EXHIBIT 24(b)4(a)
XXXX XXXXXXX LIFE INSURANCE COMPANY (U.S.A.) (XXXX XXXXXXX(R) LOGO)
A STOCK COMPANY
OVERNIGHT MAILING ADDRESS: ANNUITY SERVICE OFFICE: HOME OFFICE
[000 Xxxxxxxx Xxxxxx [P.O. Box 55230 Bloomfield Hills, MI
Boston, MA 02110-2805] Boston, MA 02205-5230
0-000-000-0000]
THIS IS A LEGAL CONTRACT - READ IT CAREFULLY.
WE AGREE to pay the benefits of this Contract in accordance with its terms.
THIS CONTRACT is issued in consideration of the Payments.
TEN DAY RIGHT TO REVIEW
THE OWNER MAY CANCEL THE CONTRACT BY RETURNING IT TO OUR ANNUITY SERVICE OFFICE
OR AGENT AT ANY TIME WITHIN 10 DAYS AFTER RECEIPT OF THE CONTRACT. WITHIN 7 DAYS
OF RECEIPT OF THE CONTRACT BY US, WE WILL PAY THE CONTRACT VALUE COMPUTED AT THE
END OF THE VALUATION PERIOD DURING WHICH THE CONTRACT IS RECEIVED BY US, TO THE
OWNER.
WHEN THE CONTRACT IS ISSUED AS AN INDIVIDUAL RETIREMENT ANNUITY, DURING THE
FIRST 7 DAYS OF THIS 10 DAY PERIOD, WE WILL RETURN THE GREATER OF (I) CONTRACT
VALUE COMPUTED AT THE END OF THE VALUATION PERIOD DURING WHICH THE CONTRACT IS
RECEIVED BY US OR (II) SUM OF ALL PAYMENTS.
SIGNED FOR THE COMPANY at Boston, Massachusetts, on the Contract Date.
DETAILS OF VARIABLE ACCOUNT PROVISIONS ON PAGE 6.1
DETAILS OF FIXED ACCOUNT PROVISIONS ON PAGE 7.1
/s/ Xxxx X. XxxXxxx XXX /s/ Xxxxxxx Xxxxx
[-----------------------------] [-----------------------------]
President Secretary
Flexible Payment Deferred Combination Fixed and Variable Annuity
Non-Participating
ANNUITY PAYMENTS AND OTHER VALUES PROVIDED BY THIS CONTRACT WHEN BASED ON THE
INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT ARE VARIABLE AND NOT GUARANTEED AS
TO FIXED DOLLAR AMOUNT.
VENTURE.100 SAMPLE
INTRODUCTION
This is a flexible payment deferred combination fixed and variable annuity
contract. This Contract provides that prior to the Maturity Date, the Contract
Value will accumulate on either a fixed or variable basis or a combination of
both. After the Maturity Date, annuity payments may be either fixed or variable,
or a combination of fixed and variable.
The variable portion of the Contract will vary with the investment performance
of your Investment Account. The fixed portion of the Contract will accumulate
based on interest rates guaranteed by the Company for the period selected.
If you select annuity payments on a variable basis, the payment amount will vary
with the investment performance of the Variable Account.
You must allocate Payments among one or more Investment Options. The Investment
Options are identified on the Specifications Page.
TABLE OF CONTENTS
PAGE
----
SPECIFICATIONS PAGE ..................................................... S.1
PART 1 - DEFINITIONS ................................................... 1.1
PART 2 - GENERAL PROVISIONS ............................................ 2.1
PART 3 - OWNERSHIP ..................................................... 3.1
PART 4 - BENEFITS ...................................................... 4.1
PART 5 - PAYMENTS ...................................................... 5.1
PART 6 - VARIABLE ACCOUNT PROVISIONS ................................... 6.1
PART 7 - FIXED ACCOUNT PROVISIONS ...................................... 7.1
PART 8 - ANNUITY PROVISIONS ............................................ 8.1
PART 9 - TRANSFERS ..................................................... 9.1
PART 10 - WITHDRAWAL PROVISIONS ......................................... 10.1
PART 11 - FEES AND DEDUCTIONS ........................................... 11.1
PART 12 - LOAN PROVISIONS ............................................... 12.1
PART 13 - PAYMENT OF CONTRACT BENEFITS .................................. 13.1
TABLE OF ANNUITY PAYMENT RATES .......................................... T.1
SPECIFICATIONS PAGE
TYPE OF CONTRACT: [QUALIFIED] MATURITY DATE: [06/08/2052]
CONTRACT DATE: [06/08/2007] CONTRACT NUMBER: [000000005]
INITIAL PAYMENT: [$3,500.00] GOVERNING LAW: [MI]
OWNER: [XXXXXX XXXXX] CO-OWNER: [_]
ANNUITANT: [XXXXXX XXXXX] OWNER'S AGE: [45]
CO-ANNUITANT: [_] ANNUITY OPTION: [Life 10-Year Certain]
PLAN [VENTURE FREEDOM]
MINIMUM GUARANTEED INTEREST RATE [3.0%] per year
ON FIXED ACCOUNTS
ASSET FEE [0.99% years 1+]
ANNUAL FEE [$30.00(1)]
[(1) Prior to the Maturity Date, when the
Annual Administration Fee is to be
assessed, if the sum of all your
Investment Accounts exceeds $[100,000],
the Annual Administration Fee will be
waived.]
MINIMUM DEATH BENEFIT [The sum of all Payments made, less any
amount deducted in connection with partial
withdrawals.
For purposes of calculating the Minimum Death
Benefit, the amount deducted in connection
with partial withdrawals will be equal to (i)
times (ii), where (i) is equal to the Minimum
Death Benefit prior to the withdrawal, and
(ii) is equal to the partial withdrawal
amount divided by the Contract Value prior to
the partial withdrawal.]
PAYMENT LIMITS [The initial Payment is shown above.
Additional Payments may be made at any time.
However, each additional Payment must be at
least [$30]. If a Payment would cause the
Contract Value to exceed [$1,000,000], or the
Contract Value already exceeds [$1,000,000],
no additional Payments will be accepted
without our prior approval.]
[RESTRICTED RENEWAL TRANSFER [If renewals to fixed Investment Options are
PORTFOLIO] restricted, the renewal amount will be
automatically transferred into the Money
Market Portfolio, unless you specify
otherwise.]
