EXHIBIT (4)(a)
AIG Life Insurance Company
[LOGO] AIG LIFE Wilmington, Delaware 19801
A capital stock company
--------------------------------------------------------------------------------
This Single Premium Immediate Annuity Contract is issued by AIG Life Insurance
Company (We, Us, Our) to the Owner(s) (You, Your) named on the Contract Schedule
in consideration of the payment of the single Premium. We will make annuity
payments to the Annuitant, and Joint Annuitant, if any, as set forth in this
Contract Schedule beginning on the Annuity Date.
READ YOUR CONTRACT CAREFULLY
RIGHT TO EXAMINE THIS CONTRACT
If, after reading the Annuity Contract, You are not satisfied for any reason,
the Annuity Contract may be returned within [ten (10)] days after it has been
received. It can be mailed or delivered to Us at Our Administrative Office. As
of the return date We will promptly refund any Premium which has been received
in consideration for said Annuity Contract, less any payments which may have
been made, and the Annuity Contract will be void. When this Contract replaces an
existing life insurance or annuity policy, the Right to Examine period will be
20 days from the day You receive the Annuity Contract.
This Contract is a Legal contract between the Contract Holder and Us.
This Contract is governed by the laws of Washington.
/s/ XXXXXXXXX X. XXXX /s/ XXXXXX X. XXXXXX, XX.
--------------------- --------------------------
Secretary President
SINGLE PREMIUM IMMEDIATE ANNUITY CONTRACT
NON-PARTICIPATING
16EIAN0403WA
TABLE OF CONTENTS
CONTRACT SCHEDULE..............................................................3
DEFINITIONS ...................................................................4
PREMIUM PAYMENT................................................................5
DEATH PRIOR TO ANNUITY DATE....................................................5
BENEFICIARIES .................................................................5
PAYMENT OF ANNUITY BENEFITS....................................................5
FACILITY OF PAYMENT............................................................5
ASSIGNMENT ....................................................................6
INFORMATION WE REQUIRE.........................................................6
EVIDENCE OF SURVIVAL...........................................................6
MISSTATEMENTS .................................................................6
ENTIRE CONTRACT................................................................6
16EIAN0403WA 2
CONTRACT SCHEDULE
CONTRACT NUMBER: 1001
OWNER Xxxx Xxx
ANNUITY CONTRACT DATE: January 25, 2004
ANNUITY DATE: March 1, 2004
ANNUITANT Xxxx Xxx
DATE OF BIRTH: January 1, 1927
GENDER: [Male]
PREMIUM PAYMENT: [$250,000.00]
ANNUITY INCOME
TYPE OF ANNUITY: [Ten Year Period Certain & Life. The Ten Year
Certain & Life Annuity provides monthly payments
to the Annuitant, beginning on the Annuity Date
and continuing during the lifetime of the
Annuitant. If the death of the Annuitant occurs
before the Annuity Date we will refund the
Premium paid with respect to this Annuity
Contract to the Owner, if living, and if not to
the Beneficiary. If the death of the Annuitant
occurs after the Annuity Date but prior to
payments having been made for 10 years, payments
will be continued during the remainder of the 10
year period to the Annuitant's beneficiary. No
other benefit is payable as a result of the
death of the Annuitant.]
ANNUITY BENEFIT [$2138.96]
FREQUENCY OF ANNUITY BENEFIT: [Monthly]
[GUARANTEE PERIOD:] [10 Years]
16EIAN0403WA 3
DEFINITIONS
In addition to the other definitions set forth in this Contract, the following
terms shall have their respective meanings as set forth below. In addition, the
masculine form of any term shall be construed as including the feminine form of
that term.
Administrative Office means Our service center to which You should direct all
requests, instructions and other communications. Our Administrative Office is
located at [Vanguard Annuity and Insurance Services, P. O. Box 1105, Valley
Forge, PA 19482-1105].
Annuitant means the person or persons designated in the Contract Schedule to
receive an Annuity Benefit under this Contract and on whose life the amount of
the Annuity Benefit is determined.
Annuity Benefit means the periodic payment made to a Payee, in accordance with
this Contract. The amount of the periodic payment is set forth in the Contract
Schedule.
Annuity Contract Date is the date that Premium is remitted for the purchase of
an Annuity Benefit and the date that the Annuity Contract becomes effective, as
shown in the Contract Schedule.
Annuity Date means the date on which the first Annuity Benefit payment will be
made to a Payee.
Application means the form used to record data given to Us for the purpose of
purchasing an Annuity Benefit under this Contract.
Beneficiary means the person named to receive any remaining benefits payable
after the later of the date of death of the Annuitant or Survivor, if any.
Home Office is Our office at [000 Xxxx Xxxxxx, Xxxxxxxxxx, Xxxxxxxx 00000].
Non-Participating means this Contract does not participate in Our divisible
surplus. No dividends are payable.
Owner(s) is the person or persons shown as Owner(s) in the Contract Schedule.
Payee means any person receiving a benefit under an Annuity Contract.
Premium means the amount We receive to purchase an Annuity Benefit.
Survivor means the person designated on a Life and Survivor Annuity to receive
the Survivor benefit, if still living after the death of the Annuitant.
Type Of Annuity means the type of annuity specified in the Application Form and
described in the Contract Schedule.
