Founded in 1867...A Mutual Company...P.O. Xxx 00000, Xxxxxxxxxx, Xxxx 00000
ANNUITANT: Xxxx Xxx
OWNER: Xxxx Xxx
CONTRACT NUMBER: 012345678
CONTRACT DATE:
WE PROMISE to pay the benefits of this contract in accordance with its terms.
LOOK AT THE APPLICATION FORMS. This contract is issued based on payment of
the initial premium and the answers in the application (see copy attached).
If all answers are not true and complete, this contract may be affected.
PLEASE READ THIS CONTRACT CAREFULLY. This is a legal contract between you
and Union Central.
10 DAY RIGHT TO EXAMINE THE CONTRACT. It is important to Union Central that
you are satisfied with this contract. You have 10 days after you receive it
to review the policy. If you are not satisfied, you may send it back to us
or give it to our agent. In such case, this contract will be void from the
beginning. We will refund, within 7 days after this contract is returned,
any premiums paid.
ALL ACCUMULATION VALUES AND ANNUITY PAYMENTS PROVIDED BY THIS CONTRACT, WHEN
BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND
ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNTS.
Signed for the Company at Cincinnati, Ohio
/s/ Xxxxx X. Xxxxxxxxxx /s/ Xxxx X. Xxxxxx
Secretary President
Flexible Premium Deferred Variable Annuity
Participating
-----------------------
Licensed Resident Agent
UC 8135-1
INTRODUCTION
This is a flexible premium deferred variable annuity. This annuity contract
provides that both the accumulation value and annuity payments may be either
fixed or variable, or a combination of fixed and variable.
You determine the investment allocation for this annuity. You may allocate
your premiums to either the guaranteed account or the variable account, or a
combination of these accounts. If you select the guaranteed account, then
your accumulation value and annuity payments will be fixed and guaranteed. If
you select the variable account, your accumulation value and annuity payments
will vary with the investment performance of the separate account's
subaccounts. If you select both the guaranteed and variable accounts, then
your values and payments will be fixed in part, and variable in part.
If you select the variable account, then you must allocate premiums among one
or more subdivisions of the variable account. These subdivisions are
identified in the contract application and on the schedule page.
CONTRACT INDEX
Page
Definitions 4
Ownership 6
Benefits 6
Premiums 8
Variable Account Provisions 8
Guaranteed Account Provisions 11
Transfers 11
Surrender Provisions 12
Charges and Deductions 13
General Provisions 13
Payment of Contract Benefits 15
Schedule Page
Initial Allocation of Net Premiums: Money Source
Separate Account: Carillon Account
SUBDIVISIONS OF THE VARIABLE ACCOUNT:
[AIM VI CAP APPRECIATION 0]%
[AIM VI GROWTH 0]
[XXXXX AMERICAN LEVERAGED ALLCAP 0]
[XXXXX AMERICAN MIDCAP GROWTH 0]
[AM CENTURY VP GROWTH & IN 0]
[AM CENTURY VP VALUE 0]
[MFS VIT EMERGING GROWTH 0]
[MFS VIT INVESTORS TRUST 0]
[MFS VIT HIGH INCOME 0]
[MFS VIT NEW DISCOVERY 0]
[MFS VIT TOTAL RETURN 0]
[XXXXXXXXX XXXXXX AMT GUARD 0]
[XXXXXXXXXXX GLOBAL SEC/VA 0]
[XXXXXXXXXXX MAIN ST/VA 0]
[XXXXXXX VSI CAP GROWTH 0]
[XXXXXXX VSI INTL 0]
[XXXXXXX VSI MONEY MARKET 0]
[XXXXXXXX SMALLCAP VALUE CLASS 2 0]
[XXXXXXXX COMM & INFO CLASS 2 0]
[SUMMIT BALANCED INDEX 0]
[SUMMIT BOND 25]
[SUMMIT NASDAQ 100 INDEX 0]
[SUMMIT XXXXXXX 2000 0]
[SUMMIT S&P MID CAP 400 0]
[SUMMIT S&P 500 INDEX 0]
[SUMMIT ZENITH 25]
[FTVIP XXXXXXXXX INTL CLASS 2 0]
GUARANTEED ACCOUNT: [50]
-------
TOTAL: 100%
Transfer Charge:
Current: [$10]
Maximum: $100
Mortality and Expense Charge:
Current: [1.20%]
Maximum: 2.00%
Administration Fee:
Current: [0.25%]
Maximum: 0.25%
Guaranteed Interest Rate: 3.00%
----------------------
Annuitant: Xxxx Xxx Contract Number: 01234567
Owner: Xxxx Xxx Maturity Date:
Joint Owner: N/A Contract Date:
UC 8135-1 - 3 -
DEFINITIONS
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ACCUMULATION Means the period before the maturity date and
PERIOD during the lifetime of the annuitant.
