EXHIBIT C(3)
Form of Group Variable Universal Life Policy (2VUL1294NY-G)
American International Life Assurance
Company of New York
00 Xxxx Xxxxxx
Xxx Xxxx, Xxx Xxxx 00000
A capital stock company
This Policy is a contract between American International Life Assurance Company
of New York ("We", "Us" or "Our") and the Policyholder ("You" or "Your") shown
on the Policy Schedule.
Subject to the terms of this Policy and the Certificates We issue to each
Certificate Owner, We will provide the benefits described in this Policy. We do
this in return for the application of the Policyholder, and the required
individual applications for life insurance coverage on the Insureds and for the
payment of the premiums.
This Policy becomes effective at 12:01 A.M. Standard Time on the Policy
Effective Date at the address of the Policyholder and will continue in force, in
accordance with the applicable provisions, unless terminated in accordance with
its provisions.
This Policy is non-participating and is not entitled to share in Our surplus
earnings.
/s/ Xxxxxxxxx X. Xxxx /s/ XX X'Xxxxxxx
Xxxxxxxxx X. Xxxx XX X'Xxxxxxx
Secretary President
GROUP FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE POLICY
Non-Participating
INDEX
Policy Sections Page
Policy Schedule 3
Table Of Guaranteed Maximum Cost Of Insurance Rates 4 & 5
Policy Provisions 6
GROUP POLICY SCHEDULE
GROUP POLICY NUMBER [00004]
GROUP POLICYHOLDER [Direct Consumer's Group Trust Dated April 8, 1996]
GROUP POLICY EFFECTIVE DATE [January 1, 1998]
ELIGIBLE PERSONS: [Customers, members or employees of participating
Financial institutions]
ANNUITY SERVICE OFFICE: [AI Life Assurance Company of New York
c/o Delaware Valley Financial Services
000 Xxxxxx Xxxx
P.O. Box 3031
Berwyn, PA 19312-0031
(000) 000-0000]
Guaranteed Monthly Cost Insurance Rates-Male
Per $1,000 of Net Amount at Risk
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Attained Monthly COI Rate Attained Monthly COI Rate
----------------------------------- ------------------------------------
Age Nonsmoker Smoker Age Nonsmoker Smoker
-----------------------------------------------------------------------------------------------------------
0 N/A 0.21921 50 0.42768 0.83403
1 N/A 0.08584 51 0.46688 0.91166
2 N/A 0.08251 52 0.51193 0.99933
3 N/A 0.08084 53 0.56365 1.09871
4 N/A 0.07751 54 0.62122 1.20729
5 N/A 0.07334 55 0.68547 1.32342
6 N/A 0.06917 56 0.75557 1.44626
7 N/A 0.06500 57 0.82985 1.57581
8 N/A 0.06250 58 0.91250 1.71209
9 N/A 0.06167 59 1.00518 1.85845
10 N/A 0.06250 60 1.10873 2.02158
11 N/A 0.06750 61 1.22400 2.20569
12 N/A 0.07667 62 1.35684 2.41331
13 N/A 0.08917 63 1.50727 2.64531
14 N/A 0.10334 64 1.67447 2.89921
15 0.11335 0.14669 65 1.85761 3.16834
16 0.12335 0.16336 66 2.05588 3.45020
17 0.13085 0.17503 67 2.26847 3.74229
18 0.13585 0.18420 68 2.49957 4.04883
19 0.13919 0.19004 69 2.75591 4.38161
20 0.14002 0.19337 70 3.04592 4.74911
21 0.13835 0.19337 71 3.37720 5.16235
22 0.13585 0.19004 72 3.75992 5.62985
23 0.13252 0.18670 73 4.19334 6.14841
24 0.12918 0.18170 74 4.67004 6.71732
25 0.12502 0.17586 75 5.18003 7.32578
26 0.12252 0.17253 76 5.71919 7.94851
27 0.12085 0.17086 77 6.28340 8.57456
28 0.12001 0.17086 78 6.87612 9.20818
29 0.12001 0.17336 79 7.51607 9.87149
30 0.12085 0.17753 80 8.22375 10.58674
31 0.12335 0.18337 81 9.01810 11.37459
32 0.12668 0.19087 82 9.91569 12.24906
33 0.13168 0.20087 83 10.91280 13.19603
34 0.13752 0.21255 84 11.99040 14.18421
35 0.14419 0.22672 85 13.12418 15.18033
36 0.15169 0.24339 86 14.29994 16.16034
37 0.16169 0.26424 87 15.49991 17.16810
38 0.17253 0.28758 88 16.71910 18.22020
39 0.18420 0.31427 89 17.97489 19.26842
40 0.19837 0.34512 90 19.28574 20.32834
41 0.21338 0.37848 91 20.68243 21.43307
42 0.22922 0.41517 92 22.21791 22.71710
43 0.24673 0.45521 93 24.04369 24.36888
44 0.26590 0.49942 94 26.50346 26.62992
45 0.28758 0.54613 95 30.20740 30.20740
46 0.31093 0.59452 96 36.35803 36.35803
47 0.33595 0.64709 97 47.21180 47.21180
48 0.36347 0.70383 98 66.20701 66.20701
49 0.39349 0.76559 99 90.90909 90.90909
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Guaranteed Monthly Cost Insurance Rates-Female
Per $1,000 of Net Amount at Risk
-----------------------------------------------------------------------------------------------------------
Attained Monthly COI Rate Attained Monthly COI Rate
----------------------------------- ------------------------------------
Age Nonsmoker Smoker Age Nonsmoker Smoker
-----------------------------------------------------------------------------------------------------------
0 N/A 0.15669 50 0.36180 0.56449
1 N/A 0.07000 51 0.38932 0.60537
2 N/A 0.06667 52 0.42101 0.65209
3 N/A 0.06500 53 0.45604 0.70383
4 N/A 0.06417 54 0.49191 0.75641
5 N/A 0.06250 55 0.53028 0.81066
6 N/A 0.06084 56 0.56866 0.86408
7 N/A 0.05917 57 0.60620 0.91417
8 N/A 0.05834 58 0.64375 0.96343
