[Symetra Financial Logo] First Symetra National Life Insurance
Company of New York
[000 Xxxxxxx Xxxxxx, 0xx Xxxxx]
[Xxx Xxxx, XX 00000]
[Mailing Address: PO Box 3882]
[Seattle, WA 98124-3882]
This is a legal Contract between the Owner (referred to in this Contract as
"you" and "your") and First Symetra National Life Insurance Company of New York
(referred to in this Contract as "First Symetra", "our", "us", and "we"). First
Symetra is a stock company with its Home Office in [New York, New York].
This Contract is issued in consideration of the application and payment of
the initial Purchase Payment. First Symetra will make annuity payments,
beginning on the Annuity Date, or pay a death benefit, subject to the terms
of this Contract. First Symetra has executed and attested this Contract as of
the contract date at our Home Office in [New York, New York].
If you have questions, comments, or complaints, please contact First Symetra at
[800-SYMETRA (800-796-3872)].
READ YOUR CONTRACT CAREFULLY
Right to Examine the Contract: If for any reason you are not satisfied with
this Contract, you may return it within 10 days from the date you received it
to First Symetra or to the registered representative who sold you this
Contract. When we receive this contract, we will provide a refund of the
contract value. This may be more or less than your Purchase Payments. The
date of surrender is the date the Contract is mailed to First Symetra or
the date the contract holder actually delivers the contract to the company
or its authorized representative. The contract holder can also surrender
the contract to an authorized sales representative or corporate officer at
one of its regional offices.
Signed for First Symetra National Life Insurance Company of New York by:
/s/Xxxxxx Xxxxx /s/Xxxxxxx X. Xxxxxx
[Xxxxxx Xxxxx] [Xxxxxxx X. Xxxxxx]
Secretary President
INDIVIDUAL FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY
NON-PARTICIPATING
THIS IS A VARIABLE ANNUITY CONTRACT. THE CONTRACT VALUE AND VARIABLE ANNUITY
PAYMENTS ARE BASED ON THE INVESTMENT EXPERIENCE OF THE SUB-ACCOUNTS. THE
CONTRACT VALUE OF THE SUB-ACCOUNTS IS BASED ON THE VALUE OF THE SEPARATE
ACCOUNT ASSETS WHICH ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNTS AND WILL
INCREASE OR DECREASE IN VALUE BASED UPON INVESTMENT RESULTS. THE SMALLEST
ANNUAL RATE OF INVESTMENT RETURN WHICH WOULD HAVE TO BE EARNED ON THE ASSETS
OF THE SEPARATE ACCOUNT SO THAT THE DOLLAR AMOUNT OF VARIABLE ANNUITY PAYMENTS
WILL NOT DECREASE IS 4%. INCOME, GAINS, AND LOSSES (REALIZED AND UNREALIZED)
RESULTING FROM ASSETS IN THE SEPARATE ACCOUNT ARE CREDITED TO OR CHARGED
AGAINST THE SEPARATE ACCOUNT WITHOUT REGARD TO OTHER INCOME, GAINS OR LOSSES
OF FIRST SYMETRA SURRENDER CHARGES MAY APPLY TO EARLY WITHDRAWALS FROM THE
CONTRACT. TRANSFERS BETWEEN INVESTMENT OPTIONS ARE SUBJECT TO RESTRICTIONS.
THIS CONTRACT CONTAINS A WAIVER OF SURRENDER CHARGE IN CERTAIN CIRCUMSTANCES.
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TABLE OF CONTENTS
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CONTRACT DATA PAGE Insert
DEFINITIONS
Accumulation Phase 1
Accumulation Unit 1
Annuitant 1
Annuity Date 1
Annuity Unit 1
Beneficiary 1
Contract 1
Contract Year 1
Income Phase 1
IRC 1
Owner 1
Portfolios 1
Purchase Payment 1
Separate Account 2
Sub-Account 2
THE ANNUITY CONTRACT
ABOUT THE CONTRACT 3
OWNER 3
ANNUITANT 3
BENEFICIARY 4
Change of Beneficiary 4
PURCHASE PAYMENT PROVISIONS
PURCHASE PAYMENTS 5
ALLOCATION OF PURCHASE PAYMENTS 5
ACCUMULATION UNITS 5
INVESTMENT OPTIONS
Sub-Accounts 7
Substitution of Shares 7
CONTRACT VALUE 7
TRANSFERS 7
Limits on Excessive Transfers 7
CHARGES
INSURANCE CHARGES 8
Mortality and Expense Risk Charge 8
Asset-Related Administration Charge 8
ANNUAL ADMINISTRATION MAINTENANCE CHARGE 8
SURRENDER CHARGE 8
WAIVER OF SURRENDER CHARGE UPON CONFINEMENT:
PROVISIONS AND RESTRICTIONS 9
WITHDRAWAL CHARGE 10
TRANSFER CHARGE 10
PREMIUM TAXES 10
INCOME OR OTHER TAXES 10
WITHDRAWAL PROVISIONS
WITHDRAWALS 11
Repetitive Withdrawals 11
ANNUITY PAYMENT PROVISIONS
ANNUITY OPTIONS 12
Life Annuity 12
Life Annuity with Guaranteed Period 12
Joint and Survivor Life Annuity 12
Automatic Option 12
ANNUITY PAYMENTS 13
Fixed Annuity Payments 13
Variable Annuity Payments 13
Changing Sub-Account Elections after the Annuity Date 14
DEATH BENEFIT PROVISIONS
DEATH OF ANNUITANT Prior to the Annuity Date 15
DEATH OF OWNER Prior to the Annuity Date 15
Guaranteed Minimum Death Benefit 15
Calculation of Death Benefit 15
Limitation on Death Benefit 16
Payment of Death Benefit 16
DEATH OF ANNUITANT On or After the Annuity Date 17
DEATH OF OWNER On or After the Annuity Date 17
GENERAL PROVISIONS
ACCOUNT STATEMENTS 18
ASSIGNMENT OF BENEFITS 18
COMMUNICATIONS 18
ESSENTIAL DATA 18
EVIDENCE OF SURVIVAL 18
INCONTESTABILITY 18
JURISDICTION 18
MISSTATEMENT OF AGE OR SEX 19
NONPARTICIPATION 19
SEPARATE ACCOUNT 19
STATE REQUIRED BENEFITS 19
SUSPENSION OF ANNUITY PAYMENTS, WITHDRAWALS, OR TRANSFERS 19
TERMINATION OF CONTRACT 19
THE CONTRACT 20
VOTING RIGHTS 20
ANNUITY PURCHASE RATE TABLES
VARIABLE ANNUITY PURCHASE RATE TABLE 21
FIXED ANNUITY PURCHASE RATE TABLE 22
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DEFINITIONS
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Accumulation Phase The period between the date we allocate your first
Purchase Payment and the Annuity Date.
