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XXXX XXXXXXX LIFE INSURANCE COMPANY (U.S.A.) (XXXX XXXXXXX(R) LOGO)
A STOCK LIFE INSURANCE COMPANY
OVERNIGHT MAILING ADDRESS: ANNUITY SERVICE OFFICE: HOME OFFICE:
[000 Xxxxxxxxx Xxxxx [P.O. Box 9505 [Bloomfield Hills, MI]
Portsmouth, NH 03801-6815] Portsmouth, NH 03802-9505
For Inquiries or Assistance in
Resolving Complaints:
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 Payment.
Xxxx Xxxxxxx Life Insurance Company (U.S.A.) ("the Company") will pay an annuity
benefit commencing on the Maturity Date to the Payee as directed by the Owner,
in accordance with the Annuity Payments provision of this Contract. Unless
another available option under this Contract is elected, annuity benefit
payments will be payable for a guaranteed period of 10 years and as long
thereafter as the Annuitant lives. If the Owner dies while this Contract is in
effect prior to the Maturity Date, we will pay a Death Benefit to the
Beneficiary upon receipt of all required claim forms and proof of death of the
Owner at the Annuity Service Office.
FIFTEEN DAY RIGHT TO REVIEW
THE OWNER MAY CANCEL THE CONTRACT BY RETURNING IT TO OUR ANNUITY SERVICE OFFICE
OR AGENT AT ANY TIME WITHIN 15 DAYS AFTER RECEIPT OF THE CONTRACT. WITHIN 7 DAYS
OF RECEIPT OF THE CONTRACT BY US, WE WILL PAY THE ACCOUNT VALUE, ADJUSTED BY ANY
MARKET VALUE ADJUSTMENT COMPUTED ON THE DATE 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 15 DAY PERIOD, WE WILL RETURN THE GREATER OF (I) ACCOUNT
VALUE, ADJUSTED BY ANY MARKET VALUE ADJUSTMENT OR (II) AN AMOUNT EQUAL TO THE
PAYMENT.
We hold reserves for our guarantees under this Contract in a non-unitized MVA
Separate Account established within the General Account. The assets of the MVA
Separate Account are subject to the liabilities that arise out of the other
business that we conduct. General Account assets are also available to meet the
guarantees under this Contract as well as our other general obligations.
SIGNED FOR US at Boston, Massachusetts, on the Contract Date.
/s/ Xxxxx X. Xxxxx /s/ Xxxxxxx Xxxxx
President Secretary
Single Payment Modified Guarantee Deferred Annuity
Non-Participating
AMOUNTS PAYABLE UNDER THIS CONTRACT MAY BE SUBJECT TO AN UPWARD OR DOWNWARD
MARKET VALUE ADJUSTMENT. AMOUNTS WITHDRAWN UNDER THIS CONTRACT MAY BE SUBJECT TO
AN EARLY WITHDRAWAL CHARGE.
09MVA ed. EJ
INTRODUCTION
This is a Single Payment Modified Guarantee Deferred Annuity. It is effective
when we receive your Payment and apply the Net Payment to the Account Value. We
determine Account Value during the Initial Guarantee Period shown on the
Specifications Page based on the Net Payment and the Initial Guaranteed Interest
Rate. After that, and prior to the Maturity Date while you are still living, the
Account Value will accumulate based on the interest rate we guarantee for each
Subsequent Guarantee Period selected. Amounts withdrawn prior to the end of any
Guarantee Period are subject to a Market Value Adjustment and possible
Withdrawal Charges, which could reduce the withdrawal amount and any remaining
Account Value below the Payment.
You must allocate the Payment to one Initial Guarantee Period.
On the Maturity Date, if the Annuitant and Owner are still living, the Contract
will provide for Annuity Payments to the Payee based upon the Annuity Option
selected. Fixed annuity dollar amounts are guaranteed by the Company.