9 N/A 0.05750 59 0.68630 1.01603
10 N/A 0.05667 60 0.73638 1.07866
11 N/A 0.05834 61 0.79814 1.15717
12 N/A 0.06084 62 0.87493 1.25825
13 N/A 0.06417 63 0.96927 1.38107
14 N/A 0.06834 64 1.07532 1.51813
15 0.07167 0.08001 65 1.18975 1.66276
16 0.07501 0.08417 66 1.30838 1.80994
17 0.07751 0.08834 67 1.42954 1.95214
18 0.08001 0.09251 68 1.55491 2.09605
19 0.08251 0.09501 69 1.69453 2.25256
20 0.08417 0.09751 70 1.85845 2.43759
21 0.08584 0.09918 71 2.05839 2.67212
22 0.08667 0.10168 72 2.30363 2.95957
23 0.08834 0.10418 73 2.59756 3.30170
24 0.09001 0.10668 74 2.93610 3.69191
25 0.09168 0.10918 75 3.31428 4.11856
26 0.09418 0.11335 76 3.72382 4.57248
27 0.09584 0.11668 77 4.16309 5.04701
28 0.09834 0.12085 78 4.63892 5.54895
29 0.10168 0.12585 79 5.16656 6.09610
30 0.10418 0.13168 80 5.76724 6.70972
31 0.10751 0.13669 81 6.45895 7.40696
32 0.11085 0.14252 82 7.25729 8.20087
33 0.11501 0.15002 83 8.15937 9.11907
34 0.12001 0.15836 84 9.15556 10.11631
35 0.12585 0.16753 85 10.23537 11.17773
36 0.13418 0.18170 86 11.39164 12.29517
37 0.14419 0.19837 87 12.62319 13.45788
38 0.15502 0.21755 88 13.93142 14.67216
39 0.16669 0.23839 89 15.32721 15.93752
40 0.18087 0.26340 90 16.82248 17.34402
41 0.19587 0.29008 91 18.45266 18.86254
42 0.21088 0.31677 92 20.28063 20.55222
43 0.22588 0.34345 93 22.43826 22.54368
44 0.24089 0.37014 94 25.22305 25.22305
45 0.25757 0.39849 95 29.24956 29.24956
46 0.27508 0.42768 96 35.72205 35.72205
47 0.29425 0.45771 97 46.86829 46.86829
48 0.31427 0.49024 98 66.09429 66.09429
49 0.33678 0.52611 99 90.90909 90.90909
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POLICY PROVISIONS
Eligible Persons. Persons eligible to become insured under this Policy are those
described as Eligible Persons on the Policy Schedule.
Certificates. We will issue a Certificate to each Certificate Owner describing
each Insured's life insurance coverage under this Policy. The certificate will
describe the benefits of this Policy, to whom the benefits will be paid, and the
limitations and conditions that apply.
A certificate may be modified by rider or endorsement issued by Us to be
attached to the certificate. The rider or endorsement will set forth the
modifications to the certificate which affect the Insured.
Premiums. All premiums are payable in advance to Us. The planned premium for
each Insured is shown on that Insured's certificate Information Page.
Required Data. The Policyholder must give Us all data that We need to administer
this Policy.
Examination Of Records. We have the right to examine all records of the
Policyholder that pertain to the life insurance provided by this Policy.
Continuation Of This Policy. This Policy will continue in force, subject to the
Policy Termination provision.
Entire Contract. The entire contract ("Policy") consists of this Policy, the
certificates, the policyholder's application, each Insured's application for
life insurance coverage under this Policy, and any attached riders, endorsements
or amendments.
We rely on the Policyholder's application to issue this Policy and the
individual applications, if any, to issue certificates providing life insurance
coverage on each Insured. Statements made by the Policyholder or any Insured or
Certificate Owner are deemed to be representations and not warranties. No such
statement will be used to contest this Policy, a certificate or a claim unless a
copy of the instrument is furnished to the person making the statement or to
his/her beneficiary.
Changing This Policy. This Policy may only be changed, in writing, by one of our
executive officers. No other person, including an agent, has any authority to
change or reinstate this Policy or extend the time for paying a premium.
Conformity With State Statutes. Any provision of this Policy that, on the Policy
Effective Date, conflicts with state laws of the governing jurisdiction is
changed to meet the minimum requirements of those laws.
Policy Termination. This Policy may only be terminated with respect to the
issuance of new certificates. Either We or the Policyholder may terminate this
Policy upon giving at least 31 days written notice to the other. We will not
terminate this Policy prior to the end of the first year following the Policy
Effective Date.
Clerical Error. Clerical error will not void any certificate issued under this
Policy which is otherwise validly in force, nor will it keep in force any
certificate that otherwise would end.
Certificate Provisions Made Part Of This Policy. The remainder of this Policy
consists of provisions that appear in the certificates, riders and endorsements.
A copy of the certificates, riders and endorsements is added to and made a part
of this Policy.
American International Life Assurance Company of New York
00 Xxxx Xxxxxx
Xxx Xxxx, Xxx Xxxx 00000
GROUP FLEXIBLE PREMIUM ADJUSTABLE LIFE INSURANCE POLICY
Non-Participating
