First Cova Life Insurance Company
A New York stock insurance company
000 Xxxxxxxx
Xxx Xxxx, Xxx Xxxx 00000
FIRST COVA LIFE INSURANCE COMPANY (the "Company") will make Annuity Payments to
the Annuitant starting on the Annuity Date subject to the terms of this
Contract. This Contract is issued in return for the Application and payment of
the initial Purchase Payment. A copy of the Application is attached to and made
a part of the Contract. This is a legal contract between the Owner and the
Company.
TEN DAY FREE LOOK
Within 10 days of the date of receipt of this Contract by the Owner, it may be
returned by delivering or mailing it to the Company or to the agent through whom
it was purchased. When this Contract is received by the Company, it will be
voided as if it had never been in force. The Company will refund the Contract
Value computed at the end of the Valuation Period during which this Contract is
mailed to or delivered to the Company at its Home Office or the agent through
whom it was purchased.
Signed for the Company.
INDIVIDUAL FLEXIBLE PURCHASE PAYMENT
DEFERRED VARIABLE AND FIXED ANNUITY CONTRACT
NONPARTICIPATING
NO DIVIDENDS
READ YOUR CONTRACT CAREFULLY
ANNUITY PAYMENTS AND VALUES PROVIDED BY THIS CONTRACT, WHEN BASED ON THE
INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT
GUARANTEED AS TO DOLLAR AMOUNT. VARIABLE ACCOUNT EXPENSES CONSIST OF A MORTALITY
AND EXPENSE RISK PREMIUM, AN ADMINISTRATIVE EXPENSE CHARGE, A CONTRACT
MAINTENANCE CHARGE AND A TRANSFER FEE. THESE CHARGES ARE SHOWN ON THE CONTRACT
DATA PAGE. VARIABLE ANNUITY PAYMENTS WILL NOT DECREASE AS LONG AS THE INVESTMENT
EXPERIENCE OF THE VARIABLE ACCOUNT EQUALS OR EXCEEDS 3% PER YEAR.
THE VARIABLE PROVISIONS OF THIS CONTRACT CAN BE FOUND ON PAGES 9 AND 11.
INDEX
Page
Definitions................................................................ 7
General Provisions......................................................... 7
The Contract............................................................... 7
Incontestability........................................................... 7
Non-Participating.......................................................... 7
Misstatement of Age or Sex................................................. 7
Contract Settlement........................................................ 8
Reports.................................................................... 8
Taxes...................................................................... 8
Evidence of Survival....................................................... 8
Modification of Contract................................................... 8
Annuitant, Ownership, Assignment Provisions................................ 8
Annuitant.................................................................. 8
Ownership.................................................................. 8
Assignment................................................................. 8
Beneficiary Provisions..................................................... 8
Beneficiary................................................................ 8
Change of Beneficiary...................................................... 8
Purchase Payment Provisions................................................ 8
Purchase Payments.......................................................... 8
Change in Purchase Payments................................................ 8
Allocation of Purchase Payments............................................ 8
No Default................................................................. 8
General Account Provisions................................................. 8
General Account Value...................................................... 8
Interest To Be Credited.................................................... 9
Contract Value Provision................................................... 9
Contract Value............................................................. 9
Variable Account Provisions................................................ 9
The Variable Account....................................................... 9
Investments of the Variable Account........................................ 9
Valuation of Assets........................................................ 9
Accumulation Unit.......................................................... 9
Mortality and Expense Risk Premium......................................... 9
Administrative Expense Charge.............................................. 9
Mortality and Expense Guarantee............................................ 10
Contract Maintenance Charge................................................ 10
Deduction for Contract Maintenance Charge.................................. 10
Transfer Provision......................................................... 10
Transfers.................................................................. 10
Death Benefit.............................................................. 10
Death of Annuitant......................................................... 10
Death of Owner............................................................. 10
Payment of Death Benefit................................................... 11
Annuity Provisions......................................................... 11
Annuity Date............................................................... 11
Election of Annuity Option................................................. 11
Frequency and Amount of Annuity Payments................................... 11
Annuity Options............................................................ 11
Xxxxxxx.................................................................... 11
Fixed Annuity.............................................................. 11
Variable Annuity........................................................... 11
Annuity Unit............................................................... 12
Net Investment Factor...................................................... 12
Transfers During the Annuity Period........................................ 12
Protection of Proceeds..................................................... 12
Withdrawal Provisions...................................................... 12
Withdrawals................................................................ 12
Withdrawal Charge.......................................................... 12
Waiver of Withdrawal Charge................................................ 13
Suspension or Deferral of Payments or Transfers from the Variable Account.. 13
Deferral of Payments or Transfers from the General Account................. 13
Reserves, Values and Benefits.............................................. 13
Tables.....................................................................14-17
CONTRACT DATA PAGE
ANNUITANT: [Xxxx Xxx] AGE AT ISSUE: [35]
OWNER: [Xxxx Xxx] AGE AT ISSUE: [35]
CONTRACT NUMBER: [123] ISSUE DATE: [6/1/1995]
INITIAL PURCHASE PAYMENT: [$25,000] ANNUITY DATE: [6/1/2025]
MINIMUM SUBSEQUENT PURCHASE
PAYMENT: [$2,000]
BENEFICIARY:
AS STATED IN THE APPLICATION FOR THIS CONTRACT UNLESS CHANGED IN
ACCORDANCE WITH THE CONTRACT PROVISIONS.
INITIAL INTEREST RATE APPLICABLE TO THE GENERAL ACCOUNT:
[7% GUARANTEED THROUGH THE END OF THE CURRENT CALENDAR YEAR]
MINIMUM GUARANTEED INTEREST RATE: 3% PER YEAR.
CONTRACT MAINTENANCE CHARGE: $30.00 EACH CONTRACT YEAR.
AFTER THE ANNUITY DATE, THE CONTRACT MAINTENANCE CHARGE WILL BE
COLLECTED ON A MONTHLY BASIS.
MORTALITY AND EXPENSE RISK PREMIUM:
EQUAL ON AN ANNUAL BASIS TO 1.25% OF THE AVERAGE DAILY NET ASSET VALUE
OF THE VARIABLE ACCOUNT.