ACCUMULATION Means a unit of measure that is used to calculate
UNIT the value of your interest in the separate account
(SA) before the maturity date.
ACCUMULATION Means the sum of the values of the guaranteed
VALUE account and the variable account credited to this
contract.
ANNUITANT Means the person(s) whose life is used to determine the
duration of any annuity payments involving life
contingencies. The annuitant is named in the
application and on the schedule page.
ANNUITY UNIT Means a unit of measure that is used to calculate
variable annuity payments.
BENEFICIARY Means the person(s) designated by you to receive the
death benefits from this contract upon your death.
CALCULATION DATE Means a date not more than 10 business days prior to the
maturity date.
CONTRACT YEAR Means a period of 12 consecutive months beginning on
the contract date or any anniversary thereafter. The
contract date is shown on the schedule page.
DUE PROOF Means one of the following:
OF DEATH 1. A certified copy of a death certificate;
2. A certified copy of a decree of a court of competent
jurisdiction as to the finding of death;
3. A written statement by a medical doctor who attended
the deceased; and
4. Any other proof satisfactory to us.
FIXED ANNUITY Means an annuity with payments fixed throughout the
annuity payment period.
GUARANTEED Means this contract's value which is held by The
ACCOUNT Union Central Life Insurance Company other than those
in its separate accounts (SA).
HOME OFFICE Means the home office of The Union Central Life
Insurance Company which is: 0000 Xxxxxxxx Xxxx
(X.X. Xxx 00000), Xxxxxxxxxx, Xxxx 00000.
MATURITY DATE Means the date on which annuity payments will begin.
This date shall be the annuitant's 95th birthday unless
an earlier date is chosen by you.
NOTICE Means information we have received at our home office
which is written, is signed by you, and is acceptable
to us.
PORTFOLIO OR Means a separate portfolio of one of the mutual funds
FUND PORTFOLIO in which separate account (SA) invests through its
subaccounts, or its successors and assigns.
SCHEDULE PAGE Means the contract schedule page, or the supplemental
contract schedule page most recently sent to you by us.
SEPARATE ACCOUNT Means the Carillon Account of The Union Central Life
("SA") Insurance Company. The separate account is divided
into several subaccounts.
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UC 8135-1 -4-
SUBACCOUNT(S) Means one or more of the subaccounts of the SA. Each
subaccount is invested in a different fund portfolio.
SUBDIVISION Means the portion of your variable account which is
invested in a specific subaccount.
VARIABLE ACCOUNT Means this contract's value which is invested in one
or more subaccounts of the SA.
VARIABLE ANNUITY Means an annuity with payments which: (1) are not
predetermined or guaranteed as to dollar amount; and
(2) vary in amount in relation to the investment
experience of one or more specified subaccounts.
WE AND YOU "We," "us," or "our" means The Union Central Life
Insurance Company. "You" or "your" means the owner
of this contract.
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UC 8135-1 -5-
OWNERSHIP
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GENERAL The owner of this contract shall be the person so
named in the application or the latest change filed
with us.