VENTURE.100.P01V00 SAMPLE
1.1
TRANSFER CHARGES AND LIMITATIONS [We reserve the right to impose a transaction
- BEFORE MATURITY DATE charge for transfers.] [In the event a charge
is imposed, it will not exceed the lesser of
$25.00 or 2% of the amount of each transfer.]
[We reserve the right to limit the amount of
the transfer and the maximum number of
transfers that can be made.]
[You must transfer at least [$300] or, if
less, the entire amount in the Investment
Account each time you make a transfer. If,
after the transfer, the amount remaining in
the Investment Account from which the
transfer is made is less than [$100], then we
will transfer the entire amount instead of
the requested amount.]
[Should we limit the maximum number of
transfers that can be made per Contract Year,
that limit will be no less than one per month
or six at any time within a Contract Year.]
TRANSFER CHARGES AND LIMITATIONS [We reserve the right to limit the maximum
- ON OR AFTER MATURITY DATE number of transfers you may make per Contract
Year after variable annuity payments have
begun.]
[If we limit the maximum number of transfers
that can be made after variable annuity
payments have begun, the maximum number of
transfers per Contract Year shall be no less
than 4.]
LIMITATIONS ON AMOUNT OF PARTIAL [Any withdrawal from an Investment Account
WITHDRAWALS must be at least [$300] or the entire balance
of the Investment Account, if less. If after
the withdrawal, the amount remaining in that
Investment Account is less than [$100], then
we will consider the withdrawal request to be
a request for withdrawal of the entire amount
held in the Investment Account. If a partial
withdrawal would reduce the Contract Value to
less than [$300], or if the amount requested
is greater than or equal to the amount
available as a total withdrawal, then we will
treat the partial withdrawal request as a
total withdrawal of the Contract Value.]
TABLE OF WITHDRAWAL CHARGES [Number of Complete Years [Withdrawal Charge
Payment has been in Contract] Percentage]
----------------------------- ------------------
[0] [6%]
[1] [6]
[2] [5]
[3] [4]
[4] [3]
[5] [2]
[6] [1]
[7+] [0]
Withdrawal charges are applied to liquidated
purchase payments. Purchase payments are
liquidated when the amount of a withdrawal
during a Contract Year exceeds the free
withdrawal amount for that year. The amount
of the payments liquidated equals the amount
of the withdrawal in excess of the free
withdrawal amount. A total withdrawal
liquidates all unliquidated purchase
payments.
1.2
FREE WITHDRAWAL AMOUNT [The Free Withdrawal Amount is defined as the
greater of:
(a) the excess of the Contract Value on
the date of withdrawal over the
unliquidated Payments, or
(b) the excess of (i) over (ii), where:
(i) equals 10% times the total
Payments; and
(ii) equals 100% of all prior
partial withdrawals, in that
Contract Year.]
1.3
INITIAL ALLOCATION OF NET
PAYMENT: (SEE REVERSE FOR ALL AVAILABLE OPTIONS)
INITIAL INITIAL GUARANTEE
FIXED INVESTMENT OPTIONS: INTEREST RATE PERIOD EXPIRES
VARIABLE INVESTMENT OPTIONS:
[American Asset Allocation]] [100.00%]
TOTAL 100.00%
[THIS PLAN IS INTENDED TO QUALIFY UNDER THE INTERNAL REVENUE CODE FOR
TAX-FAVORED STATUS. LANGUAGE CONTAINED IN THIS CONTRACT REFERRING TO FEDERAL TAX
STATUS OR RULES IS INFORMATIONAL AND INSTRUCTIONAL AND THIS LANGUAGE IS NOT
SUBJECT TO APPROVAL OR DISAPPROVAL BY THE STATE IN WHICH THE CONTRACT IS ISSUED
FOR DELIVERY. PLEASE SEEK THE ADVICE OF YOUR OWN TAX ADVISOR REGARDING YOUR
INDIVIDUAL TAX TREATMENT.]
1.4
AVAILABLE INVESTMENT OPTIONS
[FIXED INVESTMENT OPTIONS]
[6 Month DCA]
[12 Month DCA]
[One Year fixed]
[VARIABLE INVESTMENT OPTIONS]
[American Asset Allocation]
[Xxxxxxxx Xxxxxxxxx Founding Allocation]
[Money Market]
[Value & Restructuring]
[American Growth]
[International Opportunities]
[International Value]
[Strategic Bond]
[Global Bond]
LIFESTYLE PORTFOLIOS:
[Aggressive]
[Growth]
[Balanced]
[Moderate]
[Conservative]
1.5
SPECIFICATIONS PAGE (CONTINUED)
[ENHANCED DEATH BENEFIT RIDER]
[RIDER DATE:] [05/25/2007]
[RIDER FEE PERCENTAGE:] [0.20%]
[TOTAL ASSET FEE PERCENTAGE]
(ASSET FEE + RIDER FEE) [1.19%]
[GUARANTEED MINIMUM WITHDRAWAL BENEFIT RIDER MARKETING NAME]
[RIDER DATE] [06/08/2007]
[RIDER FEE PERCENTAGE] [0.40%]
OWNER: [XXXX XXX] CO-OWNER: [NONE]
ANNUITANT: [XXXX XXX] AGE: [45]
CO-ANNUITANT: [NONE] BENEFICIARY: SEE ATTACHED LIST
1.6
BENEFICIARY INFORMATION
[Play Dough]
1.7
PART 1 DEFINITIONS
------ -----------
WE AND YOU "We", "us" and "our" means Xxxx Xxxxxxx Life
Insurance Company (U.S.A.). "You" or "your"
means the Owner of this Contract.
ACCUMULATION UNIT A unit of measure that is used to calculate the
value of the variable portion of this Contract
before the Maturity Date.
ANNUITANT Any individual person or persons whose life is
used to determine the duration of annuity
payments involving life contingencies. The
Annuitant is as designated on the
Specifications Page, unless changed.
ANNUITY OPTION The method selected by you for annuity payments
made by us.
ANNUITY SERVICE OFFICE Any office designated by us for the receipt of
Payments and processing of Owner requests.
ANNUITY UNIT A unit of measure that is used after the
Maturity Date to calculate Variable Annuity
payments.
