EXHIBIT 4(a)
EMPIRE FIDELITY INVESTMENTS LIFE INSURANCE COMPANY
000 Xxxxxxx Xxxxxx, Tower A
One World Financial Center
NEW YORK, NEW YORK 10281
VARIABLE ANNUITY
Flexible Purchase Payment Annuity
with Variable and Guaranteed Accounts
Nonparticipating
Empire Fidelity Investments Life Insurance Company agrees to pay income to
the Annuitant starting on the Annuity Date and to provide the other rights
and benefits of this Contract.
These agreements are subject to all the provisions of this Contract.
This Contract has been issued in return for the attached application and
for the initial Purchase Payment made.
ALL PAYMENTS AND VALUES PROVIDED BY THIS CONTRACT, WHEN BASED ON INVESTMENT
EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO
DOLLAR AMOUNT. (SEE CONTRACT VALUE, PAGE 11.)
Signed for the Company at its Home Office, New York, New York.
\s\ Xxxxxx X. Xxxxx \s\ Xxxxx X. Xxxxxxxxx
President Secretary
RIGHT TO RETURN THE CONTRACT
To be sure you are satisfied with this Contract, you have 30 days after you
receive it from the Company to examine it. Within those 30 days you can
return the Contract for any reason. If you do, the Contract will be
canceled and the Company will pay you the Contract Value as of the date of
surrender, plus any deductions made from your Purchase Payments.
PLEASE READ YOUR CONTRACT CAREFULLY
This is a legal contract between you and the Company.
EVA-91100
GUIDE TO CONTRACT PROVISIONS
CONTRACT SCHEDULE PAGE 4
DEFINITIONS 5
GENERAL PROVISIONS 8
Entire Contract
Misstatement of Age or Sex
Reports to Owner
Proof of Survival
Protection of Proceeds
Termination
Basis of Values
Nonparticipating
Determination of Values
PURCHASE PAYMENTS 10
Purchase Payments
Net Purchase Payments
Additional Purchase Payments
Allocation of Purchase Payments
Remaining Purchase Payments
CONTRACT VALUE 11
Contract Value
Deductions from the Contract Value
THE GUARANTEED ACCOUNT 12
Guaranteed Account
Guaranteed Account Contract Value
Interest on the Guaranteed Account
Transfers of Contract Value Between the Guaranteed and Variable Accounts
THE VARIABLE ACCOUNT 13
Variable Account
Subaccounts
Accumulation Units
Accumulation Unit Value
Variable Account Contract Value
Net Investment Factor
Charges Against the Subaccounts
Transfers Among Subaccounts During Accumulation Period
Valuation Days and Valuation Periods
Additions, Deletions or Substitutions
Reserved Rights
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PROCEEDS 17
Proceeds on Surrender Prior to Annuity Date
Proceeds on Death of Owner Prior to the Annuity Date
Proceeds on Death of Last Surviving Annuitant Prior to Annuity Date
Proceeds on Death of Annuitant On or After Annuity Date
Required Distribution of Proceeds
Payment of Proceeds
Interest on Proceeds
Postponement of Payment of Proceeds
OWNER, BENEFICIARIES AND CONTINGENT ANNUITANT 20
Owner
Annuitant's Beneficiary
Owner's Beneficiary
Contingent Annuitant
Change of Owner, Annuitant and Beneficiary
Assignments
Designation of Beneficiary
SURRENDER PROVISIONS 22
Cash Surrender
Cash Surrender Value
Partial Withdrawals
Amounts Exempt from Surrender Charge
Surrender Charge
Waiver of Surrender Charge
ANNUITY PROVISIONS 24
Annuity Income Payments
Change of Annuity Date
Election of Annuity Income Option
Annuity Income Options
Fixed Annuity
Variable Annuity
Annuity Unit Value
Determination of First Variable Annuity Income Payment
Variable Annuity Income Payments After the First Payment
Exchange of Annuity Units
Adjusted Age
ANNUITY TABLES 28
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DEFINITIONS
ACCUMULATION PERIOD:
The period between the date your Contract is issued and the Annuity Date.
ACCUMULATION UNITS:
The measure used to calculate the Variable Account Contract Value during
the Accumulation Period. P
Period.
ANNUITANT:
The person on whose life Annuity Income Payments depend.
ANNUITANT'S BENEFICIARY:
The person who receives the proceeds in the event of the death of the last
surviving Annuitant.
ANNUITY DATE:
The date on which Annuity Income Payments are to begin. You may change
this date as provided in this Contract.
ANNUITY INCOME OPTION:
One of the choices offered by the Company for Annuity Income Payments. The
Annuity Income Option is elected by the Owner.
ANNUITY INCOME PAYMENTS:
Payments made to the Annuitant after the Annuity Date under an Annuity
Income Option. Annuity Income Payments may be made on a fixed dollar basis,
a variable basis, or a combination of both.
ANNUITY PERIOD:
The period starting on the Annuity Date, during which the Annuitant
receives Annuity Income Payments from the Contract.
ANNUITY UNITS:
The measure used to calculate the amount of variable Annuity Income
Payments during the Annuity Period.
THE COMPANY:
Empire Fidelity Investments Life Insurance Company.
CONTINGENT ANNUITANT:
The person who becomes the Annuitant upon the death or removal of the
Annuitant prior to the Annuity Date.
CONTRACT DATE:
The date the Contract becomes effective, from which contract anniversaries,
contract years, and contract months are determined. Your Contract Date is
shown on the Contract Schedule.
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CONTRACT VALUE:
The sum of the Guaranteed Account Contract Value and the Variable Account
Contract Value.
EXEMPT WITHDRAWAL AMOUNT:
The amount that may be withdrawn from the Contract without paying a
surrender charge.
FIXED ANNUITY:
An annuity with fixed Annuity Income Payments which are guaranteed by the
Company. The amount of the Annuity Income Payment, once begun, will not
change.
GUARANTEED ACCOUNT:
A guaranteed-rate investment option funded through the Company's general
account.
OWNER:
The person or persons who have the ownership rights and privileges of the
Contract.
OWNER'S BENEFICIARY:
The person who receives the proceeds in the event of the death of the Owner
(if no Joint Owner survives) prior to the Annuity Date.
PURCHASE PAYMENTS:
The amounts you pay for this Contract.
SUBACCOUNTS:
The divisions of the Variable Account. The Subaccounts available on the
Contract Date are named on the Contract Schedule.
VALUATION DAY:
Each day the New York Stock Exchange is open for trading and any other day
on which the Securities and Exchange Commission requires the Variable
Account to be valued.