CHANGE OF Prior to the maturity date, you may assign the owner-
OWNERSHIP ship of this contract. Such change must be made by
written notice in a form acceptable to us and received
at our home office.
CHANGE OF Prior to the maturity date, you may name a new
ANNUITANT annuitant. Such change must be made by written notice
in a form acceptable to us and received at our home
office.
BENEFITS
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ANNUITY BENEFITS We will pay an annuity benefit to the annuitant, if
living, on the maturity date. Annuity benefits will
begin on the maturity date and continue while the
annuitant is living, with monthly payments guaranteed
for 10 years, unless you elect a different annuity
option at least 30 days before the maturity date. If
you die after the annuity benefits have begun, the
entire remaining interest will continue to be dis-
tributed to the annuitant at least as rapidly as under
the annuity option being used as of the date of your
death.
We may pay the accumulation value on the maturity date
in one lump sum if it is less than $5,000. We may
change the payment frequency to quarterly, semiannually
or annually if the first monthly annuity payment would
be less than $50.
At least 30 days before the maturity date you must
select how the accumulation value will be used to
provide the annuity benefit. Any election must be
written in a form satisfactory to us and received at
our home office. If you do not so select how you
wish settlement to be effected, we will provide a
fixed annuity.
If a variable annuity is used, subsequent annuity
benefit payments will vary based on the investment
experience of the subaccount(s) used to effect the
annuity. The method used to calculate the amount of
subsequent payments is described in the Variable
Annuity Payments provision.
DEATH BENEFITS Notwithstanding any provision to the contrary, death
benefits shall always be made in accordance with the
distribution requirements of the Internal Revenue Code.
If the death benefit is paid before the maturity date,
the death benefit will be the greater of : (a) the
accumulation value on the date that due proof of death
is received; or (b) the sum of all premiums paid, less
any amounts deducted in connection with partial
surrenders.
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UC 8135-1 -6-
Death of Owner. If you are an owner and if you die
before the maturity date, the following will apply:
1. If your spouse is not the beneficiary, the death
benefit will be paid to the named beneficiary:
a. upon written request it may be paid under any
option listed in the Payment of Contract Benefits
section of this contract over a period not
exceeding the beneficiary's life expectancy.
If the death benefit is paid in installments,
the first installment payment must be made no
later than one year after the date of your death;
or
b. in a single sum. The beneficiary has the
option to elect to receive the single sum any
time within five years after the date of your
death.
2. If your spouse is the beneficiary, your spouse may
elect, by a written request to us, one of the
following options:
a. to continue this contract as the owner; or
b. to receive the death benefit under any option
listed in the Payment of Contract Benefits
section of this contract over a period not
exceeding the beneficiary's life expectancy.
If the death benefit is paid in installments,
the first installment payment must be made no
later than one year after the date of your death;
or
c. to receive the death benefit in a single sum.
Your spouse may elect to receive the single sum
any time within five years after the date of your
death.
If none of these options is elected by your spouse
within 45 days after we receive due proof of death,
option a. above shall apply.
3. If no beneficiary is living or if no beneficiary
has been named, at the date of your death, the death
benefit will be paid in a single sum to the executor
or administrator of your estate within five years
after the date of your death.
Joint Owners. If this contract is owned jointly, the
death of the first joint owner shall be treated as the
death of the owner.
Death of Annuitant before the Maturity Date. If you,
the owner, are a different person from the annuitant,
and the annuitant dies during your lifetime and before
the maturity date, you will be treated as the annuitant.
If you are not a natural person, and the annuitant dies
before the maturity date, we will pay the death benefit
to you in a single sum. You have the option to elect
to receive the single sum any time within five years of
the death of the annuitant.
Death of Annuitant on or after the Maturity Date. If the
annuitant dies on or after the maturity date, the death
benefit, if any, will depend on the annuity option in
effect on the date of the annuitant's death.