ADMINISTRATIVE EXPENSE CHARGE:
EQUAL ON AN ANNUAL BASIS TO .15% OF THE AVERAGE DAILY NET ASSET VALUE
OF THE VARIABLE ACCOUNT.
TRANSFER FEE:
$25 OR, IF SMALLER, 2% OF THE AMOUNT TRANSFERRED PER TRANSACTION IF
THERE ARE MORE THAN 12 TRANSFERS IN A CONTRACT YEAR.
ELIGIBLE INVESTMENTS:
- COVA SERIES TRUST
- X.X. XXXXXX INVESTMENT MANAGEMENT
- SELECT EQUITY PORTFOLIO
- LARGE CAPITAL STOCK PORTFOLIO
- SMALL CAPITAL STOCK PORTFOLIO
- INTERNATIONAL EQUITY PORTFOLIO
- QUALITY BOND PORTFOLIO
- LORD XXXXXX BOND DEBENTURE PORTFOLIO
- LORD XXXXXX SERIES FUND, INC.
- LORD XXXXXX GROWTH AND INCOME PORTFOLIO
- CONNING ASSET MANAGEMENT COMPANY
- MONEY MARKET
VARIABLE ACCOUNT: FIRST COVA VARIABLE ANNUITY ACCOUNT ONE
HOME OFFICE:
First Cova Life Insurance Company
000 Xxxxxxxx
Xxx Xxxx,Xxx Xxxx 00000
0 (000) 000-0000
(000) 000-0000
FOR USE WITH FIRST COVA VARIABLE ANNUITY ACCOUNT ONE
A SEPARATE INVESTMENT ACCOUNT OF
FIRST COVA LIFE INSURANCE COMPANY
DEFINITIONS
ACCOUNT -- General Account and/or one or more of the Subaccount(s) of the
Variable Account.
ACCUMULATION UNIT -- An accounting unit of measure used to calculate the
Contract Value in a Subaccount of the Variable Account.
ANNUITANT -- The natural person on whose life Annuity Payments are based.
ANNUITY OR ANNUITY PAYMENTS -- The series of payments made to the Annuitant
after the Annuity Date under the Annuity Option elected.
ANNUITY DATE -- The date on which Annuity Payments begin. The Annuity Date is
shown on the Contract Data Page.
ANNUITY PERIOD -- The period starting on the Annuity Date.
ANNUITY UNIT -- An accounting unit of measure used to calculate Variable Annuity
Payments after the Annuity Date.
ATTAINED AGE -- The age on the birthday prior to any date for which age is to be
determined.
BENEFICIARY -- The person(s) who will receive the Death Benefit.
COMPANY -- First Cova Life Insurance Company at its Home Office shown on the
Contract Data Page.
CONTRACT ANNIVERSARY -- An anniversary of the Issue Date.
CONTRACT VALUE -- The sum of the Owner's interest in the General Account and the
Subaccounts of the Variable Account.
CONTRACT YEAR -- One year from the Issue Date and from each Contract
Anniversary.
ELIGIBLE INVESTMENT(S) -- An investment entity shown on the Contract Data Page.
FIXED ANNUITY -- A series of payments made during the Annuity Period which are
guaranteed as to dollar amount by the Company and do not vary with the
investment experience of the Variable Account.
GENERAL ACCOUNT -- The Company's general investment account which contains all
the assets of the Company with the exception of Cova Variable Annuity Account
One (the "Variable Account") and other segregated asset accounts.
GENERAL ACCOUNT VALUE -- The Owner's interest in the General Account.
ISSUE DATE -- The date this Contract is issued. The Issue Date is shown on the
Contract Data Page.
OWNER -- The person or entity named in the Application who/which has all rights
under this Contract.
PORTFOLIO -- A segment of an Eligible Investment which constitutes a separate
and distinct class of shares.
SUBACCOUNT -- A segment of the Variable Account.
SUBACCOUNT VALUE -- The Owner's interest in a Subaccount.
VALUATION DATE -- The Variable Account will be valued each day that the New York
Stock Exchange is open for trading.
VALUATION PERIOD -- The period beginning at the close of business of the New
York Stock Exchange on each Valuation Date and ending at the close of business
for the next succeeding Valuation Date.
VARIABLE ACCOUNT -- A separate investment account of the Company designated on
the Contract Data Page.
VARIABLE ACCOUNT VALUE -- The sum of the Owner's interest in each of the
Subaccounts of the Variable Account.
VARIABLE ANNUITY -- A series of payments made during the Annuity Period which
vary in amount with the investment experience of each applicable Subaccount.
WITHDRAWAL VALUE -- The Withdrawal Value is:
1) the Contract Value for the Valuation Period next following the Valuation
Period during which a written request for a withdrawal is received at the
Company; less
2) any applicable taxes not previously deducted; less
3) the Withdrawal Charge, if any; less
4) the Contract Maintenance Charge, if any.
GENERAL PROVISIONS
THE CONTRACT -- The entire contract consists of:
1) this Contract;
2) the Application which is attached to this Contract; and
3) any riders or endorsements attached to this Contract.
This Contract may be changed or altered only by the President or Secretary of
the Company. A change or alteration must be made in writing.
INCONTESTABILITY -- The Company will not contest this Contract from the Issue
Date.
NON-PARTICIPATING -- This Contract will not share in any distribution of
dividends.
MISSTATEMENT OF AGE OR SEX -- The Company may require proof of age or sex of the
Annuitant before making any life Annuity Payments under this Contract. If the
age or sex of the Annuitant has been misstated, the amount payable will be the
amount that the Contract Value would have provided at the correct age or sex.
After the Annuity Date, any under payments will be made up in one sum, including
interest at 6% per year, with the next Annuity Payment. Any overpayments,
including interest at 6% per year, will be deducted from future Annuity Payments
until the total is repaid.
CONTRACT SETTLEMENT -- This Contract must be returned to the Company prior to
any settlement. Prior to any payment as a death claim, due proof of death must
be submitted to the Company.