BENEFICIARY The person, persons or entity to whom certain
benefits are payable following the death of an
Owner, or in certain circumstances, an
Annuitant.
CONTRACT ANNIVERSARY The anniversary of the Contract Date.
CONTRACT DATE The date of issue of this Contract as
designated on the Specifications Page.
CONTRACT VALUE The total of your Investment Account Values
and, if applicable, any amount in the Loan
Account attributable to your Contract.
CONTRACT YEAR The period of twelve consecutive months
beginning on the Contract Date or any
anniversary thereafter.
CONTINGENT BENEFICIARY The person, persons or entity who becomes the
Beneficiary if the Beneficiary is not alive.
DEBT Any amounts in the Loan Account attributable to
your Contract plus any accrued loan interest on
that amount. The loan provision is only
available to certain Qualified Contracts.
ENDORSEMENT An Endorsement modifies the contract to which
it is attached. Endorsements must be signed by
an officer of the Company in order to be
effective.
FIXED ANNUITY An Annuity Option with payments which are
predetermined and guaranteed as to dollar
amount.
GENERAL ACCOUNT All the assets of Xxxx Xxxxxxx Life Insurance
Company (U.S.A.) other than assets in separate
accounts.
INTERNAL REVENUE CODE The Internal Revenue Code of 1986, as amended
(IRC) from time to time, and any successor statute of
similar purposes.
INVESTMENT ACCOUNT An account established by us which represents
your interest in an Investment Option prior to
the Maturity Date.
INVESTMENT ACCOUNT VALUE The value of your investment in an Investment
Account.
INVESTMENT OPTIONS The Investment Options can be either fixed or
variable. The Investment Options available
under this Contract are shown on the
Specifications Page.
LOAN ACCOUNT The portion of the General Account that is used
for collateral when a loan is taken.
1.8
MATURITY DATE The date on which annuity benefits commence. It
is the date specified on the Specifications
Page, unless changed.
NET PAYMENT The Payment less the amount of premium tax, if
any, deducted from the Payment.
NON-QUALIFIED CONTRACTS Contracts which are not issued under Qualified
Plans.
OWNER The person, persons or entity entitled to the
ownership rights under this Contract. The Owner
is as designated on the Specifications Page,
unless changed.
PORTFOLIO OR TRUST A separate portfolio of Manufacturers
PORTFOLIO Investment Trust, a mutual fund in which the
Variable Account invests, or a portfolio of any
other mutual fund in which the Variable Account
invests.
PAYMENT An amount paid to us by you as consideration
for the benefits provided by this Contract.
RIDER A rider provides an optional benefit, which may
result in an additional charge to the Contract.
A rider supplements the contract to which it is
attached. Riders must be signed by an officer
of the Company in order to be effective.
QUALIFIED CONTRACTS Contracts issued under Qualified Plans.
QUALIFIED PLANS Retirement plans which receive favorable tax
treatment under sections 401, 403, 408 or 457,
of the Internal Revenue Code of 1986, as
amended.
SEPARATE ACCOUNT A segregated account of The Manufacturers Life
Insurance Company (U.S.A.) that is not
commingled with our general assets and
obligations.
SUB-ACCOUNT(S) One or more of the Sub-Accounts of the Variable
Account. Each Sub-Account is invested in shares
of a different Trust Portfolio.
VALUATION DATE Any date on which the New York Stock Exchange
is open for business and the net asset value of
a Trust Portfolio is determined.
VALUATION PERIOD Any period from one Valuation Date to the next,
measured from the time on each such date that
the net asset value of each Portfolio is
determined.
VARIABLE ACCOUNT Xxxx Xxxxxxx Life Insurance Company (U.S.A.)
Separate Account H.
VARIABLE ANNUITY An Annuity Option with payments which: (1) are
not predetermined or guaranteed as to dollar
amount; and (2) vary in relation to the
investment experience of one or more specified
variable Sub-Accounts.
1.9
PART 2 GENERAL PROVISIONS
------ ------------------
ENTIRE CONTRACT The entire Contract consists of this Contract,
Endorsements and Riders, if any, and the
application, if one is attached to this
Contract. Only the President, a Vice President,
or the Secretary of the Company has authority
to agree on our behalf to any alteration of the
Contract or to any waiver of our rights or
requirements. The change or waiver must be in
writing.
The benefits and values available under this
Contract are not less than the minimum required
by any statute of the state in which this
Contract is delivered. We have filed a detailed
statement of the method used to calculate the
benefits and values with the Department of
Insurance in the state in which this Contract
is delivered, if required by law.
MODIFICATION We will not change or modify this Contract
without your consent except as may be required
to make it conform to any applicable law or
regulation or any ruling issued by a government
agency; or unless we have reserved the right to
change the terms herein.
BENEFICIARY The Beneficiary is as designated on the
Specifications Page, unless changed. However,
if there is a surviving Owner, that person will
be treated as the Beneficiary. If no such
Beneficiary is living, the Beneficiary is the
"Contingent Beneficiary". If no Beneficiary or
Contingent Beneficiary is living, the
Beneficiary is the estate of the deceased
Owner.
CHANGE IN MATURITY DATE Prior to the Maturity Date, an Owner may
request in writing a change of the Maturity
Date. Any extension of the Maturity Date will
be subject to our prior approval.
ASSIGNMENT You may assign this Contract at any time prior
to the Maturity Date. No assignment will be
binding on us unless it is written in a form
acceptable to us and received at our Annuity
Service Office. We will not be liable for any
payments made or actions we take before the
assignment is accepted by us. An absolute
assignment will revoke the interest of any
revocable Beneficiary. We will not be
responsible for the validity of any assignment.
CLAIMS OF CREDITORS To the extent permitted by law, no benefits
payable under this Contract will be subject to
the claims of your, the Beneficiary's, or the
Annuitant's creditors.
MISSTATEMENT AND PROOF OF AGE, We may require proof of age, sex or survival of
SEX OR SURVIVAL any person upon whose age, sex or survival any
payments depend. If the age or sex of the
Annuitant has been misstated, the benefits will
be those which the Payments would have provided
for the correct age and sex. If we have made
incorrect annuity payments, the amount of any
underpayment will be paid immediately. The
amount of any overpayment will be deducted from
future annuity payments.