VALUATION PERIOD:
The time between the close of business on a Valuation Day and the close of
business on the next Valuation Day.
VARIABLE ACCOUNT:
The Empire Fidelity Investments Variable Annuity Account A.
VARIABLE ANNUITY:
An annuity with Annuity Income Payments which vary in amount with the
investment experience of elected Subaccounts.
WRITTEN REQUEST:
A request in a form acceptable to the Company, signed and dated by you and
delivered to the Company at the Annuity Service Center.
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YOU, YOUR:
The Owner of this Contract. The Owner may be someone other than the
Annuitant. The Owner is shown on the application and may be changed as
provided in this Contract.
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GENERAL PROVISIONS
ENTIRE CONTRACT
This Contract and the application, a copy of which is attached, are the
entire contract between you and the Company. No change in or waiver of the
provisions of the Contract is valid unless the change or waiver is signed
by the President or Secretary of the Company.
MISSTATEMENT OF AGE OR SEX
If the Annuitant's age or sex has been misstated, payments under this
Contract will be adjusted. They will be based on what would have been
provided at the correct age and sex. Any underpayments by us will be made
up in a single sum, with interest at the rate of 6% per year compounded
yearly. Any overpayments by us will be subtracted from the future
payments, with interest at the rate of 6% per year compounded yearly.
REPORTS TO OWNER
At least once each year during the Accumulation Period, the Company will
send you a statement of the Contract Value and the Annual Report of the
Separate Account. The Company will also send you any other reports that
may be required by the state in which this Contract is delivered.
PROOF OF SURVIVAL
Where any payments under this contract depend on the Annuitant or other
recipient being alive on a given date, proof of survival may be required by
the Company prior to making the payments.
PROTECTION OF PROCEEDS
Income under this Contract can not be assigned by any beneficiary prior to
the time it is due. To the extent allowed by law, income is not subject to
the claims of creditors or to legal process.
TERMINATION
This Contract will terminate on the earliest of:
The death of any Owner prior to the Annuity Date;
The death of the last surviving Annuitant prior to the Annuity Date;
The Surrender of the Contract; and
The final payment under any Annuity Income Option.
BASIS OF VALUES
All values are at least as great as those required by the law of the state
in which this Contract is delivered. A statement of the method used to
compute the minimum values has been filed with the insurance department of
the state in which this Contract is delivered.
NONPARTICIPATING
This Contract does not share in the profits or surplus of the Company.
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DETERMINATION OF VALUES
The method of determination by the Company of the number and value of
Accumulation Units, Annuity Units and other values shall be binding upon
any Owner, Annuitant, and beneficiary.
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PURCHASE PAYMENTS
PURCHASE PAYMENTS
Purchase Payments are the amounts you pay for this Contract.
NET PURCHASE PAYMENTS
A Net Purchase Payment is a Purchase Payment less any premium tax assessed
by the jurisdiction in which this Contract is delivered. In addition, the
Company reserves the right to deduct a charge reflecting any federal income
tax attributable to premium.
ADDITIONAL PURCHASE PAYMENTS
You may make additional Purchase Payments during the Accumulation Period.
The minimum additional Purchase Payment is shown on the Contract Schedule.
The Company reserves the right to limit the amount of additional Purchase
Payments it will accept.
ALLOCATION OF PURCHASE PAYMENTS
You may allocate your Net Purchase Payments to the Guaranteed Account and
among one or more of the Subaccounts of the Variable Account. The Company
may limit amounts allocated (including transfers) to the Guaranteed
Account, but not to less than $50,000 per contract year. The Company may
also restrict allocations (including transfers) to the Guaranteed Account
for up to twelve months following a withdrawal or transfer from the
Guaranteed Account. Net Purchase Payments will be allocated to the
Guaranteed Account and to the Subaccounts as you elected on the application
unless you elect a different allocation.
REMAINING PURCHASE PAYMENTS
Remaining Purchase Payments are all Purchase Payments made less any amounts
withdrawn that were subject to a surrender charge.
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CONTRACT VALUE
CONTRACT VALUE
The Contract Value at any time is:
The Guaranteed Account Contract Value PLUS The Variable Account
Contract Value.
The portion of the Contract Value invested in the Subaccounts of the
Variable Account is not guaranteed and will vary with the performance of
the elected Subaccounts.
DEDUCTIONS FROM THE CONTRACT VALUE
The Maintenance Charge is deducted from the Contract Value on each Contract
anniversary during the Accumulation period. A pro rata portion of the
charge will be deducted from the Contract Value when the Contract is
surrendered. The Maintenance Charge is not guaranteed and may be changed
by the Company. The Maintenance Charge as of the Contract Date and the
maximum Maintenance Charge are shown on the Contract Schedule.
Deductions for the Maintenance Charge will be taken from the Guaranteed
Account and from the Subaccounts of the Variable Account in the same
proportion as the value in each bears to the Contract Value on the date of
the deduction.
EVA-91100 -11-
THE GUARANTEED ACCOUNT
GUARANTEED ACCOUNT
The Guaranteed Account is part of the Company's general account. The
general account consists of all of our assets other than those in any
separate account.
GUARANTEED ACCOUNT CONTRACT VALUE
The Guaranteed Account Contract Value at any time will be:
The sum of all amounts credited to the Guaranteed Account for this
Contract;
LESS
Any amounts deducted for charges, transfers or withdrawals.
INTEREST ON THE GUARANTEED ACCOUNT
The Company will credit interest on the Guaranteed Account Contract Value.
Interest will accrue from the date a Purchase Payment is received in good
order at the Annuity Service Center or an amount is transferred into the
Guaranteed Account. Different interest rates may apply to different amounts
in the Guaranteed Account depending on when the amount came into the
Guaranteed Account. The interest rate applicable to any particular amount
may vary from time to time. However, the interest rate will never be less
than the Minimum Guaranteed Account Interest Rate shown on the Contract
Schedule.
TRANSFERS OF CONTRACT VALUES BETWEEN THE GUARANTEED AND VARIABLE ACCOUNTS
During the Accumulation Period and subject to the rules of the Company, you
may transfer values:
Held in one or more of the Subaccounts of the Variable Account into the
Guaranteed Account; and
Held in the Guaranteed Account into one or more of the Subaccounts of the
Variable Account.
The Company may limit transfers from the Guaranteed Account to one per
Contract year. The Company may also limit the amount of the transfer, but
the yearly limit will never be less than 15% of the Guaranteed Account
Contract Value at the time of the transfer.
Generally, a different set of rules will apply to the transfer of Contract
Value from the Guaranteed Account than from the Variable Account. Since
transfer rules reflect economic conditions, there could be substantial
changes to these rules.
