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LIBERTY LIFE ASSURANCE COMPANY OF BOSTON
A Member of the Liberty Mutual Group
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Home Office: 000 Xxxxxxxx Xxxxxx, X.X. Box 140, Boston, Massachusetts 02117-0140.
Service Center: 000 Xxxxxxx Xxx, Xxxxx, Xxx Xxxxxxxxx 00000-0000
READ THIS INSURANCE CERTIFICATE CAREFULLY
RIGHT TO RETURN
This is a legal contract between You and the Company. If You are not satisfied,
You may return it to Us or Your agent [10] days of its receipt and any payment
will be refunded, less the amount of any partial withdrawals.
Liberty Life Assurance Company of Boston, a stock Company has issued a Modified
Single Payment Variable Life Insurance contract to the Contractholder. We will
pay the benefits provided by the Group Contract, subject to its terms and
conditions, in consideration of Your application for coverage under the Group
Contract and the receipt of Your Initial Payment. The CERTIFICATE GUIDE on the
inside of the front cover shows where the major Certificate provisions can be
found.
This Certificate is evidence of your coverage under the Group Contract. It
contains a summary of the Group Contract. If there is a conflict between this
Certificate and the Group Contract, the provisions of the Group Contract will
govern.
THE AMOUNT AND DURATION OF THE DEATH BENEFIT AND OTHER VALUES PROVIDED BY THIS
CERTIFICATE ARE BASED ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, THE
FIXED ACCOUNT EARNINGS AND CERTIFICATE CHARGES. SEPARATE ACCOUNT VALUES ARE
VARIABLE AND MAY INCREASE OR DECREASE. THESE VALUES ARE NOT GUARANTEED AS TO
FIXED DOLLAR AMOUNT. THE DEATH BENEFIT IS DESCRIBED ON PAGE 3.
Signed for the Company.
/s/ Xxxxx X. Xxxxxx /s/ Xxxxxx X. Xxxxx
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SECRETARY PRESIDENT
CERTIFICATE DESCRIPTION
This is a GROUP MODIFIED SINGLE PAYMENT VARIABLE LIFE INSURANCE CERTIFICATE.
The Death Benefit is payable if the Insured dies while this Certificate is in
force and before the Maturity Date.
A Maturity Benefit is payable if the Insured is living on the Maturity Date.
Death Benefit and Account Value may vary with investment and earnings experience
and Certificate charges. This Certificate is not eligible for Dividends.
Page
CERTIFICATE ASSIGNMENT......................................................5
GUIDE INTEREST AND CHARGES...........................................21
CERTIFICATE LOANS..............................................10
CERTIFICATE VALUES..............................................6
DEATH BENEFIT...................................................3
DEFINITIONS.....................................................2
GENERAL CERTIFICATE PROVISIONS..................................5
GRACE PERIOD....................................................4
INCONTESTABILITY AND SUICIDE....................................6
MATURITY BENEFIT................................................4
OWNER AND BENEFICIARY...........................................6
PAYMENT OF PROCEEDS............................................16
PAYMENT OF PROCEEDS OPTIONS....................................16
REINSTATEMENT...................................................4
SEPARATE ACCOUNT PROVISIONS.....................................9
PAYMENTS........................................................4
TABLE OF GUARANTEED MONTHLY MAXIMUM
COST OF INSURANCE RATES.....................................19,20
TABLE OF WITHDRAWAL CHARGES....................................21
XXXXXXXXXX.....................................................11
ANY ADDITIONAL AGREEMENTS, ENDORSEMENTS
AND A COPY OF THE APPLICATION APPEAR
AFTER PAGE.....................................................21
DEFINITIONS This is what We mean when We use the following words in Your
Certificate:
Accumulation Unit. An accounting unit of measurement which We use
to calculate the value of a sub-account.
Attained Age. The Insured's age on his or her last birthday.
Certificate Date. The date when insurance coverage becomes
effective.
Indebtedness. Any unpaid Certificate loan and unpaid loan
interest.
Loan Account. An account established for amounts transferred from
the sub-accounts or the Fixed Account as security for outstanding
Indebtedness.
Monthly Date. The same day in each month as the Certificate Date.
The day of the month on which the Monthly Deduction is taken from
Your Account Value.
Net Death Benefit. The Death Benefit, less any Indebtedness.
Proceeds. All or part of the amount payable under any provision
of this Certificate.
Written Request. A notice in writing, satisfactory to Us, placed
on file at Our Service Center.
Valuation Day. The day when a sub-account is valued. This occurs
every day We are open and the New York Stock Exchange is open for
trading.
Valuation Period. The time period between the close of business
on successive Valuation Days.
We, Our, Us, The Company. Liberty Life Assurance Company of
Boston.
You, Your, Owner. The Owner of this Certificate, who may be
someone other than the Insured.
2
DEATH THE BENEFIT
BENEFIT If the Insured dies while this Certificate is in force, we will
pay a Death Benefit to the Beneficiary. The Death Benefit will be
the greater of:
o the Initial Death Benefit shown on the Certificate
Information page; or
o a percentage, shown below, of the Account Value.
The Initial Death Benefit is reduced proportionately for partial
withdrawals (see page 11). We will reduce the Death Benefit by
any Indebtedness. The Death Benefit will be determined on the
date We receive proof, satisfactory to Us, of the Insured's
death. The applicable percentage is based upon the Insured's
Attained Age.
Attained Age Account Attained Account Attained Age Account Value Attained Account
Value % Age Value % % Age Value %
40 & less 250 51 178 62 126 73 109
41 243 52 171 63 124 74 107
42 236 53 164 64 122 75-90 105
43 229 54 157 65 120 91 104
44 222 55 150 66 119 92 103
45 215 56 146 67 118 93 102
46 209 57 142 68 117 94-99 101
47 203 58 138 69 116 100 100
48 197 59 134 70 115
49 191 60 130 71 113
50 185 61 128 72 111
GUARANTEED DEATH BENEFIT
The Certificate has a guaranteed Death Benefit equal to the
Initial Death Benefit. In the absence of Indebtedness, this
guaranteed Death Benefit will be in effect until the Maturity
Date. The guaranteed Death Benefit is reduced proportionately for
partial withdrawals (see page 11). We will reduce the guaranteed
Death Benefit by any Indebtedness.
On any Monthly Date when the Surrender Value is not sufficient to
cover the Monthly Deduction and the Certificate has no
Indebtedness, We will waive that insufficiency and waive all
future Monthly Deductions until the Surrender Value is sufficient
to cover the Monthly Deductions.
If the Certificate has Indebtedness and the Surrender Value is
not sufficient to pay the Monthly Deduction or Loan Interest, the
Certificate will enter the Grace Period. To keep the Certificate
in force, an amount at least as large as (A) plus (B) plus (C)
must be remitted, where:
(A) is the amount by which the Monthly Deduction is
insufficient;
(B) is the next three Monthly Deductions; and
(C) is the net loan interest for the next 3 months (net loan
interest is Certificate loan interest charged less interest
credited on the loan balance).