VENTURE.100.P02V00 SAMPLE
2.1
ADDITION, DELETION OR We reserve the right, subject to compliance
SUBSTITUTION OF INVESTMENT with applicable law, to make additions to,
OPTIONS deletions from, or substitutions for the
Portfolio shares that are held by the Variable
Account or that the Variable Account may
purchase. We reserve the right to eliminate the
shares of any of the eligible Portfolios and to
substitute shares of another Portfolio of the
Trust, or of another open-end registered
investment company, if the shares of any
eligible Portfolio are no longer available for
investment, or if in our judgment further
investment in any eligible Portfolio should
become inappropriate in view of the purposes of
the Variable Account. We will not substitute
any shares attributable to your interest in a
Sub-Account without notice to you and prior
approval of the Securities and Exchange
Commission to the extent required by the
Investment Company Act of 1940. Nothing
contained herein shall prevent the Variable
Account from purchasing other securities for
other series or classes of contracts, or from
effecting a conversion between shares of
another open-end investment company.
We reserve the right, subject to compliance
with applicable law, to establish additional
Sub-Accounts which would invest in shares of a
new Portfolio of the Trust or in shares of
another open-end investment company. We also
reserve the right to eliminate existing
Sub-Accounts, to combine Sub-Accounts or to
transfer assets in a Sub-Account to another
Separate Account established by us or an
affiliated company. In the event of any such
substitution or change, we may, by appropriate
endorsement, make such changes in this and
other Contracts as may be necessary or
appropriate to reflect such substitutions or
change. If deemed by us to be in the best
interests of persons having voting rights under
the Contracts, the Variable Account may be
operated as a management company under the
Investment Company Act of 1940 or it may be
de-registered under such Act in the event such
registration is no longer required.
NON-PARTICIPATING Your Contract is non-participating and will not
share in our profits or surplus earnings. We
will pay no dividends on your Contract.
REPORTS We will send you reports containing information
required by the Investment Company Act of 1940
and applicable state law in the time periods
required by such laws.
INSULATION The portion of the assets of the Variable
Account equal to the reserves and other
contract liabilities with respect to such
account are not chargeable with liabilities
arising out of any other business we may
conduct. Moreover, the income, gains and
losses, realized or unrealized, from assets
allocated to the Variable Account shall be
credited to or charged against such account
without regard to our other income, gains or
losses.
CURRENCY AND PLACE OF PAYMENTS All payments made to or by us shall be made in
the lawful currency of the United States of
America at the Annuity Service Office or
elsewhere if we consent.
NOTICES AND ELECTIONS To be effective, all notices and elections you
make under this Contract must be in writing,
signed by you and received by us at the Annuity
Service Office. Unless otherwise provided in
this Contract, all notices, requests and
elections will be effective when received by us
at our Annuity Service Office, complete with
all necessary information and your signature.
GOVERNING LAW This Contract will be governed by the laws of
the jurisdiction indicated on the
Specifications Page.
SECTION 72(S) The provisions of this Contract shall be
interpreted so as to comply with the
requirements of Section 72(s) of the Internal
Revenue Code.
2.2
PART 3 OWNERSHIP
------ ---------
GENERAL Before the Maturity Date, the Owner of this
Contract shall be the person, persons or entity
designated on the Specifications Page or the
latest change filed with us. On the Maturity
Date the Annuitant becomes the Owner of this
Contract. If amounts become payable to the
Beneficiary under this Contract, the
Beneficiary becomes the Owner of this Contract.
CHANGE OF OWNER, Subject to the rights of an irrevocable
ANNUITANT, BENEFICIARY Beneficiary, you may change the Owner,
Annuitant, or Beneficiary by written request in
a form acceptable to us and which is received
at our Annuity Service Office. The Annuitant
may not be changed after the Maturity Date. You
need not send us the Contract unless we request
it. Any change must be approved by us. If
approved, any change of Beneficiary will take
effect on the date the request is signed. If
approved, any change of Owner or Annuitant will
take effect on the date we received the request
at the Annuity Service Office. We will not be
liable for any payments or actions we take
before the change is approved.
The substitution or addition of any Owner may
result in the resetting of the Death Benefit to
an amount equal to the Contract Value as of the
date of such change. For purposes of subsequent
calculations of the Death Benefit, described in
Part 4, Benefits, Death Benefit Before Maturity
Date, the Contract Value on the date of the
change will be treated as a Payment made on
that date. In addition, all anniversary values,
all Payments made and all amounts deducted in
connection with partial withdrawals prior to
the date of the change of Owner will not be
considered in the determination of the Death
Benefit. This paragraph will not apply if (a)
the individual whose death will cause the Death
Benefit to be paid is the same after the change
of Owner, or (b) if Ownership is transferred to
the Owner's spouse.
If any Annuitant is changed and any Owner is
not an individual, the entire interest in the
Contract must be distributed to the Owner
within five years of the change.
VENTURE.100.P03V00 SAMPLE
3.1
PART 4 BENEFITS
------ --------
ANNUITY BENEFITS We will pay a monthly income to the Annuitant,
if living, on the Maturity Date. Payments can
be fixed or variable, or a combination of fixed
and variable. Annuity benefits will commence on
the Maturity Date and continue for the period
of time provided for under the Annuity Option
indicated on the Specifications Page. On or
before to the Maturity Date, you may change the
Annuity Option.
You may select a Fixed or Variable Annuity.
Unless you indicate otherwise, we will provide
either variable or fixed, or a combination
variable and fixed annuity payments in
proportion to the Investment Account Value of
each Investment Option at the Maturity Date.
Once annuity payments commence, the Annuity
Option may not be changed.
The method used to calculate the amount of the
initial and subsequent payments is described
under the Part 8, Annuity Provisions, of this
Contract.
We may pay the Contract Value, less Debt, on
the Maturity Date in one lump sum if the
monthly income is less than $20.
DEATH BENEFIT BEFORE MATURITY A Death Benefit will be determined as of the
DATE date on which written notice and proof of death
and all required claim forms are received at
the Company's Annuity Service Office as
follows:
The Death Benefit will be determined as the
greater of the Contract Value or the Minimum
Death Benefit described on the Specifications
Page.
If there is any Debt, the Death Benefit equals
the amount described above less the Debt under
the Contract.
We will permit the Owner to limit the Death
Benefit option(s) to be offered any named
Beneficiary, if the Owner provides written
notice to the Company prior to death and the
desired option(s) is one provided for in this
Contract.