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THE VARIABLE ACCOUNT
VARIABLE ACCOUNT
The Company established the Empire Fidelity Investments Variable Annuity
Account A to support the operation of this Contract. It may also be used
with other variable annuity contracts we may offer.
The Company owns the assets in the Variable Account. Xxxxxx, gains and
losses, whether or not realized, from assets allocated to the Variable
Account will be credited to or charged against the Account without regard
to our other income, gains or losses.
Assets equal to the reserves and other liabilities of the Variable Account
will not be charged with liabilities that arise from any other business the
Company conducts. The Company has the right to transfer to our general
account any assets of the Variable Account which are in excess of those
reserves and liabilities.
All transactions (e.g., additional payments, withdrawals, and transfers)
are executed as of the date the request is received in good order at the
Annuity Service Center. All values that depend on the performance of a
Subaccount will be determined as of the end of the Valuation Period in
which the transaction is executed.
When you request a transfer from a Subaccount which invests in an
investment portfolio which is permitted, under Federal Securities
regulation, to delay the payment of proceeds to the Subaccount, then the
crediting of the amount transferred may be delayed until the subaccount
receives the proceeds from the investment portfolio. During this period,
the amount transferred will be uninvested.
The Variable Account is registered with the Securities and Exchange
Commission under the Investment Company Act of 1940. The Variable Account
is also subject to the laws of the State of New York.
SUBACCOUNTS
On the Contract Date, the Variable Account consists of the Subaccounts
listed on the Contract Schedule. The Company reserves the right to delete
any Subaccount of the Variable Account or to add new Subaccounts. The
Variable Account may invest in a series type of mutual fund, unit
investment trusts and other investment portfolios which the Company
determines to be suitable for this Contract. The assets of the Variable
Account are valued each Valuation Period.
You will share the income, gains and losses only of the Subaccounts in
which the Contract Value for this Contract has been allocated. The values
and benefits of this Contract depend on the investment performance of the
elected Subaccounts. The Company does not guarantee the investment
performance of the Subaccounts. You bear the full investment risk for
amounts applied to the elected Subaccounts.
The investment policies of a Subaccount may not be changed without all
necessary approvals of the New York State Insurance Department.
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ACCUMULATION UNITS
The portion of your Contract Value in the Variable Account is measured by
Accumulation Units. The Company will credit Net Purchase Payments in the
form of Accumulation Units. The number of Accumulation Units to be
credited to each Subaccount will be determined by dividing the Net Purchase
Payment allocated to that Subaccount by the Accumulation Unit Value of the
Subaccount. In the case of the initial Net Purchase Payment, we will
credit Accumulation Units on the Contract Date.
The amount of any partial withdrawal or charge deducted from the Variable
Account Contract Value will reduce the number of Accumulation Units
credited to the Contract in the Subaccounts. A transfer out of a Subaccount
will reduce the number of Accumulation Units credited to the Contract in
that Subaccount while a transfer into a Subaccount will increase the number
of Accumulation Units.
ACCUMULATION UNIT VALUE
The Accumulation Unit Value for each Valuation Period is the Net Investment
Factor for that period multiplied by the Accumulation Unit Value for the
immediately preceding Valuation Period. The Accumulation Unit Value for a
Valuation Period applies to each day in the period. The Accumulation Unit
Value may increase or decrease from one Valuation Period to the next.
VARIABLE ACCOUNT CONTRACT VALUE
The Variable Account Contract Value at any time will be the sum of the
values of all Accumulation Units credited to the Contract.
NET INVESTMENT FACTOR
The Net Investment Factor is an index used to measure the investment
performance of a Subaccount from one Valuation Period to the next. The Net
Investment Factor can be greater or less than one; therefore, the value of
a Subaccount Accumulation Unit may increase or decrease.
The Net Investment Factor for each Subaccount for a Valuation Period is
determined by adding (a) and (b), subtracting (c) and then dividing the
result by (a) where:
(A) is the value of the assets at the end of the preceding Valuation
Period;
(B) is the investment income and capital gains, realized or unrealized,
credited at the end of the current Valuation Period;
(C) is the sum of:
(1) the capital losses, realized or unrealized, charged during the current
Valuation Period plus any amount charged or set aside for taxes during the
current Valuation Period;
PLUS
(2) the deduction from the Subaccount during the current Valuation Period
representing a daily charge equivalent to an annual rate of 1%.
EVA-91100 -14-
CHARGES AGAINST THE SUBACCOUNTS
In determining the values for both the Accumulation and Annuity Units, the
Company makes a daily charge equivalent to an effective annual rate of 1%
against the assets of each Subaccount.
The earnings of the Variable Account are taxed as part of the operations of
the Company. At the present time, the Company does not expect to incur
taxes on the earnings of any Subaccount to the extent that earnings are
credited under the Contract. If the Company incurs taxes due to the
operation of the Variable Account, it may make charges for such taxes
against the Subaccounts.
As of the Contract Date, the Variable Account was operated as a unit
investment trust and investment and management expenses are reflected in
the value of the assets of the Subaccounts. However, if the Variable
Account is ever operated other than as a unit investment trust, investment
and management expenses may be deducted from the Variable Account.
TRANSFERS AMONG SUBACCOUNTS DURING ACCUMULATION PERIOD
You may transfer amounts among the Subaccounts by Written Request. The
minimum dollar amount you may transfer is $250 per Subaccount or, if less,
the entire amount in a Subaccount. The Company reserves the right to limit
transfers among Subaccounts, but not to fewer than six transfers per
contract year. The Company reserves the right to charge no more than
$15.00 for each transfer in excess of six per contract year.
VALUATION DAYS AND VALUATION PERIODS
A Valuation Day is:
(A) Each day the New York Stock Exchange is open for trading: and
(B) Any other day on which the Securities and Exchange Commission requires
the Variable Account to be valued.
A Valuation Period is the interval of time beginning at the close of
business on each Valuation Day and ending at the close of business on the
next Valuation Day.
ADDITIONS, DELETIONS OR SUBSTITUTIONS
The Company reserves the right to make additions to, deletions from or
substitutions for any of the investment portfolios in which the Subaccounts
invest. Such an addition, deletion or substitution would be subject to all
necessary approvals required by Federal or state law.
RESERVED RIGHTS
The Company reserves the right to:
(A) Combine the Variable Account with other variable accounts.
(B) Deregister the Variable Account under the Investment Company Act of
1940 if registration is no longer required.