TABLE OF CONTENTS PAGE
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PART 1 - DEFINITIONS ................................................... 3
PART 2 - GENERAL PROVISIONS ............................................ 4
PART 3 - OWNER, BENEFICIARY ............................................ 6
PART 4 - PAYMENT ....................................................... 6
PART 5 - GUARANTEE PERIOD, SUBSEQUENT GUARANTEE PERIODS ................ 6
PART 6 - MARKET VALUE ADJUSTMENT (MVA) FORMULA ......................... 7
PART 7 - INTEREST ON ACCOUNT VALUE ..................................... 7
PART 8 - XXXXXXXXXX(S) ................................................. 8
PART 9 - FEES AND DEDUCTIONS ........................................... 9
PART 10 - DEATH BENEFITS ................................................ 9
PART 11 - ANNUITY PAYMENTS .............................................. 10
09MVA ed. EJ
PART 1: DEFINITIONS
WE AND YOU "We", "us" and "our" means the Company. "You"
or "your" means the Owner of this Contract.
ACCOUNT VALUE The amount we hold under this Contract for
you at any given time. On the Contract Date,
the Account Value is equal to the Net
Payment. Thereafter, we determine the Account
Value as specified in the Contract, "Part 7:
Interest on Account Value."
ANNUITANT Any individual person or persons whose life
is used to determine the duration of Xxxxxxx
Payments involving life contingencies. The
Annuitant is as designated on the
Specifications Page, unless changed prior to
the Maturity Date.
ANNUITY OPTION The method selected by you for Annuity
Payments made by us.
ANNUITY PAYMENT(S) Payment(s) by us to you or your designated
Payee, which commence on or after the
Maturity Date and are in accordance with the
Annuity Option elected under the terms of
this Contract.
ANNUITY SERVICE OFFICE Any office designated by us for the receipt
of Payment and processing of Owner requests.
The Annuity Service Office is shown on the
Contract Cover Page.
BENEFICIARY The person, persons or entity to whom certain
benefits are payable following the death of
an Owner, or if the Owner is a non natural
person, an Annuitant.
CONTRACT ANNIVERSARY The anniversary of the Contract beginning
twelve consecutive months from the Contract
Date and each year thereafter.
CONTRACT DATE The date of issue of this Contract as
designated on the Specifications Page.
CONTRACT YEAR The period of time measured twelve
consecutive months from the Contract Date or
any Contract Anniversary thereafter.
CONTINGENT BENEFICIARY The person, persons or entity, who becomes
the Beneficiary if the Beneficiary is not
alive when a benefit is due and payable.
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.
GENERAL ACCOUNT All of the Company's assets other than the
assets in segregated asset accounts which are
maintained as "insulated" separate accounts
under applicable law.
GROSS WITHDRAWAL AMOUNT The amount deducted from the Account Value
for a full or partial withdrawal. For a full
withdrawal such amount is the Account Value.
For a partial withdrawal, the Gross
Withdrawal Amount is the amount you request
plus any applicable Withdrawal Charge and
adjusted by any applicable Market Value
Adjustment.
IN WRITING Unless otherwise stated, means a notice
provided in a format acceptable to us based
on the type of request, which is received at
our Annuity Servicing Office.
INTERNAL REVENUE CODE (IRC) The Internal Revenue Code of 1986, as amended
from time to time, and any successor statute
of similar purposes.
INITIAL GUARANTEE PERIOD The period of time beginning on the Contract
Date that the Initial Guaranteed Interest
Rate is in effect. The Initial Guarantee
Period continues for the period shown on the
Specifications Page.
09MVA ed. EJ Page 3
INITIAL GUARANTEED INTEREST RATE The compound annual rate, shown on the
Specifications Page of the Contract, credited
to the Account Value during the Initial
Guarantee Period under the terms of the
Contract.
MATURITY DATE The date on which Annuity Payments are
scheduled to 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.
OWNER(S) The person, persons or entity entitled to the
ownership rights under this Contract. The
Owner is as designated on the Specifications
Page, unless changed.
PAYEE Any of the person(s) or entity to whom
Annuity Payments are to be made.
PAYMENT An amount paid to us by you that we accept as
consideration for the benefits provided by
this Contract.
QUALIFIED CONTRACT A Contract issued under a Qualified Plan.
QUALIFIED PLANS Retirement plans, which receive favorable tax
treatment under sections 401, 403, 408, 408A,
414 or 457, of the Internal Revenue Code of
1986, as amended.