This remittance will be considered a loan repayment, unless
otherwise specified in writing. If the
3
amount necessary to keep the Certificate in force exceeds the
outstanding Indebtedness, only the Indebtedness is due. Once the
Indebtedness has been repaid, all future Monthly Deductions will
be waived until the Surrender Value is sufficient to cover the
Monthly Deductions.
INTEREST ON DEATH BENEFIT
We will add interest to any Death Benefit payable in one sum as
required by applicable state law.
MATURITY MATURITY BENEFIT
BENEFIT We will pay a Maturity Benefit to You if the Insured is living
and coverage under the Group Contract is in force on the Maturity
Date, which is the Certificate anniversary on or following the
Insured's 100th birthday. The amount of the Maturity Benefit is
equal to the Surrender Value.
PAYMENTS INITIAL PAYMENT
The Initial Payment is shown on the Certificate Information page
and is payable on or before delivery of the Certificate. The
payment is payable at Our Service Center or to an authorized
agent. A copy of Your application, signed by Us or Our authorized
agent, is Your receipt for Your Initial Payment.
SUBSEQUENT PAYMENTS
We will accept additional payments if:
o the payment is required to keep the Certificate in force; or
o the payment is at least $1,000 and the payment will not result
in the disqualification of coverage under the Group Contract as
life insurance under the Internal Revenue Code as it now exists
or may later be amended.
If We accept an additional payment, evidence of insurability
satisfactory to Us will be required if an increase in the Death
Benefit occurs as a result of such payment.
PAYMENT ALLOCATION
The Initial Payment will be allocated to the Fixed Account on the
date We receive the payment.
The Account Value of the Fixed Account will then be allocated to
the sub-accounts, in whole percentages, according to the payment
allocation specified in the application. We may delay such
allocation until after the expiration of the Right to Return
period stated on the front page of Your Certificate.
GRACE PERIOD
If the Certificate has Indebtedness and the Surrender Value is
insufficient to pay the Monthly Deduction or Loan Interest, a
Grace Period of 61 days will be permitted for a payment
sufficient to continue the Certificate in force. We will send a
notice to You at Your last known address requesting the amount
due. If the required amount is not received within 61 days, the
Certificate will terminate without value. If the Insured dies
during a Grace Period, the Death Benefit will be reduced by any
Monthly Deductions or Loan Interest due but not paid.
REINSTATEMENT
This Certificate may be reinstated within five years of the end
of the Grace Period and prior to the Maturity Date if We receive:
o Your Written Request to reinstate the Certificate;
o evidence of insurability satisfactory to Us; and
o a payment equal to at least three Monthly Deductions
following the effective date of reinstatement.
If the Indebtedness is not repaid, such Indebtedness will also be
reinstated.
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LIFE LIFE INSURANCE QUALIFICATION
INSURANCE Coverage under the Group Contract is intended to qualify for
QUALI- treatment as life insurance under the Internal Revenue Code as it
FICATION now exists or may later be amended. We reserve the right to amend
the Group Contract and this Certificate to comply with future
changes in the Code and its Regulations. Any amendments will be
made by an agreement approved by the proper regulatory
authorities. We will promptly provide You with a copy of any
amendment.
We reserve the right to refuse premium payments and to return
those premium payments, in whole or in part, if accepting them
would disqualify coverage under the Group Contract from favorable
tax treatment under the Code. A premium payment will not be
refused if the payment will prevent the Certificate from
terminating.
GENERAL YOUR CERTIFICATE
CERTIFICATE Your Certificate is issued in consideration of your application
PROVISIONS for coverage under the Group Contract and the Initial Payment.
This Certificate contains a summary of the terms of the Group
Contract. All statements made by the Contractholder, or by an
Owner, or an Insured are representations and not warranties. No
statement made by or on behalf of an Insured will be used by us
to rescind the coverage under the Group Contract, or defend a
claim under it, unless a copy of the instrument containing such
statement has been furnished to an Insured, if living, otherwise
to the Beneficiary of the coverage being contested.
Any additional amendments to the Certificate, summarizing changes
to the Group Contract are shown on the Certificate Information
page. These amendments are attached to and made a part of this
Certificate.
WAIVER
Only an officer of the Company can waive or change any provision
of the Group Contract or a Certificate issued under the Group
Contract, and only by means of a written instrument.
No agent may change or waive any provision of the Group Contract
or a Certificate issued under the Group Contract.
We may modify the terms and conditions of the Group Contract to
conform to any new law or regulation affecting the Group Contract
or a Certificate issued under the Group Contract. Any change to
the Group Contract or any Certificate agreed to between the
Contractholder and us will not prejudice the rights of any
individual covered under the Group Contract on the effective date
of the change.
MISSTATEMENT OF AGE OR SEX
If the age or sex of the Insured has been misstated, any Proceeds
will be adjusted to that amount which the payments paid would
have purchased at the correct age and sex. Age refers to the
Insured's age last birthday on the Certificate Date.
ASSIGNMENT
Your Certificate may be assigned. We will not be on notice of any
assignment until a duplicate of the original assignment is filed
at Our Service Center. We assume no responsibility for the
validity or effect of any assignment, and may rely solely on the
assignee's statement of interest.
CERTIFICATE ANNIVERSARY
Certificate years and anniversaries will be computed from the
Certificate Date.
COMPLIANCE WITH LAW
If any provision of this Certificate is in conflict with any
applicable law, it is hereby amended to comply with the minimum
requirements of such law.
5
OWNER AND OWNER
BENEFICIARY The Owner is as named in the application on the Certificate Date,
and may be changed from time to time. Unless otherwise provided,
the ownership rights of an individual who dies before the Insured
will belong to the surviving joint owner, or if no joint owner,
to the executors or administrators of that individual's estate.
The ownership rights of a corporation, partnership or fiduciary
will belong to its successors or assigns.
During the Insured's lifetime, the rights and privileges stated
in this Certificate may be exercised only by the Owner.
BENEFICIARY
The Beneficiary is as named in the application on the Certificate
Date, and may be changed from time to time. The interest of any
Beneficiary who dies before the Insured will terminate at the
death of that Beneficiary.
If no Beneficiary designation is in effect at the Insured's
death, or if there is no designated Beneficiary then living, You
will be the Beneficiary. However, if the Insured was the Owner,
the executors or administrators of the Insured's estate will be
the Beneficiary.
CHANGE OF OWNERSHIP OR BENEFICIARY
You may change the Owner or any Beneficiary by Written Request
during the Insured's lifetime. The change will take effect as of
the date the request is signed after We acknowledge receipt in
writing, whether or not You or the Insured is living at the time
of acknowledgment. The change will be subject to any assignment,
and to any payment made or action taken by Us before
acknowledgment.
INCONTEST- INCONTESTABILITY AFTER TWO YEARS
ABILITY AND In the absence of fraud, an Insured's coverage under the Group
SUICIDE Contract will be incontestable after it has been in force during
the Insured's lifetime;
o with respect to the Initial Death Benefit, for two years
from the Certificate Date; and
o with respect to each increase in the Initial Death Benefit,
for two years from the effective date of that increase.
SUICIDE WITHIN TWO YEARS
If the Insured dies by suicide within two years from the
Certificate Date, while sane or insane, the amount payable under
the Group Contract will be limited to the greater of the Account
Value less Indebtedness or the minimum value required by the
state where this Certificate was issued for delivery.