Death of Beneficiary. Unless otherwise provided, if
any beneficiary dies before, at the same time as, or
within 30 days after your death, that beneficiary will
be treated as if their death occurred before yours.
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UC 8135-1 -7-
PREMIUMS
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GENERAL All premiums under this contract are payable at our
home office or such other place as we may designate.
No premium may be paid under this contract unless it
is at least $50. Premiums may be paid at any time.
The amount of the premium may be increased or decreased
any time subject to the $50 minimum and a maximum of
$10,000 per contract year. We may waive the $10,000
per year maximum, but waiver in one instance does not
constitute waiver for additional premiums.
NET PREMIUM The net premium is the premium less any premium tax.
ALLOCATION OF You determine the allocation of the net premiums
NET PREMIUM between the guaranteed account and the variable account.
You may allocate the net premiums totally to the
guaranteed account, totally to the variable account
or partially to both accounts. The minimum amount of
any net premium that you can allocate to the guaranteed
account or any subdivision of the variable account is
$10.
If you allocate a part or all of your premiums to the
variable account, then you will further allocate that
portion of your premiums among one or more subdivisions
of the variable account. To the extent that you
allocate premiums to the variable account, your
accumulation value will be subject to the investment
experience of SA.
Premiums that you allocate to the guaranteed account
will be guaranteed a minimum value. We will credit
interest to amounts allocated to the guaranteed account
at a rate of at least the guaranteed interest rate as
shown on the schedule page, compounded annually. We may
credit a higher rate of interest to such amounts, but we
are not required to do so.
When we receive the premiums, the net premiums will be
allocated in accordance with the net premium allocation
percentages shown in the application or as of the most
recent change of allocation received from you. No
allocation will be made prior to the contract date. You
may change the allocation of subsequent premiums at any
time, without charge, by giving us written notice.
VARIABLE ACCOUNT PROVISIONS
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SEPARATE ACCOUNT The separate account is shown on the schedule page. It
is a unit investment trust registered with the
Securities and Exchange Commission under the Investment
Company Act of 1940. It is established under the laws
of Ohio. The assets in the separate account are kept
separate from our general assets and assets of other
separate accounts.
SUBACCOUNTS The separate account is divided into subaccounts, each
of which invests in a different portfolio.
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UC 8135-1 -8-
CREDITING OF We will credit net premiums allocated to the variable
ACCUMULATION account in the form of variable accumulation units.
UNITS The number of variable accumulation units to be credited
to this contract for each subdivision of the variable
account will be determined by dividing the net premium
allocated to each subdivision of the variable account
by the accumulation unit value for the corresponding
subaccount as of the end of the valuation period during
which the premium is received. In the case of the
initial premium, accumulation units will be credited
on the later of these dates:
1. the contract date; or
2. the date we receive the premium.
At the end of the Right to Examine period, those units
will be allocated to the subaccounts chosen on your
application.
Accumulation units are credited when amounts are
transferred into a subaccount. Accumulation units are
deducted when the charges and deductions are assessed or
when amounts are partially surrendered or transferred,
including transfer charges, out of a subaccount.
VARIABLE ACCOUNT At any time prior to the maturity date, the variable
account of this contract equals the sum for all
subdivisions of the variable account of (1) times (2)
where:
1. equals the number of accumulation units credited to
a subdivision of the variable account; and
2. equals the value of the appropriate accumulation
unit.
VALUATION DATE A valuation date is any date on which the New York
AND VALUATION Stock Exchange is open for trading and we are open
PERIOD for business. The assets of each subaccount will be
valued on each valuation date. A valuation period is
a period beginning with the close of business on a
valuation date and ending at the close of business
for the next valuation date.
ACCUMULATION The value of a variable accumulation unit for each
UNIT subaccount was arbitrarily set at $10 when funds were
first credited to the respective subaccount. The
variable accumulation unit value for any subsequent
valuation period is determined by multiplying the
variable accumulation unit value for the immediately
preceding valuation period by the "net investment
factor" for the valuation period for which the value
is being determined. The value of a variable
accumulation unit may increase or decrease from one
valuation period to the next.