MVA SEPARATE ACCOUNT A non-registered separate account that we
established within the General Account and in
which we hold reserves for our guarantees
under the Contract. Our other General Account
assets are also available to meet the
guarantees under the Contract and our other
general obligations. The assets of the MVA
Separate Account are subject to the
liabilities that arise out of the other
business that we conduct.
SUBSEQUENT GUARANTEE PERIOD A period of time beginning on the day
following expiry of the immediately preceding
Guarantee Period.
PART 2: GENERAL PROVISIONS
ENTIRE CONTRACT
This Contract is an agreement between the Owner(s) and the Company. The entire
Contract consists of this Contract, any Riders, Endorsements, Specifications
Pages and application, if one is attached.
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.
You may also have access to (i) information for you or a member of your family,
regarding elder care needs and questions, either directly or through a third
party arrangement, and (ii) assistance that may help you identify various elder
care service agencies available in your community.
MODIFICATION
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 alteration or waiver must be in
writing. 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.
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
approval.
09MVA ed. EJ Page 4
ASSIGNMENT
You may assign this Contract, except as otherwise provided, at any time prior to
the Maturity Date. Your interest, any interest of the Annuitant and of any
revocable Beneficiary shall be subject to the terms of the assignment. We will
not be on notice of any assignment unless it is in writing. 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 assume no responsibility for the validity or sufficiency of any
assignment.
If this Contract is issued in a tax qualified plan, this Contract is subject to
assignment restrictions for Federal Income Tax purposes. In such event, this
Contract shall not be sold, assigned, discounted, or pledged as collateral for a
loan or as security for the performance of an obligation or for any other
purpose, to any person other than us.
CLAIMS OF CREDITORS
All benefits and payments under this Contract shall be exempt from the claims of
creditors of the Contract Owner to the extent permitted by law.
MISSTATEMENT AND PROOF OF AGE, SEX OR SURVIVAL
We may require proof of age, sex or survival of any person upon whose age, sex
or survival an Annuity Payment depends. If the age or sex of the Annuitant has
been misstated, the benefits will be those which the Annuity Payment 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. We will uniformly
charge or credit interest in accordance with state law, as applicable.
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.
CANCELLATION FOR MINIMUM ACCOUNT VALUE
If, as a result of any partial withdrawal, the Account Value would be reduced to
less than the Minimum Account Value, indicated on the Specifications Page, we
may cancel this Contract and pay you the amount equal to that which would be
paid as a result of a Total Withdrawal, as described in Part 8, "Withdrawals".
REPORTS
We will send you any reports required by law.
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.
ISSUE STATE
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.
09MVA ed. EJ Page 5
PART 3: OWNER, BENEFICIARY
OWNER
The Owner of this Contract shall be the person, persons or entity designated on
the Specifications Page unless otherwise changed by you in writing. If amounts
become payable to the Beneficiary under this Contract, the Beneficiary becomes
the Owner of this Contract.
BENEFICIARY
Upon the death of the Owner, any surviving Owner will become the Beneficiary. If
there is no surviving Owner, the Beneficiary will be as designated on the
Specifications Page, unless otherwise changed during the Owner's lifetime. 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 OF OWNER, ANNUITANT, BENEFICIARY
Subject to the rights of an irrevocable Beneficiary, you may request to change
the Owner, Annuitant, or Beneficiary by sending us notice in writing. Any such
request must be received at our Annuity Service Office and approved by us. If we
approved a change of Beneficiary, it will take effect on the date the request is
signed. If we approve a change of Owner or Annuitant, it will take effect on the
date we received the request at the Annuity Service Office. The Annuitant may
not be changed after the Maturity Date. You need not send us the Contract unless
we request it. We will not be liable for any payments or actions we take before
we approve the change.
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.
PART 4: PAYMENT
The Contract is not effective until Payment is received by us at our Annuity
Service Office or such other place as we may designate. The Payment deposited
into the Contract can not exceed the Maximum Payment shown on the Specifications
Page. Upon request we will consider, applying nondiscriminatory financial
factors, waiving any of the above conditions.