CERTIFICATE ACCOUNT VALUE
VALUES Your Account Value on the Certificate Date is equal to the
Initial Payment less the Monthly Deduction for the first
Certificate month.
On each Monthly Date, Your Account Value equals:
o the sum of the value of Your Accumulation Units in the
sub-accounts; plus
o Your Account Value in the Fixed Account; plus
o the value of Your Loan Account, if any; minus
o the Monthly Deduction.
On each Valuation Day, other than a Monthly Date, Your Account
Value equals:
o the sum of the value of Your Accumulation Units in the
sub-accounts; plus
o Your Account Value in the Fixed Account; plus
o the value of Your Loan Account, if any.
6
CASH VALUE
A Withdrawal Charge will be subtracted from the Account Value to
determine the Cash Value. The Withdrawal Charges are shown on the
Interest and Charges page.
SURRENDER VALUE
Your Surrender Value is equal to Your Cash Value, minus the
Certificate Fee, and minus any Indebtedness.
ACCOUNT VALUE IN FIXED ACCOUNT
The Account Value in the Fixed Account on the Certificate Date is
equal to the Initial Payment less the Monthly Deduction for the
first Certificate month.
On each Monthly Date, the Account Value in the Fixed Account is
equal to:
o the Account Value in the Fixed Account on the preceding
Monthly Date with one month's interest; plus
o the Account Values transferred to the Fixed Account since
the preceding Monthly Date and interest from the date the
Account Value is transferred to the Monthly Date; minus
o the Account Values transferred from the Fixed Account since
the preceding Monthly Date and interest from the date the
Account Value is transferred to the Monthly Date; minus
o all withdrawals from the Fixed Account since the preceding
Monthly Date plus interest from the date of the withdrawal
to the Monthly Date; minus
o the portion of the Monthly Deduction allocated to the
Account Value in the Fixed Account, to cover the Certificate
month following the Monthly Date.
On any date other than a Monthly Date, the Account Value will be
calculated on a consistent basis.
SUB-ACCOUNT VALUES
Amounts allocated to sub-accounts are applied to provide
Accumulation Units in each sub-account. An Accumulation Unit is
used to calculate the value of a sub-account. The number of
Accumulation Units credited to each sub-account is determined by
dividing the amount allocated to a sub-account by the dollar
value of one Accumulation Unit for such sub-account. The number
of Your Accumulation Units is not affected by any subsequent
change in the value of the units. The Accumulation Unit values in
each sub-account may increase or decrease daily.
SUB-ACCOUNT ACCUMULATION UNIT VALUE
The Accumulation Unit value for each sub-account will vary to
reflect the investment experience of the applicable sub-account
and will be determined on each Valuation Day by multiplying the
Accumulation Unit value of the particular sub-account on the
preceding Valuation Day by a net investment factor for that
sub-account for the Valuation Period then ended. The net
investment factor for each sub-account is equal to the net asset
value per share of the corresponding investment at the end of the
Valuation Period (plus the per share amount of any dividend or
capital gain distributions paid by that investment in the
Valuation Period then ended) divided by the net asset value per
share of the corresponding investment at the beginning of the
Valuation Period, less the Separate Account Expense Charge.
While We are not currently making a provision for current taxes,
any new taxes or increase in taxes attributable to the operations
of the Separate Account, We reserve the right to deduct such a
charge from the Accumulation Unit value.
SUB-ACCOUNT ACCUMULATION VALUE
Your accumulation value in any sub-account equals:
o the number of Your Accumulation Units in that sub-account on
the Valuation Day;
o multiplied by that sub-account's Accumulation Unit value on
the Valuation Day.
7
EMERGENCY PROCEDURE
With the exception of weekends or holidays, if a national stock
exchange is closed, or trading is restricted due to an existing
emergency as defined by the Securities and Exchange Commission
(SEC) so that We cannot value the sub-accounts, or as otherwise
ordered by the SEC, We may postpone all procedures which require
valuation of the sub-accounts until valuation is possible. Any
provision of this Certificate which specifies a Valuation Day
will be superseded by the emergency procedure.
COST OF INSURANCE
The Cost of Insurance is determined on the Monthly Date and is
computed as follows:
o Divide the Death Benefit on the first day of the Certificate
month by 1 plus the Guaranteed Monthly Equivalent Interest
Rate shown on the Interest and Charges page;
o Reduce the result by the Account Value on that day before
computing the Monthly Deduction for the Cost of Insurance;
and
o Multiply the difference by the Cost of Insurance Rate for
that month divided by 1000.
COST OF INSURANCE RATE
The Cost of Insurance Rate is the rate applied to the insurance
under this Certificate to determine the Cost of Insurance. It is
based on the Attained Age, sex and rating classification of the
Insured. The Cost of Insurance Rate will not be greater than the
guaranteed rates shown in the Table of Guaranteed Monthly Maximum
Cost of Insurance Rates (see pages 18 and 19).
MONTHLY DEDUCTION
A Monthly Deduction is made for the Cost of Insurance,
Certificate Fee, the Expense Charge on the Fixed Account and the
cost of any Additional Benefit Agreements. The Monthly Deduction
for a Certificate month will be calculated by adding:
o the Certificate Fee, if due;
o the Expense Charge on the Fixed Account;
o the Cost of Insurance for the Certificate month; and
o the cost for the Certificate month of any Additional
Benefits.
The Expense Charge on the Fixed Account will be deducted from
Your Fixed Account balance. The remainder of the Monthly
Deduction for a Certificate month will be allocated among the
Fixed Account and the sub-accounts of the Separate Account in
proportion to the Account Value in each account. When determining
these proportions, the Account Values are used net of any
Indebtedness at the beginning of the month. The Monthly Deduction
for each date that falls on a Certificate anniversary also
includes the Certificate Fee.
CERTIFICATE FEE
On each Certificate anniversary, the Certificate Fee shown on the
Interest and Charges page will be deducted from the Fixed Account
and the sub-accounts in proportion to the Account Value in each
account. The Certificate Fee is also deducted upon full surrender
of the Certificate.
FIXED ACCOUNT EXPENSE CHARGE
On each Monthly Date, an expense charge equal to the monthly
equivalent of the annual rate as shown on the Interest and
Charges page is deducted from the Fixed Account.
INTEREST RATES
The Guaranteed Interest Rate for the Fixed Account is shown on
the Interest and Charges page. Interest rates are expressed as
effective annual rates. The rate is compounded daily and is used
to calculate Account Values of the Fixed Account. We may credit
interest in excess of the Guaranteed Interest Rate. Such excess
interest will be at Our sole discretion.
8
The Account Value allocated to the Fixed Account will be
guaranteed and the rate of interest will be guaranteed for at
least the balance of the Certificate year. We determine interest
rates in accordance with market conditions and other factors. We
may change the rate guaranteed on new allocations at any time.
This may cause the guaranteed interest rate on Account Values at
the beginning of a Certificate year to differ from the guaranteed
rate on values transferred in at a later date. Once We guarantee
an interest rate for an amount in the Fixed Account, We will not
change it until the end of the current guarantee period.