REPORTS -- At least once each calendar year, the Company will furnish the Owner
with a report showing the Contract Value and any other information as may be
required by law. The Company will also furnish an annual report of the Variable
Account. Reports will be sent to the last known address of the Owner.
TAXES -- Any taxes paid to any governmental entity relating to this Contract
will be deducted from the Purchase Payments or Contract Value when incurred. The
Company will, in its sole discretion, determine when taxes have resulted from:
the investment experience of the Variable Account; receipt by the Company of the
Purchase Payments; or commencement of Annuity Payments. The Company may, at its
sole discretion, pay taxes when due and deduct that amount from the Contract
Value at a later date. Payment at an earlier date does not waive any right the
Company may have to deduct amounts at a later date. The Company will deduct any
withholding taxes required by applicable law.
EVIDENCE OF SURVIVAL -- The Company may require satisfactory evidence of the
continued survival of any person(s) on whose life Annuity Payments are based.
MODIFICATION OF CONTRACT -- This Contract may not be modified by the Company
without the consent of the Owner except as may be required by applicable law.
ANNUITANT, OWNERSHIP, ASSIGNMENT PROVISIONS
ANNUITANT -- The Annuitant is the person on whose life Annuity Payments are
based. The Annuitant is the person designated in the Application, unless
changed.
OWNERSHIP -- The Owner has all rights and may receive all benefits under this
Contract. Prior to the Annuity Date, the Owner is the person designated in the
Application, unless changed. On and after the Annuity Date:
1) the Annuitant is the Owner; and
2) upon the death of the Annuitant, the Beneficiary is the Owner.
The Owner may change the Owner at any time. A change of Owner will automatically
revoke any prior designation of Owner. A request for change must be:
1) made in writing; and
2) received at the Company.
The change will become effective as of the date the written request is signed. A
new designation of Owner will not apply to any payment made or action taken by
the Company prior to the time it was received.
ASSIGNMENT -- The Owner may, at any time during his or her lifetime, assign his
or her rights under this Contract. The Company will not be bound by any
assignment until written notice is received by the Company. The Company is not
responsible for the validity of any assignment. The Company will not be liable
as to any payment or other settlement made by the Company before receipt of the
assignment.
BENEFICIARY PROVISIONS
BENEFICIARY -- The Beneficiary is named in the Application, unless changed. The
Beneficiary is entitled to receive the benefits to be paid at the death of the
Owner.
Unless the Owner provides otherwise, the Death Benefit will be paid in equal
shares or all to the survivor as follows:
1) to the Primary Beneficiaries who survive the Owner's death; or if there are
none,
2) to the Contingent Beneficiaries who survive the Owner's death; or if there
are none,
3) to the estate of the Owner.
CHANGE OF BENEFICIARY -- Subject to the rights of any irrevocable Beneficiary,
the Owner may change the Primary Beneficiary or Contingent Beneficiary. A change
may be made by filing a written request with the Company. The change will take
effect as of the date the notice is signed. The Company will not be liable for
any payment made or action taken before it records the change.
PURCHASE PAYMENT PROVISIONS
PURCHASE PAYMENTS -- The Initial Purchase Payment is due on the Issue Date.
Thereafter, a Purchase Payment may be made at any time in any amount, subject to
the Minimum Subsequent Purchase Payment shown on the Contract Data Page. The
Company reserves the right to reject any Application or Purchase Payment.
CHANGE IN PURCHASE PAYMENTS -- Subject to the minimum shown on the Contract Data
Page, the Owner may increase or decrease or change the frequency of subsequent
Purchase Payments.
ALLOCATION OF PURCHASE PAYMENTS -- The allocation of the initial Purchase
Payment is elected by the Owner on the Application. Unless elected otherwise by
the Owner, subsequent Purchase Payments are allocated in the same manner as the
initial Purchase Payment. Allocation of the Purchase Payments is subject to the
terms and conditions imposed by the Company.
NO DEFAULT -- Unless the Owner makes a total withdrawal, this Contract will
remain in force until the Annuity Date. This Contract will not be in default if
subsequent Purchase Payments are not made.
GENERAL ACCOUNT PROVISIONS
GENERAL ACCOUNT VALUE -- The General Account Value at any time is equal to:
1) the Purchase Payments allocated to the General Account; plus
2) amounts transferred to the General Account; plus
3) interest credited to the General Account; less
4) any prior partial withdrawals and Withdrawal Charges deducted from the
General Account; less
5) amounts transferred from the General Account; less
6) any applicable premium taxes, Contract Maintenance Charge or Transfer Fee.
INTEREST TO BE CREDITED -- The Company guarantees that the interest rate
credited to the General Account will not be less than the Minimum Guaranteed
Interest Rate. The Minimum Guaranteed Interest Rate is 3% per year. The Company
may credit additional interest at its sole discretion.
CONTRACT VALUE PROVISION
CONTRACT VALUE -- Each Purchase Payment is allocated to a Subaccount of the
Variable Account and/or the General Account. A Purchase Payment allocated to a
Subaccount of the Variable Account is converted into Accumulation Units. The
number of Accumulation Units in a Subaccount credited to this Contract is
determined by dividing the Purchase Payment allocated to that Subaccount by the
Accumulation Unit Value for that Subaccount. The Contract Value on any Valuation
Date is the sum of the Owner's interest in the General Account and the
Subaccounts of the Variable Account. The value of the Owner's interest in a
Subaccount is determined by multiplying the number of Accumulation Units
attributable to that Subaccount by the Accumulation Unit Value for that
Subaccount.
Withdrawals will result in the cancellation of Accumulation Units in a
Subaccount or a reduction of the General Account Value.
VARIABLE ACCOUNT PROVISIONS
THE VARIABLE ACCOUNT -- The Variable Account is a separate investment account of
the Company. It is shown on the Contract Data Page. The Company has allocated a
part of its assets for this and certain other contracts to the Variable Account.
The assets of the Variable Account are the property of the Company. However,
they are not chargeable with the liabilities arising out of any other business
the Company may conduct.