ALLOCATION OF NET PAYMENT
When we receive the Payment, the Net Payment will be allocated to the Initial
Guarantee Period as shown on the Specifications Page.
PART 5: GUARANTEE PERIOD, SUBSEQUENT GUARANTEE PERIODS
GUARANTEE PERIOD
The Guarantee Period may be either the Initial Guarantee Period or a Subsequent
Guarantee Period. We allocate the Payment to the Initial Guarantee Period
elected and shown on the Specifications Page. Thereafter, any allocation of your
Account Value will be in a Subsequent Guarantee Period then available under this
Contract. The Initial Guarantee Period is measured from the Contract Date. All
Subsequent Guarantee Periods are measured from the first day following the last
day of the immediately preceding Guarantee Period.
09MVA ed. EJ Page 6
SUBSEQUENT GUARANTEE PERIODS
At least 15 days, but not more than 45 days prior to the expiration of the
initial Guarantee Period and any Subsequent Guarantee Period, we will provide
you with a written notice of the expiry of the Guarantee Period and notice of
the Subsequent Guarantee Periods available. Unless we receive written
instructions from You selecting a Subsequent Guarantee Period from those then
available, upon expiration of any Guarantee Period, a Subsequent Guarantee
Period of one year will commence. If a one year Guarantee Period is not
available, you will be placed in the next shortest available Guarantee Period.
Any Subsequent Guarantee Period will begin the day after the expiration of the
immediately proceeding Guarantee Period. We do not subject an amount to a Market
Value Adjustment when it is applied to a Subsequent Guarantee Period.
If your Subsequent Guarantee Period extends beyond the Maturity Date shown on
the Specifications Page, your Maturity Date will be extended to the last day of
that Subsequent Guarantee Period. In no event will you be permitted to elect a
Subsequent Guarantee Period longer than the shortest Guarantee Period ending on
or after the Maximum Maturity Date shown on the Specifications Page.
PART 6: MARKET VALUE ADJUSTMENT (MVA) FORMULA
Any amounts withdrawn or converted to Annuity Payments on any date other than
the period 30 days after the expiration of the Guarantee Period may be adjusted
upward or downward by the application of a Market Value Adjustment Factor
described below.
The Market Value Adjustment Factor is determined by the following formula:
[(1+i/1+j+k)](n/12)
Where i, j, k and n are defined as follows:
i = guaranteed rate in effect for the current Guarantee Period for this
Contract
j = rate offered on a Guarantee Period equal to number of months remaining in
the current Guarantee Period, as of the date your request is processed. For
purposes of this calculation, months remaining will be rounded up to the
next nearest whole number. If a rate for this duration is not available
(for new purchases), the Company will declare a rate solely for this
purpose that is consistent with rates for durations that are currently
available
k = Adjustment Factor, as indicated on the Specifications Page
n = number of months from date that any amounts withdrawn or converted to
Annuity Payments are processed to the end of your current Guarantee Period.
In the case of partial months, n is rounded up to the next month.
The amount of Market Value Adjustment, if any, upon withdrawal is specified in
Part 8, "Withdrawals."
The Market Value Adjustment is equal to A x (B-1) where A is the amount subject
to adjustment, and B is the Market Value Adjustment factor above. The Market
Value Adjustment may be positive or negative.
PART 7: INTEREST ON ACCOUNT VALUE
The Account Value is the value of the amount allocated to the Guarantee Period,
reduced by any Gross Withdrawal Amounts and reduced by any other applicable
charges described in the Contract and accumulated with interest. The Account
Value will accumulate at a rate of interest determined by us and in effect on
the date the amount is allocated to the Guarantee Period. The Initial Guaranteed
Interest Rate is shown on the Specification Page. The Initial Guaranteed
Interest Rate may vary based on the amount of the Payment allocated to the
Guarantee Period and will apply throughout the Initial Guarantee Period. At the
commencement of any Subsequent Guarantee Period, the
09MVA ed. EJ Page 7
interest rate credited will be at least equal to our declared interest rate
then in effect for new policies of the same size with Guarantee Periods of the
same duration commencing at the beginning of the Subsequent Guarantee Period.
