THE AMERICAN LIFE INSURANCE COMPANY OF NEW YORK
Home Office: 000 Xxxxxx Xxxxxx, 0xx Xxxxx, Xxx Xxxx, Xxx Xxxx 00000
This contract ("Contract") creates a legal agreement between The American Life
Insurance Company of New York (the "Company," "we," or "us") and the Owner
("you" or "your"). The amounts that you contribute to this Contract and that we
accept are your "Contributions." . As the purchaser of the Contract, you are
both the Annuitant and the Owner, unless we accept a different arrangement that
you have requested. We will not contest this Contract.
PLEASE READ YOUR CONTRACT CAREFULLY. DURING A [10-DAY] FREE LOOK PERIOD, YOU
HAVE THE RIGHT TO CANCEL THIS CONTRACT. If you are not satisfied, simply return
it to us , within [10 days] of receipt. We will promptly void it and send you
all Contributions plus or minus any investment performance without deducting any
Charges.
CERTAIN BENEFITS UNDER THIS CONTRACT ARE VARIABLE, BASED UPON THE INVESTMENT
EXPERIENCE OF A VARIABLE ACCOUNT. SUCH ACCOUNTS MAY INCREASE OR DECREASE IN
VALUE AS DESCRIBED IN THE CONTRACT AND ARE NOT GUARANTEED AS TO AMOUNT.
MARKET VALUE ADJUSTMENT (MVA) ACCOUNTS, IF APPLICABLE, ARE SUBJECT TO A MARKET
VALUE ADJUSTMENT IF TRANSFERRED OR WITHDRAWN DURING THE GUARANTEE PERIOD.
Your new Contract provides for an Account Value, a Death Benefit and an Annuity
Benefit.
YOUR ACCOUNT VALUE reflects (I) Contributions, (II) net investment performance
for Variable Account(s), AND credited interest and market value adjustments, if
APPLICABLE, for Fixed Account(s), LESS (III) all applicable charges outlined on
your Schedule Page ("Charges"), and withdrawals or transfers.
YOUR DEATH BENEFIT guarantees that your Beneficiary will never receive less than
the Account Value(s) or an Enhanced Death Benefit, as shown on the Schedule
Page, minus Partial Withdrawals on the applicable Death Benefit Date(s). The
Death Benefit is based on the life of the Owner.
YOUR ANNUITY BENEFIT makes fixed payments guaranteed for 10 years or for life,
if longer.
If the Annuitant lives to the Retirement Date (as defined on your Schedule
Page), we will apply your entire Account Value to your choice of the Annuity
Benefits we then offer.
You may allocate all, a portion, or none of your Account Value to any Separate
Account, Subaccount or other accumulation option then available under this
Contract ("Account").
WE WANT TO HEAR FROM YOU. If you have questions, complaints, or need any other
help with your Contract, please contact our Administrative Office at 000
Xxxxxxxxxx Xxxxxxx, Xxxxx 000, Xxxxxxxxxx, Xxxxxxxx 00000, call us at
0-000-000-0000 or email us at xxxxxxx@xxxxxxxxxxxxxx.xxx.
/s/ Xxxxx X. Xxxxxxx /s/ Xxxxx Xxxxxx
Xxxxx X. Xxxxxxx Xxxxx Xxxxxx
President Secretary
FLEXIBLE PREMIUM VARIABLE ANNUITY
NON-PARTICIPATING
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INDEX
ACCOUNTS PAGE 2 SCHEDULE PAGE PAGE 3
BENEFITS PAGE 5 OTHER TERMS PAGE 5
ANNUITY BENEFIT TABLE PAGE 6
ACCOUNTS
ACCOUNT VALUES of your Contract or of any Account equal: All Contributions
allocated to VARIABLE ACCOUNT(S) adjusted to reflect daily net investment
results, PLUS all Contributions allocated to FIXED ACCOUNT(S) adjusted to
reflect daily interest credited and Adjustments made, if applicable, LESS
Charges and withdrawals or transfers. The Contract is nonparticipating, does not
pay dividends or share in our profits or surplus earnings. We calculate Account
Values as of the end of each Company business day ("Business Day"). We will
provide you a report showing your Account Value at least annually. Once Annuity
or Death Benefit requirements have been submitted, the Contract no longer has an
Account Value.
SEPARATE ACCOUNTS are segregated asset accounts that we may divide into one or
more Subaccounts. We own the assets of each Subaccount and keep them separate
from the assets of our General Account. This means that the income, gains and
losses of each Subaccount will be credited to, or charged against, that Account
without regard to any income, gains, losses or claims of creditors in our
General Account or in any other investment account. We must hold assets in each
Subaccount at least equal to all statutory reserves required for such Account;
we will never use such assets to support any other business, and we will
transfer assets to any such Account from our General Account if necessary to
meet this requirement. We may use excess assets in any Account in any way we
choose.
VARIABLE ACCOUNTS are Subaccounts invested in designated portfolios. At the end
of each Business Day, we adjust Variable Account Values to reflect the net
investment results in such portfolios. You may withdraw or transfer your
Variable Account Values subject to Charges and other Contract terms.