EVA-91100 -15-
(C) Operate the Variable Account as a management investment company under
the Investment Company Act of 1940 or in any other form allowed by law.
(D) Make changes required by any change in the Investment Company Act of
1940 or other applicable federal or state law.
EVA-91100 -16-
PROCEEDS
PROCEEDS ON SURRENDER PRIOR TO ANNUITY DATE
If you surrender this Contract prior to the Annuity Date, the proceeds will
be the Cash Surrender Value.
PROCEEDS ON DEATH OF OWNER PRIOR TO ANNUITY DATE
If any Owner dies before the Annuity Date, the proceeds are the Contract
Value on the date proof of death is received by the Company. The proceeds
are payable to the Joint Owner, if living on the date proof of death is
received; otherwise, to the Owner's Beneficiary. If no Owner's Beneficiary
is living on the date proof of death is received, the proceeds will be paid
to the estate of the Owner.
PROCEEDS ON DEATH OF LAST SURVIVING ANNUITANT PRIOR TO ANNUITY DATE
If the last surviving Annuitant dies prior to the Annuity Date, the
proceeds will be the Death Benefit. The Death Benefit is payable to the
Annuitant's Beneficiary, if living on the date proof of death is received;
otherwise, the Death Benefit will be paid to the Owner.
If the death of the last surviving Annuitant occurs prior to the Annuity
Date and on or before his or her 70th birthday, the Death Benefit will be
the greater of:
(A) the Purchase Payments paid, adjusted for any partial withdrawals and
any applicable taxes; and
(B) the Contract Value on the date that proof of death is received by the
Company.
If the death of the last surviving Annuitant occurs prior to the Annuity
Date and after his or her 70th birthday, the Death Benefit will be the
Contract Value on the date that proof of death is received by the Company.
PROCEEDS ON DEATH OF ANNUITANT ON OR AFTER ANNUITY DATE
If the Annuitant dies on or after the Annuity Date, the proceeds will be
any remaining Annuity Income Payments due under the Annuity Income Option
selected.
REQUIRED DISTRIBUTION OF PROCEEDS
To the extent this Contract conflicts with any applicable provision of the
Internal Revenue Code with respect to distributions on death, this Contract
shall be considered amended to conform to the Code.
The proceeds must be distributed within five years after the date of death
of any Owner (including any Joint Owner) prior to the Annuity Date unless:
(A) The proceeds are payable over the lifetime (or over a period not
extending beyond the life expectancy) of the recipient of the proceeds with
distributions beginning within one year of the date of death; or
EVA-91100 -17-
(B) Your spouse is the recipient of the proceeds, in which case your spouse
may elect to continue this Contract and become the Owner.
For purposes of the distribution rules, if the Owner of the Contract is a
corporation or other non-individual, the Annuitant shall be treated as the
Owner of the Contract.
If the Owner dies on or after the Annuity Date, any proceeds must be
distributed as rapidly as under the Annuity Income Option being used as of
the date of death.
PAYMENT OF PROCEEDS
If at the time of death of any Owner prior to the Annuity Date, that Owner
is also the last surviving Annuitant, proceeds will be paid as if the last
surviving Annuitant had died.
Before payment of any proceeds, the Company will determine what proof is
needed as to:
(A) The time of death of any Owner or Annuitant; and
(B) The identity, age or other facts about any person designated to receive
the proceeds.
The payment of proceeds on the basis of such proof shall satisfy all
liability of the Company for the payment of proceeds under this Contract.
Proceeds will be paid as a single sum unless applied to an Annuity Income
Option. It is currently the Company's practice to deduct any applicable
tax at the time proceeds become payable; however, the Company reserves the
right to deduct the tax when due. The Company may require that you return
this Contract before the proceeds are paid. Any proceeds will be paid in
accordance with the applicable law governing such payments.
INTEREST ON PROCEEDS
If the proceeds are not paid within 10 days after they become payable, we
will pay interest on the unpaid proceeds. Interest will accrue from the
date the proceeds are payable to the date of payment at a rate of 3.5% per
year compounded annually or, if greater, at the rate required by law.
POSTPONEMENT OF PAYMENT OF PROCEEDS
The Company will usually pay proceeds payable on surrender or partial
withdrawal within seven days after it receives your Written Request. The
Company will usually pay proceeds payable as a result of the death of any
Owner or the last surviving Annuitant within seven days after it receives
proof of death. However, any payment involving a determination of the
Variable Account Contract Value may be postponed whenever:
(A) The New York Stock Exchange is closed other than customary weekend and
holiday closings, or trading is restricted as determined by the Securities
and Exchange Commission; or
(B) The Securities and Exchange Commission by order permits postponement
for the protection of contract owners; or
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(C) A state of emergency exists, as determined by the Securities and
Exchange Commission, which would make valuation of the net assets of the
Variable Account impracticable.
The Company can postpone the date of any surrender or partial withdrawal
payment from the Guaranteed Account for not more than six months. If
payment is postponed for more than 10 days, it will be credited with
interest from the date of surrender or partial withdrawal. The rate of
interest will not be less than 3.5% per year or, if greater, the rate
required by law.
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OWNER, BENEFICIARIES AND CONTINGENT ANNUITANT
OWNER
The Owner of the Contract is named on the application unless later changed.
The new Owner will succeed to all rights of ownership, including the right
to make a further change of owner. Joint Owners own the Contract as joint
tenants. On the Annuity Date the Annuitant becomes the Owner and all
rights of ownership pass to the Annuitant.
ANNUITANT'S BENEFICIARY
The Annuitant's Beneficiary is named on the application unless later
changed. The Death Benefit will be paid to the Annuitant's Beneficiary
upon the the death of the last surviving Annuitant prior to the Annuity
Date. If no Annuitant's Beneficiary survives, the Death Benefit will be
paid to the Owner or to the Owner's estate.
OWNER'S BENEFICIARY
The Owner's Beneficiary is named on the application unless later changed.
The Contract Value will be paid to the Joint Owner, if any, otherwise to
the Owner's Beneficiary upon the death of any Owner prior to the Annuity
Date. If no Owner's Beneficiary survives, the Contract Value will be paid
to the Owner's estate.
If at the time of death of any Owner prior to the Annuity Date, that Owner
is also the last surviving Annuitant, proceeds will be paid to the
Annuitant's Beneficiary.
CONTINGENT ANNUITANT
Once prior to the Annuity Date, the Owner may name a Contingent Annuitant.