Accumulation Unit A measurement used to calculate the value of a
Portfolio during the Accumulation Phase.
Annuitant The natural person(s) on whose life/lives annuity
payments are based. You are the Annuitant unless you
designate someone else before the Annuity Date.
Annuity Date The date annuity payments begin under an annuity option.
For Life Annuity Options, the Annuity Date must not be
less than 12 months from the contract date shown on the
contract data page. You may elect to commence annuity
payments as early as thirteen months from the contract
date. The Annuity Date must be a date which is prior
to the date on which the maximum annuitization age shown
on the contract data page is attained.
Annuity Unit A measurement used to calculate variable annuity
payments during the Income Phase.
Beneficiary The person(s) named by the Owner and joint Owner, if
any, to receive any death benefit payable in accordance
with the provisions of this Contract.
Contract This Flexible Premium Deferred Variable Annuity.
Contract Year A 12-month period starting on the contract date shown on
your contract data page and each anniversary of that
date.
Income Phase The period beginning on the Annuity Date during which
the payee receives annuity payments.
IRC The Internal Revenue Code of 1986, as amended.
Owner The person(s) or entity(ies) named on the contract
application, unless changed. The Owner has all ownership
rights under this Contract.
Portfolios The variable investment options available under the
Separate Account.
Purchase Payment An amount paid to First Symetra for allocation under
this Contract, less any premium tax due at the time this
payment is made.
Separate Account A segregated asset account established under New York
law and shown on the contract data page.
Sub-account A division of the Separate Account for which Accumulation
Units and Annuity Units are separately maintained. Each
Sub-account invests exclusively in a particular Portfolio.
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THE ANNUITY CONTRACT
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ABOUT THE CONTRACT This Contract is an agreement between First Symetra
and you, the Owner, where we promise to pay an income
in the form of annuity payments, beginning on the date
you select, or a death benefit. When you are investing
money, your Contract is in the Accumulation Phase.
Once you begin receiving annuity payments, your
Contract is in the Income Phase.
You purchased this Contract with the initial Purchase
Payment you paid, and the Contract became effective on
the contract date, shown on your contract data page.
The minimum initial and subsequent Purchase Payments are
shown on the contract data page.
The Contract is called a variable annuity because you
allocate money among Sub-accounts available within the
Separate Account. The investment performance of the
Sub-account(s) you select may be positive or negative
and affects the value of your Contract and the amount
of any variable annuity payments.
OWNER The Owner is shown on the application, unless changed.
On the contract date, the Owner must not have been older
than the maximum issue age shown on the contract data
page. The Owner may exercise all ownership rights under
this Contract.
If this Contract is owned by joint Owners, they must
jointly exercise their ownership rights, unless we are
directed otherwise by both joint Owners in writing. On
the contract date, each joint Owner must not have been
older than the maximum issue age shown on the contract
data page. An Owner who is a non-natural person (for
example, a corporation or a trust) may not name a
joint Owner.
You may change the Owner or joint Owner by sending us
a signed and dated request. If you designate someone
else as Owner, that person must not have been older
than the maximum issue age on the contract date. Unless
you specify otherwise, a change in ownership is
effective as of the date you signed the notice of
change, subject to any payments made or actions we
may take prior to receipt of the notice.
ANNUITANT The Annuitant is/are the person(s) on whose life/lives
annuity payments are based. You are the Annuitant
unless you designate someone else before the Annuity
Date. If you designate someone else as Annuitant, that
person must not be older than the maximum issue age on
the contract date and the maximum annuitization age when
annuity payments begin. The maximum issue age and the
maximum annuitization age are shown on the contract
data page.
An Owner who is a non-natural person may not change
the Annuitant.
BENEFICIARY The Beneficiary receives any death benefit payable in
accordance with the provisions of this Contract. You
initially name your Beneficiaries on the contract
application.
Change of You may change your Beneficiary designation at any
Beneficiary time by sending us a signed and dated request. However,
if a Beneficiary designation is irrevocable, that
Beneficiary must consent in writing to any change. A
new Beneficiary designation revokes any prior
designation and is effective when signed by the Owner.
We are not responsible for the validity of any
Beneficiary designation nor for any actions we may
take prior to receiving and recording a Beneficiary
change.
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PURCHASE PAYMENT PROVISIONS
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PURCHASE During the Accumulation Phase, you may make additional
PAYMENTS Purchase Payments. You may change the amount and
frequency of Purchase Payments. The minimum dollar
amounts are shown on the contract data page. If you
stop making Purchase Payments, all benefits under this
Contract continue until the contract value is completely
withdrawn.
Purchase Payments must be in lawful currency of the
United States and submitted to our Administrative
Office at [P.O. Box 3882, Seattle, WA 98124-3882], or
in a manner agreed to by First Symetra.
We reserve the right to reject any application by an
Owner or Annuitant who is ineligible for this Contract,
any incomplete application, any Purchase Payment which
does not meet the minimum payment amount shown on the
contract data page, and any Purchase Payment in excess
of $1 million dollars. If we do not accept a Purchase
Payment, we will return it within five business days.
ALLOCATION OF Your initial Purchase Payment will be allocated
PURCHASE according to your instructions on your application.
PAYMENTS Unless you tell us otherwise, subsequent Purchase
Payments will be allocated in the same proportion as
your most recent Purchase Payment (unless that was a
Purchase Payment you directed us to allocate on a
one-time-only basis).
Once we receive your Purchase Payment, the allocation to
the Portfolios is effective and valued as of the next
close of the New York Stock Exchange (NYSE). If for
any reason the NYSE is closed when we receive your
Purchase Payment, it will be valued as of the close of
the NYSE on its next regular business day.
When we are required to guarantee a return of Purchase
Payments during the Right to Examine period, we reserve
the right to initially apply amounts to the [Fidelity
VIP Money Market Portfolio - Service Class 2] as shown
on the cover page of this Contract. These amounts
will then be allocated in the manner you selected,
unless you have canceled the Contract.
ACCUMULATION When you make Purchase Payments or transfers into a
UNITS Sub-account, we credit your Contract with Accumulation
Units. Similarly, when you request a withdrawal or a
transfer of money from a Sub-account, Accumulation Units
are liquidated. In either case, the increase or
decrease in the number of your Accumulation Units is
determined by taking the dollar amount of the Purchase
Payment, transfer, or withdrawal and dividing it by the
value of an Accumulation Unit on the date the
transaction occurs.
We calculate the value of an Accumulation Unit for each
Portfolio after the NYSE closes each day. To determine
the current Accumulation Unit value, we take the prior
day's Accumulation Unit value and multiply it by the Net
Investment Factor for the current day.
The Net Investment Factor is used to measure the daily
change in Accumulation Unit value for each Sub-account.