Interest on Indebtedness will be credited on each Certificate
anniversary at the Guaranteed Interest Rate for the Fixed
Account, as shown on the Interest and Charges page.
BASIS OF VALUES
The method used in computing Account Values and reserves in the
Separate Account is in accordance with actuarial procedures that
recognize the variable nature of the Separate Account. A detailed
statement of the method of computing values has been filed with
the Insurance Department of the state in which the Group Contract
was issued for delivery. All Certificate values are equal to or
in excess of the minimum values required and all comply with the
laws of that state.
SEPARATE SEPARATE ACCOUNT
ACCOUNT The assets of the Separate Account will be used to provide values
PROVISIONS and benefits under this Certificate and any similar policies. The
assets of the Separate Account are owned by Us and cannot be
charged with liabilities which may arise from any other business
the Company may conduct. The assets of the Separate Account are
not part of Our general account. We may transfer to Our general
account any assets of the Separate Account which exceed the
reserves and other Certificate liabilities of the account. Unless
otherwise permitted by law, the investment policy of the Separate
Account will not be changed without the express or deemed
approval of the state where this Certificate was issued for
delivery.
INVESTMENT ALLOCATIONS
The Separate Account is divided into several sub-accounts. We use
amounts allocated to a sub-account to buy shares or units of the
investment option shown in the prospectus for that sub-account.
The Initial Payment is initially allocated to the Fixed Account.
Subsequently, the payment will be allocated as You requested in
the application. We may delay such allocation until after the
expiration of the Right to Return period stated on the front page
of Your Certificate.
SUBSTITUTION
We may substitute another underlying investment without Your
consent. Substitution would occur if We determine that the use of
such underlying investment is no longer possible or if We
determine it is no longer appropriate for the purposes of the
Certificate. No substitution will be made without notice to You
and without the prior approval of the SEC and the state where
this Certificate was issued for delivery, if required. Should a
substitution, addition or deletion occur, You will be allowed to
select from the then current sub-accounts and substitution may be
made with respect to both existing payments and the investment of
future payments.
TRANSFERS
You may transfer Account Values among the sub-accounts or from
the sub-accounts into the Fixed Account, upon request. The value
transferred from any sub-account must be at least $250 or the
entire balance, if less. The Account Value remaining in a
sub-account after any transfer must be at least $500. If the
balance remaining in a sub-account as a result of a transfer is
less than $500, we may require You to transfer the entire
balance.
Transfers may be subject to a transfer charge. This charge will
not exceed $25.
9
Transfers from the Fixed Account to the sub-accounts must occur
within 60 days after each Certificate anniversary. The largest
amount that may be transferred out in each Certificate year is
the greater of the amount transferred in the prior Certificate
year or 20% of the balance in the Fixed Account. A transfer of
all of the Account Value from the Separate Account to the Fixed
Account will not be subject to a transfer charge.
We may modify or terminate the transfer privilege at any time.
SEPARATE ACCOUNT EXPENSE CHARGE
On each Valuation Day, an expense charge equal to the daily
equivalent of the annual rate as shown on the Interest and
Charges page is deducted proportionately from the sub-accounts.
REPORTS ANNUAL REPORT
At least once each year, We will send You a report which shows:
o the current Death Benefit;
o the current Account Value;
o the current Cash Value;
o the Payments paid;
o investment gain/loss;
o any Indebtedness;
o the Cost of Insurance;
o the Expense Charge;
o the current Surrender Value; and
o any other information required by the state in which the
Group Contract was issued for delivery.
ILLUSTRATION OF BENEFITS
During any Certificate year, We will provide You with one
illustration of hypothetical future Account Values and Death
Benefits at any time upon Written Request. We may charge a
reasonable fee for any subsequent illustrations during the same
Certificate year. However, the fee will not be greater than $25.
CERTIFICATE LOANS
LOANS Your Certificate has a Loan Value which is equal to 90% of the
Cash Value (see page 6) as of the date of the loan. Loans must be
at least $250. You may borrow the Loan Value by assigning this
Certificate to Us as security for the loan. The assignment form
must be satisfactory to Us. Loans may be made at any time while
an Insured is covered under the Group Contract. We may defer the
granting of a loan for up to 6 months.
You may decide the proportions in which to allocate the
Certificate loan among the sub-accounts of the Separate Account.
If You do not specify the allocation, then the Certificate loan
will be allocated among the sub-accounts of the Separate Account
and the Fixed Account in proportion to the Account Value in each
account. The Account Value equal to the portion of the
Certificate loan allocated to a sub-account and the Fixed Account
will be transferred from that sub-account and the Fixed Account
to the Loan Account and the Account Value in that sub-account and
the Fixed Account will be reduced by the amount transferred. If
loan interest is not paid when due, an amount of Account Value
equal to the loan interest will also be transferred.
If on any Certificate anniversary, the Certificate's Indebtedness
exceeds the Account Value in the Loan Account, We will transfer
Account Value equal to the excess Indebtedness from the Fixed
Account and the sub-accounts of the Separate Account to the Loan
Account as security for the excess debt in the same manner as the
original loan.
PREFERRED LOAN
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The amount available for a Preferred Loan is the earnings of the
Certificate since its inception.
Earnings equals (A) minus (B) minus (C) minus (D) plus (E); where
(A) is the Account Value;
(B) is total payments made;
(C) is the preferred loan balance;
(D) is accrued loan interest; and
(E) is all prior partial withdrawals in excess of earnings.
LOAN INTEREST
Interest on Certificate loans equals the Guaranteed Interest Rate
For the Fixed Account, as shown on the Interest and Charges page,
plus 2%. Interest on Preferred Loans equals the Guaranteed
Interest Rate For the Fixed Account, as shown on the Interest and
Charges page. Interest will accrue daily from the date of the
loan, and is due on each Certificate anniversary. Unpaid interest
will be added to existing Indebtedness, and will accrue interest
at the same rate.
REPAYMENT
While this Certificate is in force during the Insured's lifetime,
any loan may be repaid in whole or in part. When a loan repayment
is made, the Account Value in the Loan Account will be reduced by
the loan repayment, and this amount will be allocated
proportionately among the Fixed Account and sub-accounts of the
Separate Account.
WITHDRAWAL WITHDRAWAL
You may withdraw from this Certificate its full Surrender Value
upon Written Request at any time during the lifetime of the
Insured and while an Insured is covered under the Group Contract.
Upon withdrawal of the full Surrender Value, this Certificate
will terminate.
You may also make a partial withdrawal under this Certificate.
Partial withdrawals must be at least $250. For any partial
withdrawal after the first in any Certificate year, We may charge
a transaction fee of the lesser of $25 or 2% of the amount of the
partial withdrawal. You may select the sub-accounts from which to
deduct the amount of the partial withdrawal. If You do not
indicate where the funds will be deducted from, the amount of the
partial withdrawal will be deducted on a pro rata basis from the
sub-accounts and the Fixed Account. The Initial Death Benefit is
reduced on the date of the partial withdrawal in the same
proportion that the Account Value was reduced. If a partial
withdrawal less any applicable Withdrawal Charge, as described
below, reduces the Account Value to below Our current minimum,
then the withdrawal request will be treated as a request to
withdraw the full Surrender Value.