INVESTMENTS OF THE VARIABLE ACCOUNT -- Purchase Payments applied to the Variable
Account are allocated to a Subaccount of the Variable Account. The assets of the
Subaccount are allocated to the Eligible Investment(s) and the Portfolio(s), if
any, within an Eligible Investment shown on the Contract Data Page. The Company
may, from time to time, and with the prior approval of the Superintendent of
Insurance of the state of New York, add additional Eligible Investments or
Portfolios to those shown on the Contract Data Page. The Owner may be permitted
to transfer Contract Values to the additional Eligible Investments or
Portfolios. However, the right to make any transfer will be limited by the terms
and conditions imposed by the Company.
If the shares of any of the Eligible Investment(s) or any Portfolio(s) within
the Eligible Investments become unavailable for investment by the Variable
Account, or the Company's Board of Directors deems further investment in these
shares inappropriate, the Company may substitute shares of another Eligible
Investment for shares already purchased under this Contract.
VALUATION OF ASSETS -- Assets of the Variable Account are valued at their fair
market value in accordance with procedures of the Company.
ACCUMULATION UNIT -- A Purchase Payment allocated to the Variable Account is
converted into Accumulation Units for each elected Subaccount. The number of
Accumulation Units in a Subaccount credited to this Contract is determined by
dividing the Purchase Payment allocated to that Subaccount by the Accumulation
Unit Value for that Subaccount as of the Valuation Period during which the
Purchase Payment is allocated to the Subaccount. The Accumulation Unit Value for
each Subaccount was arbitrarily set initially at $10. The Accumulation Unit
Value for any later Valuation Period is determined by subtracting (b) from (a)
and dividing the result by (c) where:
(a) is the net result of
1) the assets of the Subaccount; i.e., the aggregate value of the
underlying Eligible Investment shares held at the end of such Valuation
Period; plus or minus
2) the cumulative charge or credit for taxes reserved which is determined
by the Company to have resulted from the operation of the Subaccount of
the Variable Account;
(b) is the cumulative unpaid charge for the Mortality and Expense Risk Premium
and for the Administrative Expense Charge which are shown on the Contract
Data Page; and
(c) is the number of Accumulation Units in a Subaccount of the Variable Account
outstanding at the end of the Valuation Period.
Withdrawals from a Subaccount will result in the cancellation of Accumulation
Units in each Subaccount of the Variable Account. The Contract Value
attributable to a Subaccount of the Variable Account is determined by
multiplying the number of Accumulation Units attributable to the Subaccount by
the Accumulation Unit Value for that Subaccount. An Accumulation Unit Value may
increase or decrease from Valuation Period to Valuation Period.
MORTALITY AND EXPENSE RISK PREMIUM -- The Company deducts a Mortality and
Expense Risk Premium from the Variable Account which is equal, on an annual
basis, to the amount shown on the Contract Data Page. The Mortality and Expense
Risk Premium compensates the Company for assuming the mortality and expense
risks under this Contract.
ADMINISTRATIVE EXPENSE CHARGE -- The Company deducts an Administrative Expense
Charge from the Variable Account which is equal, on an annual basis, to the
amount shown on the Contract Data Page. The Administrative Expense Charge
compensates the Company for the costs associated with the administration of this
Contract and the Variable Account.
MORTALITY AND EXPENSE GUARANTEE -- The Company guarantees that the dollar amount
of each Annuity Payment after the first Annuity Payment will not be affected by
variations in mortality or expense experience.
CONTRACT MAINTENANCE CHARGE
DEDUCTION FOR CONTRACT MAINTENANCE CHARGE -- The Company deducts an annual
Contract Maintenance Charge from the Contract Value by cancelling Accumulation
Units from each applicable Subaccount or reducing the General Account Value to
reimburse it for expenses relating to maintenance of this Contract. The Contract
Maintenance Charge is shown on the Contract Data Page. The Contract Maintenance
Charge will be deducted from the Contract Value on each Contract Anniversary
while this Contract is in force.
If a total withdrawal is made on other than a Contract Anniversary, the Contract
Maintenance Charge will be deducted at the time of withdrawal. If the Annuity
Date is not a Contract Anniversary, a prorata portion of the annual Contract
Maintenance Charge will be deducted on the Annuity Date. After the Annuity Date,
the Contract Maintenance Charge will be collected on a monthly basis and will
result in a reduction of each Annuity Payment.
TRANSFER PROVISION
TRANSFERS -- Prior to the Annuity Date, the Owner may transfer all or part of an
Account without the imposition of any fee or charge if there have been no more
than 12 transfers made in the Contract Year. All transfers are subject to the
following:
1) if more than 12 transfers have been made in the Contract Year, the Company
will deduct a Transfer Fee. The Transfer Fee is shown on the Contract Data
Page. The Transfer Fee will be deducted from the Account from which the
transfer is made. However, if the entire interest in an Account is being
transferred, the Transfer Fee will be deducted from the amount which is
transferred.
2) the minimum amount which may be transferred is the lesser of: (A) $500; or
(B) the Owner's entire interest in the Account.
3) transfers will be effected during the Valuation Period next following
receipt by the Company of a written transfer request containing all
required information. However, no transfer may be made effective within
seven calendar days of the Annuity Date.
4) any transfer direction must clearly specify: (A) the amount which is to be
transferred; and (B) the Accounts which are to be affected.
If the Owner elects to use the transfer privilege, neither the Company nor its
Home Office will be liable for transfers made in accordance with the Owner's
instructions.
DEATH BENEFIT
DEATH OF ANNUITANT -- Upon death of the Annuitant prior to the Annuity Date, the
Owner must designate a new Annuitant. If no designation is made within 30 days
of the death of the Annuitant, the Owner will become the Annuitant.
Upon death of the Annuitant after the Annuity Date, the Death Benefit, if any,
will be as specified in the Annuity Option elected and the remaining Annuity
Payments will be distributed at least as rapidly as prior to the Annuitant's
death.
DEATH OF OWNER -- Upon death of the Owner prior to the Annuity Date, the Death
Benefit will be paid to the Beneficiary designated by the Owner.
Upon death of the Owner after the Annuity Date, the Death Benefit, if any, will
be as specified in the Annuity Option elected and the remaining Annuity Payments
will be distributed at least as rapidly as prior to the Owner's death.
