior to withdrawal; and
(3) is the amount of the applicable Death Benefit component immediately prior to
the withdrawal. Separate adjustments will apply to amounts in the Special and
non-Special Funds.
Change of Owner
A change of Owner will result in recalculation of the Death Benefit and the
Guaranteed Death Benefit. If the new Owner's Attained Age at the time of the
change is less than 86, the Guaranteed Death Benefit in effect prior to the
change will remain in effect and the Death Benefit provision shall apply. If the
new Owner's Attained Age is 86 or greater at the time of the change, the
Guaranteed Death Benefit will be zero, and the Death Benefit will then be the
Cash Surrender Value.
Spousal Continuation upon Death of Owner
If at the Owner's death, the surviving spouse of the deceased Owner is the
Beneficiary and such surviving spouse elects to continue the Contract as their
own pursuant to Internal Revenue Code Section 72(s) or the equivalent provisions
of U.S. Treasury Department rules for qualified plans, the following will apply:
(a) If the Guaranteed Death Benefit as of the date we receive due proof of
death of the Owner, minus the Accumulation Value, also as of that
date, is greater than zero, we will add such difference to the
Accumulation Value. Such addition will be allocated to the Divisions
of the Separate Account then available in the same proportion as the
Accumulation Value in each available Division bears to the
Accumulation Value in all such Divisions. If there is no Accumulation
Value in any Division then available, the addition will be allocated
to the Liquid Asset Division, or its successor.
(b) The Guaranteed Death Benefit will continue to apply, with all age
criteria using the surviving spouse's age as the determining age.
(c) At subsequent surrender, any Surrender Charge applicable to premiums
paid prior to the date we receive due proof of death of the Owner will
be waived. Any premiums paid later will be subject to any applicable
Surrender Charge.
GA-IA-1108 19
BENEFIT OPTION PACKAGES (continued)
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Non Spousal Continuation upon Death of Owner
If, at the Owner's death, the non spouse beneficiary of the deceased Owner
elects to continue the Contract for the purpose of taking distributions pursuant
to Internal Revenue Code Section 72(s) or the equivalent provisions of U.S.
Treasury Department rules for qualified plans, the following will apply:
(a) If the Guaranteed Death Benefit as of the date we receive due proof of
death of the Owner, minus the Accumulation Value, also as of that
date, is greater than zero, we will add such difference to the
Accumulation Value. Such addition will be allocated to the Divisions
of the Separate Account then available in the same proportion as the
Accumulation Value in each available Division bears to the
Accumulation Value in all such Divisions. If there is no Accumulation
Value in any Division then available, the addition will be allocated
to the Liquid Asset Division, or its successor.
(b) Thereafter, the Guaranteed Death Benefit will no longer be available
under this Contract, and the amount payable upon the death of the non
spouse beneficiary, if such beneficiary dies while receiving
distributions under this Contract, will be the Accumulation Value as
of the date we receive due proof of such beneficiary's death.
(c) No additional premium payments may be made under this Contract
following the date we receive due proof of death of the Owner.
(d) At subsequent surrender, any applicable Surrender Charges will be
waived.
DESCRIPTION OF BENEFIT OPTION PACKAGE II
Benefit Option Package II is not available if there are Joint Contract Owners or
if, at the time of election, the Contract's Accumulation Value is less than
$5,000 ($1,500 for Qualified Plans)..
Death Benefit
The Death Benefit is the greatest of (i), (ii), (iii) and (iv) below, where:
(i) is the Accumulation Value;
(ii) is the Guaranteed Death Benefit;
(iii) is the Cash Surrender Value; and
(iv) is the Minimum Death Benefit.
Minimum Death Benefit
The Minimum Death Benefit shall be the sum of the following:
1. The Accumulation Value allocated to Special Funds; and
2. Adjusted Premium for non-Special Funds.
Adjusted Premium for non-Special Funds shall mean all premium allocated to
non-Special Funds, plus an adjustment for any amounts transferred to non-Special
Funds, less a prorata adjustment for any amounts transferred or withdrawn from
non-Special Funds. The amount of the prorata adjustment will equal (a) times (b)
divided by (c), where (a) is the Adjusted Premium for non-Special Funds prior to
the transfer or withdrawal; (b) is the Accumulation Value of the transfer or
withdrawal; and (c) is the Accumulation Value allocated to non-Special Funds
before the transfer or withdrawal. Adjusted Premium for Special Funds has the
same definition, but with respect to amounts allocated to Special Funds.