NET INVESTMENT The net investment factor is an index that measures
FACTOR the investment performance of a subaccount from one
valuation period to the next. The net investment
factor for each subaccount for any valuation period
is determined by dividing (1) by (2) and subtracting
(3) from the result, where:
1. is the net result of:
a. the net asset value per share of a portfolio
share held in the subaccount determined as of the
end of the current valuation period, plus
b. the per share amount of any dividend or capital
gain distributions made by the portfolio on
shares held in the subaccount if the "exdividend"
date occurs during the current valuation period,
plus or minus
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UC 8135-1 -9-
c. a per share charge or credit for any taxes
incurred by or reserved for in the subaccount,
which is determined by us to have resulted from
the maintenance of the subaccount; and
2. is the net result of:
a. the net asset value per share of a portfolio
share held in the subaccount determined as of
the end of the immediately preceding valuation
period (adjusted for an "exdividend"), plus or
minus
b. the per share charge or credit for any taxes
reserved for the immediately preceding valuation
period; and
3. is a factor representing the charges deducted from the
subaccounts on a daily basis for administrative
expenses and mortality and expense risks. Such factor
is equal on an annual basis to the amount shown on the
schedule page
VARIABLE ANNUITY The amount of the first variable annuity payment is
PAYMENT determined by applying the variable account
accumulation value of your contract, measured as of
the calculation date (minus any applicable premium
taxes), to the appropriate Option Table contained in
this contract. This is done separately for each
subdivision of the variable account. We will determine
subsequent payments by dividing the first payment
derived from each subdivision of the variable account
by the annuity unit value determined as of the
calculation date. This number of annuity units is
then multiplied by the annuity unit value for each
subsequent determination date which is a uniformly
applied date not more than 10 business days before
payment is due.
ANNUITY UNIT The value of an annuity unit for each subaccount
VALUE was arbitrarily set at $10 when funds were first
credited to the respective subaccount. Subsequently,
the value of an annuity unit in each subaccount for
any valuation period is determined as follows:
(a) the net investment factor for each subaccount for
the valuation period for which the annuity unit
value is being calculated is multiplied by the
value of the annuity unit on the preceding valuation
date; and
(b) the result is adjusted to compensate for the
interest rate assumed in the Option Tables used to
determine the first variable annuity payment.
The dollar value of annuity units may change from one
valuation period to the next.
ADDITION, We reserve the right, subject to compliance with
DELETION, OR applicable law, to make additions to, deletions
SUBSTITUTION OF from, or substitution for the portfolio shares that
INVESTMENTS are held by the separate account or that the separate
account may purchase. We reserve the right to
eliminate the shares of any of the eligible portfolios
and to substitute shares of another portfolio, or of
another open-end, registered investment company, if
the shares of an eligible portfolio are no longer
available for investment, or if in our judgment further
investment in any eligible portfolio should become
inappropriate in view of the purposes of the separate
account. We will not substitute any shares
attributable to your interest in a subaccount without
notice to you and prior approval of the Securities and
Exchange Commission, to the extent required by the
Investment Company Act of 1940. Nothing contained
herein shall prevent the separate account from
purchasing other securities for other series or classes
of policies, or from effecting a conversion between
series or classes of policies on the basis of requests
made by owners.
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UC 8135-1 -10-
We reserve the right to establish additional subaccounts,
each of which would invest in a new portfolio, or in
shares of another open-end investment company. We also
reserve the right to eliminate existing subaccounts.
In the event of any such substitution or change, we may,
by appropriate endorsement, make such changes in this
and other policies as may be necessary or appropriate
to reflect such substitution or change. If deemed by
us to be in the best interest of persons having voting
rights under the policies, the separate account may be
operated as a management company under the Investment
Company Act of 1940 or it may be deregistered under
such Act in the event such registration is no longer
required.