If a Contingent Annuitant has been named, the Owner may remove either the
Annuitant or Contingent Annuitant. If the Contingent Annuitant dies or is
removed, another Contingent Annuitant can not be named. Upon the death (if
the Annuitant is not an Owner) or removal of the Annuitant prior to the
Annuity Date, the Contingent Annuitant, if any, becomes the Annuitant. When
a Contingent Annuitant becomes the Annuitant, the Company will change the
Annuity Date to the later of the first day of the month immediately
following the latest of three following dates: (a) the Annuitant's 85th
birthday, (b) the fifth contract anniversary, and (c) the date the
Contingent Annuitant becomes the Annuitant.
The Contingent Annuitant feature will not be applicable if the Contract is
owned by a corporation or other non-natural person.
CHANGE OF OWNER, ANNUITANT AND BENEFICIARY
You may change any Owner, Annuitant or beneficiary by a Written Request.
The change will be subject to all payments made and actions taken by the
Company under the Contract before the Written Request is received by the
Company.
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ASSIGNMENTS
An absolute assignment of the Contract by the Owner is a change of owner
and beneficiary to the assignee. A collateral assignment of the Contract
by the Owner is not a change of owner or beneficiary; but their rights will
be subject to the terms of the assignment. Assignments will be subject to
all payments made and actions taken by the Company before a signed copy of
the assignment form is received by the Company at the Annuity Service
Center. The Company will not be responsible for determining whether or not
an assignment is valid.
DESIGNATION OF BENEFICIARY
A numbered sequence can be used to name contingent beneficiaries. Multiple
beneficiaries will receive equal shares unless otherwise stated. In naming
beneficiaries, unless otherwise stated:
"Child" includes an adopted or posthumous child;
"Provision for issue" means that if a beneficiary does not survive the
Owner or Annuitant, the share of that beneficiary will be taken by his or
her living issue by right of representation; and
A family relation such as "wife", "husband", or "child" means the
relationship to the:
Owner, for an Owner's Beneficiary; and
Xxxxxxxxx, for an Annuitant's Beneficiary.
At the time for payment of any proceeds, the Company can rely on an
affidavit of any Owner or other responsible person to determine family
relations or members of a class.
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SURRENDER PROVISIONS
CASH SURRENDER
You may surrender this Contract for the Cash Surrender Value at any time
prior to the Annuity Date by Written Request. The Cash Surrender Value
will be paid in a single sum unless applied to an Annuity Income Option.
CASH SURRENDER VALUE
The Cash Surrender Value is the Contract Value on the date the Company
receives your request for surrender, less any surrender charge, less any
pro-rata Maintenance Charge and less any applicable charges for taxes.
PARTIAL WITHDRAWALS
You may withdraw part of the Cash Surrender Value at any time during the
Accumulation Period by Written Request. The request for a partial
withdrawal will be effective as of the date the Written Request is received
by the Company. The partial withdrawal may not be less than $500.
On the date of withdrawal, the amount withdrawn plus any surrender charge
will be subtracted from the Death Benefit and the Contract Value.
The Company will deduct the amount withdrawn plus any surrender charge from
the Variable Account. If the total amount exceeds your Variable Account
Contract Value, the excess will be deducted from the Guaranteed Account.
Unless you request otherwise, the amount deducted from the Variable Account
will be allocated to the Subaccounts of the Variable Account in the same
proportion as the value in each bears to the Variable Account Contract
Value on the date of the partial withdrawal.
The maximum withdrawal allowed will be an amount that, along with the
appropriate surrender charges, will not reduce the Contract Value to less
than $2,500.
AMOUNTS EXEMPT FROM SURRENDER CHARGE
During each of the first five contract years, you may withdraw up to the
Exempt Withdrawal Amount without incurring a surrender charge. The Exempt
Withdrawal Amount equals:
(A) 10% of Remaining Purchase Payments;
LESS
(B) Any amounts previously withdrawn during the contract year that were not
subject to a surrender charge.
SURRENDER CHARGE
After the fifth contract year there will never be a surrender charge. In
each of the first five contract years, a surrender or partial withdrawal in
excess of the Exempt Withdrawal Amount will incur a surrender charge. The
amount of the surrender charge deducted from the Contract Value will equal:
EVA-91100 -22-
(A) The applicable surrender charge percentage:
MULTIPLIED BY
(B) The lesser of the:
(1) Amount surrendered or withdrawn in excess of the Exempt Withdrawal
Amount;
and
(2) Remaining Purchase Payments.
The surrender charge percentages are shown in the Table of Surrender Charge
Percentages on the Contract Schedule.
There will be no surrender charge on the Annuity Date when the Contract
Value is applied to an Annuity Income Option.
WAIVER OF SURRENDER CHARGE
The Company will notify you of the occurrence of any of the following
events:
(A) The renewal interest rate on any portion of the Contract Value
allocated to the Guaranteed Account decreases by more than 1% from the
expiring interest rate.
(B) The Maintenance Charge is increased above the amount stated in the
Contract Schedule.
(C) The Company, as a result of a change in practice, imposes the
Maintenance Charge if that charge had been waived for this Contract.
The Company will allow you to surrender this Contract without imposition of
the surrender charge for thirty days after notification is mailed to the
Owner.
EVA-91100 -23-
ANNUITY PROVISIONS
ANNUITY INCOME PAYMENTS
On the Annuity Date the Contract Value, less any applicable taxes, will be
applied to make Annuity Income Payments. All Annuity Income Payments will
be determined as of the first business day of a month. The first payment
will be determined as of the Annuity Date. This date is shown on the
Contract Schedule unless later changed. Before payments begin we may
require proof of the Annuitant's age and sex. We may offer Annuity Income
Options other than those described in this contract. If you select one of
these options, we may require that you exchange this Contract for a
supplemental contract.
Annuity Income Payments under the Annuity Income Options will be based on
the sex and adjusted age of the Annuitant on the Annuity Date. The Annuity
Income Payment will be the greater of:
(A) The payment based on the rates shown in the Annuity Table for the
Annuity Income Option chosen; and
(B) The payment based on the annuity rates in effect on the Annuity Date
for the same class of annuitants with the same Annuity Income Option.
In lieu of providing Annuity Income Payments, the company may make a single
sum payment of the Contract Value if the Contract Value would provide less
than $20.00 of monthly income.
CHANGE OF ANNUITY DATE
You may change the Annuity Date shown for this Contract by Written Request.
The Annuity Date must be the first day of a month. Any change must be
received by the Company at least 30 days prior to the Annuity Date being
changed. However, the Annuity Date may not be later than the first day of
the month immediately following the Annuitant's 85th birthday or, if later,
the fifth contract anniversary. The new date you select must be at least
30 days after the Company receives your Written Request.