The Net Investment Factor equals:
- the net asset value per share of a Sub-account
at the end of the current day plus the per
share amount of any dividend or income
distributions made by the Sub-account that day;
divided by
- the net asset value per share of a Sub-account
at the end of the prior day plus the per share
amount of any dividend or income distributions
made by the Sub-account that day; minus
- the daily insurance charges, expressed as a
percentage of the total net assets of the
Sub-account.
The value of an Accumulation Unit will usually go up
or down from day to day.
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INVESTMENT OPTIONS
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SUB-ACCOUNTS You may allocate money to the Sub-accounts shown on
the contract data page. We reserve the right to add,
combine, restrict, or remove any Sub-account as an
investment option of this Contract. Sub-accounts
have different investment objectives. The investment
performance of a Sub-account may be positive or negative.
Substitution If any shares of the Sub-accounts are no longer
of Shares available, or if in our view no longer meet the purpose
of the Contract, it may be necessary to substitute
shares of another Sub-account. We will seek prior
approval of the Securities and Exchange Commission
(SEC) to the extent required by law and give you
notice before doing this.
CONTRACT VALUE Your contract value is the sum of the values in the
Sub-accounts attributable to your Contract. We
calculate this by:
- adding all the Purchase Payments you invested;
- subtracting the charges which have been
deducted;
- subtracting the withdrawals you have made;
- adjusting for each Sub-account's gain or loss;
- subtracting the amounts withdrawn for an
annuity option; and
- subtracting the amounts withdrawn to pay the
death benefit.
TRANSFERS During the Accumulation Phase, you can transfer money
among the Portfolios. The minimum amounts that can be
transferred are shown on the contract data page. In
each Contract Year a specified number of transfers are
free of charge. Each additional transfer in a Contract
Year may have a transfer charge. The number of free
transfers and the transfer charge are shown on the
contract data page.
We reserve the right to modify, suspend, or terminate
transfer privileges at any time if they violate the
provisions outlined in the "Limits on Excessive
Transfers" section of this Contract.
Limits on We may restrict or eliminate the right to make
Excessive transfers among Sub-accounts if such rights are
Transfers executed by you, a market timing firm, or other third
party authorized to initiate transfers or exchange
transactions on your behalf. For example, we reserve
the right to reject any transfer request if, in our
judgment, you are engaging in a pattern of transfer that
may disadvantage other contract owners or would cause a
Portfolio to be unable to invest effectively in
accordance with its investment objectives and policies
or would otherwise be potentially adversely affected.
In addition, if we or any affected Portfolio believes
you are engaging in activity as described above or
similar activity which will potentially hurt the rights
or interests of other contract owners, we have the right
to restrict the number of transfers you make.
We will continue to monitor the transfer activity
occurring among the Sub-accounts and may modify these
transfer restrictions at any time if we deem it
necessary to protect the interest of all contract
owners. These modifications may include curtailing
or eliminating, without notice, certain methods to
request transfers. Portfolios offered in this Contract
may have their own market timing policies and
procedures and impose redemption fees for short-term
investments in their Portfolios. We have the right to
deduct those redemption fees from your contract value.
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CHARGES
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The following charges apply to your Contract:
INSURANCE CHARGES Each day we make deductions for our insurance charges.
We do this as part of our calculation of the value of
Accumulation Units and Annuity Units. The insurance
charges are as follows:
Mortality and Expense The mortality and expense risk charge is equal, on
Risk Charge an annual basis, to a percentage of the average daily
net assets of each Sub-account. The percentage is
shown on the contract data page.
Asset-Related The asset-related administration charge is equal, on
Administration an annual basis, to a percentage of the average daily
Charge net assets of each Sub-account. The percentages are
shown on the contract data page.
The asset-related administration charge is determined
at the start of each Contract Year. The contract value
at the start of a Contract Year determines the
applicable asset-related administration charge. The
asset-related administration charge applies for the
current Contract Year. The applicable charge may go up
or down based on market conditions, deposits,
withdrawals, and surrenders. It may be different for
each Contract and each Contract Year.
ANNUAL ADMINISTRATION The annual administration maintenance charge, shown on
MAINTENANCE the contract data page, will be deducted from your
CHARGE Contract on the last day of each Contract Year and if
you withdraw the entire contract value. The Sub-account
from which this charge is deducted is determined by the
hierarchical order of the Sub-accounts shown on the
contract data page.
We will not deduct this charge if your contract value
is at least equal to the amount shown on the contract
data page when the deduction is to be made. During the
Income Phase, we will not deduct this charge.
SURRENDER CHARGE A surrender charge may be applied to any withdrawal
from the Contract. The surrender charge is a percentage
of the amount withdrawn. The surrender charge is based
on the length of time each Purchase Payment has been
in your Contract according to the schedule shown on
the contract data page. We treat Purchase Payments as
being withdrawn on a first in, first out basis. For
purposes of applying the surrender charge, all
withdrawals are assumed to come from Purchase Payments
first.
You can withdraw 10% of your contract value each
Contract Year without a surrender charge. The
determination of whether more than 10% of the contract
value has been withdrawn is made at the time of
surrender. If you take more than one withdrawal in a
Contract Year, the previous withdrawals in the Contract
Year are added to the current contract value to determine
whether more than 10% of the contract value has been
withdrawn in that Contract Year.
Surrender charges will not be assessed on the following:
- withdrawals, if the total amount withdrawn
during the Contract Year does not exceed 10% of
the contract value;
- withdrawals taken for payment of the annual
administration maintenance charge, withdrawal
charges, transfer charges, or premium taxes;
- repetitive withdrawals, if the withdrawals are
equal or substantially equal and are expected
to deplete the contract value over your life
expectancy or the joint life expectancy of you
and your joint Owner (or, if applicable you and
your Beneficiary). If you take additional
withdrawals or otherwise modify or stop the
repetitive withdrawals, however, the repetitive
withdrawals taken during the Contract Year will
be included when determining whether more than
10% of the contract value has been withdrawn;
- annuity payments; and
- withdrawals taken on account of your death.
WAIVER OF Surrender charges will also not be assessed on the
SURRENDER following:
CHARGES UPON
CONFINEMENT: - withdrawals taken after you have been
PROVISIONS AND confined to a hospital or nursing
RESTRICTIONS home for 30 consecutive days if the
withdrawal is taken:
- during confinement; or
- within 60 days after confinement ends.
The 30-day period may be satisfied by confinement in
a combination of hospitals, nursing homes, or
home care. Separate periods of confinement
occurring within 6 months of the start of a
previous 30 consecutive day period
of confinement for the same or related condition
will be considered the same confinement.
A new 30 consecutive day period will be applied for
a confinement due to a new or non-related cause or
to a confinement occurring more than six months
from the most recent confinement for the same or
related condition.
If you are confined to a hospital or nursing home
on the contract date, you are not eligible for
this waiver of surrender charges until after the
first Contract Year.