FIXED ACCOUNTS are offered as General Account options. We credit interest on
your Fixed Account Values, if any, at interest rates we have declared effective
for such Accounts ("Rates"). Each Rate will be guaranteed for a period of time
we declare ("Guarantee Period"). We may declare Rates that are level guarantees,
external indexes not in our control, or combinations of the two. Fixed Account
Values (after Adjustments, if applicable, but not Charges) will always equal at
least the minimum values required by all applicable standard nonforfeiture law.
We reserve the right to declare and credit additional interest based on
contribution or withdrawal dates, economic conditions or on any other lawful,
nondiscriminatory basis. Unless declared otherwise, interest accrues and is
compounded daily.
VARIABLE AND FIXED ACCOUNTS may be fully or partially withdrawn at any time
before we begin payment of Retirement or Death Benefits, subject to Charges,
Market Value Adjustments ("MVA"), if applicable and Transfer Restrictions, all
as described on your Schedule Page, and any other restrictions designated on
your Schedule Page. Unless you have elected otherwise, at the end of any
Guarantee Period, we will renew that allocation in the same or most similar
Account then available that will not extend past the Retirement Date.
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SCHEDULE PAGE
Owner: [Xxxx Xxx]
Annuitant: [Xxxx Xxx]
Contract Number: [1234567]
Contract Date: [August 15, 2002]
Retirement Date: [Age 98]
Initial Contribution: Please see your confirmation notice for the initial
allocation breakdown of your Contribution.
VARIABLE ACCOUNTS:
[The American Separate Account 5]
FIXED ACCOUNTS:
Guarantee Period(s): [90-days]
Interest Rate: [Declared at the time funds are allocated
and guaranteed for 90-days.]
CONTRACT FEATURES:
Contributions: [$1,000 minimum initial contribution. Initial
allocation will be placed into the Money Market
account until the Free Look period has expired.
$1,000,000 maximum contribution without prior
home office approval.]
Transfer Restrictions: [Transfers executed after 4 pm Eastern Time
will be processed the next business day. We
reserve the right to limit the number of
transfers you may make in any Contract year
or to refuse any transfer request if: (1) we
determine, in our sole discretion, that your
transfer patterns among the Subaccounts
reflect a market timing strategy; or (2) we
are informed by one or more of the
underlying funds that the purchase or
redemption of shares is to be restricted
because of excessive transfers, or that a
specific transfer or group of transfers is
expected to have a detrimental effect on
share prices of the underlying funds; or (3)
we believe, in our sole discretion, that
your transfers may have a detrimental effect
on Subaccount Accumulation Unit values or
the share prices of the underlying funds.]
[Certain transfers may be subject to
a short-term redemption fee.]
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[Certain transactions involving International
Subaccounts may adversely affect existing Contract
Owners. Accordingly, we will not accept an order
for an International Subaccount that:
(1) is placed between 9:00 a.m. ET and 4:00 p.m.
ET on a Valuation Day; AND
(2) is for a withdrawal or transfer whose
amount is equal to or greater than $50,000.
If your order is not accepted by us because
of this limitation, we will inform you. If your
order was not accepted, you can re-submit
it (1) before 4:00 p.m. ET in an amount less
than $50,000 for processing at that Valuation
Day's Accumulation Unit value or (2) after 4 p.m.
ET (but before 9:00 a.m. ET on the following
Valuation Day) for processing at the
following Valuation Day's Accumulation
Unit value.]
Withdrawal Restrictions: [None]
Enhanced Death Benefit: [Before the Contract Owner's 80th birthday,
the Death Benefit amount will be the greater
of: (1) the sum of all Contributions, less
adjusted partial withdrawals; or (2) your
Account Value. On or after the Contract
Owner's 80th birthday, the Death Benefit
amount will be the Account Value.]
[For these purposes, an adjusted partial
withdrawal is equal to (a) the partial withdrawal
amount plus any applicable premium tax withheld;
multiplied by (b) the Death Benefit immediately
prior to the partial withdrawal; divided by
(c) the Account Balance immediately prior to
the partial withdrawal.]
Stepped Up Death Benefit
(Spousal Continuation): [If your surviving spouse is the Beneficiary,
then he or she may decline the Death Benefit and
continue as the new Owner. Upon a spouse's
continuation of the Contract, we will contribute
to the Account Value an amount by which the death
benefit that would have been paid to the
Beneficiary upon the death of the original Owner
exceeds the Account Value ("Continuation
Contribution"), if any.]
COMPANY CHARGES:
Administration Charges: [None]
Transfer Charges: [None]
Mortality and Expense Charges: [.47%]
Withdrawal Charges: [None]
Market Value Adjustment: [None]
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BENEFITS
DEATH OF OWNER DURING ACCUMULATION PERIOD: Upon the death of the Owner during
the accumulation period, the Death Benefit will be paid to the Beneficiary (ies)
designated by the Owner. However, if the Beneficiary is the spouse of the Owner,
he or she may decline the Death Benefit and continue the Contract as the new
Owner, at the then current Account Value, in his or her name and exercise all
the ownership rights under this Contract.