ELECTION OF ANNUITY INCOME OPTION
By Written Request to the Company at least 30 days before the Annuity Date,
you may elect an Annuity Income Option and whether Annuity Income Payments
are to be paid on a fixed dollar basis, a variable basis, or a combination
of both. The Annuity Income Option may not be changed during the Annuity
Period.
The Company may require that Annuity Income Payments be made on a fixed
dollar basis if the amount to be applied to a variable basis would provide
an initial monthly income of less than $50.00.
EVA-91100 -24-
If the Company has not received your Written Request at least 30 days
before the Annuity Date:
(A) Annuity Income Payments will be made according to Option 3 with Annuity
Income Payments guaranteed for ten years.
(B) The Guaranteed Account Contract Value less any applicable taxes will be
applied to purchase a Fixed Annuity, and the Variable Account Contract
Value less any applicable taxes will be applied to purchase a Variable
Annuity.
ANNUITY INCOME OPTIONS
Subject to the terms of this Contract, Annuity Income Payments may be made
on a fixed dollar basis, a variable basis, or a combination of both. You
may choose Annuity Income Payments according to one of the options below or
another option agreed to by the Company.
OPTION 1: LIFE ANNUITY
Annuity Income Payments will be made during the lifetime of the Annuitant.
No income will be paid after the Annuitant dies.
OPTION 2: JOINT AND SURVIVOR ANNUITY
Annuity Income Payments will be made during the lifetime of the Annuitant
and a designated second person.
OPTION 3: ANNUITY FOR A GUARANTEED PERIOD AND LIFE THEREAFTER
Annuity Income Payments will be made for a guaranteed period as elected.
If the Annuitant lives beyond the guaranteed period, the Annuity Income
Payments will continue until the Annuitant's death.
If the Annuitant dies before the end of the guaranteed period, Annuity
Income Payments will be continued to the Annuitant's Beneficiary until the
end of the guaranteed period. If no Annuitant's Beneficiary is living on
the date proof of death is received, any remaining unpaid guaranteed
Annuity Income Payments will be paid to the Annuitant's estate.
The Annuitant's Beneficiary may elect to have the remaining unpaid
guaranteed Annuity Income Payments paid in a single sum. If the Annuitant's
Beneficiary dies before the remaining guaranteed Annuity Income Payments
have been paid, the remaining unpaid guaranteed Annuity Income Payments
will be paid in a single sum to the estate of the Annuitant's Beneficiary.
The remaining guaranteed Annuity Income Payments will be discounted to
reflect the interest rate used to determine the payments.
EVA-91100 -25-
FIXED ANNUITY
A Fixed Annuity is an annuity with income that is guaranteed by the Company
as to dollar amount. The income is determined by applying the portion of
the Contract Value (less any applicable taxes) that you allocate to
providing fixed payments to the appropriate Annuity Table for the Option
chosen. Annuity Income Payments under a Fixed Annuity will not vary.
VARIABLE ANNUITY
A Variable Annuity is an annuity with income which:
(A) Is not guaranteed as to dollar amount; and
(B) Varies in amount with the investment experience of the elected
Subaccounts.
ANNUITY UNIT VALUE
The Annuity Unit Value for each Subaccount for any Valuation Period is
equal to (a) multiplied by (b) multiplied by (c) where:
(A) Is the Net Investment Factor for the Valuation Period for which the
Annuity Unit Value is being calculated;
(B) Is the Annuity Unit Value for the preceding Valuation Period; and
(C) Is the investment result adjustment factor (.99990575 per day) which
recognizes an annual interest rate of 3.5% used in determining the variable
annuity income amount. A different investment result adjustment factor
will be used with different assumed interest rates.
DETERMINATION OF FIRST VARIABLE ANNUITY INCOME PAYMENT
The portion of the Contract Value (less any applicable taxes) that you
allocate to providing variable payments, will be applied to the appropriate
Annuity Table. This will be done for the Valuation Period in which the
Annuity Date occurs and in accordance with the Annuity Income Option
chosen. The minimum amount payable for the first payment for each $1,000
so applied is shown in the Annuity Table for the Option chosen based on an
assumed interest rate of 3.5%. The Company may make available variable
Annuity Income Payments based on other assumed interest rates.
VARIABLE ANNUITY INCOME PAYMENTS AFTER THE FIRST PAYMENT
Variable Annuity Income Payments after the first vary in amount. The amount
changes with the investment performance of the elected Subaccounts. The
dollar amount of variable Annuity Income Payments after the first is not
fixed. It may change from payment to payment. The dollar amount of such
payments is determined as follows:
EVA-91100 -26-
(A) The dollar amount of the first Annuity Income Payment is divided by the
Annuity Unit Value as of the Valuation Period in which the Annuity Date
occurs. This result establishes the fixed number of Annuity Units for each
Annuity Income Payment after the first. This number of Annuity Units
remains fixed during the Annuity Period, except for the effect of any
exchange of Annuity Units.
(B) The fixed number of Annuity Units is multiplied by the Annuity Unit
Value as of the Valuation Period in which the payment is due. This result
establishes the dollar amount of the payment.
The dollar amount of each Annuity Income Payment after the first will not
be affected by variations in expenses or mortality experience.
EXCHANGE OF ANNUITY UNITS
Annuity Units of any Subaccount may be exchanged for Annuity Units of any
other Subaccount by Written Request. The exchange will affect Annuity
Income Payments determined after that valuation period. The exchange will
be based on the relative value of the Subaccount Annuity Units. The value
of the Annuity Units being exchanged must provide at least a $50.00 annuity
income payment at the time of the exchange, unless all of the Annuity Units
of a Subaccount are being exchanged. Once Annuity Income Payments start,
no exchanges may be made to or from any Fixed Annuity. The Company
reserves the right to limit exchanges to six per contract year.
ADJUSTED AGE
Annuity Income Payments are based on the adjusted age of the Annuitant as
of the Annuity Date. The joint and survivor annuity income rates are based
on the adjusted ages of both the Annuitant and the designated second person
as of the Annuity Date. The adjusted age is:
(a) The age on the Annuity Date;
LESS
(b) The age adjustment shown below which is based on the calendar year in
which the Annuity Date occurs.