We may require proof of confinement. Proof of
confinement may include a billing statement from the
hospital or nursing home showing the dates of
confinement and service or a certification of
confinement signed by your attending physician.
Hospital is defined in one of two ways:
(1) a lawfully operated institution that is
licensed as a hospital by the Joint Commission
of Accreditation of Hospitals; or
(2) a lawfully operated institution that provides
in-patient treatment under the direction of a
staff of physicians and has 24-hour per
day nursing services.
Nursing home is defined as a facility operated
pursuant to state law that provides convalescent or
chronic care for in-patients who, by reason of
illness or infirmity, are unable to properly care for
themselves.
Physician means a health care practitioner licensed,
board certified or board eligible in the state of
New York, who is qualified to practice in the area of
medicine or in a specialty appropriate to treat the
Owner's condition or disease. It does not include the
Owner, the Annuitant, or a member of the
Owner'(s) or Annuitant'(s) family.
Home care means the care and treatment of the Owner who
is under the care of a physician but only if confinement
in a hospital or nursing home would otherwise
have been required f home care was not provided. The
plan covering the home health service must be
established and approved in writing by the attending
physician.
WITHDRAWAL CHARGE The withdrawal charge, shown on the contract data page,
is deducted for each withdrawal after the first
withdrawal in a Contract Year. This charge will be
deducted from your remaining contract value, unless you
tell us otherwise.
We will not deduct this charge for annuity payments,
repetitive withdrawals using electronic funds transfer
(EFT), or if the entire contract value is withdrawn.
TRANSFER CHARGE The transfer charge is deducted from your Contract for
each transfer in excess of the number of free transfers
allowed in a Contract Year. The transfer charge and
the number of free transfers are shown on the contract
data page.
Scheduled transfers authorized by us as part of an
investment strategy such as dollar cost averaging,
appreciation sweep, Sub-account rebalancing, or asset
allocation programs do not count against your free
transfers.
PREMIUM TAXES The contract data page shows whether or not premium tax
is charged in your state as of the contract date.
INCOME OR OTHER TAXES Currently we do not pay income or other taxes on
earnings attributable to your Contract. However, if we
ever incur such taxes, we reserve the right to deduct
them from your Contract.
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WITHDRAWAL PROVISIONS
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WITHDRAWALS During the Accumulation Phase, you may withdraw part
or all of your contract value. The minimum amount
that can be withdrawn is shown on the contract data
page.
To take withdrawals, you must send a written request
to our Administrative Office. Unless you tell us
differently, partial withdrawals will be made pro
rata from each Sub-account. Once we receive your
request, withdrawals from the Sub-accounts will be
effective as of the next close of the NYSE.
A withdrawal may have a surrender charge, a withdrawal
charge, and, if you withdraw the entire contract value,
an annual administration maintenance charge.
Repetitive You may request repetitive withdrawals of a
Withdrawals predetermined amount on a monthly, quarterly, or
annual basis by completing the appropriate form.
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ANNUITY PAYMENT PROVISIONS
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ANNUITY OPTIONS The Income Phase will start no later than the maximum
annuitization age shown on the contract data page,
or an earlier date if required by law. During the
Income Phase, the payee (you or someone you choose)
receives regular annuity payments beginning on the Annuity Date.
To start the Income Phase, you must notify us in
writing at least 30 days prior to the date that you
want annuity payments to begin. You may choose annuity
payments under an annuity option described in this
Contract or another annuity option that you want and
that we agree to provide. You cannot start the Income
Phase until the Contract has been in effect for at
least one year. If the amount applied to an annuity
option is less than $2,000, we may make payment in a
lump sum where permitted by state law. We reserve the
right to change the payment frequency if payment
amounts would be less than $250.
Switching to the Income Phase is irrevocable. Once you
begin receiving annuity payments, you cannot switch
back to the Accumulation Phase. You cannot add
Purchase Payments, change or add an Annuitant, change
the annuity option, or change between fixed and
variable annuity payments. When the Contract switches
to the Income Phase, the guaranteed minimum death
benefit will no longer be applicable.
The annuity benefits at the time of their commencement
will not be less than those that are provided by the
application of the amount to purchase any single
consideration immediate annuity contract offered by
First Symetra at the same time to the same class of
annuitants.
Annuity payment options based on a life ensure that the
annuitant or annuitants cannot outlive the annuity
payments. The duration of the annuitant's life or
annuitants lives determines how long payments continue
under the following options:
Life Annuity The payee receives monthly annuity payments as long as
the Annuitant is living. Annuity payments stop when the
Annuitant dies.
Life Annuity with The payee receives monthly annuity payments for the
Guaranteed Period longer of the Annuitant's life or a guaranteed period of
five or more years as selected by you and agreed to by
us. If the Annuitant dies before all guaranteed payments
have been made, the remaining payments due will be made
to the payee designated by the Owner. Annuity payments
stop the later of the date the Annuitant dies or the date
the last guaranteed payment is made.
As an alternative to monthly payments, the Owner may
elect to have the present value of the guaranteed
variable annuity payments remaining as of the date
the notice of death is received by us commuted at
the assumed investment return of 4% and paid in a
single payment.
Joint and Survivor Life The payee receives monthly annuity payments as long
Annuity as the Annuitant is living. After the Annuitant dies,
the payee receives a specified percentage of each
annuity payment as long as the joint Annuitant is
living. You name the joint Annuitant and payment
percentage at the time you elect this option. Annuity
payments stop the later of the date the Annuitant dies
or the date the joint Annuitant dies.
Automatic Option If you do not choose an annuity option at least 30 days
before the latest Annuity Date allowed under this
Contract, we will make variable annuity payments under
the Life Annuity with Guaranteed Period annuity option.
The guaranteed period will be equal to 10 years, unless
otherwise required by the IRC.
ANNUITY PAYMENTS You can choose whether annuity payments will be made on
a fixed basis, variable basis, or both. After the
Annuity Date, you may not switch between fixed annuity
payments and variable annuity payments.
Fixed Annuity Payments The dollar amount of each fixed annuity payment will
stay the same. Annuity payments will be determined
by applying the contract value that you want to use to
purchase fixed annuity payments to the Fixed Annuity
Purchase Rate Table of this Contract, or the current
rates at that time if more favorable to you. If
premium taxes are required by state law, these taxes
will be deducted before the annuity payments are
calculated.
Variable Annuity The dollar amount of each variable annuity payment will
Payments vary depending on the investment performance of the
Sub-accounts that you selected. Unless we receive
different instructions, variable annuity payments will
be based on the investment allocations in place on the
Annuity Date. Variable annuity payments will be
determined as described below.