Transfers from Special Funds increase the Adjusted Premium for non-Special Funds
by the lesser of the reduction of the Adjusted Premium for Special Funds and net
Accumulation Value transferred. Transfers from non-Special Funds increase the
Adjusted Premium for Special Funds by the reduction in the Adjusted Premium for
non-Special Funds.
Guaranteed Death Benefit
The Guaranteed Death Benefit for the Contract is equal to the sum of I and II
below.
I. The Guaranteed Death Benefit Base for non-Special Funds
II. The Accumulation Value allocated to Special Funds
GA-IA-1108 20
BENEFIT OPTION PACKAGES (continued)
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On the Contract Date, the Guaranteed Death Benefit Base for non-Special Funds is
the initial premium allocated to non-Special Funds. On subsequent Valuation
Dates, the Guaranteed Death Benefit Base for non-Special Funds is calculated as
follows:
(1) Start with the Guaranteed Death Benefit Base for non-Special Funds on
the prior Valuation Date.
(2) Add to (1) any additional premium allocated to the non-Special Funds
during the current Valuation Period and adjustments for transfers from
Special Funds during the current Valuation Period and subtract from
(1) any adjustment for transfers to Special Funds during the current
Valuation Period and any Prorata Partial Withdrawal Adjustments for
any Partial Withdrawals taken from non-Special Funds during the
current Valuation Period.
(3) On a Valuation Date that occurs on or prior to the Owner's Attained
Age 90, which is also a Contract Anniversary, we set the Guaranteed
Death Benefit Base for non-Special Funds equal to the greater of (2)
or the Accumulation Value allocated to non-Special Funds. On all other
Valuation Dates, the Guaranteed Death Benefit Base for non-Special
Funds is equal to (2).
The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds Transfers
from Special Funds to non-Special Funds will reduce the Guaranteed Death Benefit
Base for Special Funds on a prorata basis. The resulting increase in the
Guaranteed Death Benefit Base for non-Special Funds will equal the lesser of the
reduction in the Guaranteed Death Benefit Base for Special Funds and the net
Accumulation Value transferred.
Transfers from non-Special Funds to Special Funds will reduce the Guaranteed
Death Benefit Base for non-Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for Special Funds will equal the
reduction in Guaranteed Death Benefit Base for non-Special Funds.
Prorata Partial Withdrawal Adjustments
For any partial withdrawal, the Death Benefit components will be reduced by
Prorata Partial Withdrawal Adjustments. The Prorata Partial Withdrawal
Adjustment to a Death Benefit component for a partial withdrawal is equal to (1)
divided by (2) multiplied by (3), where: (1) is the Accumulation Value
withdrawn; (2) is the Accumulation Value immediately prior to withdrawal; and
(3) is the amount of the applicable Death Benefit component immediately prior to
the withdrawal. Separate adjustments will apply to amounts in the Special and
non-Special Funds.
Change of Owner
If there is a change in ownership and the new Owner's Attained Age at the time
of the change is less than 81, the Guaranteed Death Benefit in effect prior to
the change will remain in effect and the provisions for Benefit Option Package
II will continue to apply. If the new Owner's Attained Age at the time of the
change is 81 or greater, or if Joint Owners are named, the provisions of Benefit
Option Package I will apply and we will issue a new Schedule reflecting the
Schedule Date and the revised charges, if any, applicable to Benefit Option
Package I.
Spousal Continuation upon Death of Owner
If at the Owner's death, the surviving spouse of the deceased Owner is the
Beneficiary and such surviving spouse elects to continue the Contract as their
own pursuant to Internal Revenue Code Section 72(s) or the equivalent provisions
of U.S. Treasury Department rules for qualified plans, the following will apply:
(a) If the greater of (ii) and (iv) in the Death Benefit provision as of
the date we receive due proof of death of the Owner, minus the
Accumulation Value, also as of that date, is greater than zero, we
will add such difference to the Accumulation Value. Such addition will
be allocated to the Divisions of the Separate Account than available
in the same proportion as the Accumulation Value in each available
Division bears to the Accumulation Value in all such Divisions. If
there is no Accumulation Value in any Division then available, the
addition will be allocated to the Liquid Asset Division, or its
successor.
GA-IA-1108 21
BENEFIT OPTION PACKAGES (continued)
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(b) The Guaranteed Death Benefit and the Minimum Death Benefit will
continue to apply, using the surviving spouse's age as the determining
age.