Prior to the Owner, or a Joint Owner, attaining age 80, the Death Benefit will
be the greater of:
1) the Purchase Payments less any Withdrawals and any applicable Withdrawal
Charge;
2) the Contract Value; or
3) the Contract Value on the most recent seven year Contract Anniversary plus
any subsequent Purchase Payments less any subsequent Withdrawals and any
applicable Withdrawal Charge.
After the Owner, or a Joint Owner, attains age 80, the Death Benefit will be the
greater of:
1) Purchase Payments less any Withdrawals and any applicable Withdrawal
Charge;
2) the Contract Value; or
3) the Contract Value on the most recent seven year Contract Anniversary on or
before the Owner's 80th birthday plus any subsequent Purchase Payments less
any subsequent Withdrawals and any applicable Withdrawal Charge.
If Joint Owners are named, the Death Benefit is payable upon the first death of
a Joint Owner. However, a surviving Joint Owner who is both the spouse of the
other Joint Owner and the Beneficiary may elect that this Contract remain in
effect.
The Death Benefit will be determined and paid as of the Valuation Period next
following the date of receipt by the Company of both due proof of death and an
election for a single sum payment or election under an Annuity Option.
If a single sum payment is requested, the proceeds will be paid within seven (7)
days of receipt of proof of death and the election. Payment under an Annuity
Option may only be elected during the sixty-day period beginning with the date
of receipt of proof of death or a single sum payment will be made to the
Beneficiary at the end of the sixty-day period.
The entire Death Benefit must be paid within five (5) years of the date of death
unless the Beneficiary elects to have the Death Benefit payable under an Annuity
Option over the Beneficiary's lifetime or for a period not extending beyond the
Beneficiary's life expectancy, beginning within one (1) year of the date of
death.
If the Beneficiary is the spouse of the Owner, the spouse may elect to become
the Owner and continue this Contract in effect at the then current Contract
Value.
PAYMENT OF DEATH BENEFIT -- The Company will require due proof of death before
any Death Benefit is paid. Due proof of death will be:
1) a certified death certificate;
2) a certified decree of a court of competent jurisdiction as to the finding of
death;
3) a written statement by a medical doctor who attended the deceased; or
4) any other proof satisfactory to the Company.
Any Death Benefit will be paid in accordance with applicable law or regulations
governing death benefit payments.
ANNUITY PROVISIONS
ANNUITY DATE -- The Annuity Date is elected by the Owner on the Application. The
Annuity Date is shown on the Contract Data Page. The Annuity Date must be the
first day of a calendar month and must be at least one year after the Issue
Date. The Annuity Date may not be later than the first day of the calendar month
following the Annuitant's 90th birthday.
Prior to the Annuity Date, the Owner may, subject to the above, change the
Annuity Date upon 30 days prior written notice to the Company.
ELECTION OF ANNUITY OPTION -- The Annuity Option is elected by the Owner on the
Application. If no Annuity Option is elected, Option 2 with 10 years guaranteed
will automatically be applied. Prior to the Annuity Date, the Owner may, upon 30
days prior written notice to the Company, change the Annuity Option.
FREQUENCY AND AMOUNT OF ANNUITY PAYMENTS -- Annuity Payments will be paid as
monthly installments. The Contract Value on the Annuity Date is applied to the
Annuity Table for the Annuity Option elected. If the amount of the Contract
Value to be applied under an Annuity Option is less than $2,000, the Company
reserves the right to make one lump sum payment in lieu of Annuity Payments. If
the amount of any Annuity Payment would be or become less than $20, the Company
will reduce the frequency of payments to an interval which will result in each
payment being at least $20.
The Annuity Tables are based on the 1983 Individual Annuity Mortality Tables
with interest at the rate of 3% per year.
ANNUITY OPTIONS -- The following Annuity Options or any other Annuity Option
acceptable to the Company may be elected.
Option 1 -- Life Annuity -- The Company will make monthly payments during the
life of the Annuitant.
Option 2 -- Life Annuity with 5, 10 or 20 Years Guaranteed -- The Company will
make monthly Annuity Payments during the life of the Annuitant. If payments have
been made for less than the guaranteed period at the death of the Annuitant,
payments will continue to the Beneficiary for the remainder of the guaranteed
period. However, the Beneficiary may elect to receive a single sum payment. A
single sum payment will be equal to the present value of remaining payments as
of the date of receipt of due proof of death commuted at the assumed investment
rate of 3%. If any life income optional settlement with a period certain
provides for installment payments of the same amount at some ages for different
periods certain, the contract must provide that the insurer will deem an
election to have been made for the longest period certain which could have been
elected for such age and amount.
Option 3 -- Joint and Last Survivor Annuity -- The Company will make monthly
Annuity Payments for the joint lifetime of the Annuitant and another person. At
the death of either Xxxxx, Annuity Payments will continue to be made to the
survivor Payee. The survivor's Annuity Payments will be equal to 100%, 66 2/3%
or 50% of the amount payable during the joint lifetime, as chosen.
ANNUITY -- If all of the Contract Value on the seventh calendar day before the
Annuity Date is allocated to the General Account, the Annuity will be paid as a
Fixed Annuity. If all of the Contract Value on the Annuity Date is allocated to
the Variable Account, the Annuity will be paid as a Variable Annuity. If the
Contract Value on the Annuity Date is allocated to both the General Account and
the Variable Account, the Annuity will be paid as a combination of a Fixed
Annuity and a Variable Annuity to reflect the allocation between the Accounts.
Variable Annuity Payments will reflect the investment performance of the
Variable Account in accordance with the allocation of the Contract Value to the
Subaccounts on the Annuity Date.
The Contract Value will be applied to the applicable Annuity Tables. The Annuity
Table used will depend upon the Annuity Option elected. The amount of the first
payment for each $1,000 of Contract Value is shown in the Annuity Tables. If, as
of the Annuity Date, the then current Single Premium Immediate Annuity rates
applicable to this class of contracts provide a first Annuity Payment greater
than guaranteed under the same Annuity Option under this Contract, the greater
payment will be made.