First Variable Annuity Payment: The dollar amount of
the first variable annuity payment is the sum of the
payments from each Sub-account determined by applying
the contract value used to purchase variable annuity
payments, as of the 15th day of the preceding month,
to the Variable Annuity Purchase Rate Table of this
Contract. If the NYSE is not open on that date, the
calculation will be made on the next day that the NYSE
is open. If premium taxes are required by state law,
these taxes will be deducted before the annuity payment
is calculated.
Subsequent Variable Annuity Payments: The dollar amount
of each subsequent variable annuity payment is the sum
of the payments from each Sub-account, which are
determined by multiplying the number of Annuity Units
credited for that Portfolio by the Annuity Unit value
of that Sub-account as of the 15th of the month
preceding the annuity payment. If the NYSE is not
open on that date, the calculation will be made on the
next day that the NYSE is open.
Number of Variable Annuity Units: The number of
Annuity Units credited for each Sub-account is
the amount of the first annuity payment
attributable to that Sub-account divided by the
value of the applicable Annuity Unit for that
Sub-account as of the 15th day of the month
preceding the Annuity Date. The number of
Annuity Units used to calculate the variable
annuity payment each month remains constant
unless you change Sub-account elections.
Value of Variable Annuity Units: The value of
an Annuity Unit will usually increase or
decrease from one month to the next. For
each month after the first month, the value
of an Annuity Unit of a particular Sub-account
is:
- the value of that Annuity Unit as of
the 15th day of the preceding month
(or the next day that the NYSE is open);
- multiplied by the Net Investment
Factors for that Sub-account; and
- divided by the Assumed Investment
Factor for the period.
The Net Investment Factor is a number that
represents the change in the Accumulation Unit
value of a Sub-account on successive days when
the NYSE is open. The Net Investment Factor for
any Sub-account for any valuation day is
determined by dividing the current Accumulation
Unit value by the prior day's Accumulation Unit
value. The Net Investment Factor will likely
be different than the Assumed Investment Factor,
and therefore the Annuity Unit value will usually
increase or decrease.
The Assumed Investment Factor for a one-day
valuation period is 1.00010746. This factor
neutralizes the assumed investment return of 4%
in the Variable Annuity Purchase Rate Table.
We guarantee that the dollar amount of each variable
annuity payment made after the first payment will not
be adversely affected by variations in actual mortality
experience or actual expenses incurred in excess of the
expense deductions provided for in the Contract.
Changing Sub-account If you have selected variable annuity payments, after
Elections after the Annuity Date you may request to change Sub-account
the Annuity Date elections once a month. Changes will affect the number
of units used to calculate annuity payments.
-------------------------------------------------------------------------------
DEATH BENEFIT PROVISIONS
-------------------------------------------------------------------------------
DEATH OF ANNUITANT If the Annuitant is not an Owner and the Annuitant dies
Prior to the Annuity before the Annuity Date, you must designate a new
Date Annuitant. If no designation is made within 30 days
after we are notified of the Annuitant's death, you
will become the Annuitant.
If this Contract is owned by a non-natural person (for
example, a corporation or trust), the death of the
Annuitant will be treated as the death of the Owner.
In this case, all references to "Owner" and "joint
Owner" in these provisions are replaced by "Annuitant"
and "joint Annuitant".
DEATH OF OWNER If any Owner dies before the Annuity Date, we will pay
Prior to the a death benefit to the:
Annuity Date - surviving Owner; or if none, then
- surviving primary Beneficiary(ies); or if none,
then
- surviving contingent Beneficiary(ies); or if
none, then
- the estate of the last Owner to die.
If the death benefit is payable to the Owner's spouse,
the spouse will have the option to continue the Contract
and will then be the Owner of the Contract.
Guaranteed The guaranteed minimum death benefit is initially equal
Minimum Death to the first Purchase Payment. It is immediately
Benefit increased by additional Purchase Payments and
proportionately reduced for withdrawals. After such
withdrawals, the guaranteed minimum death benefit will
be recalculated by multiplying the prior guaranteed
minimum death benefit by the ratio of the contract
value after the withdrawal to the contract value
before the withdrawal.
Calculation of Death If the Owner or older joint Owner is under age 75 at
Benefit the time of death, the death benefit on the calculation
date is the sum of:
(1) the contract value; plus
(2) any excess of the guaranteed minimum death
benefit over the contract value.
If the Owner is age 75 or older at the time of death,
the death benefit is the contract value.
The guaranteed minimum death benefit is always
calculated on the life of the oldest original Owner, as
shown on the original application for this Contract.
The amount payable on the death of any Owner other than
the oldest original Owner will be the current contract
value. If the oldest original Owner ceases to be an
Owner of the Contract, the guaranteed minimum death
benefit will be terminated.
When determining (1) and (2) above, the calculations are
based on the earlier of:
- the date we receive proof of death and the first
election of how to take the death benefit
payment; or
- six months from the date of death.
If we receive due proof of death and the first death
benefit payment election within 6 months of the date of
death: If the guaranteed minimum death benefit exceeds
the contract value, we will add the difference to the
contract value on the date we receive the required
information so that the contract value will equal the
guaranteed minimum death benefit. This additional amount
will be allocated to the Sub-accounts in the same
proportion that Purchase Payments were last allocated.
Thereafter, the contract value will be subject to
investment performance and applicable charges until the
date the death benefit is paid.
If we receive due proof of death and the first death
benefit payment election more than 6 months after the
date of death: If the guaranteed minimum death benefit
exceeds the contract value on the 6-month anniversary of
the date of death, we will credit the difference with
interest at the currently offered money market
Sub-account rate from the 6-month anniversary until the
date we receive the required information. At that time
we will allocate this additional amount, with the
credited interest, to the Portfolios in the same
proportion that Purchase Payments were last allocated.
Thereafter, the contract value will be subject to
investment performance and applicable contract charges
until the date payment is made.
Limitation on Death At most, one guaranteed minimum death benefit will be
Benefit paid during the life of the Contract. In addition, the
maximum amount that we will add to the contract value
is limited to $1 million. This limitation applies to
any amount added to the contract value so that the
contract value equals the guaranteed minimum death
benefit.
Payment of Death To pay the death benefit, we need proof of death
Benefit acceptable to us, such as a certified copy of a death
certificate, plus written direction regarding how to pay
the death benefit payment. If the death benefit is
payable to an Owner's estate, we will pay it in a single
payment.
Upon receiving due proof of death we will credit interest
at the rate required by law.
The death benefit may be paid as:
- a lump sum payment or series of withdrawals
that are completed within five years from the
date of death; or
- annuity payments made over life or life
expectancy. To receive annuity payments, this
election must be made within 60 days from our
receipt of proof of death. Annuity payments
must begin within one year from the date of
death. Once annuity payments begin, they
cannot be changed.
If a person entitled to receive a death benefit dies
before the death benefit is distributed, we will pay
the death benefit to that person's named beneficiary
or, if none, to that person's estate.