(c) At subsequent surrender, any Surrender Charge applicable to premiums
paid prior to the date we receive due proof of death of the Owner will
be waived. Any premiums paid later will be subject to any applicable
Surrender Charge.
Non Spousal Continuation upon Death of Owner
If, at the Owner's death, the non spouse beneficiary of the deceased Owner
elects to continue the Contract for the purpose of taking distributions pursuant
to Internal Revenue Code Section 72(s) or the equivalent provisions of U.S.
Treasury Department rules for qualified plans, the following will apply:
(a) If the greater of the Guaranteed Death Benefit and Minimum Death
Benefit as of the date we receive due proof of death of the Owner,
minus the Accumulation Value, also as of that date, is greater than
zero, we will add such difference to the Accumulation Value. Such
addition will be allocated to the Divisions of the Separate Account
then available in the same proportion as the Accumulation Value in
each available Division bears to the Accumulation Value in all such
Divisions. If there is no Accumulation Value in any Division then
available, the addition will be allocated to the Liquid Asset
Division, or its successor.
(d) Thereafter, the Guaranteed Death Benefit and Minimum Death Benefit
will no longer be available under this Contract, and the amount
payable upon the death of the non spouse beneficiary, if such
beneficiary dies while receiving distributions under this Contract,
will be the Accumulation Value as of the date we receive due proof of
such beneficiary's death.
(e) No additional premium payments may be made under this Contract
following the date we receive due proof of death of the Owner.
(d) At subsequent surrender, any applicable Surrender Charges will be
waived.
GA-IA-1108 22
CHOOSING AN INCOME PLAN
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ANNUITY BENEFITS
If you and the Annuitant are living on the Annuity Commencement Date, we will
begin making payments to you. We will make these payments under the Annuity
Option (or Options) elected by you. You may elect to apply any portion of the
Accumulation Value (minus any applicable premium tax) to any Annuity Option by
making a written request at least 30 days prior to the Annuity Commencement
Date. When the Annuity Option is elected, you must also tell us if payments are
to be made as a Fixed Annuity, a Variable Annuity or some combination of Fixed
and Variable Annuity. If Variable Annuity payments are elected, you must also
select the Assumed Interest Rate (AIR) and specify the portion of the
Accumulation Value (less any applicable premium tax) to be allocated to the
available Divisions. If no Annuity Option has been elected by the Required
Annuity Commencement Date shown in the Schedule, payments will be made as a
Fixed Annuity under Option 2 on a 10-year period certain basis. The amount 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 May Defer). After payments begin, only those payable as
Variable Annuity Payments under Option 1 may be commuted to a lump sum.
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.
Fixed Annuity Payments
If Fixed Annuity payments are chosen, the payment rate for the option chosen,
shown in the tables in the Schedule, reflects the minimum guaranteed interest
rate. Interest rates actually paid may be higher.
Variable Annuity Payments
If Variable Annuity payments are chosen, the initial payment for the option
chosen, shown in the Schedule, reflects the Assumed Interest Rate selected by
you. Thereafter, the Divisions must earn this rate plus enough to cover any
deductions stated in the Schedule if future Annuity Payments are to remain
level. If earnings exceed this amount, Annuity Payments will increase; if
earnings are less, Annuity Payments will decrease.
Annuity Units
The Number of Annuity Units is based on the amount of the first Variable Annuity
Payment which is equal to:
(1) The portion of the Accumulation Value applied to pay a Variable
Annuity Payment (minus any applicable premium tax); divided by
(2) 1,000; multiplied by
(3) The payment rate in the tables shown in the Schedule for the option
chosen.
Such amount, or portion, of the Variable Annuity Payment will be divided by the
appropriate Annuity Unit Value on the tenth Valuation Date before the due date
of the first payment to determine the number of Annuity Units. Thereafter, the
number of Annuity Units remains unchanged. Each future payment is equal to the
sum of the products of each Annuity Unit Value multiplied by the appropriate
number of Annuity Units. The Annuity Unit Value on the tenth Valuation Date
prior to the due date of the payment is used.
Annuity Unit Value
On any Valuation Date, an Annuity Unit Value is equal to:
(1) The Annuity Unit Value on the on the previous Valuation Day;
multiplied by
(2) The Annuity Net Return Factor(s) for the Valuation Date; multiplied by
(3) A Factor to reflect the AIR.
The Annuity Unit Value and Annuity Payment amount may go up or down due to
investment gain or loss.
GA-IA-1108 23
CHOOSING AN INCOME PLAN (continued)
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Net Return Factor
The Net Return Factor(s) is(are) used to compute all Variable Annuity Payments
for any Division in the Variable Separate Account. The Net Return Factor for
each Division is equal to 1.0000 plus the Net Rate of Return.