We may defer the payment of Your withdrawal from the Fixed
Account for up to 6 months.
WITHDRAWAL CHARGE
Unless waived by Us, a Withdrawal Charge will be deducted from
the Account Value in the event of a withdrawal.
For a full withdrawal, the Withdrawal Charge is calculated by
multiplying (B) by (C) and subtracting the product from (A),
where:
(A) is the Initial Payment multiplied by the applicable
percentage rate from the Table of Withdrawal Charges;
(B) is each previous withdrawal charge collected; and
(C) is the Withdrawal Charge percentage in effect at the time of
a full withdrawal divided by the Withdrawal Charge
percentage at the time each withdrawal was made.
For a partial withdrawal, the Withdrawal Charge is calculated by
multiplying the applicable percentage rate from the Table of
Withdrawal Charges by the amount of the partial withdrawal. The
total of the Withdrawal Charges in a Certificate year may not be
greater than the applicable percentage rate from the Table of
Withdrawal Charges multiplied by the portion of the Initial
11
Payment not previously withdrawn as of the beginning of the
Certificate year.
WAIVER OF WITHDRAWAL CHARGE
We will waive the Withdrawal Charge on that portion of a
withdrawal not exceeding the greater of:
o 10% of the Account Value less any prior partial withdrawals
and Preferred Loans taken during the Certificate year; or
o the earnings of the Certificate since its inception (see
page 10).
We will also waive the Withdrawal Charge in the event of a
Qualifying Medical Stay. To qualify for this waiver:
o the Insured must have a Qualifying Medical Stay which begins
after the first Certificate year and lasts at least 45 days
during any continuous 60 day period; or
o the Insured's spouse must have a Qualifying Medical Stay
which begins after the first Certificate year and lasts at
least 45 days during any continuous 60 day period; and
o You must mail Your Written Request for this waiver, together
with proof, satisfactory to Us, of the stay, within 180 days
of initial eligibility.
If the Insured's spouse had a Qualifying Medical Stay within 45
days prior to the Certificate Date, a waiver of the Withdrawal
Charge will not be considered for the Insured's spouse, until the
later of:
o 6 months from the date of the last Qualifying Medical Stay;
or
o the first Certificate anniversary.
Qualifying Medical Stay means: 1) confinement in a Qualifying
Institution; and 2) treatment by a Qualifying Medical
Professional.
Qualifying Institution means a licensed hospital or licensed
skilled or intermediate care nursing facility at which: 1)
medical treatment is available on a daily basis; and 2) daily
medical records are kept on each patient. It does not include: 1)
a facility whose purpose is to provide accommodations, board or
personal care services to individuals who do not need medical or
nursing care; or 2) a place mainly for rest.
A Qualifying Medical Professional is a legally qualified
practitioner of the healing arts who is: 1) acting within the
scope of his or her license; 2) not a resident of Your household;
and 3) not a member of Your immediate family (children,
grandchildren, parents, grandparents, siblings and their
spouses).
Treatment means the rendering of medical care or advice related
to a specific medical condition. Treatment includes diagnosis and
subsequent care. It does not include routine monitoring unless
medically necessary.
ACCELERATED THE RECEIPT OF AN ACCELERATED DEATH BENEFIT MAY BE TAXABLE. YOU
DEATH SHOULD CONSULT YOUR PERSONAL TAX OR LEGAL ADVISOR BEFORE APPLYING
BENEFIT FOR THIS BENEFIT.
PROVISIONS
THE DEATH BENEFIT, ACCOUNT VALUE AND LOAN VALUE WILL BE REDUCED
IF AN ACCELERATED DEATH BENEFIT IS PAID.
ACCELERATED DEATH BENEFIT
If, while this Certificate is in force, We receive proof,
satisfactory to Us, that the Insured either:
(1) has a Terminal Condition; or
(2) is Chronically Ill;
We will pay a portion of the Certificate's Death Benefit to You
as an Accelerated Death Benefit.
12
The balance of the Death Benefit is payable upon the Insured's
Death. Only one Accelerated Death Benefit payment is payable
under this Certificate.
DEFINITION OF TERMINAL CONDITION
Terminal Condition means a medical condition which is expected to
result in the Insured's death within 24 months from the date of
the medical certification submitted to Us in connection with the
application for the Accelerated Death Benefit and from which
there is no reasonable prospect of recovery. Such Terminal
Condition must be certified by a physician who meets the
definition of a physician under Section 101(g) of the Internal
Revenue Code.
DEFINITION OF CHRONICALLY ILL
Chronically Ill means any Insured who has been certified by a
licensed health care practitioner within the last 12 months as:
(1) being unable to perform, without substantial assistance from
another individual, at least two activities of daily living
for a period of at least 90 days due to a loss of functional
capacity; or
(2) requiring substantial supervision to protect such individual
from threats to health and safety due to severe cognitive
impairment.
Such licensed health care practitioner must meet the definition
of a licensed health care practitioner under Section 7702B(c) of
the Internal Revenue Code.
ACTIVITIES OF DAILY LIVING
The activities of daily living prescribed in item (1) above are:
o eating
o toileting
o transferring
o bathing
o dressing
o continence
AMOUNT OF ACCELERATED DEATH BENEFIT
We first calculate the Benefit Base, which equals the Death
Benefit as defined in the DEATH BENEFIT section of the
Certificate (before subtracting any Indebtedness).
We then calculate the Maximum Available Accelerated Death Benefit
by multiplying the Benefit Base by 90%.
You may elect all or a portion of this Maximum Available
Accelerated Death Benefit. However, the amount elected may not be
less than $10,000, nor greater than $250,000. Additionally, the
Initial Death Benefit for the Certificate remaining in force must
be no less than $10,000.
You will receive less than the amount You elect because We:
(1) discount the amount You receive because it is an early
payment;
(2) deduct a processing fee, not to exceed $100; and
(3) repay and reduce any Indebtedness by the percentage of Death
Benefit accelerated.
In discounting the amount You elect, We will assume that the
Death Benefit would have been paid 24 months after the date the
Accelerated Death Benefit is paid. The discount rate will equal
the greater of:
(1) the current yield on 90 day treasury bills; or
(2) the current maximum statutory adjustable Certificate loan
interest rate based on the greater of:
(a) Moody's Corporate Bond Yield Averages-Monthly Average
Corporates-published by Xxxxx'x Investors Services, Inc., or
any successor thereto for the calendar month ending two
months before the date of application for an accelerated
payment; and (b) the Certificate's Guaranteed Annual
Interest Rate for the Fixed Account rate plus 1%.
13
No Withdrawal Charge will apply when You receive an Accelerated
Death Benefit.
TERMINAL CONDITION OPTION
This option provides that the Accelerated Death Benefit will be
paid to You in equal monthly installments for 12 months. For each
$1,000 of Accelerated Death Benefit, each payment will be at
least $84.65. This assumes an annual interest rate of 3.5%.
If the Insured dies before all the payments have been made, We
will pay the Beneficiary in one sum. The one sum payment will be
the present value of the payments that remain. We will compute
the value based on the interest rate We used to determine those
payments.