Written Notice means information given in written form either by the Owner, the
Annuitant, or Us. If given by the Owner or the Annuitant, such Written Notice
must be signed and be in a form which is satisfactory to Us.
16EIAN0403WA 4
PREMIUM PAYMENT
Your Premium Payment is shown on the Contract Schedule. The Premium is used to
purchase the selected Annuity Benefit, to commence on the indicated Annuity
Date. We will only be liable for those Annuity Benefits for which the
appropriate Premium has been duly received.
DEATH PRIOR TO ANNUITY DATE
If neither the Annuitant nor the Survivor, if any, is alive on the Annuity Date,
a refund with respect to the Annuity Contract will be payable to You or , if You
are not living, to Your estate. The refund will be equal to the Premium paid in
consideration for the Annuity Contract less any payments which have been made,
and shall be payable once We receive a notification of death acceptable to Us.
In the event an Annuitant dies after the Annuity Date, any remaining Annuity
Benefit will be paid in accordance with the terms of this Annuity Contract. We
may require a death certificate, physician's written statement certifying the
death of the Annuitant or Joint Annuitant, if any, or any other reasonable
evidence to constitute proof of death. Any death benefit paid by Us in good
faith in accordance with the terms of this Annuity Contract shall, to the extent
of such death benefit, fully discharge Us from any further liability.
BENEFICIARIES
Unless the Beneficiaries have been designated as irrevocable, the Beneficiaries
may be changed at any time by submitting a written notice to Us. Prior to the
Annuity Date You may name the Beneficiaries. After that date the Annuitant may
name or change the Beneficiaries. If a Beneficiary has been designated as
irrevocable, the Beneficiary's consent is needed for a change of Beneficiary. A
change of Beneficiary will take effect as of the date the written notice is
signed. However, the change will not affect any Annuity Benefit paid or action
taken before the change is recorded at Our Administrative Office. If the
Annuitant dies and there is no living Survivor, any death benefit will first be
payable to the most recently designated primary Beneficiary, and if such
Beneficiary is deceased, then to the most recently designated secondary
Beneficiary. If no Beneficiary is named or if no named Beneficiary survives the
Annuitant, any death benefit will be payable to the Annuitant's estate.
PAYMENT OF ANNUITY BENEFITS
The amount of the Annuity Benefit will be paid periodically to the Annuitant, in
the frequency shown on the Contract Schedule page, beginning on the Annuity
Date, in accordance with the Type Of Annuity selected on the Application.
However, if such periodic Annuity Benefit is less than $50, We shall have the
right at any time to pay such Annuity Benefit less frequently, in advance, but
in no event less frequently than annually.
FACILITY OF PAYMENT
If any Payee who is receiving an Annuity Benefit under this Contract is adjudged
to be legally, physically or mentally, incapable or incompetent, We may pay such
Annuity Benefit to the legal guardian or other legal representative of such
person. Any such payment shall constitute a full discharge of Our obligation to
the extent thereof.
16EIAN0403WA 5
ASSIGNMENT
Unless prohibited by the terms of this Annuity Contract or by law, the Payee may
assign any or all payments provided under this Annuity Contract. We will not be
bound by any assignment of this Annuity Contract unless the assignment is
received in writing at Our Administrative Office. We are not responsible for the
validity of such assignments. The rights of the Payee and those of any
Beneficiary (except an irrevocable Beneficiary) will be subject to the
assignment. An assignment will not affect any payments We may make or actions We
may take before such assignment has been recorded at Our Administrative Office.
Adverse federal income tax consequences may result from an assignment.
INFORMATION WE REQUIRE
We may require proof of the age and sex of the Annuitant and the Joint
Annuitant, if any, before making any annuity income payments. We have the right
to rely and act on such information in the administration of this Annuity
Contract. If the age, sex or any other relevant fact has been misstated with
respect to a person for whom an Annuity Benefit is measured, an equitable
adjustment will be made. In no event shall We be liable for any greater Annuity
Benefit with respect to an Annuitant than that which would be payable based on
the correct information and the Premium We received for such Annuity Benefit.
EVIDENCE OF SURVIVAL
We retain the right to require due proof of any Payee's survival when an Annuity
Benefit is contingent upon survival of the Payee. Further, the Payee, for
himself, his heirs, and successors represents by negotiation of Our check or
bank draft that the Payee is living on the date any Annuity Benefit payment is
made.
MISSTATEMENTS
If the term or the amount of any Annuity Benefit provided under this Annuity
Contract, issued in accordance with the Contract, is incorrect due to clerical
error or due to a misstatement of any fact pertaining to the Annuity Benefit,
such Annuity Benefit will be adjusted in accordance with the correct data.
Overpayments by Us will be deducted from future payments due the Payee.
Underpayments by Us will be paid to the Payee in a lump sum. No interest will be
either credited or charged during such adjustments.
ENTIRE CONTRACT
The entire Contract consists of this form and any attached endorsements or
riders.
16EIAN0403WA 6
[LOGO] AIG LIFE
AIG LIFE INSURANCE COMPANY
[000 XXXX XXXXXX
XXXXXXXXXX, XXXXXXXX 00000]
SINGLE PREMIUM IMMEDIATE ANNUITY CONTRACT
NON-PARTICIPATING
16EIAN0403WA