Calendar
Years 1990-99 2000-09 2010-19 2020-29 2030-39 After 2039
Age adjustment 0 1 2 3 4 5
EVA-91100 -27-
ANNUITY TABLES
DOLLAR AMOUNT OF THE ANNUITY INCOME WHICH IS PURCHASED WITH
EACH $1,000 OF PROCEEDS APPLIED
GUARANTEED MONTHLY INCOME
OPTION 1 OPTION 3
Life Annuity Life Annuity Life Annuity
ADJUSTED 10 Years Guaranteed 20 Years Guaranteed
AGE MALE FEMALE MALE FEMALE MALE FEMALE
60 5.21 4.69 5.10 4.64 4.77 4.48
61 5.33 4.79 5.20 4.73 4.83 4.55
62 5.47 4.89 5.32 4.82 4.90 4.62
63 5.61 5.00 5.44 4.92 4.96 4.69
64 5.76 5.11 5.57 5.03 5.03 4.76
65 5.93 5.24 5.70 5.14 5.09 4.83
66 6.10 5.37 5.84 5.26 5.16 4.90
67 6.29 5.52 5.98 5.38 5.22 4.97
68 6.50 5.67 6.13 5.52 5.27 5.05
69 6.71 5.84 6.29 5.66 5.33 5.12
70 6.95 6.02 6.45 5.81 5.38 5.19
71 7.19 6.22 6.62 5.96 5.43 5.25
72 7.46 6.43 6.79 6.13 5.48 5.32
73 7.74 6.66 6.97 6.30 5.52 5.38
74 8.05 6.92 7.14 6.49 5.56 5.43
75 8.38 7.19 7.33 6.68 5.59 5.49
76 8.73 7.49 7.51 6.87 5.62 5.53
77 9.11 7.81 7.69 7.07 5.65 5.57
78 9.52 8.16 7.87 7.28 5.67 5.61
79 9.96 8.54 8.05 7.49 5.69 5.64
80 10.42 8.96 8.22 7.70 5.71 5.67
81 10.93 9.41 8.39 7.90 5.72 5.69
82 11.47 9.90 8.55 8.11 5.73 5.71
83 12.04 0.43 8.70 8.30 5.74 5.73
84 12.65 11.01 8.85 8.49 5.75 5.74
85 13.30 11.64 8.98 8.67 5.75 5.74
JOINT AND SURVIVOR ANNUITY
OPTION 2
Male Adjusted Female Adjusted Age
Age 60 65 70 75 80 85
60 4.27 4.48 4.68 4.86 4.99 5.08
65 4.39 4.68 4.98 5.26 5.50 5.68
70 4.49 4.85 5.26 5.70 6.10 6.43
75 4.57 4.99 5.51 6.12 6.75 7.32
80 4.62 5.09 5.70 6.48 7.38 8.29
85 4.65 5.15 5.83 6.75 7.92 9.24
Basis = Modification of 1983a Individual Annuitant Mortality at 3.5% annual
interest, using age nearest birthday.
The amount of annuity income for any age or combination of ages not shown
in the Annuity Tables, or for any other annuity option agreed to by us,
will be furnished on request.
EVA-91101 -28-
ANNUITY TABLES
DOLLAR AMOUNT OF THE ANNUITY INCOME WHICH IS PURCHASED WITH
EACH $1,000 OF PROCEEDS APPLIED
GUARANTEED MONTHLY INCOME
OPTION 1 OPTION 3
ADJUSTED 10 Years Guaranteed 20 Years Guaranteed
AGE Life Annuity Life Annuity Life Annuity
60 4.69 4.64 4.48
61 4.79 4.73 4.55
62 4.89 4.82 4.62
63 5.00 4.92 4.69
64 5.11 5.03 4.76
65 5.24 5.14 4.83
66 5.37 5.26 4.90
67 5.52 5.38 4.97
68 5.67 5.52 5.05
69 5.84 5.66 5.12
70 6.02 5.81 5.19
71 6.22 5.96 5.25
72 6.43 6.13 5.32
73 6.66 6.30 5.38
74 6.92 6.49 5.43
75 7.19 6.68 5.49
76 7.49 6.87 5.53
77 7.81 7.07 5.57
78 8.16 7.28 5.61
79 8.54 7.49 5.64
80 8.96 7.70 5.67
81 9.41 7.90 5.69
82 9.90 8.11 5.71
83 10.43 8.30 5.73
84 11.01 8.49 5.74
85 11.64 8.67 5.74
JOINT AND SURVIVOR ANNUITY
OPTION 2
Adjusted Age Adjusted Age Second Annuitant
First Annuitant 60 65 70 75 80 85
60 4.15 4.30 4.42 4.52 4.59 4.63
65 4.30 4.52 4.73 4.90 5.04 5.13
70 4.42 4.73 5.05 5.35 5.60 5.78
75 4.52 4.90 5.35 5.83 6.28 6.64
80 4.59 5.04 5.60 6.28 7.00 7.68
85 4.63 5.13 5.78 6.64 7.68 8.78
Basis = Modification of 1983a Individual Annuitant Mortality at 3.5% annual
interest, using age nearest birthday.
The amount of annuity income for any age or combination of ages not shown
in the Annuity Tables, or for any other annuity option agreed to by us,
will be furnished on request.
EVA-91-unisex -28-
EMPIRE FIDELITY INVESTMENTS LIFE INSURANCE COMPANY
NEW YORK, NEW YORK
VARIABLE ANNUITY
FLEXIBLE PURCHASE PAYMENT ANNUITY
WITH VARIABLE AND GUARANTEED ACCOUNTS
NONPARTICIPATING
ALL PAYMENTS AND VALUES PROVIDED BY THIS CONTRACT, WHEN BASED ON INVESTMENT
EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO
DOLLAR AMOUNT. (SEE CONTRACT VALUE, PAGE 11.)
EVA-91100
EMPIRE FIDELITY INVESTMENTS LIFE INSURANCE COMPANY
ENDORSEMENT
As of the Date of Issue of this Contract all references to sex are deleted.
All values and benefits are determined without regard to gender.
Secretary President
XXX-91-unisex
EMPIRE FIDELITY INVESTMENTS LIFE INSURANCE COMPANY
ENDORSEMENT: INDIVIDUAL RETIREMENT ANNUITY
This Endorsement is a part of the Contract. The effective date of this
Endorsement is the Contract Date shown on the Contract Schedule.
This Contract is issued on a tax qualified basis under Section 408(b) of
the Internal Revenue Code of 1986, as amended (the "Code"), so the
following provisions apply and replace any contrary Contract provisions:
(1) The Owner of the Contract must also be the Annuitant. A Contingent
Annuitant cannot be designated. The Contract is not transferable (other
than a transfer incident to a divorce decree in accordance with Section
408(d)(6) of the Code) and is established for the exclusive benefit of the
Owner and his or her designated beneficiary.