If You do not want monthly payments, We will pay You the
Accelerated Death Benefit in one sum, upon Written Request. Such
payment will be calculated described in the Amount of Accelerated
Death Benefit provision.
CHRONICALLY ILL PAYMENT OPTION
This option provides level monthly payments for the number of
years shown in the table that follows. For each $1,000 of
Accelerated Death Benefit, each payment will be at least the
minimum amount shown in the table. The table uses an annual
interest rate of 3.5%; We may use a higher rate.
ATTAINED PAYMENT MINIMUM MONTHLY
AGE OF PERIOD IN PAYMENT FOR EACH
INSURED YEARS $1,000 OF DISCOUNTED BENEFIT
64 and under 10 $9.83
65-67 8 $11.90
68-70 7 $13.38
71-73 6 $15.35
74-77 5 $18.12
78-81 4 $22.27
82-86 3 $29.19
87 and over 2 $43.05
If the Insured dies before all the payments have been made, We
will pay the beneficiary in one sum. The one sum We pay will be
the present value of the payments that remain. We will compute
the value based on the interest rate We used to determine those
payments.
If We agree, You may choose a longer payment period than that
shown in the table; if You do, monthly payments will be reduced
so that the present value of the payments is the same. We will
use an interest rate of at least 3.5%.
We reserve the right to set a maximum monthly benefit that We
will pay under this option. If We do so, it will be at least
$5,000.
If You do not want monthly payments, We will pay You the
Accelerated Death Benefit in one sum, upon Written Request. Such
payment will be calculated as described in the Amount of
Accelerated Death Benefit provision with the exception of the
period over which the payment will be discounted. The lump sum
payment will be discounted over a period not less than the
Payment Period in Years section of this provision. If the Insured
dies before the end of the discount period, we will recalculate
the Accelerated Benefit based upon the number of years between
the end of the discount period and the date of death. The
Beneficiary will be paid the difference between this recalculated
amount and the amount that was received, minus the processing
fee.
EFFECT ON THIS CERTIFICATE
When We pay the Accelerated Death Benefit, We will calculate a
percentage which equals:
14
(1) the amount You elect to receive (before any reductions);
divided by
(2) the Benefit Base.
We will reduce by that percentage:
(1) the Initial Death Benefit;
(2) the Account Value; and
(3) any Indebtedness.
Any future Monthly Deductions, Cost of Insurance charges, or
Withdrawal Charges will be based on the reduced amount of
insurance.
Once We approve Your claim, We will send You a new Certificate
Information page with these changes. The subsequent payment of a
Death Benefit or Maturity Benefit of this Certificate will
constitute full settlement of the obligations of the Group
Contract and of this Certificate.
CONDITIONS
Your right to receive the Accelerated Death Benefit is subject to
the following conditions:
(1) We must receive evidence, satisfactory to Us, of the
Insured's eligibility for this Benefit. Evidence
satisfactory to Us, may include, but is not limited to:
o the records of the Insured's attending physician,
including a prognosis of the Insured;
o all pertinent facts concerning the Insured's health;
and
o a medical examination of the Insured conducted by a
physician chosen by Us and at Our expense. If there is
a difference of opinion as to the prognosis of the
Insured, the opinion of a licensed physician,
acceptable to both Us and the Insured, will control.
(2) You must choose the option in writing in a form that meets
Our needs.
(3) If You have assigned all or a portion of this Certificate,
You must also give Us a signed consent form from the
assignee.
(4) All beneficiaries must consent in writing to the payment of
the Accelerated Death Benefit on the date the Benefit is
requested.
(5) You must send Us the Certificate.
EXCEPTIONS
This Benefit will not be paid if:
(1) the Insured is required by a governmental agency to claim
this Benefit in order to apply for, receive, or continue a
government benefit or entitlement;
(2) the Insured is required by law to use this Benefit to meet
the claims of creditors, whether in bankruptcy or otherwise;
(3) all or part of the Certificate's Death Benefit must be paid
to the Insured's children or spouse or former spouse as part
of a divorce decree, separate maintenance or property
settlement Certificate; or
(4) the Insured is married and lives in a community property
state, unless the Insured's spouse has given Us signed
written consent.
TERMINATION TERMINATION OF AN INSURED'S COVERAGE
An Insured's coverage under the Group Contract will terminate
when one of the following events occur:
o an Insured dies;
o an Insured's coverage matures;
o the date an Insured's coverage ends without value;
o the date an Insured's coverage is surrendered for its
Surrender Value;
o the date the Group Contract terminates or is discontinued,
except as provided in the Continuation of Insureds' Coverage
After Discontinuance provision.
CONTINUATION OF INSUREDS' COVERAGE AFTER DISCONTINUANCE
If the Group Contract is discontinued, any insurance then in
effect will remain in force under this
15
Certificate, provided it is not cancelled or surrendered by the
Owner.
PAYMENT OF PAYMENT
PROCEEDS The Proceeds of this Certificate will be subject first to the
interest of an assignee, to whom payment will be made in one sum.
We will pay any remaining Proceeds to You before the Insured's
death, and to the Beneficiary after the Insured's death.
Payment to the Beneficiary will be made only if We receive proof,
satisfactory to Us, of the Insured's death. Unless otherwise
provided, payment will be made in equal shares to those
Beneficiaries entitled to receive the Proceeds.
DELAY OF PAYMENT
We will pay Surrender Values, withdrawals and Certificate loans
allocated to the Separate Account within seven days after We
receive Your Written Request. We will pay death Proceeds
allocated to the Separate Account within seven days, only after
We receive Your Written Request and receive proof, satisfactory
to Us, of the Insured's death. Payment may be delayed if:
o the New York Stock Exchange is closed on other than
customary weekend and holiday closings or trading on the New
York Stock Exchange is restricted as determined by the SEC;
or
o an emergency exists, as determined by the SEC, as a result
of which disposal of securities is not reasonably
practicable to determine the value of the sub-accounts; or
o the SEC, by order, permits postponement for the protection
of Certificate owners.
PAYMENT OF PAYMENT OF PROCEEDS OPTIONS
PROCEEDS The Proceeds may be applied under one of the following Options.
OPTIONS An Option must be selected by Written Request. You may select an
Option during the Insured's lifetime. If You have not selected an
Option before the Insured's death, the Beneficiary may choose
one. We will not permit surrenders or partial withdrawals after
payments under a proceeds option involving life contingencies
commence.
THE OPTIONS
1. Interest. We will pay interest monthly on Proceeds left on
deposit with Us. We will declare the interest rate each year. It
will never be less than 3-1/2% a year.
2. Fixed Amount. We will pay equal monthly installments, first
payment immediately, until the Proceeds and the interest have
been exhausted. Interest will be credited on unpaid balances at
the rate which We will declare each year. It will never be less
than 3-1/2%, compounded annually.
3. Fixed Period. We will pay equal monthly installments, first
payment immediately, for not more than 25 years. The minimum
amount of each installment may be determined from the OPTION 3
TABLE on page 17. This Table is based on a guaranteed interest
rate of 3-1/2%, compounded annually.