DEATH OF ANNUITANT: On the death of the last
surviving Annuitant, the Owner becomes the new
Annuitant, if the Owner is an individual. If
any Owner is not an individual the death of any
Annuitant is treated as the death of an Owner
and the Death Benefit will be determined by
substituting the Annuitant for the Owner as
described below.
DEATH OF OWNER: We will pay the Death Benefit
to the Beneficiary if any Owner dies prior to
the Maturity Date. The Death Benefit may be
taken in one sum immediately, in which case the
Contract will terminate. If the Death Benefit
is not taken in one sum immediately, the
Contract will continue subject to the following
provisions:
(a) The Beneficiary becomes the Owner.
(b) The excess, if any, of the Death Benefit
over the Contract Value will be allocated
to and among the Investment Accounts in
proportion to their values as of the date
on which the Death Benefit is determined.
(c) No additional Payments may be applied to
the Contract.
(d) If the Beneficiary is not the deceased
Owner's spouse, the entire interest in the
Contract must be distributed under one of
the following options:
VENTURE.100.P04V00 SAMPLE
4.1
(i) The entire interest in the Contract
must be distributed over the life of
the Beneficiary, or over a period not
extending beyond the life expectancy
of the Beneficiary, with
distributions beginning within one
year of the Owner's death; or
(ii) the entire interest in the Contract
must be distributed within 5 years of
the Owner's Death.
If the Beneficiary dies before the
distributions required by (i) or (ii) are
complete, the entire remaining Contract
Value must be distributed in a lump sum
immediately.
e) If the Beneficiary is the deceased Owner's
spouse, the Contract will continue with
the surviving spouse as the new Owner. The
surviving spouse may name a new
Beneficiary (and, if no Beneficiary is so
named, the surviving spouse's estate will
be the Beneficiary).
(f) Withdrawal Charges will be waived on any
withdrawals.
If there is more than one Beneficiary, the
foregoing provisions will independently apply
to each Beneficiary, to the extent of that
Beneficiary's share.
DEATH BENEFIT ON OR AFTER If annuity payments have been selected based on
MATURITY DATE an Annuity Option providing for payments for a
guaranteed period, and the Annuitant dies on or
after the Maturity Date, we will make the
remaining guaranteed payments to the
Beneficiary. Any remaining payments will be
made as rapidly as under the method of
distribution being used as of the date of the
Annuitant's death. If no Beneficiary is living,
we will commute any unpaid guaranteed payments
to a single sum (on the basis of the interest
rate used in determining the payments) and pay
that single sum to the estate of the last to
die of the Annuitant and the Beneficiary.
PROOF OF DEATH Proof of death is required upon the death of
the Annuitant or the Owner. Proof of death is
one of the following received at the Annuity
Service Office:
(a) A certified copy of a death certificate.
(b) A certified copy of a decree of a court of
competent jurisdiction as to the finding
of death.
(c) Any other proof satisfactory to us.
4.2
PART 5 PAYMENTS
------ --------
GENERAL All Payments under this Contract are payable at
our Annuity Service Office or such other place
as we may designate. Payment Limits are
identified on the Specifications Page.
NONPAYMENT OF PAYMENTS FOR If, prior to the Maturity Date, no Payments
TWO YEARS have been made for two consecutive Contract
Years, and if both:
(a) the total Payments made, less any partial
withdrawals, are less then $2,000; and
(b) the Contract Value at the end of such two
year period is less than $2,000;
We may cancel this Contract and pay you the
Contract Value (measured as of the Valuation
Period during which the cancellation occurs),
less the Debt and Annual Administration Fee.
ALLOCATION OF NET PAYMENTS When we receive Payments, the Net Payments will
be allocated among Investment Options in
accordance with the allocation percentages
shown on the Specifications Page. You may
change the allocation of subsequent Net
Payments at any time, without charge, by giving
us written notice in a form acceptable to us.
VENTURE.100.P05V00 SAMPLE
5.1
PART 6 VARIABLE ACCOUNT PROVISIONS
------ ---------------------------
INVESTMENT ACCOUNT We will establish a separate Investment Account
for you for each variable Investment Option to
which you allocate amounts. The Investment
Account represents the number of your
Accumulation Units in an Investment Option.
INVESTMENT ACCOUNT VALUE The Investment Account Value of an Investment
Account is determined by (a) times (b) where:
(a) equals the number of Accumulation Units
credited to the Investment Account; and,
(b) equals the value of the appropriate
Accumulation Unit.
ACCUMULATION UNITS We will credit Net Payments to your Investment
Accounts in the form of Accumulation Units. The
number of Accumulation Units to be credited to
each Investment Account of the Contract will be
determined by dividing the Net Payment
allocated to that Investment Account by the
Accumulation Unit value for that Investment
Account.
Accumulation Units will be adjusted for any
transfers and will be canceled on payment of a
death benefit, withdrawal, maturity or
assessment of certain charges based on their
value for the Valuation Period in which such
transaction occurs.
VALUE OF ACCUMULATION UNIT The Accumulation Unit value for a particular
Investment Account for any Valuation Period is
determined by multiplying the Accumulation Unit
value for the immediately preceding Valuation
Period by the "net investment factor" for the
Valuation Period for which the value is being
determined. The value of an Accumulation Unit
may increase, decrease or remain the same from
one Valuation Period to the next.
NET INVESTMENT FACTOR The net investment factor is an index that
measures the investment performance of a
Sub-Account from one Valuation Period to the
next. The net investment factor for any
Valuation Period is determined by dividing (a)
by (b) and subtracting (c) from the result
where:
(a) is the net result of:
1) the net asset value per share of a
Portfolio share held in the
Sub-Account determined as of the end
of the current Valuation Period,
plus:
2) the per share amount of any dividend
or capital gain distributions made by
the Portfolio on shares held in the
Sub-Account if the "ex-dividend" date
occurs during the current Valuation
Period, and
(b) is the net asset value per share of a
Portfolio share held in the Sub-Account
determined as of the end of the
immediately preceding Valuation Period,
and
(c) is the Asset Fee shown on the
Specifications Page.
The net investment factor may be greater or
less than, or equal to, one.