DEATH OF ANNUITANT If the Annuitant is not the Owner and dies after the
On or After the Annuity Date, then we will continue paying any remaining
Annuity Date annuity payments to the payee designated by the Owner.
DEATH OF OWNER If the Owner dies after the Annuity Date, any amounts
On or After the paid will depend on the annuity option then in effect.
Annuity Date The right to change the payee for remaining annuity
payments is determined as follows:
- the surviving Owner; or if none, then
- the surviving primary Beneficiary(ies); or if
none, then
- the surviving contingent Beneficiary(ies); or
if none, then
- the estate of the last Owner to die.
-------------------------------------------------------------------------------
GENERAL PROVISIONS
-------------------------------------------------------------------------------
ACCOUNT STATEMENTS At least once each calendar year we will furnish you
with a statement with a date not more than four months
prior to the mailing date showing your contract value
or, if applicable and required by law, your Annuity
Units and the Annuity Unit values.
ASSIGNMENT OF BENEFITS You may assign your rights under this Contract unless
restricted by applicable law. If this Contract is
assigned, we will treat it as a change of ownership
and all rights will be transferred. The new Owner
must not have been older than the maximum issue age
on the contract date. We are not bound by any
assignment unless it is in writing. We are not
responsible for the validity of any assignment.
Assignments are effective on the date the notice of
assignment is signed by the Owner, subject to all
payments made and actions taken by us before a signed
copy of the assignment form is received by us at our
Administrative Office. To the extent allowed by law,
payments under this Contract are not subject to legal
process for the claims of creditors.
COMMUNICATIONS All written communications to you will be addressed to
you at your last known address on file with First
Symetra.
All written communications to First Symetra must be
addressed to First Symetra at its Administrative Office
at [P.O. Box 3882, Seattle, Washington 98124-3882].
ESSENTIAL DATA You and each person entitled to receive benefits under
this Contract must provide us with any information we
need to administer this Contract. We are entitled to
rely exclusively on the completeness and accuracy of
data furnished by you, and we will not be liable with
respect to any omission or inaccuracy.
EVIDENCE OF SURVIVAL When any payments under this Contract depend upon any
person being alive on a given date, we may require
satisfactory proof that the person is living before
making such payments.
INCONTESTABILITY This Contract and any rider(s) or endorsement(s)
presently attached to this Contract are incontestable as
to the material facts of the application for the
Contract and to the representations of the Owner after
such Contract has been in force during the lifetime of
the Owner for two years from its date of issue. If any
rider or endorsement subsequently attached to this
Contract provides supplemental benefits that the Owner
applied for after the Contract was issued, such rider
or endorsement is incontestable as to the material
facts of the application for the supplemental benefit
and to the representations of the Owner after such
rider or endorsement has been in force during the
lifetime of the Owner for two years from its date of issue.
JURISDICTION In the event of a dispute, the laws of the jurisdiction
in which the Contract is delivered will apply.
MISSTATEMENT OF AGE We may require satisfactory proof of correct age or sex
OR SEX at any time.
- If annuity payments are based on life or life
expectancy and the age or sex of any Annuitant
has been misstated, annuity payments will be
based on the corrected information.
Underpayments will be made up in a lump sum
with the next scheduled payment. Overpayments
will be deducted from future payments until the
total is repaid. We will not credit interest
on underpayments or charge interest on overpayments.
- If the age of any Annuitant or Owner has been
misstated, the amount of any death benefit payable
will be determined based on the correct age of
the Annuitant or Owner.
NONPARTICIPATION This Contract is nonparticipating, which means it will
not share in any distribution of profits, losses, or
surplus of First Symetra.
SEPARATE ACCOUNT The Separate Account holds the assets that underlie the
contract values invested in the Portfolios. The assets
in the Separate Account are the property of First
Symetra. However, assets in the Separate Account
that are attributable to Contracts are not chargeable
with liabilities arising out of any other business we
may conduct. Income, gains and losses (realized and
unrealized), resulting from assets in the Separate
Account are credited to or charged against the Separate
Account without regard to other income, gains or losses
of First Symetra.
STATE REQUIRED BENEFITS The death benefit, contract value and paid up annuity
benefits under this Contact will not be less than the
minimum benefits required by any statute of any state
in which this Contract is delivered.
SUSPENSION OF ANNUITY We may be required to suspend or postpone payment of
PAYMENTS, WITHDRAWALS, annuity payments, withdrawals, or transfers from
OR TRANSFERS the Sub-accounts for any period of time when:
- the NYSE is closed (other than customary
weekend or holiday closings);
- trading on the NYSE is restricted;
- an SEC declared emergency exists such that
disposal of or determination of the value of
the Sub-account shares is not reasonably
practicable; or
- the SEC, by order, so permits for your
protection.
TERMINATION OF CONTRACT This Contract will terminate when First Symetra has
completed all of its duties and obligations under the
Contract.
THE CONTRACT The entire Contract between you and First Symetra
consists of this Contract, contract data page, any
endorsements, amendments or riders, and contract
application, a copy of which is attached to the
Contract.
All statements made by or under the authority of the
applicant for issuance of the contract are deemed to be
representations and not warranties.
The terms and conditions of this Contract may be amended
by written endorsement or amendment and signed by an
authorized officer of First Symetra. Any change must be
in writing. No other person can change any of the terms
or conditions of this Contract. First Symetra reserves
the right to change the provisions of this Contract to
conform to any applicable law, regulation, or ruling
issued by a government agency.
VOTING RIGHTS First Symetra is the legal owner of the Portfolios'
shares. However, when a Portfolio solicits proxies in
connection with a shareholder vote, we are required to
ask you for instructions as to how to vote those
shares. All shares are voted in the same proportion
as the instructions we received. Should we determine
that we are no longer required to comply with the above,
we will vote the shares in our own right. In addition,
we may disregard shareholder voting instructions:
- if required by regulatory officials if such
instructions would require us to vote the
shares so as to cause a change in sub-
classification or investment objectives of one
or more of the Portfolios, or to approve or
disapprove an investment advisory agreement;
- if such instructions would require changes in
the investment objective or investment advisor
of a Portfolio or be inconsistent with the
investment objectives of a Portfolio;
- vary from the general quality and nature of
investments and investment techniques used by
other Portfolios with similar investment
objectives and underlying other variable
contracts offered by First Symetra Life or of
an affiliated insurance company; or
- violate state or federal law.
If we disregard voting instructions, we will notify
contract owners of our actions and of our reasons for
doing so in our next semi-annual report.
-------------------------------------------------------------------------------
ANNUITY PURCHASE RATE TABLES
-------------------------------------------------------------------------------
VARIABLE ANNUITY PURCHASE RATE TABLE
MORTALITY TABLE USED: The rates in the Variable Annuity Purchase Rate Table
are based upon the Annuity 2000 Mortality Table projected using a generational
approach with an initial projection of 20 years. An age setback of 1 year will
be used if the annuity payments begin in the year 2013-2022, 2 years if the
annuity payments begin in the year 2023-2032, and an additional 1-year setback
for each additional 10 years. The assumed investment return in the table is
4.00%. Age is to be taken for the exact number of years and completed months.