4. Life Income. We will pay equal monthly installments, first
payment immediately, for the lifetime of the payee with or
without a guaranteed period. The minimum amount of each
installment may be determined from the OPTION 4 TABLE on page 17.
This Table is based on a guaranteed interest rate of 3-1/2%,
compounded annually. The guaranteed period selected may be: (1)
10 years; (2) 15 years; or (3) 20 years.
5. Other Payment. We will pay the Proceeds in any other manner
that may be mutually agreed upon.
AVAILABILITY
No Option may be selected unless the amount to be applied is more
than $2,000 and will provide an installment payment of at least
$20. Unless We consent, these Options will not be available if
16
the payee is an assignee, administrator, executor, trustee,
association, partnership or corporation.
ADDITIONAL INTEREST
At our discretion, additional interest may be declared annually
on all Payment Options. This interest will lengthen the period
under Option 2, and increase the installment amounts under
Options 3 and 4.
17
OPTION 3 TABLE
MINIMUM MONTHLY INSTALLMENT PAYMENT PER $1,000 APPLIED
-------------------------------------------------------------------------------------------------------------------
Number Monthly Number Monthly Number Monthly Number Monthly Number Monthly
of Years Payment of Years Payment of Years Payment of Years Payment of Years Payment
-------------------------------------------------------------------------------------------------------------------
1 $84.65 6 $15.35 11 $9.09 16 $6.76 21 $5.56
-------------------------------------------------------------------------------------------------------------------
2 43.05 7 13.38 12 8.46 17 6.47 22 5.39
-------------------------------------------------------------------------------------------------------------------
3 29.19 8 11.90 13 7.94 18 6.20 23 5.24
-------------------------------------------------------------------------------------------------------------------
4 22.27 9 10.75 14 7.49 19 5.97 24 5.09
-------------------------------------------------------------------------------------------------------------------
5 18.12 10 9.83 15 7.10 20 5.75 25 4.96
-------------------------------------------------------------------------------------------------------------------
OPTION 4 TABLE
MINIMUM MONTHLY INSTALLMENT PAYMENT PER $1,000 APPLIED
-------------------------------------------------------------------------------------------------------------------
MALE FEMALE
-------------------------------------------------------------------------------------------------------------------
No Guaranteed Guaranteed Guaranteed No Guaranteed Guaranteed Guaranteed
Guaranteed Period Period Period Guaranteed Period Period Period
Age Period 10 Years 15 Years 20 Years Age Period 10 Years 15 Years 20 Years
50 $4.45 $4.41 $4.36 $4.29 50 $4.11 $4.09 $4.07 $4.04
51 4.52 4.47 4.42 4.34 51 4.16 4.15 4.12 4.09
52 4.59 4.55 4.48 4.40 52 4.22 4.20 4.18 4.14
53 4.67 4.62 4.55 4.45 53 4.29 4.27 4.24 4.19
54 4.76 4.70 4.62 4.51 54 4.36 4.33 4.30 4.24
55 4.85 4.78 4.70 4.57 55 4.43 4.40 4.36 4.30
56 4.94 4.87 4.77 4.63 56 4.50 4.47 4.42 4.36
57 5.04 4.96 4.85 4.70 57 4.58 4.54 4.49 4.42
58 5.15 5.06 4.93 4.76 58 4.67 4.62 4.57 4.48
59 5.26 5.16 5.02 5.82 59 4.76 4.71 4.64 4.55
60 5.39 5.26 5.11 4.89 60 4.85 4.80 4.72 4.61
61 5.52 5.38 5.20 4.95 61 4.95 4.89 4.81 4.68
62 5.66 5.50 5.29 5.01 62 5.06 4.99 4.89 4.75
63 5.80 5.62 5.39 5.08 63 5.18 5.10 4.98 4.82
64 5.96 5.75 5.49 5.14 64 5.30 5.21 5.08 4.89
65 6.14 5.89 5.58 5.20 65 5.43 5.32 5.18 4.96
66 6.32 6.03 5.68 5.26 66 5.57 5.45 5.28 5.03
67 6.51 6.18 5.78 5.31 67 5.72 5.58 5.38 5.10
68 6.72 6.33 5.88 5.37 68 5.89 5.72 5.49 5.17
69 6.94 6.49 5.98 5.42 69 6.06 5.86 5.60 5.23
70 7.18 6.65 6.08 5.46 70 6.25 6.01 5.71 5.30
71 7.44 6.82 6.18 5.50 71 6.45 6.18 5.82 5.36
72 7.71 6.99 6.27 5.54 72 6.67 6.34 5.93 5.41
73 7.99 7.16 6.36 5.58 73 6.91 6.52 6.04 5.46
74 8.30 7.33 6.44 5.61 74 7.17 6.70 6.15 5.51
75 8.63 7.51 6.52 5.63 75 7.45 6.89 6.26 5.55
76 8.99 7.68 6.60 5.66 76 7.75 7.08 6.36 5.59
77 9.37 7.86 6.67 5.68 77 8.08 7.28 6.45 5.62
78 9.77 8.03 6.73 5.69 78 8.43 7.48 6.54 5.65
79 10.21 8.19 6.79 5.71 79 8.81 7.68 6.62 5.67
80 10.67 8.36 6.84 5.72 80 9.22 7.88 6.70 5.69
-------------------------------------------------------------------------------------------------------------------
18
TABLE OF GUARANTEED MONTHLY MAXIMUM COST OF INSURANCE RATES
PER $1,000 OF INSURANCE NET AMOUNT AT RISK
NON-TOBACCO
Attained Monthly Cost of Attained Monthly Cost of Attained Monthly Cost of
Age Insurance Rate Age Insurance Rate Age Insurance Rate
Male Female Male Female Male Female
0 0.2193 0.1567 35 0.1442 0.1259 70 3.0703 1.8585
1 0.0859 0.0701 36 0.1517 0.1342 71 3.4033 2.0584
2 0.0826 0.0667 37 0.1617 0.1442 72 3.7600 2.3037
3 0.0809 0.0651 38 0.1726 0.1551 73 4.1934 2.5976
4 0.0776 0.0642 39 0.1843 0.1667 74 4.6701 2.9361
5 0.0734 0.6254 40 0.1984 0.1809 75 5.1801 3.3143
6 0.0692 0.0609 41 0.2134 0.1959 76 5.7192 3.7239
7 0.0651 0.0592 42 0.2293 0.2109 77 6.2835 4.1631
8 0.0626 0.0584 43 0.2468 0.2259 78 6.8762 4.6390
9 0.0617 0.0576 44 0.2660 0.2409 79 7.5161 5.1666
10 0.0626 0.0567 45 0.2876 0.2576 80 8.2238 5.7673
11 0.0676 0.0584 46 0.3110 0.2751 81 9.0181 6.4590
12 0.0767 0.0609 47 0.3360 0.2943 82 9.9157 7.2573
13 0.0892 0.0642 48 0.3635 0.3143 83 10.9129 8.1594
14 0.1034 0.0684 49 0.3935 0.3368 84 11.9904 9.1556
15 0.1134 0.0717 50 0.4277 0.3618 85 13.1242 10.2354
16 0.1234 0.0751 51 0.4669 0.3894 86 14.3000 11.3917
17 0.1309 0.0776 52 0.5120 0.4211 87 15.5000 12.6232
18 0.1359 0.0801 53 0.5637 0.4561 88 16.7191 13.9315
19 0.1392 0.0826 54 0.6213 0.4920 89 17.9749 15.3273
20 0.1401 0.0842 55 0.6855 0.5303 90 19.2858 16.8225
21 0.1384 0.0859 56 0.7556 0.5687 91 20.6825 18.4527
22 0.1359 0.0867 57 0.8299 0.6063 92 22.2180 20.2807
23 0.1326 0.0884 58 0.9125 0.6438 93 24.0437 22.4383
24 0.1292 0.0901 59 1.0052 0.6864 94 26.5035 25.2231
25 0.1251 0.0917 60 1.1088 0.7364 95 30.2074 29.2496
26 0.1226 0.0942 61 1.2240 0.7982 96 36.3581 35.7221
27 0.1209 0.0959 62 1.3569 0.8750 97 47.2118 46.8683
28 0.1201 0.0984 63 1.5073 0.9693 98 66.2071 66.0943
29 0.1201 0.1017 64 1.6745 1.0754 99 82.5000 81.6667
30 0.1209 0.1042 65 1.8577 1.1898
31 0.1234 0.1076 66 2.0559 1.3084
32 0.1267 0.1109 67 2.2685 1.4296
33 0.1317 0.1151 68 2.4996 1.5550
34 0.1376 0.1201 69 2.7560 1.6946
Class A Guaranteed Monthly Maximum Insurance Rates are equal to 250% of the
Guaranteed Maximum Insurance Rates for the Standard Class.