VENTURE.100.P06V00 SAMPLE
6.1
PART 7 FIXED ACCOUNT PROVISIONS
------ ------------------------
INVESTMENT ACCOUNT We will establish a separate Investment Account
for you each time you allocate amounts to a
fixed Investment Option. Amounts invested in
these Investment Accounts will earn interest at
the guaranteed rate in effect on the date the
amounts are allocated for the duration of the
guarantee period.
We will determine the guaranteed rates from
time to time for Net Payments, renewal amounts
and amounts transferred to a fixed Investment
Option.
We reserve the right to restrict Payments,
renewals and transfers to the fixed Investment
Options if the effective annual rate of
interest that would apply to the Payment,
renewal or transfer is equal to the Minimum
Guaranteed Interest Rate on Fixed Accounts, as
specified on the Specifications Page.
GUARANTEE PERIODS For any amounts allocated to the fixed
Investment Options, you have the choice of the
guarantee periods available as shown on the
Specifications Page. The amount can be
allocated into any combination of the fixed
Investment Options offered under this Contract.
Separate Investment Accounts will be
established for each guarantee period. The
guarantee period will be the duration of the
fixed Investment Option selected measured from
the date the amount is allocated to the
Investment Account. Amounts cannot be allocated
to a fixed Investment Option that would extend
the guarantee period beyond the Maturity Date.
RENEWALS The renewal amount is the Investment Account
Value at the end of the particular guarantee
period. The renewal amount will be
automatically renewed in the same Investment
Option at the end of the guarantee period,
unless you specify otherwise. If renewals to
fixed Investment Options are restricted, the
renewal amount will be automatically
transferred into the Restricted Renewal
Transfer Portfolio as described on the
Specifications Page, unless you specify
otherwise. If renewal in a particular
Investment Option would result in the guarantee
period for that Investment Account extending
beyond the Maturity Date, the renewal amount
may not be renewed in that Investment Option.
The renewal amount will be applied to the
longest guarantee period of a fixed Investment
Option such that the guarantee period does not
extend beyond the Maturity Date.
INVESTMENT ACCOUNT VALUE The amount in the fixed Investment Accounts
will accumulate at a rate of interest
determined by us and in effect on the date the
amount is allocated to the Investment Account.
The Investment Account Value is the accumulated
value of the amount invested in the Investment
Account reduced by any withdrawals, loans,
transfers or charges taken from the Investment
Account. In no event will the sum of the
Investment Account Values for all fixed
Investment Options be less than the Minimum
Investment Account Value.
MINIMUM INVESTMENT ACCOUNT The Minimum Investment Account Value is the sum
VALUE of the amounts allocated to all fixed
Investment Accounts reduced by any withdrawals,
loans, transfers or charges taken from all
fixed Investment Accounts, accumulated at the
Minimum Guaranteed Interest Rate on Fixed
Accounts, as specified on the Specifications
Page.
VENTURE.100.P07V00 SAMPLE
7.1
PART 8 ANNUITY PROVISIONS
------ ------------------
VARIABLE ANNUITY PAYMENTS The amount of the first Variable Annuity
payment is determined by applying the portion
of the Contract Value used to effect a Variable
Annuity (minus any applicable premium taxes) to
the appropriate table(s) contained in this
Contract. If the table in use by us on the
Maturity Date is more favorable to you, we will
use that table. The portion of the Contract
Value used to effect a Variable Annuity will be
measured as of a date not more than 10 business
days prior to the Maturity Date.
Subsequent payments will be based on the
investment performance of one or more
Sub-Accounts as you select. The amount of such
payments is determined by the number of Annuity
Units credited for each Sub-Account. Such
number is determined by dividing the portion of
the first payment allocated to that Sub-Account
by the Annuity Unit value for that Sub-Account
determined as of the same date that the
Contract Value used to effect annuity payments
was determined. This number of Annuity Units
for each Sub-Account is then multiplied by the
appropriate Annuity Unit value for each
subsequent determination date, which is a
uniformly applied date not more than 10
business days before the payment is due.
MORTALITY AND EXPENSE We guarantee that the dollar amount of each
GUARANTEE variable annuity payment will not be affected
by changes in mortality and expense experience.
ANNUITY UNIT VALUE The value of an Annuity Unit for each
Sub-Account for any Valuation Period is
determined as follows:
(a) The net investment factor for the
Sub-Account for the Valuation Period for
which the Annuity Unit value is being
calculated is multiplied by the value of
the Annuity Unit for the preceding
Valuation Period; and
(b) The result is adjusted to compensate for
the interest rate assumed in the tables
used to determine the first Variable
Annuity payment.
The dollar value of Annuity Units may increase,
decrease or remain the same from one Valuation
Period to the next.
FIXED ANNUITY PAYMENTS The amount of each Fixed Annuity payment is
determined by applying the portion of the
Contract Value used to effect a Fixed Annuity
measured as of a date not more than 10 business
days prior to the Maturity Date (minus any
applicable premium taxes) to the appropriate
table(s) contained in the Contract. If the
table in use by us on the Maturity Date is more
favorable to the Owner, we will use that table.
We guarantee the dollar amount of Fixed Annuity
payments.
VENTURE.100.P08V00 SAMPLE
8.1
PART 9 TRANSFERS
------ ---------
TRANSFERS BEFORE MATURITY DATE Before the Maturity Date, you may transfer
amounts among Investment Accounts of the
Contract. Amounts will be canceled from the
Investment Accounts from which amounts are
transferred and credited to the Investment
Account to which amounts are transferred. We
will effect such transfers so that the Contract
Value on the date of transfer will not be
affected by the transfer.
We reserve the right to defer, modify or
terminate the transfer privilege at any time
that we are unable to purchase or redeem shares
of the Trust Portfolios. Transfer charges and
limitations are identified on the
Specifications Page.
Amounts may not be transferred from a fixed
Investment Account unless those amounts have
been in the fixed Investment Account for at
least one year.
We reserve the right to restrict transfers to
the fixed Investment Options if the effective
annual rate of interest that would apply to the
transfer is equal to the Minimum Guaranteed
Interest Rate on Fixed Accounts shown on the
Specifications Page.