The investment contract of the separate account will
not be changed without the approval of the Insurance
Commissioner of the State of Ohio. If required, the
approval process is on file with the Commissioner of
the state in which this contract is issued.
GUARANTEED ACCOUNT PROVISIONS
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GUARANTEED The guaranteed account of your contract at any time
ACCOUNT equals:
1. the total of all net premiums allocated to the
guaranteed account; plus
2. the total of all amounts transferred to the
guaranteed account from the variable account; minus
3. the total of all amounts transferred from the
guaranteed account to the variable account
(including the transfer fee); minus
4. the total of all partial surrenders from the
guaranteed account; plus
5. interest.
GUARANTEED The guaranteed interest rate used in the calculation
ACCOUNT INTEREST of the guaranteed account is found on the schedule
RATE page. Interest in excess of the guaranteed rate may be
used in the calculation of the guaranteed account at
such increased rates and in such a manner as we may
determine.
FIXED ANNUITY We guarantee the amount of fixed annuity payments.
PAYMENTS The payment amount depends only on the annuity option
elected, the age (and possibly sex) of the annuitant,
and the amount applied to purchase the fixed annuity,
in accordance with the Option Tables contained in the
contract.
TRANSFERS
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TRANSFERS BEFORE Before the maturity date you may transfer amounts
MATURITY DATE between the guaranteed account and subdivisions of the
variable account or among subdivisions. Transfers from
subdivisions of the variable account will be made based
on the accumulation unit values at the end of the
valuation period during which we receive the request
for transfer. You must transfer at least $300 or, if
less, the entire amount in the guaranteed account or a
subdivision each time you make a transfer. If after the
transfer the amount remaining in the guaranteed account
or any subdivision of the variable account from which the
transfer is made is less than $25, then we will transfer
the entire amount instead of the requested amount. A
transfer charge as shown on the schedule page will be
imposed for each transfer. The charge will be deducted
from the account from which the transfer is made.
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UC 8135-1 -11-
TRANSFERS AFTER After annuity payments have been made for at least
MATURITY DATE 12 months, you may, no more than once each 12 months,
change all or part of the investment upon which your
annuity payments are based from one subaccount to
another. After your death, the annuitant assumes this
right. To do this, we will convert the number of
annuity units being changed to the number of annuity
units of the subaccount to which you are changing so as
to result in the next annuity payment being of the same
amount that it would have been without the change. After
that, annuity payments will reflect changes in the values
of your new annuity units. You must give us notice at
least 30 days before the due date of the first annuity
payment to which the change will apply.
No transfers may be made with respect to fixed annuity
payments.
SURRENDER PROVISIONS
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PAYMENT OF You may totally or partially surrender the contract
SURRENDERS and receive all of the accumulation value at any time
before the earlier of the death of the annuitant or
the maturity date, by sending us a written request. We
will pay all surrenders from the variable account
within seven days of receipt of the written request,
subject to postponement for any period during which
the New York Stock Exchange is closed for trading
(except for normal holiday closing) or when the
Securities and Exchange Commission has determined that
a state of emergency exists. We reserve the right to
postpone surrenders from the guaranteed account for up
to six months after we receive the request.
PARTIAL SURRENDER If you are partially surrendering the contract, you
should specify the amounts that should be withdrawn
from the guaranteed account or each subdivision of the
variable account. If you do not so specify, the
requested amount will be withdrawn from the guaranteed
account and each subdivision of the variable account in
which you have an interest, in the same proportion that
your interest therein bears to the accumulation value.
You may pre-authorize periodic surrenders by entering
into a separate agreement with us. Under this
agreement, you may withdraw part of your accumulation
value at a regular interval chosen by you. You may
choose to withdraw a level dollar amount or a
percentage of your accumulation value. If you choose
the latter, the accumulation value for the first year
you choose to make these withdrawals is set on the date
we approve your request. In later years, the
accumulation value is set on the first day of the
contract year. These surrenders may be subject to the
10% federal tax on early withdrawals.