19
TABLE OF GUARANTEED MONTHLY MAXIMUM COST OF INSURANCE RATES
PER $1,000 OF INSURANCE NET AMOUNT AT RISK
TOBACCO
Attained Monthly Cost of Attained Monthly Cost of Attained Monthly Cost of
Age Insurance Rate Age Insurance Rate Age Insurance Rate
Male Female Male Female Male Female
0 0.2193 0.1567 35 0.2268 0.1676 70 4.7492 2.4376
1 0.0859 0.0701 36 0.2434 0.1817 71 5.1624 2.6722
2 0.0826 0.0667 37 0.2643 0.1984 72 5.6299 2.9596
3 0.0809 0.0651 38 0.2876 0.2176 73 6.1485 3.3017
4 0.0776 0.0642 39 0.3143 0.2384 74 6.7174 3.6920
5 0.0734 0.0626 40 0.3452 0.2635 75 7.3258 4.1186
6 0.0692 0.0609 41 0.3785 0.2901 76 7.9486 4.5725
7 0.0651 0.0592 42 0.4152 0.3168 77 8.5746 5.0471
8 0.0626 0.0584 43 0.4553 0.3435 78 9.2082 5.5490
9 0.0617 0.0576 44 0.4995 0.3702 79 9.8715 6.0962
10 0.0626 0.0567 45 0.5462 0.3985 80 10.5868 6.7098
11 0.0676 0.0584 46 0.5946 0.4277 81 11.3746 7.4070
12 0.0767 0.0609 47 0.6471 0.4578 82 12.2491 8.2009
13 0.0892 0.0642 48 0.7039 0.4903 83 13.1961 9.1191
14 0.1034 0.0684 49 0.7656 0.5262 84 14.1843 10.1164
15 0.1467 0.0801 50 0.8341 0.5645 85 15.1804 11.1778
16 0.1634 0.0842 51 0.9117 0.6054 86 16.1604 12.2952
17 0.1751 0.0884 52 0.9994 0.6521 87 17.1682 13.4579
18 0.1843 0.0926 53 1.0988 0.7039 88 18.2203 14.6722
19 0.1901 0.0951 54 1.2073 0.7565 89 19.2685 15.9376
20 0.1934 0.0976 55 1.3235 0.8107 90 20.3284 17.3441
21 0.1934 0.0992 56 1.4463 0.8641 91 21.4331 18.8626
22 0.1901 0.1017 57 1.5759 0.9142 92 22.7172 20.5523
23 0.1868 0.1042 58 1.7121 0.9635 93 24.3689 22.5437
24 0.1817 0.1067 59 1.8585 1.0161 94 26.6300 25.2231
25 0.1759 0.1092 60 2.0216 1.0787 95 30.2074 29.2496
26 0.1726 0.1134 61 2.2057 1.1572 96 36.3581 35.7221
27 0.1709 0.1167 62 2.4134 1.2583 97 47.2118 46.8683
28 0.1709 0.1209 63 2.6454 1.3811 98 66.2071 66.0943
29 0.1734 0.1259 64 2.8993 1.5182 99 82.5000 81.6667
30 0.1776 0.1317 65 3.1684 1.6628
31 0.1834 0.1367 66 3.4502 1.8100
32 0.1909 0.1426 67 3.7423 1.9522
33 0.2009 0.1501 68 4.0489 2.0961
34 0.2126 0.1584 69 4.3817 2.2526
Class A Guaranteed Monthly Maximum Insurance Rates are equal to 250% of the
Guaranteed Maximum Insurance Rates for the Standard Class.
20
INTEREST AND CHARGES
Interest Rates
Guaranteed Annual Interest Rate For the Fixed Account [3.50%]
Guaranteed Monthly Equivalent Interest Rate [0.28709%]
Certificate Charges
Certificate Fee [$30.00] per year
Cost of Insurance as defined on page 8.
Fixed Account Expense Charge [0.48%] per year
Separate Account Expense Charge [1.65%] per year
Withdrawal Charge on Withdrawal as defined on page 11.
Table of Withdrawal Charges
This table applies to the Initial Payment in the event of a
Withdrawal in the first [7] Certificate years.
Certificate Percentage Certificate Percentage
Year Year
[1 9.75% 5 7.25%
2 9.50% 6 5.00%
3 9.25% 7 4.75%
4 7.50% 8 and thereafter 0.00%]
Mortality Table
1980 Commissioners Standard Ordinary Age Last Birthday Smoker or Non-smoker
The Certificate may end before the Maturity Date if the payments are not
sufficient to continue the Certificate to that date. If current values change,
this will also affect the benefits.
21
[Logo]
--------------------------------------------------------------------------------
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON
A Member of the Liberty Mutual Group
--------------------------------------------------------------------------------
CERTIFICATE DESCRIPTION
This is a GROUP MODIFIED SINGLE PAYMENT VARIABLE LIFE INSURANCE CERTIFICATE.
The Death Benefit is payable if the Insured dies while this Certificate is in
force and before the Maturity Date.
A Maturity Benefit is payable if the Insured is living on the Maturity Date.
Death Benefit and Account Value may vary with investment and earnings experience
and Certificate charges.
This Certificate is not eligible for Dividends.
22
CONTRACT INFORMATION
[First] Insured [Xxxx Xxx]
Contract Number [NV-12345678]
Issue Age/Sex [65] [Male]
Contract Date [January 1, 1999]
Rating Class [Standard] [Non-Tobacco]
Additional Agreements
[none]