All such declared interest rates will be expressed on an annual effective basis
and will never be less than the guaranteed minimum interest rate required by
law, if any. The interest credited on any given day will be a rate which, if
compounded daily for one year, would equal the applicable declared interest
rate.
PART 8: WITHDRAWALS
You may withdraw part or all of the Account Value at any time before the earlier
of the death of an Owner or Annuitant if the Owner is a non natural person or
the Maturity Date by sending us a notice in writing.
We will not defer payment more than six months beyond the date we receive such
notice. If we defer payment for more than 30 days, the amount deferred will earn
interest at a rate not less than the minimum required by law.
FREE WITHDRAWAL AMOUNT
The Free Withdrawal Amount will equal the greater of a) the annual Required
Minimum Distribution amount for Owners of Qualified Contracts aged 70 1/2 or
more or b) the amount of any interest credited to the Account Value during the
12 months prior to the date of your request, less any Gross Withdrawal Amount(s)
taken during this 12 month period.
TOTAL WITHDRAWAL
Upon receipt of your request to withdraw all of your Account Value, we will
terminate the Contract and we will pay you the following amount:
F + [(A-F) x M] -W, WHERE:
F = the Free Withdrawal Amount;
A = the Account Value, reduced by any applicable Annual Fee;
M = the Market Value Adjustment Factor;
W = the Withdrawal Charge.
PARTIAL WITHDRAWAL(S)
You may withdraw less than your entire Account Value. However, requests for
amounts in excess of the Free Withdrawal Amount are subject to a Withdrawal
Charge, a Market Value Adjustment and will be determined using the following
calculation:
F + [(G -F) x M] -W, WHERE:
F = the Free Withdrawal Amount;
G = the Gross Withdrawal Amount;
M = the Market Value Adjustment Factor;
W = the Withdrawal Charge.
We do not restrict the frequency of withdrawals. However, the Gross Withdrawal
Amount withdrawn must be no less than the Minimum Partial Withdrawal Amount
shown on the Contract's Specifications Pages. Any withdrawal which would reduce
the Account Value to less than the Minimum Account Value, indicated on the
Specifications Page, may be treated as a request for a Total Withdrawal of your
Account Value.
WITHDRAWAL CHARGE
09MVA ed. EJ Page 8
If a withdrawal is made from the Contract prior to the Maturity Date, a
Withdrawal Charge may be assessed against the portion of the Account Value being
withdrawn. The amount of the Withdrawal Charge and when it is assessed is
discussed below
1) The Free Withdrawal Amount is defined above and may be withdrawn free
of a Withdrawal Charge and is not subject to a Market Value
Adjustment.
2) Any amounts withdrawn in excess of the Free Withdrawal Amount will be
subject to a Withdrawal Charge, if any. The Withdrawal Charge is
determined by multiplying the Gross Withdrawal Amount less any annual
administration fee and Free Withdrawal Amount by the applicable
Withdrawal Charge percentage shown on the Specifications Page.
3) No Withdrawal Charge will apply to withdrawals made at the end of a
Guarantee Period as described in "Part 5: Guarantee Period, Subsequent
Guarantee Period". A request for withdrawal at the end of a Guarantee
Period must be received in writing during the 30 day period
immediately following the end of that Guarantee Period.
PART 9: FEES AND DEDUCTIONS
ANNUAL FEE
To compensate us for assuming certain administrative expenses, we may charge an
Annual Fee as set forth on the Specifications Page. Prior to the Maturity Date,
the Annual Fee is deducted from the Account Value on each Contract Anniversary.
If the Account 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 may charge certain taxes against your Payment, Account Value, payment of
Death Benefit, or Annuity Payments (either at the time of Payment, full
withdrawal, or when Annuity Payments commence), as appropriate. Such taxes may
include premium taxes or other taxes levied by any government entity which we
determine have resulted from the establishment or maintenance of the MVA
Separate 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.
PART 10: DEATH BENEFITS
DEATH BEFORE MATURITY DATE
If any Owner dies prior to the Maturity Date (or date Annuity Payments begin, if
earlier) the Death Benefit will be equal to the Account Value, as of the date on
which written notice and proof of death and all required claim forms are
received in good order at the Company's Annuity Service Office.