Values for fractional ages are obtained by simple interpolation. Consideration
for ages or combination of lives not shown will be furnished by First Symetra
upon request.
Consideration Required to Purchase $1 of Monthly Variable Annuity*
Life Annuity Life Annuity Life Annuity Joint & Survivor**
No Period Certain 5 Years Certain 10 Years Certain
5 Years
Life Certain
Age Male Female Male Female Male Female Annuity and Life
60 $197.53 $212.16 $198.19 $212.54 $200.20 $213.72 $230.94 $230.94
61 193.64 208.52 194.37 208.94 196.57 210.24 227.76 227.76
62 189.65 204.77 190.44 205.23 192.88 206.66 224.45 224.46
63 185.55 200.90 186.42 201.42 189.13 202.98 221.03 221.04
64 181.35 196.93 182.31 197.50 185.33 199.22 217.48 217.50
65 177.06 192.84 178.12 193.47 181.50 195.37 213.81 213.83
66 172.68 188.65 173.87 189.33 177.63 191.43 210.02 210.04
67 168.23 184.34 169.56 185.09 173.76 187.42 206.09 206.12
68 163.72 179.91 165.22 180.74 169.88 183.34 202.05 202.08
69 159.18 175.37 160.85 176.29 166.01 179.20 197.88 197.92
70 154.60 170.71 156.48 171.73 162.17 175.01 193.59 193.64
71 150.02 165.94 152.11 167.08 158.37 170.78 189.18 189.24
72 145.44 161.07 147.76 162.36 154.62 166.52 184.66 184.74
73 140.86 156.11 143.42 157.57 150.93 162.26 180.03 180.13
74 136.27 151.08 139.09 152.73 147.30 158.01 175.30 175.43
75 131.68 145.99 134.77 147.87 143.74 153.79 170.48 170.63
76 127.09 140.88 130.49 143.00 140.26 149.63 165.58 165.76
77 122.51 135.74 126.25 138.13 136.87 145.54 160.59 160.83
78 117.95 130.59 122.05 133.29 133.58 141.54 155.55 155.83
79 113.42 125.44 117.92 128.46 130.42 137.65 150.44 150.79
80 108.93 120.28 113.85 123.67 127.38 133.89 145.29 145.72
81 104.49 115.13 109.87 118.94 124.48 130.28 140.10 140.62
82 100.10 110.01 105.98 114.28 121.74 126.86 134.89 135.53
83 95.78 104.94 102.19 109.72 119.16 123.63 129.67 130.45
84 91.53 99.92 98.50 105.28 116.75 120.62 124.46 125.41
85 87.36 94.99 94.94 100.98 114.50 117.82 119.27 120.42
86 83.26 90.15 91.50 96.85 112.41 115.23 114.12 115.52
87 79.24 85.43 88.21 92.92 110.47 112.85 109.02 110.72
88 75.30 80.83 85.06 89.19 108.68 110.66 103.99 106.04
89 71.50 76.43 82.09 85.70 107.04 108.66 99.07 101.53
90 67.84 72.24 79.28 82.44 105.56 106.88 94.29 97.19
* The consideration shown refers to the net value of the Portfolios used
to purchase a variable annuity after premium taxes or other applicable
charges are deducted. For example, if the Annuitant is a 65-year old
male, a Life Annuity initially equivalent to a monthly income of
$1,000 will cost $177,060. However, because this is a variable
annuity, the dollar amount of this monthly income is not guaranteed
and may increase or decrease.
** Annuitant and joint Annuitant are assumed to be the same age. The rate
table for the Joint & Survivor is calculated based on 100% of annuity
payments to the surviving Annuitant.
FIXED ANNUITY PURCHASE RATE TABLE
MORTALITY TABLE USED: The rates in the Fixed Annuity Purchase Rate Table are
based upon the Annuity 2000 Mortality Table projected using a generational
approach with an initial projection of 20 years. The effective interest
rate assumed in the table is 2.00%.
Age is to be taken for the exact number of years and completed months. Values
for fractional ages are obtained by simple interpolation. Consideration for
ages or combination of lives not shown will be furnished by First Symetra upon
request.
Consideration Required to Purchase $1 of Monthly Fixed Annuity*
Life Annuity Life Annuity Life Annuity Joint & Survivor**
No Period Certain 5 Years Certain 10 Years Certain 5 Years
Life Certain
Age Male Female Male Female Male Female Annuity and Life
60 $255.94 $279.92 $256.65 $280.33 $258.98 $281.70 $311.12 $311.13
61 249.36 273.38 250.13 273.83 252.70 275.34 304.87 304.88
62 242.72 266.76 243.56 267.26 246.40 268.91 298.51 298.52
63 236.01 260.05 236.93 260.60 240.09 262.42 292.04 292.05
64 229.25 253.27 230.27 253.88 233.78 255.88 285.46 285.48
65 222.44 246.42 223.57 247.09 227.50 249.29 278.79 278.81
66 215.61 239.50 216.87 240.23 221.25 242.67 272.02 272.04
67 208.76 232.51 210.18 233.31 215.06 236.02 265.15 265.18
68 201.92 225.45 203.52 226.33 208.93 229.36 258.20 258.23
69 195.12 218.32 196.91 219.30 202.90 222.69 251.16 251.21
70 188.37 211.14 190.37 212.22 196.98 216.04 244.06 244.11
71 181.68 203.90 183.91 205.12 191.19 209.41 236.88 236.95
72 175.07 196.62 177.54 198.00 185.53 202.84 229.66 229.74
73 168.55 189.33 171.28 190.88 180.01 196.34 222.38 222.49
74 162.10 182.04 165.10 183.81 174.64 189.94 215.08 215.21
75 155.71 174.78 159.01 176.79 169.43 183.67 207.75 207.91
76 149.41 167.58 153.04 169.85 164.39 177.55 200.41 200.61
77 143.20 160.44 147.18 163.00 159.52 171.61 193.08 193.33
78 137.08 153.39 141.45 156.26 154.85 165.86 185.77 186.08
79 131.07 146.41 135.87 149.64 150.39 160.32 178.49 178.87
80 125.19 139.52 130.43 143.14 146.14 155.02 171.25 171.71
81 119.42 132.74 125.16 136.80 142.13 149.99 164.06 164.63
82 113.80 126.08 120.06 130.63 138.35 145.25 156.95 157.64
83 108.31 119.55 115.13 124.65 134.83 140.82 149.93 150.77
84 102.96 113.18 110.38 118.89 131.56 136.71 143.01 144.03
85 97.76 106.98 105.83 113.37 128.54 132.93 136.21 137.45
86 92.70 100.97 101.48 108.12 125.74 129.45 129.54 131.05
87 87.79 95.16 97.34 103.14 123.18 126.28 123.02 124.85
88 83.02 89.57 93.42 98.48 120.82 123.38 116.67 118.88
89 78.46 84.26 89.74 94.14 118.68 120.77 110.53 113.17
90 74.10 79.24 86.28 90.11 116.76 118.46 104.61 107.73
*The consideration shown refers to the net value used to purchase a
fixed annuity after premium taxes or other applicable charges are deducted.