The Net Rate of Return is equal to:
(1) The value of the shares of the Division at the end of a Valuation
Date; minus
(2) The value of shares of the Division at the start of the Valuation
Date; plus or minus
(3) Taxes (or reserves for taxes) on the Separate Account (if any);
divided by
(4) The value of shares of the Division at the start of the Valuation
Date; minus
(5) The daily Asset Based Administrative Charges and Mortality and Expense
Risk Charges described in the Schedule for each day in the Valuation
Period.
A Net Return Rate may be more or less than 0%.
The value of a share in a Division is equal to the net assets of the Division
divided by the number of shares outstanding.
Annuity Payments shall not be changed due to mortality or expense results.
ALLOCATION CHANGES
You have the right to request allocation changes among Divisions of the Variable
Separate Account to any other Division then available. After the Annuity
Commencement Date, allocation changes in excess of four in any Contract Year are
subject to the Excess Allocation Charge as stated in the Schedule. After Annuity
Payments begin, allocation changes are not allowed between values providing
Fixed Annuity Payments and Variable Annuity Payments.
ANNUITY COMMENCEMENT DATE SELECTION
You select the Annuity Commencement Date. You may select any date following the
first Contract Anniversary but before the required date of Annuity Commencement
as shown in the Schedule. On the Annuity Commencement Date, the age of the
Annuitant plus the number of years payments are guaranteed must not exceed 100.
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 choose one or more Annuity Options for the payment of Death Benefit
proceeds. If, at the time of your 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 you 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.
GA-IA-1108 24
CHOOSING AN INCOME PLAN (continued)
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THE ANNUITY OPTIONS
Option 1. Income for a Fixed Period
Payment is made in equal installments for a fixed number of years. The number of
years must be at least 5 and not more than 30.
Option 2. Single Life Income
Payment is made to the person named in equal monthly installments based on one
of the following, as elected by you:
(a) Payments continue as long as the Annuitant is living and cease at the
Annuitant's death.
(b) Payments continue for a period certain and continue thereafter as long
as the Annuitant is living. The period certain may be between 5 and 30
years as specified by you.
(c) Payments continue until as long as the Annuitant is living. At the
Annuitant's death, the difference between the sum of the payments made
and the Accumulation Value applied to this option is paid to the
Beneficiary in a lump sum. This "Cash Refund" feature is available
only if the total amount applied to the Option is taken as a Fixed
Annuity payment.
Option 3. Joint Life Income
This Option is available if there are two Annuitants, one of whom is designated
the Primary Annuitant and the other the Secondary Annuitant. Monthly payments
continue as long as at least one of the Annuitants is living based on one of the
following, as elected by you:
(a) Payments continue as long as either Annuitant is living;
(b) Payments continue for a period certain and continue thereafter as long
as either Annuitant is living. The period certain may be between 5 and
30 years as specified by you;
(c) Payments continue as long as either Annuitant is living. At the death
of both Annuitants, the difference between the sum of the payments
made and the Accumulation Value applied to this option is paid to the
Beneficiary in a lump sum. This "Cash Refund" feature is available
only if the total amount applied to the Option is taken as a Fixed
Annuity payment.
If Fixed Annuity Payments are chosen under Options 1, 2(a), 2(b), 3(a) or 3(b),
you may also elect to have payments increase annually at 1%, 2% or 3% compounded
annually.
Payment may be made under any other method mutually agreed upon by you and us.
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 or
Option 3, payments will be continued.
(2) For Option 2a and 2b, no amounts are payable after the Annuitant's
death.
(3) For Option 3a and 3b, no amounts are payable after the death of both
Annuitants.
GA-IA-1108 25
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. The
Beneficiary's rights may be subordinate to those of an assignee unless the
Beneficiary was designated as an irrevocable Beneficiary prior to 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.
GA-IA-1108 26
OTHER IMPORTANT INFORMATION (continued)
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NON-PARTICIPATING
This Contract does not participate in the divisible surplus of Golden American
Life Insurance Company.
CONTESTABILITY
This Contract is incontestable from its date of issue.
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 in 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 or greater if required by state law, on any Cash Surrender Value
payment derived from the Fixed Allocations or 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, has the authority to:
(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-1108 27
FLEXIBLE PREMIUM 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. Partial Withdrawal Option. Non-participating. Investment results
reflected in values.
GA-IA-1108