On the death of the last surviving Annuitant, the Owner becomes the new
Annuitant, if the Owner is an individual. If any Owner is a non natural person,
the death of an Annuitant is treated as the death of an Owner.
If the co-Owner predeceases the Owner, the Owner will be treated as the
Beneficiary.
The Beneficiary may continue the Contract as the Owner, subject to the
requirements of Section 72(s) of the Internal Revenue Code. If the Contract
cannot continue under Section 72(s), or if the Beneficiary elects not to
continue the Contract, the Death Benefit will be distributed under one of the
following provisions:
(i) as an Annuity Option as described within Part 11: "Annuity Payments";
or
(ii) over the life of the Beneficiary, or over a period not to extend
beyond the life expectancy of the Beneficiary, with all such
distributions beginning within one year from the date of the Owner's
Death; or
(iii) the entire interest in the Contract must be distributed within five
(5) years of the Owner's Death; or
09MVA ed. EJ Page 9
(iv) in one lump sum.
Withdrawal Charges will be waived on any withdrawals under (ii), (iii) or (iv).
If the Beneficiary dies before distributions under (ii) or (iii) are complete,
the remaining Death Benefit must be distributed in a lump sum immediately. If
there is more than one Beneficiary, the foregoing provisions will independently
apply to each Beneficiary.
The Contract will terminate if the Death Benefit is taken in one sum.
If the Beneficiary decides to continue the Contract as the Owner, subject to
Section 72(s), the new Owner must carry out the current Guarantee Period and
thereafter, applicable Market Value Adjustments will apply to amounts withdrawn
as described under the Contract. Such amounts may be adjusted upward or downward
by the application of a Market Value Adjustment Factor. Subject to the rights of
an irrevocable Beneficiary, the new Owner in such instance may name a new
Beneficiary and, if no Beneficiary is so named, the decedent Beneficiary's
estate will be the Beneficiary.
If the Contract is held as part of a Qualified Plan, the terms of your Qualified
Plan Endorsement form will control.
We will permit the Owner to limit the Death Benefit option(s) to be offered to
any named Beneficiary, if the Owner provides notice in writing to the Company
prior to death and the desired option(s) is one provided for in this Contract.
DEATH BENEFIT ON OR AFTER MATURITY DATE
On or after the date Annuity Payments begin, if the Annuitant dies, the Death
Benefit will depend on the Annuity Option selected in accordance with Part 11:
"Annuity Payments".
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.
PART 11: ANNUITY PAYMENTS
GENERAL
Any amounts payable under this Contract may be converted to Annuity Payments 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 and the Annuitant may not be changed.
We will pay annuity benefits in the form of Annuity Payment(s) on the life of
the Annuitant, to the Payee, if living, on the Maturity Date. Annuity Payments
will commence on or after the Maturity Date and continue for the period of time
provided for under the Annuity Option you elect.
MATURITY DATE
On the Maturity Date or other date elected to commence Annuity Payments, we will
convert the Account Value adjusted by any Market Value Adjustment as described
in Part 6 of this Contract, into Annuity Payments. The amount used to determine
the first Annuity Payment will be measured as of a date not more than 10
business days prior to the Maturity Date.
Only a Contract Value of $5,000 or more may be applied to one of the annuity
payment options offered. If the amount of the first annuity payment would be
less than our minimum requirements then in effect, we may make a single payment,
adjusted by any Market Value Adjustment as described in Part 6 of this Contract,
on the date the first payment is payable. This single payment is in place of all
other benefits provided by this Contract.
09MVA ed. EJ Page 10
CALCULATION USED TO DETERMINE ANNUITY PAYMENT(S)
The amount of each Annuity Payment is determined by applying the amounts which
will be converted to Annuity Payment(s) to the appropriate table(s) identified
by this Contract. We guarantee the dollar amount of each Annuity Payment.
Annuity Payments will never be less than that available by applying the Account
Value adjusted by any Market Value Adjustment as described in Part 6 of this
Contract, to buy a single premium immediate annuity then offered by us, or by
one of our affiliated companies if we do not offer a single premium immediate
annuity.