TRANSFERS ON OR AFTER MATURITY Once variable annuity payments have begun, you
DATE may transfer all or part of the investment upon
which your variable annuity payments are based
from one Sub-Account to another. To do this, we
will convert the number of variable Annuity
Units you hold in the Sub-Account from which
you are transferring to a number of variable
Annuity Units of the Sub-Account to which you
are transferring so that the next annuity
payment, if it were made at that time, would be
the same amount that it would have been without
the transfer. After the transfer, the variable
annuity payments will reflect changes in the
values of your new variable Annuity Units. You
must give us notice at least 30 days before the
due date of the first variable annuity payment
to which the transfer will apply. Transfer
charges and limitations are identified on the
Specifications Page.
After the Maturity Date, transfers will not be
allowed from a fixed to a variable Annuity
Option, or from a variable to a fixed Annuity
Option.
VENTURE.100.P09V00 SAMPLE
9.1
PART 10 WITHDRAWAL PROVISIONS
------- ---------------------
CONTRACT VALUE Your Contract Value is equal to the total of
your Investment Account Values and, if
applicable, any amount in the Loan Account
attributable to the Contract.
PAYMENTS OF WITHDRAWALS You may withdraw part or all of the Contract
Value, less any Debt, at any time before the
earlier of the death of an Owner or the
Maturity Date, by sending us a written request.
We will pay all withdrawals within seven days
of receipt at the Annuity Service Office
subject to postponement in certain
circumstances, as specified below.
SUSPENSION OF PAYMENTS We may defer the right of withdrawal from, or
postpone the date of payments from, the
variable Investment Accounts for any period
when: (1) the New York Stock Exchange is closed
(other than customary weekend and holiday
closings); (2) trading on the New York Stock
Exchange is restricted; (3) an emergency exists
as a result of which disposal of securities
held in the Variable Account is not reasonably
practicable or it is not reasonably practicable
to determine the value of the Variable
Account's net assets; or (4) the Securities and
Exchange Commission, by order, so permits for
the protection of security holders; provided
that applicable rules and regulations of the
Securities and Exchange Commission shall govern
as to whether the conditions described in (2)
and (3) exist.
We may defer the right of withdrawal from the
fixed Investment Accounts for not more than six
months from the day we receive written request
and the Contract, if required. If such payments
are deferred 30 days or more, the amount
deferred will earn interest at a rate not less
than the Minimum Guaranteed Interest Rate on
Fixed Accounts shown on the Specifications
Page.
TOTAL WITHDRAWAL Upon receipt of your request to withdraw the
entire Contract Value, we will terminate the
Contract and pay you the Contract Value, less
any applicable Debt, Withdrawal Charges and the
Annual Fee.
PARTIAL WITHDRAWAL If you are withdrawing part of the Contract
Value, you should specify the amount that
should be withdrawn from each Investment Option
of the Contract. If there are multiple
Investment Accounts under a fixed Investment
Option, the requested amount from that
Investment Option must be withdrawn from those
Investment Accounts on first-in-first-out
basis. If you do not specify, the requested
amount will be withdrawn in the following
order:
a) Variable Investment Accounts, on a pro
rata basis,
b) Fixed Investment Options beginning with
the shortest guarantee period first and
the longest guarantee period last.
We will deduct the Withdrawal Charge, if
applicable, from the Contract Value remaining
after payment of the requested amount.
Partial withdrawals will reduce the Minimum
Death Benefit, as described on the
Specifications Page.
VENTURE.100.P10V00 SAMPLE
10.1
WITHDRAWAL CHARGE If a withdrawal is made from the Contract
before the Maturity Date, a Withdrawal Charge
(contingent deferred sales charge) may be
assessed against Payments. The amount of the
Withdrawal Charge and when it is assessed is
discussed below:
1. The Free Withdrawal Amount is defined on
the Specifications Page.
The Free Withdrawal Amount may be
withdrawn free of a Withdrawal Charge.
The Free Withdrawal Amount will be applied
to your requested withdrawal in the
following order:
(a) withdrawals from the variable
Investment Accounts,
(b) withdrawals from the fixed Investment
Options beginning with the shortest
guarantee period first and the
longest guarantee period last.
2. If a withdrawal is made for an amount
greater than the Free Withdrawal Amount,
Payments will be liquidated on a
first-in-first-out basis. We will
liquidate Payments in the order such
Payments were made: the oldest
unliquidated Payment first, the next
Payment second, etc. until all Payments
have been liquidated.
3. Any Payments liquidated may be subject to
a Withdrawal Charge based on the length of
time the Payment has been in the Contract.
The Withdrawal Charge is determined by
multiplying the amount of the Payment
being liquidated by the applicable
Withdrawal Charge Percentage obtained from
the table shown on the Specifications
Page.
The total Withdrawal Charge will be the
sum of the Withdrawal Charges for the
Payments being liquidated.
4. The Withdrawal Charge is deducted from the
Contract Value remaining after you are
paid the amount requested, except in the
case of a complete withdrawal when it is
deducted from the amount otherwise
payable. In the case of a partial
withdrawal, the amount requested from an
Investment Account may not exceed the
value of that Investment Account less any
applicable Withdrawal Charge.
FREQUENCY AND AMOUNT OF You may make as many partial withdrawals as you
PARTIAL WITHDRAWALS wish. Limitations on the amount of partial
withdrawals are set forth on the Specifications
Page.
10.2
PART 11 FEES AND DEDUCTIONS
------- -------------------
ASSET FEE To compensate us for assuming mortality and
expense risks, and certain administration
expenses, we deduct from each variable
Investment Option a fee each Valuation Period
at an annual rate set forth on the
Specifications Page. A portion of this Asset
Fee may also be used to reimburse us for
distribution expenses. This fee is reflected in
the Net Investment Factor used to determine the
value of Accumulation Units and Annuity Units
of the Contract.
ANNUAL FEE To compensate us for assuming certain
administrative expenses, we charge an Annual
Fee as set forth on the Specifications Page.
Prior to the Maturity Date, the Annual Fee is
deducted on each Contract Anniversary. It is
withdrawn from each Investment Option in the
same proportion that the value of the
Investment Accounts of each Investment Option
bears to the Contract Value. If the Contract
Value is totally withdrawn on any date other
than the Contract Anniversary, we will deduct
the total amount of the Annual Fee from the
amount paid. After the Maturity Date, the
Annual Fee is deducted on a pro rata basis from
each annuity payment.