(2) Any premium for this Contract must be a rollover contribution, as
permitted by Sections 402(a)(5), 402(a)(7), 403(a)(4), 403(b)(8), or
408(d)(3) of the Code. No other premium may be paid. Premiums will not be
refunded except that within 30 days of the date of the receipt of the
Contract, the application may be revoked and the Company will pay you the
Contract Value as of the date it receives your Contract, plus any
deductions made from your Purchase Payment.
(3) The Owner's entire interest in the Contract is nonforfeitable, subject
to the surrender charges specified in the Contract.
(4) In order to satisfy the minimum distribution requirements of Code
Section 408(b)(3), the Owner's interest in the Contract must be paid in a
single sum or distributed in equal or substantially equal payments at least
annually over: the life of the Owner or the lives of the Owner and a second
person designated by the Owner; or a period not to extend beyond the life
expectancy of the Owner or the joint and last survivor expectancy of the
Owner and a designated second person. If the designated second person is
not the Owner's spouse, payments will comply with the minimum distribution
incidental benefit requirements applicable to IRAs. This will require a
specified percentage of the distributions be distributed to the Owner
depending on the age of the Owner and the designated second person. The
Owner may elect:
(A) that the Company pay the Cash Surrender Value;
(B) that the Contract Value be applied to an Annuity Income Option that
complies with Code Section 408(b)(3); or
EVA-91200
(C) to take a series of partial withdrawals from the Contract that,
together with distributions from other IRA's, comply with Code Section
408(b)(3). Such withdrawals will be subject to the terms described in the
contract to which this endorsement applies. Withdrawals cannot be taken
after the Annuity Date. The latest permissible Annuity Date is described
in the Contract.
(5) Unless the Owner elects otherwise by Written Request, the Annuity Date
will be April 1 of the calendar year following the calendar year in which
the Owner attains age 70 1/2 (the "Required Beginning Date.")
(6) If this Contract is the Owner's only IRA, the Owner must begin taking
distributions from the Contract no later than the Required Beginning Date.
(7) If this Contract is not the Owner's only IRA, the Owner may satisfy the
minimum distribution requirements by taking a series of partial withdrawals
from this Contract or from any other IRAs he or she owns beginning no later
than the Required Beginning Date.
(8) By Written Request to the Company at least 30 days prior to the Annuity
Date, the Owner may elect an Annuity Income Option or other disposition of
any amount to be paid under the contract. Unless the Owner elects
otherwise by Written Request, payments will be made according to Annuity
Income Option 3 of the Contract with Annuity Income Payments guaranteed for
ten years.
(9) In the event of the Owner's death, the entire interest in this Contract
must be distributed in accordance with Code Section 408(b)(3), and the
Contract's provisions relating to the death of the Owner are changed to the
extent necessary to conform with the Code as follows:
(A) If the Owner dies after the Required Beginning Date, the remaining
portion of his or her interest will continue to be distributed at least as
rapidly as under the method of distribution being used prior to the Owner's
death.
(B) If the Owner dies before the Required Beginning Date, the Owner's
entire interest will be distributed in accordance with one of the following
four provisions:
(1) The Owner's entire interest will be paid in full before December 31
of the calendar year containing the fifth anniversary of the date of the
Owner's death.
EVA-91200
(2) If the Owner's interest is payable to a designated Beneficiary of the
Owner and the designated Beneficiary has not elected (1) above, then the
entire interest will be distributed in substantially equal installments at
least annually over the life or a period not to extend beyond the life
expectancy of the designated Beneficiary commencing no later than December
31 of the year following the date of the Owner's death. The designated
Beneficiary may, at any time prior to the commencement of distribution,
elect to accelerate the payments, that is, increase the frequency or amount
of the payments.
(3) If the designated Beneficiary of the Owner is the Owner's surviving
spouse, distributions are not required to begin until December 31 of the
later of: (i) the calendar year following the date of death of the Owner
or (ii) the calendar year in which the deceased Owner would have attained
age 70 1/2. The surviving spouse may, at any time prior to the
commencement of distribution, elect to accelerate the payments, that is,
increase the frequency or amount of the payments.
(4) If the designated Beneficiary of the Owner is the Owner's surviving
spouse, the spouse may treat the Contract as his or her own individual
retirement annuity (IRA).
For purposes of this requirement, any amount paid to a child of the Owner
will be treated as if it had been paid to the surviving spouse if the
remainder of the interest becomes payable to the surviving spouse when the
child reaches the age of majority.
(10) For purposes of any distribution rule, life expectancies will be
calculated by use of the return multiples specified in Section 1.72-9 of
the Treasury Regulations.
(11) This Contract cannot be sold, assigned, discounted or pledged as
collateral for a loan or as security for the performance of an obligation
or for any other purpose (other than a transfer incident to a divorce
decree in accordance with Section 408(d)(6) of the Code).
(12) The Company reserves the right to amend this Endorsement in any aspect
at any time so that it may conform to the applicable provisions of the Code
as in effect from time to time. Any such amendment will be subject to any
necessary regulatory approvals.
Signed for the Company at its Home Office, New York, New York.
President Secretary
XXX-91200
ANNUITY SERVICE CENTER
P.O. BOX 3767, NEW YORK, NEW YORK 10277-0433
CONTRACT SCHEDULE
CONTRACT NUMBER EF0000000
CONTRACT DATE APRIL 1, 1991
ANNUITY DATE APRIL 1, 2041
ANNUITANT XXXXX XXXXXX
ISSUE AGE/SEX 35/MALE
CONTINGENT ANNUITANT XXXXX XXXXXX
INITIAL PURCHASE PAYMENT $5,000
VARIABLE ACCOUNT SUBACCOUNTS
MONEY MARKET EQUITY-INCOME
HIGH INCOME GROWTH
ASSET MANAGER OVERSEAS
INVESTMENT GRADE BOND INDEX 500
MINIMUM GUARANTEED ACCOUNT INTEREST RATE: 3.5% per year
compounded annually
MINIMUM ADDITIONAL PURCHASE PAYMENT: $250
DEDUCTIONS FROM THE CONTRACT VALUE:
MAINTENANCE CHARGE: $30 per year on the Contract Date not to exceed $50 per
year.
TABLE OF SURRENDER CHARGES
CONTRACT PERCENTAGE OF
YEAR PURCHASE PAYMENTS
1 5%
2 4%
3 3%
4 2%
5 1%
THEREAFTER 0%
If you choose to receive income from your Annuity based upon an assumed
interest rate of 3.5%, the smallest annual rate of investment return which
a Subaccount would have to earn to prevent a decrease in the dollar amount
of income payments from that Subaccount is 4.55%.
EVA-91100 -4-