During the accumulation period, this Death Benefit is the Contract Account
Value(s) or such Enhanced Death Benefit as described on your Schedule Page;
reduced pro rata for Partial Withdrawals in any case. On or after the Retirement
Date, this Death Benefit is each of any remaining Payments Certain, payable when
originally due.
DEATH OF ANNUITANT: Upon the death of an Annuitant, who is not the Owner, during
the accumulation period, the Owner automatically becomes the Annuitant. The
Owner may designate a new Annuitant, subject to the Company's underwriting rules
then in effect. If the Owner is a non-natural person, the death of an Annuitant
will be treated as the death of the Owner and a new Annuitant may not be
designated.
Upon death of an Annuitant, who is not the Owner, on or after the Retirement
Date, the Death Benefit, will be the annuity option elected. Death benefits will
be paid at least as rapidly as under the method of distribution in effect at the
Annuitant's death.
TAX RULES: If the Owner dies before the Retirement Date we must pay any benefit
due to a non-spousal Beneficiary: a) in a lump sum within five years of death or
b) starting within a year of death, in annuity payments payable for such
Beneficiary's life expectancy or less. We further reserve the right to, and we
shall, administer all Contracts which are Non-Qualified or "Qualified" contracts
under applicable sections of the Internal Revenue Code of 1986, as amended, in
accordance with all applicable laws and regulations in effect from time to time
(all of which are hereby fully incorporated herein by reference and shall govern
over any other provisions of the Contract to the contrary), or as otherwise
required in our reasonable judgment to maintain such Non-Qualified or Qualified
status or treatment, subject to all applicable legal and regulatory approvals.
ANNUITY BENEFIT: If the Annuitant lives to the Retirement Date, we guarantee
monthly annuity payments for the Annuitant's lifetime with a minimum of 10
years' payments ("Payments Certain"). The amount of each payment is based on
your last Account Value, subject to Charges LESS any applicable premium taxes
and all other Contract terms, with 3% interest under the 2000 Individual Annuity
Mortality Table. We may offer more favorable rates and other Annuity Benefits.
OTHER TERMS
MAXIMUM CHARGES: Charges will never exceed any legal limits in the state where
the Contract is delivered. Asset-based Charges will never apply to Fixed
Accounts.
RIGHTS RESERVED: Subject to required approvals by federal and state authorities
and to all Company administrative rules or published procedures which are
lawful, nondiscriminatory and consistent with this Contract, we reserve the
right to: require reasonable documentation or Company-approved forms prior to
administering any transaction or benefit; waive or reduce restrictions or
Charges, including fees of underlying funds; increase benefits; defer the
payment of withdrawals from Fixed Accounts for up to six months; deduct (as an
additional Charge) any premium tax or other tax assessed on us for the Contract;
add, substitute, combine, delete, deregister or operate (as a management
investment company or in any other lawful form) any Account; refuse any Premium;
declare (or change) prospectively any rules regarding maximum or minimum
Contributions, Account Value balances, Annuity Benefit amounts, allocations,
transfers, other transactions, the use of electronic or other communications
media or any other administrative rules. You will be notified of all material
rules that affect your Contract. New rules will only be declared prospectively.
ENTIRE CONTRACT: The Contract, together with the application and any riders or
endorsements, is our entire agreement with you. The Contract may not be endorsed
or amended unless executed by one of our executive officers and delivered to
you; no others have any authority to amend or waive its provisions.
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MISSTATEMENT OF AGE OR SEX: If we learn that an Annuitant's age or sex is
misstated, any benefits will be those that would have been purchased at the
correct age and sex. Any overpayments or underpayments made by us will be
charged, credited or offset with interest at the rate then declared by the
Company, in accordance with applicable state laws.
PROOF OF AGE, SEX OR SURVIVAL: We may require satisfactory proof of age, sex or
survival of any person on whose life any payment under this Contract depends.
ASSIGNMENT: The Owner may assign this Contract. No assignment will be binding
until it has been received and recorded by the Company. It will not apply to any
payment made before the assignment was recorded. The Company will not be
responsible for its validity. An assignment will not, and an assignee cannot,
change the beneficiary. The rights of the beneficiary will be subject to the
rights of any assignee. An assignment is not a change in Owner. An assignee is
not an Owner as used in this Contract.
ANNUITY BENEFIT PAYABLE ON THE LIFE ANNUITY FORM*
(MINIMUM MONTHLY INCOME PER $1,000 OF ACCOUNT VALUE)
FIXED ANNUITY BENEFIT
WITH 10 YEARS OF PAYMENTS GUARANTEED
(INTEREST RATE OF 3%)
AGE OF
ANNUITANT MALES FEMALES
--------- ----- -------
60 $4.93 $4.58
61 $5.05 $4.68
62 $5.16 $4.79
63 $5.29 $4.90
64 $5.42 $5.01
65 $5.55 $5.14
66 $5.69 $5.27
67 $5.84 $5.40
68 $5.99 $5.55
69 $6.15 $5.70
70 $6.31 $5.86
* Based on 3% interest and the Annuity 2000 Mortality Table on an Age Last
Birthday basis.
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