FREQUENCY AND You may make as many partial surrenders as you wish.
AMOUNT OF Any surrender from the guaranteed account or a sub-
SURRENDERS division of the variable account must be at least $100
or the entire balance of the guaranteed account or
subdivision of the variable account. If, after the
surrender, the amount remaining in the guaranteed
account or a subdivision is less than $25, then we may
consider the surrender request to be a request for
surrender of the entire amount held in the guaranteed
account or subdivision. If a partial surrender would
reduce the accumulation value to less than $100, then
we may treat the partial surrender request as a total
surrender of the contract.
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CHARGES AND DEDUCTIONS
----------------------------------------------------------------------
MORTALITY AND To compensate us for assuming the mortality and expense
EXPENSE RISK risks, we deduct from the variable account a charge each
CHARGE valuation period. The current charge is shown on the
schedule page as is the maximum effective annual rate
that can be charged. We will deduct the charge from
each subdivision of the variable account in the same
proportion that the value of each subdivision bears to
the variable account.
SURRENDER CHARGE A surrender charge will never be imposed on total or
partial surrenders of this contract.
ADMINISTRATION We deduct from the variable account a charge each
FEE valuation period to partially defray the expenses of
maintaining the contract. The current charge is shown
on the schedule page and is the maximum effective
annual rate that can be charged.
TAXES We will charge certain taxes against your premiums,
accumulation value, or annuity payments, when incurred.
These taxes include any premium taxes or other taxes
levied by any government entity which we, in our sole
discretion, determine have resulted from:
1. the establishment or maintenance of the variable
account; or
2. from the investment experience of the variable
account; or
3. from the receipt by us of the premium; or
4. from the issuance of this contract, or
5. from the commencement or continuance of annuity
payments under this contract.
GENERAL PROVISIONS
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ENTIRE CONTRACT This contract is a legal contract that you have entered
into with us. The entire contract consists of this
contract, any endorsements, schedule pages, amendments,
and the attached copy of the application and
supplemental applications. Any change in the contract
must be written and signed by our President, one of
our Vice Presidents, our Secretary or Assistant
Secretary. No agent or person other than the above-
named has the authority to change or modify this policy
or waive any of its provisions. Words that can be
interpreted as singular or plural shall mean both
singular and plural.
BENEFICIARY The primary and any contingent beneficiaries of this
contract are named in the application. If changed,
the beneficiary is as shown in the latest change.
Unless the beneficiary designation provides otherwise,
any death benefits will be divided equally among
beneficiaries of the same class. The contingent
beneficiary will receive the death benefits if no
primary beneficiary is living at the time of the event
giving rise to the benefit payment. Prior to the
maturity date, if no beneficiary survives you, your
estate will be the beneficiary. The interest of any
beneficiary is subject to that of any assignee.
CHANGE OF You may change the beneficiary, unless an irrevocable
BENEFICIARY designation has been made. Any such change must be made
by written notice in a form acceptable to us and
received at our home office. If you die after the
maturity date, the annuitant may change the beneficiary
unless an irrevocable designation has been made.
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CHANGE IN Prior to the maturity date, you may change the maturity
MATURITY DATE date by written request at least 30 days before the
previously specified maturity date. After the election,
the new maturity date will become the maturity date.
ASSIGNMENT You may assign this contract. No assignment will be
binding on us unless it is written in a form acceptable
to us and received at our home office. We will not be
responsible for the validity of any assignment. We will
not be liable for any payments we make or actions we
take before we receive notice of an assignment.
CLAIMS OF Any accumulation value, before paid, under this contract,
CREDITORS will not be subject to the claims of a beneficiary's
creditors, except as required by law.
MISSTATEMENT AND We may require proof of age, sex, or survival of any
PROOF OF AGE, SEX person upon whose age, sex, or survival any payments
OR SURVIVAL depend.