For example, if the Annuitant is a 65-year old male, a Life Annuity which
provides a guaranteed monthly income of $1,000 will cost $222,440.
**Annuitant and joint Annuitant are assumed to be the same age. The
rate table for the Joint & Survivor is calculated based on 100% of annuity
payments to the surviving Annuitant.
INDIVIDUAL FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY
NON-PARTICIPATING
CONTRACT DATA PAGE
PRODUCT: [First Symetra[registered trademark symbol] Focus Variable Annuity]
OWNER: [Xxxx Xxx] JOINT OWNER: [Xxxx Xxx]
Address: [0000 Xxxx Xx.] Address: [0000 Xxxx Xx.]
[Xxx Xxxx, XX 00000-0000] [Any City, ST 00000-0000]
Date of Birth: [1/01/1970] Date of Birth: [2/01/1970]
Age: [35] Sex: [Male] Age: [35] Sex: [Female]
ANNUITANT: [Xxxx Xxx] JOINT ANNUITANT: [Xxxx Xxx]
Address: [0000 Xxxx Xx.] Address: [0000 Xxxx Xx.]
[Xxx Xxxx, XX 00000-0000] [Any Xxxx, XX 00000-0000]
Date of Birth: [1/01/1970] Date of Birth: [2/01/1970]
Age: [35] Sex: [Male] Age: [35] Sex: [Female]
CONTRACT NUMBER: [LP12345678]
CONTRACT DATE: [5/01/2005]
PRODUCT TYPE: [Non-Qualified]
ANNUITY DATE: Not Later Than [12/31/2065]
INITIAL PURCHASE PAYMENT: [$50,000]
GUARANTEED MINIMUM DEATH BENEFIT
AGE EXTENSION RIDER: [Yes or No]
DELIVERED IN THE STATE OF New York AND GOVERNED BY ITS LAWS.
MAXIMUM ISSUE AGE: [85]. The contract date must be prior to the Owner's and Annuitant's
(including any Joint Owner's and Joint Annuitant's) [86th] birthday.
MAXIMUM ANNUITIZATION AGE: [95]. Annuity payments must begin prior to the Annuitant's
(including any Joint Annuitant's) [96th] birthday.
MINIMUM INITIAL PURCHASE PAYMENT: [$10,000]
MINIMUM SUBSEQUENT PURCHASE PAYMENT: [$10,000]
INSURANCE CHARGES:
MORTALITY AND EXPENSE RISK CHARGE: Equal on an annual basis to 1.10% of the average
daily net assets of each Portfolio.
ASSET-RELATED ADMINISTRATION CHARGE: Equal on an annual basis of the average daily net
assets of each Portfolio as follows:
0.45% if contract value is less than $100,000
0.35% if contract value is between $100,000 and $249,999.99
0.25% if contract value is between $250,000 and $499,999.99
0.15% if contract value is between $500,000 and $999,999.99
0.05% if contract value equal or exceeds $1,000,000
The contract value at the start of the current Contract Year will determine the asset-
related administration charge to be applied to the Contract for that Contract Year.
ANNUAL ADMINISTRATION MAINTENANCE CHARGE: $[40] each Contract Year. The charge may be changed
prior to the Annuity Date, but will never exceed $50 each Contract Year. The charge will not be
deducted if the contract value is $50,000 or more when the charge is to be deducted.
MINIMUM WITHDRAWAL: $500. You must withdraw the entire amount out of an investment option if, after
a withdrawal, the remaining balance in the investment option would be less than $500. You must
withdraw the entire contract value and your Contract will terminate if, after a withdrawal, the
remaining contract value would be less than $5,000.
SURRENDER CHARGE SCHEDULE:
Complete Years Elapsed Surrender Charge As A
Since Receipt of Purchase Percentage Of
Payment Purchase Payments Withdrawn
-----------------------------------------------------------------------------------------
0 7%
1 7%
2 7%
3 6%
4 6%
5 5%
6 4%
7 or more 0%
-----------------------------------------------------------------------------------------
WITHDRAWAL CHARGE: [$25] for each withdrawal after the first withdrawal in a Contract Year. We
will not charge for annuity payments, repetitive withdrawals through electronic funds transfer (EFT),
or if the entire contract value is withdrawn. The maximum withdrawal charge will never exceed $100 for
each withdrawal after the first withdrawal in a Contract Year.
TRANSFERS: The minimum amount you can transfer out of any investment option at one time is $500,
or the entire value of the investment option if less. You must transfer the entire amount of the
investment option if, after a transfer, the remaining balance would be less than $500. The minimum amount
you can transfer into any investment option is $50.
TRANSFER CHARGE: Each Contract Year, 12 transfers are free of charge. For each transfer after
the 12th transfer in a Contract Year, the transfer charge is $10 or 2% of the amount transferred,
whichever is less.
PREMIUM TAXES: Do not apply when issued in New York.
SEPARATE ACCOUNT: [First Symetra Separate Account S ]
ELIGIBLE INVESTMENTS:
[1. Fidelity VIP Money Market Portfolio-Service Class 2] [8. Vanguard VIF Total Stock Market Portfolio]
[2. Fidelity VIP Index 500] [9. Vanguard VIF Total Bond Market Portfolio]
[3. Vanguard VIF International Portfolio] [10. Ibbotson VIT Aggressive Growth Asset Allocation]
[4. Vanguard VIF REIT Index Portfolio] [11. Ibbotson VIT Growth Asset Allocation]
[5. Vanguard VIF Balanced Index Portfolio] [12. Ibbotson VIT Balanced Asset Allocation]
[6. Vanguard VIF High Yield Index Portfolio] [13. Ibbotson VIT Income and Growth Asset Allocation]
[7. Vanguard VIF Mid-Cap Index Portfolio] [14. Ibbotson VI T Conservative Asset Allocation]
ANNUITY SERVICE OFFICE:
Home Office: Mailing Address: Telephone: [800-SYMETRA]
First Symetra National Life Insurance First Symetra National Life
Company of New York Insurance Company of New York [800-796-3872]
[000 Xxxxxxx Xxxxxx, 0xx Floor ] [Retirement Services] Fax: [000-000-0000]
[New York, NY 10017] [P.O. Box 3882]
[Seattle, WA 98124-3882]