FIXED ANNUITY -- The General Account Value on the day immediately preceding the
Annuity Date will be used to determine the Fixed Annuity monthly payment. The
first monthly Annuity Payment will be based upon the Annuity Option elected and
the appropriate Annuity Option Table.
VARIABLE ANNUITY -- Variable Annuity Payments:
1) are not predetermined as to dollar amount; and
2) will vary in amount with the net investment results of the applicable
Subaccount(s) of the Variable Account at the Annuity Date.
The dollar amount of Variable Annuity Payments for each applicable Subaccount
after the first is determined as follows:
1) the dollar amount of the first Variable Annuity Payment is divided by the
value of an Annuity Unit for each applicable Subaccount as of the Annuity
Date. This establishes the number of Annuity Units for each monthly
payment. The number of Annuity Units for each applicable Subaccount remains
fixed during the Annuity Period;
2) the fixed number of Annuity Units per payment in each Subaccount is
multiplied by the Annuity Unit Value for that Subaccount for the last
Valuation Period of the month preceding the month for which the payment is
due. This result is the dollar amount of the payment for each applicable
Subaccount.
The total dollar amount of each Variable Annuity Payment is the sum of all
Subaccount Variable Annuity Payments reduced by the applicable Contract
Maintenance Charge.
ANNUITY UNIT -- The value of an Annuity Unit for each Subaccount of the Variable
Account was initially set on an arbitrary basis. This was done when the first
Eligible Investment shares were purchased.
The Subaccount Annuity Unit Value at the end of any subsequent Valuation Period
is determined by multiplying the Subaccount Annuity Unit Value for the
immediately preceding Valuation Period by the net investment factor for the day
for which the Annuity Unit Value is being calculated; and multiplying the result
by 0.999919 for each day within the Valuation Period.
NET INVESTMENT FACTOR -- The Net Investment Factor for any Subaccount of the
Variable Account for any Valuation Period is determined by dividing:
1) the Accumulation Unit Value as of the close of the current Valuation
Period; by
2) the Accumulation Unit Value as of the close of the immediately preceding
Valuation Period.
The Net Investment Factor may be greater or less than one, as the Annuity Unit
Value may increase or decrease.
TRANSFERS DURING THE ANNUITY PERIOD -- During the Annuity Period, the Owner may
make transfers, by written request, as follows:
1) the Owner may make a transfer once each Contract Year between Subaccounts
of the Variable Account.
2) the Owner may at any time, make a transfer from one or more Subaccounts to
the General Account. The Owner may not make a transfer from the General
Account to the Variable Account.
The amount transferred to the General Account from a Subaccount of the Variable
Account will be equal to the annuity reserve for the payee's interest in that
Subaccount. The annuity reserve is the product of "(a)" multiplied by "(b)"
multiplied by "(c)", where (a) is the number of Annuity Units representing the
Owner's interest in the Subaccount per Annuity Payment; (b) is the Annuity Unit
Value for the Subaccount; and (c) is the present value of $1.00 per payment
period as of the Attained Age of the Owner at time of transfer for the Annuity
Option, determined using the 1983 Individual Annuity Mortality Tables with
interest at 3% per year. Xxxxxxx transferred to the General Account will be
applied under the Annuity Option elected at the attained age of the Owner at the
time of the transfer. All amounts and Annuity Unit Values will be determined as
of the end of the Valuation Period preceding the effective date of the transfer.
PROTECTION OF PROCEEDS -- No Payee may commute, encumber, alienate or assign any
payments under this Contract. To the extent permitted by law, no payments will
be subject to the debts, contracts or engagements of any Payee or to any
judicial process to levy upon or attach the same for payment thereof.
WITHDRAWAL PROVISIONS
WITHDRAWALS -- Prior to the Annuity Date, the Owner may, upon written request
received by the Company, make a total or partial withdrawal of the Withdrawal
Value. A withdrawal will result in the cancellation of Accumulation Units from
each applicable Subaccount of the Variable Account or a reduction in the General
Account Value in the ratio that the Subaccount Value and/or the General Account
Value bears to the total Contract Value. The Owner must specify in writing in
advance which units are to be cancelled or values are to be reduced if other
than the above method is desired. The Company will pay the amount of any
withdrawal within seven (7) days of receipt of a request in good order unless
the Suspension Or Deferral Of Payments Or Transfers From The Variable Account
provision or the Deferral Of Payments Or Transfers From The General Account
provision is in effect.
Each partial withdrawal must be for an amount which is not less than $500 or, if
smaller, the remaining Withdrawal Value. The remaining Withdrawal Value must be
at least $1,000 after a partial withdrawal is completed.
WITHDRAWAL CHARGE -- A Withdrawal Charge may be deducted in the event of a
withdrawal of all or a portion of the Contract Value. The Withdrawal Charge is
imposed on a withdrawal of Contract Value attributable to a Purchase Payment
within seven (7) years of receipt of the Purchase Payment. The Withdrawal
Charge, if any, is equal to 7% of the Purchase Payment withdrawn within first
and second years following receipt, 5% of the Purchase Payment withdrawn during
third, fourth and fifth years following receipt and 3% of the Purchase Payment
withdrawn during sixth and seventh years following receipt.
For a partial withdrawal, the Withdrawal Charge will be deducted from the
remaining Withdrawal Value, if sufficient, or from the amount withdrawn. The
Withdrawal Charge will be deducted by cancelling Accumulation Units from each
applicable Subaccount or reducing the General Account Value in the ratio that
the Subaccount Value and/or General Account bears to the total Contract Value.
The Owner must specify in writing in advance if other than the above method of
cancellation is desired.
WAIVER OF WITHDRAWAL CHARGE -- A withdrawal of 10% of the aggregate Purchase
Payments may be made without the Withdrawal Charge on a non-cumulative basis as
follows:
1) Once each Contract Year after the first Contract Year, as a single sum
payment if the Contract Value prior to the withdrawal exceeds $5,000; or
2) At any time, subject to any conditions the Company may impose, as equal
periodic installments.
Any equal periodic installments made to which the Waiver of Withdrawal Charge
applies are made in accordance with the following:
1) Total monthly withdrawals cannot exceed 10% of Purchase Payments in any 12
month period; and
2) The Owner must be over age 591/2.