DESCRIPTION OF ANNUITY OPTIONS
The following annuity payment options are available under this contract for a
single life:
a. Life Annuity with a Guaranteed Period of 5, 10, or 20 Years. Under
this option we will make payments for the guaranteed period elected,
and as long thereafter as the Annuitant lives.
b. Life Annuity. Under this option, we will make payments throughout the
lifetime of the Annuitant. No further payments will be made after the
death of the Annuitant.
c. A single sum or any other option which we may make available including
joint lives.
ALTERNATIVE ANNUITY OPTIONS
Instead of settlement in accordance with the Annuity Options described above,
you may choose an alternate form of settlement acceptable to us. Once Annuity
Payments commence, the form of settlement may not be changed.
ANNUITY PAYMENT INTERVALS
You may elect to receive your Annuity Payments monthly, quarterly, semi-annually
or annually.
09MVA ed. EJ Page 11
TABLE OF PAYMENT RATES
The rates shown below are guaranteed minimum rates. The actual rates that we
will apply will be the greater of these guaranteed minimum rates and the current
rates in effect at the time Annuity Payments begin. Information regarding our
current rates will be available to any Owner upon request.
MONTHLY ANNUITY PAYMENT RATE TABLE
AGE OF MEASURING LIFE ANNUITY WITH GUARANTEED
PERSON ON BIRTHDAY PERIOD
NEAREST DATE --------------------------------------------
OF FIRST PAYMENT 5 YEARS 10 YEARS 20 YEARS LIFE ANNUITY
------------------ ------- -------- -------- ------------
55 3.07 3.05 3.00 3.07
56 3.14 3.13 3.07 3.14
57 3.21 3.20 3.13 3.22
58 3.29 3.28 3.20 3.30
59 3.38 3.36 3.27 3.39
60 3.47 3.45 3.34 3.48
61 3.57 3.54 3.42 3.58
62 3.67 3.64 3.50 3.68
63 3.78 3.74 3.58 3.79
64 3.89 3.85 3.66 3.91
65 4.02 3.97 3.74 4.03
66 4.15 4.09 3.83 4.17
67 4.29 4.22 3.91 4.31
68 4.44 4.36 4.00 4.46
69 4.60 4.50 4.08 4.63
70 4.78 4.66 4.17 4.81
71 4.96 4.82 4.25 5.00
72 5.16 4.99 4.32 5.21
73 5.38 5.17 4.40 5.44
74 5.61 5.36 4.47 5.69
75 5.83 5.56 4.53 5.95
76 6.13 5.76 4.59 6.24
77 6.41 5.97 4.64 6.55
78 6.71 6.18 4.69 6.89
79 7.03 6.40 4.73 7.25
80 7.38 6.62 4.77 7.65
81 7.74 6.83 4.80 8.08
82 8.13 7.04 4.82 8.55
83 8.54 7.25 4.84 9.06
84 8.97 7.45 4.86 9.61
85 9.41 7.63 4.87 10.21
86 9.87 7.80 4.88 10.86
87 10.33 7.96 4.89 11.57
88 10.80 8.10 4.90 12.32
89 11.26 8.23 4.90 13.12
90 11.71 8.35 4.91 13.96
91 12.15 8.45 4.91 14.84
92 12.57 8.54 4.91 15.75
93 12.97 8.62 4.91 16.69
94 13.35 8.69 4.91 17.66
95 and over 13.73 8.75 4.91 18.67
These rates are based on the Annuity 2000 mortality table for Females projected
for improvement using projection scale G. Interest is at an annual effective
rate of 1.5%.
09MVA ed. EJ Page 12
Communications about this annuity contract may be sent to the Company at its
Servicing Office.
Single Payment Modified Guarantee Deferred Annuity
Non-Participating
Amounts withdrawn under this contract may be subject to a Withdrawal Charge and
a Market Value Adjustment
XXXX XXXXXXX LIFE INSURANCE COMPANY (U.S.A.) (XXXX XXXXXXX(R) LOGO)
A STOCK LIFE INSURANCE COMPANY
09MVA ed. EJ Printed in the U.S.A.