TAXES We reserve the right to charge certain taxes
against your Payments (either at the time of
payment or liquidation), Contract Value,
payment of Death Benefit, or annuity payments,
as appropriate. Such taxes may include premium
taxes or other taxes levied by any government
entity which we, in our sole discretion,
determine have resulted from the establishment
or maintenance of the Variable Account, or from
the receipt by us of Payments, or from the
issuance of this Contract, or from the
commencement or continuance of annuity payments
under this Contract.
VENTURE.100.P11V00 SAMPLE
11.1
LOAN PROVISIONS
PART 12 (CERTAIN QUALIFIED CONTRACTS ONLY)
------- ----------------------------------
GENERAL This loan provision applies only to certain
Qualified Contracts. All provisions and terms
of a loan are included in the Qualified Plan
Endorsement, if attached.
VENTURE.100.P12V00 SAMPLE
12.1
PART 13 PAYMENT OF CONTRACT BENEFITS
------- ----------------------------
GENERAL Benefits payable under this Contract may be
applied in accordance with one or more of the
Annuity Options described below, subject to any
restrictions of Internal Revenue Code section
72(s). Once annuity payments commence, the
Annuity Option may not be changed.
ALTERNATE ANNUITY OPTIONS Instead of settlement in accordance with the
Annuity Options described below, you may choose
an alternate form of settlement acceptable to
us. Once annuity payments commence, the form of
settlement may not be changed.
DESCRIPTION OF ANNUITY OPTIONS Option 1: Life Annuity
a) Life Non-Refund. We will make payments
during the lifetime of the Annuitant. No
payments are due after the death of the
Annuitant.
b) Life 10-Year Certain. We will make
payments for 10 years and after that
during the lifetime of the Annuitant. No
payments are due after the death of the
Annuitant or, if later, the end of the
10-year period.
Option 2: Joint and Survivor Life Annuity
The second Annuitant named shall be referred to
as the Co-Annuitant.
a) Joint and Survivor Non-Refund. We will
make payments during the joint lifetime of
the Annuitant and Co-Annuitant. Payments
will then continue during the remaining
lifetime of the survivor. No payments are
due after the death of the last survivor
of the Annuitant and Co-Annuitant.
b) Joint and Survivor with 10-Year Certain.
We will make payments for 10 years and
after that during the joint lifetime of
the Annuitant and Co-Annuitant. Payments
will then continue during the remaining
lifetime of the survivor. No payments are
due after the death of the survivor of the
Annuitant and Co-Annuitant or, if later,
the end of the 10-year period.
VENTURE.100.T01V00 SAMPLE
13.1
TABLE OF ANNUITY PAYMENT RATES
ANNUITY PAYMENT RATES The annuity payment rates on the attached
tables show, for each $1,000 applied, the
dollar amount of both: (a) the first monthly
variable annuity payment based on the assumed
interest rate of 3% per year; and (b) the
monthly fixed annuity payment, when this
payment is based on the minimum guaranteed
interest rate of 3% per year. The annuity
payment rates for payments made on a less
frequent basis (quarterly, semiannual or
annual) will be quoted by us upon request.
The annuity payment rates are based on the 1983
Table A projected at Scale G with interest at
the rate of 3% per year, and assume births in
the year 1942. The amount of each annuity
payment will depend upon the sex and adjusted
age of the Annuitant, the Co-Annuitant, if any,
or other payee. The adjusted age is determined
from the actual age nearest birthday at the
time the first monthly annuity payment is due,
as follows:
Calendar Year of Birth Adjustment to Actual Age
---------------------- ------------------------
1899 - 1905 +6
1906 - 1911 +5
1912 - 1918 +4
1919 - 1925 +3
1926 - 1932 +2
1933 - 1938 +1
1939 - 1945 0
1946 - 1951 -1
1952 - 1958 -2
1959 - 1965 -3
1966 - 1972 -4
1973 - 1979 -5
1980 - 1986 -6
1987 - 1993 -7
1994 + -8
The dollar amount of annuity payment for any
age or combination of ages not shown following
or for any other form of Annuity Option agreed
to by us will be quoted on request.
T.1
AMOUNT OF FIRST MONTHLY PAYMENT
PER $1000 OF CONTRACT VALUE
OPTION 1: LIFE ANNUITY
Option 1(A): Non-Refund
Adjusted Age of
Annuitant Male Female
--------------- ----- ------
55 4.27 3.86
60 4.69 4.19
65 5.25 4.61
70 6.02 5.19
75 7.01 5.99
80 8.34 7.10
85 10.13 8.64
Option 1(B): 10-Year Certain
Adjusted Age of
Annuitant Male Female
--------------- ---- ------
55 4.22 3.84
60 4.61 4.15
65 5.10 4.55
70 5.71 5.07
75 6.42 5.73
80 7.20 6.52
85 7.97 7.37
OPTION 2: JOINT AND SURVIVOR LIFE ANNUITY
Option 2(A): Non-Refund
Age of Co-Annuitant
----------------------------------------------------------------
Adjusted Age of 10 Years 5 Years Same 5 Years 10 Years
Male Annuitant Younger Younger Age Older Older
--------------- -------- ------- ---- ------- --------
55 3.25 3.39 3.55 3.72 3.87
60 3.41 3.60 3.81 4.02 4.21
65 3.62 3.87 4.14 4.41 4.67
70 3.89 4.21 4.57 4.95 5.29
75 4.24 4.67 5.17 5.67 6.11
80 4.71 5.30 5.97 6.63 7.19
85 5.35 6.15 7.05 7.92 8.60
Option 2(B): 10 Year Certain
Age of Co-Annuitant
----------------------------------------------------------------
Adjusted Age of 10 Years 5 Years Same 5 Years 10 Years
Male Annuitant Younger Younger Age Older Older
--------------- -------- ------- ---- ------- --------
55 3.25 3.39 3.55 3.72 3.87
60 3.41 3.60 3.80 4.01 4.21
65 3.62 3.86 4.13 4.41 4.66
70 3.89 4.21 4.56 4.92 5.24
75 4.24 4.66 5.13 5.58 5.95
80 4.69 5.25 5.85 6.39 6.78
85 5.28 6.00 6.71 7.27 7.67
Monthly installments for ages not shown will be furnished on request.
T.2
XXXX XXXXXXX LIFE INSURANCE COMPANY (U.S.A.) (XXXX XXXXXXX(R) LOGO)
A STOCK COMPANY