SUSPENSION OR DEFERRAL OF
PAYMENTS OR TRANSFERS FROM
THE VARIABLE ACCOUNT
The Company reserves the right to suspend or postpone payments for a withdrawal
or transfer for any period when:
1) the New York Stock Exchange is closed (other than customary weekend and
holiday closings);
2) trading on the New York Stock Exchange is restricted;
3) an emergency exists as a result of which disposal of securities held in the
Variable Account is not reasonably practicable or it is not reasonably
practicable to determine the value of the Variable Account's net assets; or
4) during any other period when the Securities and Exchange Commission, by
order, so permits for the protection of Owners; provided that applicable
rules and regulations of the Securities and Exchange Commission will govern
as to whether the conditions described in (2) and (3) exist.
DEFERRAL OF PAYMENTS OR TRANSFERS FROM THE GENERAL ACCOUNT
The Company reserves the right to defer payment for a withdrawal or transfer
from the General Account for the period permitted by law but not for more than
six months after written election is received by the Company.
RESERVES, VALUES AND BENEFITS
All reserves are greater to or equal to those required by statute. Any values
and death benefits that may be available under this Contract are not less than
the minimum benefits required by any statute of the state in which this Contract
is delivered.
ANNUITY TABLE 1
Monthly Annuity Payment Under Option 1
For Each $1,000 Of Contract Value Applied
Male Female Male Female Male Female
Monthly Monthly Monthly Monthly Monthly Monthly
Age Payment Payment Age Payment Payment Age Payment Payment
...... ........... ........... ...... ........... ........... ..... ........... ...........
5 2.82 2.76 32 3.35 3.19 59 5.18 4.63
6 2.83 2.77 33 3.38 3.21 60 5.31 4.74
7 2.85 2.78 34 3.42 3.24 61 5.45 4.85
8 2.86 2.79 35 3.46 3.27 62 5.61 4.97
9 2.87 2.80 36 3.50 3.30 63 5.77 5.10
10 2.88 2.81 37 3.54 3.33 64 5.95 5.24
11 2.90 2.82 38 3.58 3.37 65 6.13 5.38
12 2.91 2.83 39 3.62 3.40 66 6.34 5.54
13 2.93 2.84 40 3.67 3.44 67 6.55 5.71
14 2.94 2.85 41 3.72 3.48 68 6.78 5.89
15 2.96 2.87 42 3.77 3.52 69 7.02 6.08
16 2.97 2.88 43 3.83 3.56 70 7.29 6.29
17 2.99 2.90 44 3.88 3.60 71 7.57 6.51
18 3.01 2.91 45 3.94 3.65 72 7.87 6.76
19 3.03 2.93 46 4.01 3.70 73 8.19 7.02
20 3.05 2.94 47 4.07 3.75 74 8.53 7.31
21 3.07 2.96 48 4.14 3.80 75 8.90 7.62
22 3.09 2.97 49 4.21 3.86 76 9.30 7.96
23 3.11 2.99 50 4.29 3.92 77 9.72 8.33
24 3.13 3.01 51 4.36 3.98 78 10.18 8.73
25 3.15 3.03 52 4.45 4.05 79 10.67 9.16
26 3.18 3.05 53 4.53 4.12 80 11.19 9.63
27 3.20 3.07 54 4.63 4.19 81 11.75 10.14
28 3.23 3.09 55 4.72 4.27 82 12.35 10.69
29 3.26 3.11 56 4.83 4.36 83 12.99 11.29
30 3.29 3.14 57 4.94 4.44 84 13.66 11.94
31 3.32 3.16 58 5.05 4.54 85+ 14.37 12.64
ANNUITY TABLE 2
Monthly Annuity Payment Under Option 2
For Each $1,000 Of Contract Value Applied
Male 5 Years 10 Years 20 Years Male 5 Years 10 Years 20 Years
Age Guaranteed Guaranteed Guaranteed Age Guaranteed Guaranteed Guaranteed
.......... .............. .............. ............. ........ .............. .............. ..............
5 2.82 2.82 2.82 46 4.00 3.98 3.88
6 2.83 2.83 2.83 47 4.06 4.04 3.94
7 2.84 2.84 2.84 48 4.13 4.10 3.99
8 2.86 2.86 2.85 49 4.20 4.17 4.04
9 2.87 2.87 2.86 50 4.27 4.27 4.10
10 2.88 2.88 2.88 51 4.35 4.31 4.16
11 2.90 2.89 2.89 52 4.43 4.39 4.22
12 2.91 2.91 2.90 53 4.52 4.47 4.28
13 2.92 2.92 2.92 54 4.61 4.56 4.34
14 2.94 2.94 2.93 55 4.70 4.65 4.40
15 2.96 2.95 2.95 56 4.80 4.74 4.47
16 2.97 2.97 2.96 57 4.91 4.84 4.53
17 2.99 2.99 2.98 58 5.03 4.94 4.60
18 3.01 3.00 3.00 59 5.15 5.05 4.66
19 3.03 3.02 3.02 60 5.28 5.17 4.73
20 3.04 3.04 3.04 61 5.41 5.29 4.79
21 3.06 3.06 3.05 62 5.56 5.42 4.86
22 3.09 3.08 3.07 63 5.72 5.55 4.92
23 3.11 3.10 3.10 64 5.88 5.69 4.98
24 3.13 3.13 3.12 65 6.06 5.84 5.04
25 3.15 3.15 3.14 66 6.25 5.99 5.10
26 3.18 3.17 3.16 67 6.45 6.15 5.15
27 3.20 3.20 3.19 68 6.66 6.31 5.20
28 3.23 3.23 3.21 69 6.88 6.48 5.24
29 3.26 3.25 3.24 70 7.12 6.65 5.29
30 3.29 3.28 3.27 71 7.37 6.82 5.32
31 3.32 3.31 3.30 72 7.63 7.00 5.36
32 3.34 3.34 3.33 73 7.91 7.18 5.39
33 3.38 3.38 3.36 74 8.20 7.36 5.41
34 3.42 3.41 3.39 75 8.51 7.53 5.43
35 3.45 3.45 3.42 76 8.83 7.71 5.45
36 3.49 3.49 3.46 77 9.16 7.88 5.47
37 3.53 3.53 3.49 78 9.51 8.05 5.48
38 3.58 3.57 3.53 79 9.88 8.21 5.49
39 3.62 3.61 3.57 80 10.25 8.37 5.50
40 3.67 3.66 3.61 81 10.64 8.51 5.51
41 3.72 3.71 3.65 82 11.03 8.65 5.51
42 3.77 3.76 3.70 83 11.42 8.78 5.52
43 3.82 3.81 3.74 84 11.82 8.90 5.52
44 3.88 3.86 3.79 85+ 12.21 9.00 5.52
45 3.91 3.92 3.84
ANNUITY TABLE 2
Monthly Annuity Payment Under Option 2
For Each $1,000 Of Contract Value Applied
Female 5 Years 10 Years 20 Years Female 5 Years 10 Years 20 Years
Age Guaranteed Guaranteed Guaranteed Age Guaranteed Guaranteed Guaranteed
........... .............. .............. ............. ......... .............. .............. ..............