If the age or sex of the annuitant has been misstated,
the benefits will be those which the premiums would
have provided for the correct age and sex. If we have
made incorrect annuity payments, we will adjust future
payments. The adjustments will reflect any overpayment
or underpayment.
DIVIDEND As long as this contract is in force, you will receive
any dividends declared by us. It is anticipated that
no dividends will be declared.
You have these options:
1. take the dividends in cash; or
2. use the dividends to be credited as additional
accumulation units with respect to the variable
account or added to the guaranteed account.
You may choose either option or change options by
notice to us. If none is chosen, the second option
will be used.
REPORTS At least once a year we will send you a report showing:
1. the accumulation unit value as of the beginning date
of the report;
2. the accumulation unit value as of the ending date of
the report;
3. the total number of accumulation units as of the
ending date of the report;
4. the value of the guaranteed account and/or each
subdivision of the variable account on the beginning
date of the report;
5. the value of the guaranteed account and/or each
subdivision of the variable account on the ending
date of the report; and
6. the gain or loss for each subdivision of the
variable account and/or the guaranteed account.
For the column headings within the report, the
accumulation unit is referred to as "unit."
INSULATION The assets of SA are not chargeable with liabilities
arising out of any other business we may conduct.
OWNERSHIP OF We shall have exclusive and absolute ownership and
ASSETS control of our assets, including the assets of SA.
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MODIFICATION We may not modify this contract without your consent
OF CONTRACT except:
1. to make the contract meet the requirements of the
Investment Company Act of 1940;
2. to make the contract comply with any changes in the
Internal Revenue Code; or
3. as required by any other applicable law in order to
continue treatment of the contract as an annuity.
INCONTESTABILITY We cannot contest this contract after it has been in
force during the lifetime of the annuitant for a period
of two years from the date of issue.
PAYMENT OF CONTRACT BENEFITS
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GENERAL Annuity benefits under this contract are payable in
accordance with the Option Tables given below or under
such other annuity options as we may agree to.
ALTERNATE Instead of an annuity in accordance with the Option
ANNUITY OPTIONS Tables given below, you may choose an alternate type
of fixed annuity payment. Such alternate annuity
option shall be based on rates at least as favorable
as those for fixed dollar single premium immediate
annuities being issued by us on the maturity date.
They may only be elected within 30 days before that date.
DESCRIPTION OF Option 1: Life Annuity
ANNUITY OPTIONS
(a) Nonrefund. We will make payments during the
lifetime of the annuitant. No payments are due
after the death of the annuitant.
(b) 5-Years Certain. We will make payments for 5 years
and after that during the lifetime of the annuitant.
No payments are due after the death of the annuitant
or, if later, the end of the 5-year period certain.
(c) 10-Years Certain. We will make payments for 10
years and after that during the lifetime of the
annuitant. No payments are due after the death
of the annuitant or, if later, the end of the
10-year period certain.
(d) Installment Refund. We will make payments for a
period certain and after that during the lifetime
of the annuitant. No payments are due after the
death of the annuitant or, if later, the end of
the period certain. The number of period certain
payments is equal to the amount applied under this
Installment Refund Option divided by the amount of
the first annuity payment; provided, however, that
the amount of the final period certain payment
shall be multiplied by that part of the preceding
quotient which is not an integer.
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Option 2: Joint and Survivor Life Annuity
(a) Joint and Survivor Nonrefund. We will make
payments during the joint lifetime of the
annuitant and contingent annuitant. Payments
will then continue during the remaining lifetime
of the survivor of them. No payments are due
after the death of the last survivor of the
annuitant and contingent annuitant.
(b) Joint and Survivor with 10-Years Certain. We will
make payments for 10 years and after that during
the joint lifetime of the annuitant and contingent
annuitant. Payments will then continue during the
remaining lifetime of the survivor of them. No
payments are due after the death of the survivor of
the annuitant and contingent annuitant or, if later,
the end of the 10-year period certain.
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Flexible Premium Deferred Variable Annuity
Participating
UC 8135-1