5 2.76 2.76 2.75 46 3.70 3.69 3.65
6 2.77 2.77 2.76 47 3.75 3.74 3.69
7 2.78 2.78 2.77 48 3.80 3.79 3.74
8 2.79 2.79 2.78 49 3.86 3.84 3.79
9 2.80 2.80 2.79 50 3.92 3.90 3.84
10 2.81 2.81 2.80 51 3.98 3.96 3.89
11 2.82 2.82 2.82 52 4.04 4.03 3.94
12 2.83 2.83 2.83 53 4.11 4.09 4.00
13 2.84 2.84 2.84 54 4.19 4.16 4.06
14 2.85 2.85 2.85 55 4.26 4.24 4.12
15 2.87 2.87 2.86 56 4.35 4.32 4.18
16 2.88 2.88 2.88 57 4.43 4.40 4.25
17 2.90 2.90 2.89 58 4.53 4.49 4.31
18 2.91 2.91 2.91 59 4.62 4.58 4.38
19 2.92 2.92 2.92 60 4.73 4.68 4.45
20 2.94 2.94 2.94 61 4.84 4.78 4.52
21 2.96 2.96 2.95 62 4.95 4.89 4.60
22 2.97 2.97 2.97 63 5.08 5.00 4.67
23 2.99 2.99 2.99 64 5.21 5.12 4.74
24 3.01 3.01 3.00 65 5.35 5.25 4.81
25 3.03 3.03 3.02 66 5.50 5.38 4.88
26 3.05 3.05 3.04 67 5.66 5.53 4.95
27 3.07 3.07 3.06 68 5.83 5.68 5.02
28 3.09 3.09 3.08 69 6.02 5.83 5.08
29 3.11 3.11 3.10 70 6.22 6.00 5.14
30 3.14 3.14 3.13 71 6.43 6.17 5.20
31 3.16 3.16 3.15 72 6.66 6.35 5.25
32 3.19 3.19 3.17 73 6.90 6.54 5.29
33 3.21 3.21 3.20 74 7.17 6.73 5.33
34 3.24 3.24 3.23 75 7.45 6.93 5.37
35 3.27 3.27 3.25 76 7.75 7.13 5.40
36 3.30 3.30 3.28 77 8.06 7.33 5.43
37 3.33 3.33 3.31 78 8.40 7.53 5.45
38 3.36 3.36 3.34 79 8.76 7.73 5.47
39 3.40 3.40 3.38 80 9.14 7.93 5.48
40 3.44 3.44 3.41 81 9.54 8.12 5.49
41 3.47 3.47 3.45 82 9.95 8.30 5.50
42 3.51 3.51 3.48 83 10.39 8.47 5.51
43 3.56 3.56 3.52 84 10.83 8.63 5.51
44 3.60 3.60 3.56 85+ 11.29 8.78 5.52
45 3.65 3.65 3.60
ANNUITY TABLE 3
Monthly Annuity Payment Under Option 3
For Each $1,000 Of Contract Value Applied
Joint And 50% Survivor Annuity
Female
Age Male Age
......... ......................................................................
50 55 60 65 70 75
..... ...... ..... ..... ..... ......
50 4.03 4.21 4.42 4.68 4.98 5.32
55 4.20 4.40 4.63 4.92 5.25 5.62
60 4.41 4.63 4.89 5.21 5.58 6.01
65 4.67 4.91 5.21 5.57 6.00 6.49
70 4.97 5.25 5.59 6.01 6.52 7.10
75 5.34 5.67 6.06 6.56 7.17 7.87
Joint And 662/3% Survivor Annuity
Female
Age Male Age
......... ......................................................................
50 55 60 65 70 75
..... ...... ..... ..... ..... ......
50 3.86 4.00 4.16 4.33 4.51 4.70
55 4.02 4.19 4.38 4.58 4.79 5.02
60 4.20 4.40 4.63 4.87 5.14 5.41
65 4.40 4.64 4.91 5.22 5.55 5.89
70 4.61 4.90 5.23 5.62 6.04 6.49
75 4.85 5.18 5.58 6.06 6.62 7.22
Joint And 100% Survivor Annuity
Female
Age Male Age
......... ......................................................................
50 55 60 65 70 75
..... ...... ..... ..... ..... ......
50 3.57 3.65 3.72 3.76 3.80 3.82
55 3.71 3.83 3.94 4.02 4.08 4.13
60 3.83 4.01 4.17 4.31 4.42 4.50
65 3.94 4.17 4.41 4.64 4.83 4.98
70 4.02 4.31 4.63 4.96 5.28 5.54
75 4.09 4.42 4.82 5.27 5.74 6.19
Information about different age combinations will be furnished upon
request.
INDIVIDUAL FLEXIBLE PURCHASE PAYMENT
DEFERRED VARIABLE AND FIXED ANNUITY CONTRACT
NONPARTICIPATING
NO DIVIDENDS
First Cova Life Insurance Company
000 Xxxxxxxx
New York, New York 10271
CNY-672 (4/96)
